Long-term effect of patient decision aids on use of joint replacement and health care costs.

OBJECTIVE: Shared decision-making supported by patient decisions aids may improve care and reduce healthcare costs for persons considering total joint replacement. Observational studies and randomized controlled trials (RCTs) have evaluated the short-term impact of decision aids on uptake of surgery and costs, however the long-term effects are unclear. This analysis aimed to evaluate the effect of patient decision aids on 1) use of joint replacement up to 7-years of follow-up, and 2) osteoarthritis-related health system costs. METHODS: 324 participants in a Canadian RCT with 2-years follow-up who were randomized to either a decision aid (n = 161) or usual care (n = 163) had their trial and health administrative data linked. The proportion undergoing surgery up to 7-years were compared using cumulative incidence plots and competing risk regression. Mean per-patient costs were compared using two sample t-tests. RESULTS: At 2-years, 119 of 161 (73.9%) patients in the decision aid arm and 129 of 163 (79.1%) patients in the usual care arm had surgery. Between two and 7-years, 17 additional patients in both the decision aid (of 42, 40.4%) and usual care (of 34, 50.0%) arms underwent surgery. At 7-years, patients exposed to decision aids had a similar likelihood of undergoing surgery (HR = 0.92, 95% CI:0.73 to 1.17, p = 0.49) and mean per-patient costs ($21,965 vs $23,681, incremental cost: -$1,717, 95% CI:-$5,631 to $2,198) compared to those in usual care. CONCLUSIONS: This is the first study to assess the long-term impact of decision aids on use of joint replacement and healthcare costs. These results are not conclusive but can inform future trial design. CLINICAL TRIAL REGISTRATION: The full trial protocol is available at ClinicalTrials.Gov (NCT00911638).

Decision aids for patients considering total joint replacement: a cost-effectiveness analysis alongside a randomised controlled trial.

BACKGROUND: Shared decision-making (SDM) is a key priority to improve patient-centred care, and can play an important role in helping patients decide whether to undergo total joint arthroplasty (TJA). Patient decision aids can support SDM; however, they may incur an upfront cost. We aimed to estimate the health and economic effects of patient decision aids for TJA. METHODS: A cost-effectiveness analysis of a randomised controlled trial (RCT) with 2-year follow-up. 343 patients were recruited from two orthopedic screening clinics in Ottawa, Canada. Patients were randomized to either a patient decision aid plus surgeon preference report (decision aid) or usual care. Primary outcomes were costs (in 2014 CAD$), quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Costs were calculated by multiplying self-reported resource use by unit costs. QALYs were calculated by mapping the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to EuroQol 5-Dimension (EQ-5D) health utilities. Costs and QALYs were discounted at 5%. Multiple imputation was used to handle missing data, and bootstrapping was used to estimate uncertainty. RESULTS: The sample comprised 167 intervention and 167 control group patients. The decision aid arm had fewer surgeries over the 2-year period thereby incurring a negative incremental cost of -$560 (95% CI: -$1358 to $426) per patient while providing 0.05 (95% CI: -0.04 to 0.13) additional QALYs per patient. Consequently, the decision aid arm was dominant. CONCLUSION: The use of a patient decision aid was associated with fewer health care costs, while producing similar health outcomes. CLINICAL TRIAL REGISTRATION NUMBER: CT00911638 (clinicaltrials.gov).

Interventions for improving employment outcomes among individuals with spinal cord injury: a systematic review.

STUDY DESIGN: Systematic literature review. OBJECTIVE: The primary aim of this study was to evaluate interventions aimed at improving employment outcomes for individuals with spinal cord injuries (SCI). METHODS: An electronic search of Medline/PubMed, EMBASE, Cochrane database, CINAHL, PsycINFO, Social Science Abstracts and Social Work Abstract databases was performed on 31 December 2013. To be included in the review, studies needed to investigate interventions among individuals with SCI where employment was an outcome. Exclusion criteria include (i) reviews, (ii) studies not published in English and (iii) non-peer reviewed publications. RESULTS: Fourteen studies met the inclusion criteria, two were randomized controlled trials. The strongest evidence finds that supported employment can improve employment outcomes among individuals with SCI. The use of service dogs has also been shown to improve employment outcomes. The remaining 12 studies are observational and predominantly focus on vocational rehabilitation programs. CONCLUSION: There is a dearth of high-quality intervention research that targets employment outcomes in individuals with SCI. Consequently, conclusions are mostly based on evidence from observational studies. Vocational rehabilitation programs are the primary focus of this evidence, but conclusions may be confounded, as individuals may be self-selecting for these programs. Additional randomized trials on employment interventions are needed to overcome these limitations. Studies should aim to identify which components of these programs have the greatest influence on employment outcomes.

Improved estimation of the health and economic burden of chronic disease risk factors in Manitoba.

INTRODUCTION: There are analytic challenges involved with estimating the aggregate burden of multiple risk factors (RFs) in a population. We describe a methodology to account for overlapping RFs in some sub-populations, a phenomenon that leads to "double-counting" the diseases and economic burden generated by those factors. METHODS: Our method uses an efficient approach to accurately analyze the aggregate economic burden of chronic disease across a multifactorial system. In addition, it involves considering the effect of body weight as a continuous or polytomous exposure that ranges from no excess weight through overweight to obesity. We then apply this method to smoking, physical inactivity and overweight/obesity in Manitoba, a province of Canada. RESULTS: The annual aggregate economic burden of the RFs in Manitoba in 2008 is about $1.6 billion ($557 million for smoking, $299 million for physical inactivity and $747 million for overweight/obesity). The total burden represents a 12.6% downward adjustment to account for the effect of multiple RFs in some individuals in the population. CONCLUSION: An improved estimate of the aggregate economic burden of multiple RFs in a given population can assist in prioritizing and gaining support for primary prevention initiatives.

TITRE: Meilleure estimation du fardeau que représentent les facteurs de risque de maladie chronique pour la santé et l'économie au Manitoba. INTRODUCTION: L'estimation du fardeau global que représentent les facteurs de risque multiples au sein d'une population présente certains défis d'ordre analytique. Nous décrivons une méthodologie permettant de tenir compte des facteurs de risque se chevauchant dans certaines sous-populations et entraînant un « double compte ¼ des maladies et du fardeau économique qu'ils engendrent. MÉTHODOLOGIE: Notre démarche permet d'analyser avec précision le fardeau économique global des maladies chroniques dans un cadre multifactoriel tout en tenant compte de l'incidence du poids en tant qu'exposition continue ou polytomique (allant de l'absence d'excédent de poids au surpoids et à l'obésité). Nous appliquons cette méthode au tabagisme, à l'inactivité physique et au surpoids et à l'obésité à la province du Manitoba (Canada). RÉSULTATS: En 2008, le fardeau économique global annuel des facteurs de risque au Manitoba était d'environ 1,6 milliard de dollars (557 millions pour le tabagisme, 299 millions pour l'inactivité physique et 747 millions pour le surpoids et l'obésité). Le fardeau total représente un rajustement à la baisse de 12,6 % lorsqu'on tient compte de l'effet des facteurs de risque multiples chez certaines personnes. CONCLUSION: Une meilleure estimation du fardeau économique global des facteurs de risque multiples au sein d'une population peut faciliter l'établissement des priorités et améliorer le soutien aux initiatives de prévention primaire.

The economic burden of traumatic spinal cord injury in Canada.

INTRODUCTION: The purpose of this study is to estimate the current lifetime economic burden of traumatic spinal cord injury (tSCI) in Canada from a societal perspective, including both direct and indirect costs, using an incidence-based approach. METHODS: Available resource use and cost information for complete/incomplete tetraplegia and paraplegia was applied to the estimated annual incidence of tSCI, by severity, in Canada. RESULTS: The estimated lifetime economic burden per individual with tSCI ranges from $1.5 million for incomplete paraplegia to $3.0 million for complete tetraplegia. The annual economic burden associated with 1389 new persons with tSCI surviving their initial hospitalization is estimated at $2.67 billion. CONCLUSION: While the number of injuries per year in Canada is relatively small, the annual economic burden is substantial.

TITLE: Fardeau économique lié aux traumatismes de la moelle épinière au Canada. INTRODUCTION: Cette étude vise à mesurer, au moyen d'une approche fondée sur l'incidence, le fardeau économique à vie lié aux traumatismes de la moelle épinière (TME) au Canada du point de vue social, en incluant les coûts directs et indirects. MÉTHODOLOGIE: Les ressources disponibles et l'information sur les coûts liés aux cas de tétraplégie et de paraplégie complètes et incomplètes ont été appliquées à l'incidence annuelle estimative des TME au Canada en fonction de leur gravité. RÉSULTATS: Le fardeau économique à vie d'une personne atteinte d'un TME varie de 1,5 million de dollars pour une paraplégie incomplète à 3 millions de dollars pour une tétraplégie complète. Le fardeau économique annuel lié aux 1 389 nouveaux cas de TME où le patient a survécu à son hospitalisation est estimé à 2,67 milliards de dollars. CONCLUSION: Malgré leur fréquence annuelle relativement faible au Canada, ces blessures entraînent un fardeau économique annuel important.

The influence of depression on physical complications in spinal cord injury: behavioral mechanisms and health-care implications.

STUDY DESIGN: This study is a literature review and a proposed conceptual model. OBJECTIVES: The objective of this study is to develop a conceptual model to explore the relationship between the presence of depressive symptoms and secondary physical complications such as pressure ulcers, urinary tract infections and autonomic dysreflexia in spinal cord injury (SCI). SETTING: Community setting for individuals with SCI. METHODS: A conceptual model explaining the mechanism underlying the relationship between depression and secondary physical SCI complications was developed based on the International Classification of Functioning, Disability and Health (ICF). A literature review was conducted to develop the model and to identify potential mechanisms responsible for the association. RESULTS: A conceptual model based on ICF was created, informed by the literature discussing the link between depression and secondary physical SCI complications. Evidence in the literature was located that supports both a causal connection between depression and increased physical complications and/or the potential mechanisms mediating that connection. CONCLUSION: The proposed model can be utilized to encourage further research on the influence of depression on SCI outcomes and the importance of prompt and effective identification and treatment of depressive symptoms. Additional research is needed to assess the relationship between depression and secondary physical SCI complications, and to test the validity of the model.