Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 32
Filtrar
1.
Artigo em Inglês | MEDLINE | ID: mdl-34639614

RESUMO

This study compares the empirical performance of a commonly used functional-status measure, the Barthel Index (BI), to that of a widely used generic preference-based instrument, the EuroQoL-5-Dimensions 3 Level (EQ-5D-3L), in older people. Data from older people receiving rehabilitation services were used to test the validity of the BI and EQ-5D-3L. Convergent validity was investigated using Spearman's correlation, exploratory factor analysis (EFA), scatter plots, Krippendorff's alpha and modified Bland-Altman plots. Discriminant validity was examined using Kruskal Wallis tests, ceiling effects and EFA. A total of 1690 participants were included in the analysis. The BI total and EQ-5D-3L utility scores showed moderate correlation (r = 0.51; Krippendorff's alpha = 0.52). Kendall's Tau-B correlations between BI items and EQ-5D-3L dimensions measuring the same construct were weak to moderate (0.05 ≤ absolute r ≤ 0.54). In the EFA, some BI items cross-loaded onto the same factors as EQ-5D-3L dimensions, suggesting that the instruments were interrelated. The BI, however, focuses more on physical functioning, while the EQ-5D-3L measures broader wellbeing concepts. Both instruments showed good discriminant validity and would therefore be equally valuable for measuring subgroup differences. Researchers should consider using the BI in rehabilitation to capture more physical functioning-specific constructs not measured by the EQ-5D-3L.

2.
PLoS One ; 16(8): e0254698, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34383776

RESUMO

BACKGROUND: Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients. METHODS: A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves. RESULTS: In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds. CONCLUSIONS: Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.


Assuntos
Abdome/cirurgia , Clorexidina/uso terapêutico , Modelos Teóricos , Pneumonia/prevenção & controle , COVID-19 , Análise Custo-Benefício , Humanos , Antissépticos Bucais , Pandemias , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios , Estudos Prospectivos , África do Sul
3.
Eur J Pain ; 25(10): 2081-2093, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34101299

RESUMO

BACKGROUND: Patients with musculoskeletal pain in different body sites share common prognostic factors. Using prognosis to stratify and treatment match can be clinically and cost-effective. We aimed to refine and validate the Keele STarT MSK Tool for prognostic stratification of musculoskeletal pain patients. METHODS: Tool refinement and validity was tested in a prospective cohort study, and external validity examined in a pilot cluster randomized controlled trial (RCT). Study population comprised 2,414 adults visiting U.K. primary care with back, neck, knee, shoulder or multisite pain returning postal questionnaires (cohort: 1,890 [40% response]; trial: 524). Cohort baseline questionnaires included a draft tool plus refinement items. Trial baseline questionnaires included the Keele STarT MSK Tool. Physical health (SF-36 Physical Component Score [PCS]) and pain intensity were assessed at 2- and 6-month cohort follow-up; pain intensity was measured at 6-month trial follow-up. RESULTS: The tool was refined by replacing (3), adding (3) and removing (2) items, resulting in a 10-item tool. Model fit (R2 ) was 0.422 and 0.430 and discrimination (c statistic) 0.839 and 0.822 for predicting 6-month cohort PCS and pain (respectively). The tool classified 24.9% of cohort participants at low, 41.7% medium and 33.4% high risk, clearly discriminating between subgroups. The tool demonstrated model fit of 0.224 and discrimination 0.73 in trial participants. Multiple imputation confirmed robustness of findings. CONCLUSIONS: The Keele STarT MSK Tool demonstrates good validity and acceptable predictive performance and clearly identifies groups of musculoskeletal pain patients with different characteristics and prognosis. Using prognostic information for stratification and treatment matching may be clinically/cost-effective. SIGNIFICANCE: The paper presents the first musculoskeletal pain prognostic stratification tool specifically for use among all primary care patients with the five most common musculoskeletal pain presentations (back, neck, knee, shoulder or multisite pain). The Keele STarT MSK Tool identifies groups of musculoskeletal pain patients with clearly different characteristics and prognosis. Using this tool for stratification and treatment matching may be clinically and cost-effective.

4.
Med Decis Making ; 41(6): 667-684, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33813933

RESUMO

Economic evaluations conducted alongside randomized controlled trials are a popular vehicle for generating high-quality evidence on the incremental cost-effectiveness of competing health care interventions. Typically, in these studies, resource use (and by extension, economic costs) and clinical (or preference-based health) outcomes data are collected prospectively for trial participants to estimate the joint distribution of incremental costs and incremental benefits associated with the intervention. In this article, we extend the generalized linear mixed-model framework to enable simultaneous modeling of multiple outcomes of mixed data types, such as those typically encountered in trial-based economic evaluations, taking into account correlation of outcomes due to repeated measurements on the same individual and other clustering effects. We provide new wrapper functions to estimate the models in Stata and R by maximum and restricted maximum quasi-likelihood and compare the performance of the new routines with alternative implementations across a range of statistical programming packages. Empirical applications using observed and simulated data from clinical trials suggest that the new methods produce broadly similar results as compared with Stata's merlin and gsem commands and a Bayesian implementation in WinBUGS. We highlight that, although these empirical applications primarily focus on trial-based economic evaluations, the new methods presented can be generalized to other health economic investigations characterized by multivariate hierarchical data structures.

5.
Rheumatology (Oxford) ; 60(9): 4175-4184, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33410493

RESUMO

OBJECTIVES: To determine whether physiotherapist-led exercise intervention and US-guided subacromial CS injection is cost-effective when compared with standard advice and exercise leaflet and unguided injection in patients with subacromial pain (impingement) syndrome. METHODS: An incremental cost-utility analysis using patient responses to the five-level EuroQoL-5D (EQ-5D-5L) questionnaire was undertaken from a healthcare perspective alongside a 2 × 2 factorial randomized trial with 256 participants over a 12-month follow-up period. Uncertainty was explored through the use of cost-effectiveness acceptability curves. RESULTS: The cost-utility analysis indicated that physiotherapist-led exercise was associated with an incremental cost of £155.99 (95% CI 69.02, 241.93) and 0.031 (95% CI -0.01, 0.07) additional quality-adjusted life-years (QALYs), an incremental cost-effectiveness ratio (ICER) of £5031 per QALY gained and an 85% chance of being cost-effective at a threshold of £20 000 per QALY gained compared with the advice and exercise leaflet. US-guided injection was associated with an incremental cost of £15.89 (95% CI -59.36, 109.86) and 0.024 (95% CI -0.02, 0.07) additional QALYs, an ICER of £662 per QALY gained and a 83% chance of being cost-effective at a threshold of £20 000 per QALY gained compared with unguided injection. CONCLUSION: Physiotherapist-led exercise was cost-effective compared with the advice and exercise leaflet, and US-guided injection was cost-effective when compared with unguided injection. CLINICAL TRIAL REGISTRATION: ISRCTN, http://www.isrctn.com, ISRCTN42399123.


Assuntos
Corticosteroides/uso terapêutico , Terapia por Exercício/economia , Qualidade de Vida , Síndrome de Colisão do Ombro/terapia , Corticosteroides/administração & dosagem , Corticosteroides/economia , Adulto , Análise Custo-Benefício , Feminino , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Síndrome de Colisão do Ombro/tratamento farmacológico
6.
Br J Sports Med ; 55(5): 262-271, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32816787

RESUMO

OBJECTIVES: To compare the clinical effectiveness of (1) physiotherapist-led exercise versus an exercise leaflet, and (2) ultrasound-guided subacromial corticosteroid injection versus unguided injection for pain and function in subacromial pain (formerly impingement) syndrome (SAPS). METHODS: This was a single-blind 2×2 factorial randomised trial. Adults with SAPS were randomised equally to one of four treatment groups: (1) ultrasound-guided corticosteroid injection and physiotherapist-led exercise, (2) ultrasound-guided corticosteroid injection and an exercise leaflet, (3) unguided corticosteroid injection and physiotherapist-led exercise and (4) unguided corticosteroid injection and an exercise leaflet. The primary outcome was the Shoulder Pain and Disability Index (SPADI), collected at 6 weeks, 6 and 12 months and compared at 6 weeks for the injection interventions and 6 months for the exercise interventions by intention to treat. RESULTS: We recruited 256 participants (64 treatment per group). Response rates for the primary outcome were 94% at 6 weeks, 88% at 6 months and 80% at 12 months. Greater improvement in total SPADI score was seen with physiotherapist-led exercise than with the exercise leaflet at 6 months (adjusted mean difference -8.23; 95% CI -14.14 to -2.32). There were no significant differences between the injection groups at 6 weeks (-2.04; -7.29 to 3.22), 6 months (-2.36; -8.16 to 3.44) or 12 months (1.59; -5.54 to 8.72). CONCLUSIONS: In patients with SAPS, physiotherapist-led exercise leads to greater improvements in pain and function than an exercise leaflet. Ultrasound guidance confers no additional benefit over unguided corticosteroid injection. TRIAL REGISTRATION NUMBER: ISRCTN42399123.


Assuntos
Corticosteroides/uso terapêutico , Terapia por Exercício/métodos , Síndrome de Colisão do Ombro/terapia , Adulto , Idoso , Terapia Combinada , Avaliação da Deficiência , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Pessoa de Meia-Idade , Medição da Dor , Método Simples-Cego , Resultado do Tratamento , Ultrassonografia de Intervenção
7.
Pain ; 162(3): 702-710, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32868748

RESUMO

ABSTRACT: The STarT Back approach comprises subgrouping patients with low back pain (LBP) according to the risk of persistent LBP-related disability, with appropriate matched treatments. In a 12-month clinical trial and implementation study, this stratified care approach was clinically and cost-effective compared with usual, nonstratified care. Despite the chronic nature of LBP and associated economic burden, model-based economic evaluations in LBP are rare and have shortcomings. This study therefore produces a de novo decision model of this stratified care approach for LBP management to estimate the long-term cost-effectiveness and address methodological concerns in LBP modelling. A cost-utility analysis from the National Health Service perspective compared stratified care with usual care in patients consulting in primary care with nonspecific LBP. A Markov state-transition model was constructed where patient prognosis over 10 years was dependent on physical function achieved at 12 months. Data from the clinical trial and implementation study provided short-term model parameters, with extrapolation using 2 cohort studies of usual care in LBP. Base-case results indicate this model of stratified care is cost-effective, delivering 0.14 additional quality-adjusted life years at a cost saving of £135.19 per patient over a time horizon of 10 years. Sensitivity analyses indicate the approach is likely to be cost-effective in all scenarios and cost saving in most. It is likely this stratified care model will help reduce unnecessary healthcare usage while improving the patient's quality of life. Although decision-analytic modelling is used in many conditions, its use has been underexplored in LBP, and this study also addresses associated methodological challenges.


Assuntos
Dor Lombar , Análise Custo-Benefício , Humanos , Dor Lombar/terapia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Medicina Estatal
8.
JMIR Res Protoc ; 9(7): e17939, 2020 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-32442141

RESUMO

BACKGROUND: Musculoskeletal (MSK) pain is a major cause of pain and disability. We previously developed a prognostic tool (Start Back Tool) with demonstrated effectiveness in guiding primary care low back pain management by supporting decision making using matched treatments. A logical next step is to determine whether prognostic stratified care has benefits for a broader range of common MSK pain presentations. OBJECTIVE: This study seeks to determine, in patients with 1 of the 5 most common MSK presentations (back, neck, knee, shoulder, and multisite pain), whether stratified care involving the use of the Keele Start MSK Tool to allocate individuals into low-, medium-, and high-risk subgroups, and matching these subgroups to recommended matched clinical management options, is clinical and cost-effective compared with usual nonstratified primary care. METHODS: This is a pragmatic, two-arm parallel (stratified vs nonstratified care), cluster randomized controlled trial, with a health economic analysis and mixed methods process evaluation. The setting is UK primary care, involving 24 average-sized general practices randomized (stratified by practice size) in a 1:1 ratio (12 per arm) with blinding of trial statistician and outcome data collectors. Randomization units are general practices, and units of observation are adult MSK consulters without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records are tagged and individuals invited using a general practitioner (GP) point-of-consultation electronic medical record (EMR) template. The intervention is supported by an EMR template (computer-based) housing the Keele Start MSK Tool (to stratify into prognostic subgroups) and the recommended matched treatment options. The primary outcome using intention-to-treat analysis is pain intensity, measured monthly over 6 months. Secondary outcomes include physical function and quality of life, and an anonymized EMR audit to capture clinician decision making. The economic evaluation is focused on the estimation of incremental quality-adjusted life years and MSK pain-related health care costs. The process evaluation is exploring a range of potential factors influencing the intervention and understanding how it is perceived by patients and clinicians, with quantitative analyses focusing on a priori hypothesized intervention targets and qualitative approaches using focus groups and interviews. The target sample size is 1200 patients from 24 general practices, with >5000 MSK consultations available for anonymized medical record data comparisons. RESULTS: Trial recruitment commenced on May 18, 2018, and ended on July 15, 2019, after a 14-month recruitment period in 24 GP practices. Follow-up and interview data collection was completed in February 2020. CONCLUSIONS: This trial is the first attempt, as far as we know, at testing a prognostic stratified care approach for primary care patients with MSK pain. The results of this trial should be available by the summer of 2020. TRIAL REGISTRATION: ISRCTN Registry ISRCTN15366334; http://www.isrctn.com/ISRCTN15366334. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17939.

9.
Ann Rheum Dis ; 79(2): 276-284, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31666237

RESUMO

OBJECTIVES: To compare the effectiveness and safety of naproxen and low-dose colchicine for treating gout flares in primary care. METHODS: This was a multicentre open-label randomised trial. Adults with a gout flare recruited from 100 general practices were randomised equally to naproxen 750 mg immediately then 250 mg every 8 hours for 7 days or low-dose colchicine 500 mcg three times per day for 4 days. The primary outcome was change in worst pain intensity in the last 24 hours (0-10 Numeric Rating Scale) from baseline measured daily over the first 7 days: mean change from baseline was compared between groups over days 1-7 by intention to treat. RESULTS: Between 29 January 2014 and 31 December 2015, we recruited 399 participants (naproxen n=200, colchicine n=199), of whom 349 (87.5%) completed primary outcome data at day 7. There was no significant between-group difference in average pain-change scores over days 1-7 (colchicine vs naproxen: mean difference -0.18; 95% CI -0.53 to 0.17; p=0.32). During days 1-7, diarrhoea (45.9% vs 20.0%; OR 3.31; 2.01 to 5.44) and headache (20.5% vs 10.7%; 1.92; 1.03 to 3.55) were more common in the colchicine group than the naproxen group but constipation was less common (4.8% vs 19.3%; 0.24; 0.11 to 0.54). CONCLUSION: We found no difference in pain intensity over 7 days between people with a gout flare randomised to either naproxen or low-dose colchicine. Naproxen caused fewer side effects supporting naproxen as first-line treatment for gout flares in primary care in the absence of contraindications. TRIAL REGISTRATION NUMBER: ISRCTN (69836939), clinicaltrials.gov (NCT01994226), EudraCT (2013-001354-95).


Assuntos
Colchicina/administração & dosagem , Supressores da Gota/administração & dosagem , Gota/tratamento farmacológico , Naproxeno/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Exacerbação dos Sintomas , Resultado do Tratamento
11.
Appl Health Econ Health Policy ; 17(4): 467-491, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30941658

RESUMO

BACKGROUND: Low back pain (LBP) and sciatica place significant burden on individuals and healthcare systems, with societal costs alone likely to be in excess of £15 billion. Two recent systematic reviews for LBP and sciatica identified a shortage of modelling studies in both conditions. OBJECTIVES: The aim of this systematic review was to document existing model-based economic evaluations for the treatment and management of both conditions; critically appraise current modelling techniques, analytical methods, data inputs, and structure, using narrative synthesis; and identify unresolved methodological problems and gaps in the literature. METHODS: A systematic literature review was conducted whereby 6512 records were extracted from 11 databases, with no date limits imposed. Studies were abstracted according to a predesigned protocol, whereby they must be economic evaluations that employed an economic decision model and considered any management approach for LBP and sciatica. Study abstraction was initially performed by one reviewer who removed duplicates and screened titles to remove irrelevant studies. Overall, 133 potential studies for inclusion were then screened independently by other reviewers. Consensus was reached between reviewers regarding final inclusion. RESULTS: Twenty-one publications of 20 unique models were included in the review, five of which were modelling studies in LBP and 16 in sciatica. Results revealed a poor standard of modelling in both conditions, particularly regarding modelling techniques, analytical methods, and data quality. Specific issues relate to inappropriate representation of both conditions in terms of health states, insufficient time horizons, and use of inappropriate utility values. CONCLUSION: High-quality modelling studies, which reflect modelling best practice, as well as contemporary clinical understandings of both conditions, are required to enhance the economic evidence for treatments for both conditions.


Assuntos
Técnicas de Apoio para a Decisão , Dor Lombar/economia , Ciática/economia , Análise Custo-Benefício , Humanos , Dor Lombar/terapia
12.
Lancet ; 392(10156): 1423-1433, 2018 10 20.
Artigo em Inglês | MEDLINE | ID: mdl-30343858

RESUMO

BACKGROUND: To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome. METHODS: We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452. FINDINGS: Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference -0·32; 95% CI -0·48 to -0·16; p=0·0001). No adverse events were reported. INTERPRETATION: A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care. FUNDING: Arthritis Research UK.


Assuntos
Anti-Inflamatórios/administração & dosagem , Síndrome do Túnel Carpal/terapia , Injeções , Metilprednisolona/análogos & derivados , Contenções , Adulto , Idoso , Síndrome do Túnel Carpal/economia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Metilprednisolona/administração & dosagem , Acetato de Metilprednisolona , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Inquéritos e Questionários , Resultado do Tratamento
13.
Artigo em Inglês | MEDLINE | ID: mdl-30116525

RESUMO

Background: Antimicrobial resistance (AMR) poses a colossal threat to global health and incurs high economic costs to society. Economic evaluations of antimicrobials and interventions such as diagnostics and vaccines that affect their consumption rarely include the costs of AMR, resulting in sub-optimal policy recommendations. We estimate the economic cost of AMR per antibiotic consumed, stratified by drug class and national income level. Methods: The model is comprised of three components: correlation coefficients between human antibiotic consumption and subsequent resistance; the economic costs of AMR for five key pathogens; and consumption data for antibiotic classes driving resistance in these organisms. These were used to calculate the economic cost of AMR per antibiotic consumed for different drug classes, using data from Thailand and the United States (US) to represent low/middle and high-income countries. Results: The correlation coefficients between consumption of antibiotics that drive resistance in S. aureus, E. coli, K. pneumoniae, A. baumanii, and P. aeruginosa and resistance rates were 0.37, 0.27, 0.35, 0.45, and 0.52, respectively. The total economic cost of AMR due to resistance in these five pathogens was $0.5 billion and $2.9 billion in Thailand and the US, respectively. The cost of AMR associated with the consumption of one standard unit (SU) of antibiotics ranged from $0.1 for macrolides to $0.7 for quinolones, cephalosporins and broad-spectrum penicillins in the Thai context. In the US context, the cost of AMR per SU of antibiotic consumed ranged from $0.1 for carbapenems to $0.6 for quinolones, cephalosporins and broad spectrum penicillins. Conclusion: The economic costs of AMR per antibiotic consumed were considerable, often exceeding their purchase cost. Differences between Thailand and the US were apparent, corresponding with variation in the overall burden of AMR and relative prevalence of different pathogens. Notwithstanding their limitations, use of these estimates in economic evaluations can make better-informed policy recommendations regarding interventions that affect antimicrobial consumption and those aimed specifically at reducing the burden of AMR.


Assuntos
Antibacterianos/economia , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/economia , Farmacorresistência Bacteriana , Antibacterianos/uso terapêutico , Bactérias/classificação , Bactérias/efeitos dos fármacos , Bactérias/genética , Bactérias/isolamento & purificação , Infecções Bacterianas/microbiologia , Carbapenêmicos/economia , Carbapenêmicos/uso terapêutico , Uso de Medicamentos/economia , Humanos , Macrolídeos/economia , Macrolídeos/uso terapêutico , Quinolonas/economia , Quinolonas/uso terapêutico , Tailândia , Estados Unidos
14.
J Antimicrob Chemother ; 73(11): 3189-3198, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30165522

RESUMO

Objectives: Overprescribing of antibiotics by general practitioners (GPs) is seen as a major driver of antibiotic resistance. Training in communication skills and C-reactive protein (CRP) testing both appear effective in reducing such prescribing. This study assesses the cost-effectiveness (compared with usual care) of: (i) training GPs in the use of CRP testing; (ii) training GPs in communication skills; and (iii) training GPs in both CRP testing and communication skills. Methods: Economic analyses [cost-utility analysis (CUA) accounting for the cost of antibiotic resistance and cost-effectiveness analysis (CEA)] were both conducted from a healthcare perspective with a time horizon of 28 days alongside a multinational, cluster, randomized, factorial controlled trial in patients with respiratory tract infections in five European countries. The primary outcome measures were QALYs and percentage reduction in antibiotic prescribing. Hierarchical modelling was used to estimate an incremental cost per QALY gained and an incremental cost per percentage reduction in antibiotic prescribing. Results: Overall, the results of both the CUA and CEA showed that training in communication skills is the most cost-effective option. However, excluding the cost of antibiotic resistance in the CUA resulted in usual care being the most cost-effective option. Country-specific results from the CUA showed that training in communication skills was cost-effective in Belgium, UK and Netherlands whilst training in CRP was cost-effective in Poland. Conclusions: Internet-based training in communication skills is a cost-effective intervention to reduce antibiotic prescribing for respiratory tract infections in primary care if the cost of antibiotic resistance is accounted for.


Assuntos
Antibacterianos/uso terapêutico , Educação/economia , Prescrição Inadequada/prevenção & controle , Internet/economia , Médicos de Atenção Primária/educação , Infecções Respiratórias/tratamento farmacológico , Proteína C-Reativa/análise , Comunicação , Análise Custo-Benefício , Europa (Continente) , Feminino , Clínicos Gerais/educação , Humanos , Masculino , Padrões de Prática Médica , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/métodos , Infecções Respiratórias/diagnóstico
15.
BMC Musculoskelet Disord ; 19(1): 218, 2018 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-30021588

RESUMO

BACKGROUND: Evidence on the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis is limited and conflicting. The primary objective of the Hip Injection Trial (HIT) is to compare pain intensity over 6 months, in people with hip OA between those receiving an ultrasound-guided intra-articular hip injection of corticosteroid with 1% lidocaine hydrochloride plus best current treatment with those receiving best current treatment alone. Secondary objectives are to determine specified comparative clinical and cost-effectiveness outcomes, and to explore, in a linked qualitative study, the lived experiences of patients with hip OA and experiences and impact of, ultrasound-guided intra-articular hip injection. METHODS: The HIT trial is a pragmatic, three-parallel group, single-blind, superiority, randomised controlled trial in patients with painful hip OA with a linked qualitative study. The current protocol is described, in addition to details and rationale for amendments since trial registration. 204 patients with moderate-to-severe hip OA will be recruited. Participants are randomised on an equal basis (1:1:1 ratio) to one of three interventions: (1) best current treatment, (2) best current treatment plus ultrasound-guided intra-articular hip injection of corticosteroid (triamcinolone acetonide 40 mg) with 1% lidocaine hydrochloride, or (3) best current treatment plus an ultrasound-guided intra-articular hip injection of 1% lidocaine hydrochloride alone. The primary endpoint is patient-reported hip pain intensity across 2 weeks, 2 months, 4 months and 6 months post-randomisation. Recruitment is over 29 months with a 6-month follow-up period. To address the primary objective, the analysis will compare participants' 'average' follow-up pain NRS scores, based on a random effects linear repeated-measures model. Data on adverse events are collected and reported in accordance with national guidance and reviewed by external monitoring committees. Individual semi-structured interviews are being conducted with up to 30 trial participants across all three arms of the trial. DISCUSSION: To ensure healthcare services improve outcomes for patients, we need to ensure there is a robust and appropriate evidence-base to support clinical decision making. The HIT trial will answer important questions regarding the clinical and cost-effectiveness of intra-articular corticosteroid injections. TRIAL REGISTRATION: ISRCTN: 50550256 , 28th July 2015.


Assuntos
Anestésicos Locais/economia , Análise Custo-Benefício/métodos , Glucocorticoides/economia , Osteoartrite do Quadril/tratamento farmacológico , Osteoartrite do Quadril/economia , Ultrassonografia de Intervenção/economia , Corticosteroides/administração & dosagem , Corticosteroides/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais/administração & dosagem , Feminino , Seguimentos , Glucocorticoides/administração & dosagem , Humanos , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/métodos , Lidocaína/administração & dosagem , Lidocaína/economia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Osteoartrite do Quadril/diagnóstico por imagem , Medição da Dor/efeitos dos fármacos , Medição da Dor/economia , Medição da Dor/métodos , Método Simples-Cego , Resultado do Tratamento , Triancinolona Acetonida/administração & dosagem , Triancinolona Acetonida/economia , Ultrassonografia de Intervenção/métodos
16.
Ann Thorac Surg ; 106(3): 757-763, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29709502

RESUMO

BACKGROUND: Ventilator-associated pneumonia (VAP) is common and costly. In a recent randomized controlled trial, the Venner-PneuX (VPX) endotracheal tube system (Qualitech Healthcare Limited, Maidenhead, United Kingdom) was found to be superior to standard endotracheal tubes (SET) in preventing VAP. However, VPX is considerably more expensive. We evaluated the costs and benefits of VPX to determine whether replacing SET with VPX is a cost-effective option for intensive care units. METHODS: We developed a decision analytic model to compare intubation with VPX or SET for patients requiring mechanical ventilation after cardiac operations. The model was populated with existing evidence on costs, effectiveness, and quality of life. Cost-effectiveness and cost-utility analyses were conducted from a National Health Service hospital perspective. Uncertainty was assessed through deterministic and probabilistic sensitivity analyses. RESULTS: Compared with SET, VPX is associated with an expected cost saving of £738 per patient. VPX led to a small increase in quality-adjusted life years, indicating that the device is overall less costly and more effective than SET. The probability of VPX being cost-effective at £30,000 per quality-adjusted life year is 97%. VPX would cease to be cost-effective if (1) it led to a risk reduction smaller than 0.02 compared with SET, (2) the acquisition cost of VPX was as high as £890, or (3) the cost of treating a case of VAP was lower than £1,450. CONCLUSIONS: VPX resulted in improved outcomes and savings that far offset the cost of the device, suggesting that replacing SET with VPX is overall beneficial. Findings were robust to extreme values of key variables.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Análise Custo-Benefício , Intubação Intratraqueal/instrumentação , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Cuidados Pós-Operatórios/economia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Técnicas de Apoio para a Decisão , Desenho de Equipamento , Feminino , Humanos , Intubação Intratraqueal/economia , Intubação Intratraqueal/métodos , Masculino , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Reino Unido
17.
J Intensive Care Soc ; 19(2): 94-100, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29796064

RESUMO

Background: Ventilator-associated pneumonia is associated with significant morbidity, mortality and healthcare costs. Most of the cost data that are available relate to general intensive care patients in privately remunerated institutions. This study assessed the cost of managing ventilator-associated pneumonia in a cardiac intensive care unit in the National Health Service in the United Kingdom. Methods: Propensity-matched study of prospectively collected data from the cardiac surgical database between April 2011 and December 2014 in all patients undergoing cardiac surgery (n = 3416). Patients who were diagnosed as developing ventilator-associated pneumonia, as per the surveillance definition for ventilator-associated pneumonia (n = 338), were propensity score matched with those who did not (n = 338). Costs of treating post-op cardiac surgery patients in intensive care and cost difference if ventilator-associated pneumonia occurred based on Healthcare Resource Group categories were assessed. Secondary outcomes included differences in morbidity, mortality and cardiac intensive care unit and in-hospital length of stay. Results: There were no significant differences in the pre-operative characteristics or procedures between the groups. Ventilator-associated pneumonia developed in 10% of post-cardiac surgery patients. Post-operatively, the ventilator-associated pneumonia group required longer ventilation (p < 0.01), more respiratory support, longer cardiac intensive care unit (8 vs 3, p < 0.001) and in-hospital stay (16 vs 9) days. The overall cost for post-operative recovery after cardiac surgery for ventilator-associated pneumonia patients was £15,124 compared to £6295 for non-ventilator-associated pneumonia (p < 0.01). The additional cost of treating patients with ventilator-associated pneumonia was £8829. Conclusion: Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for the cost for general intensive care unit patients in privately reimbursed systems.

18.
Rheumatology (Oxford) ; 57(6): 1056-1063, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-29554338

RESUMO

Objectives: The aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care. Methods: An incremental cost-utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves. Results: Differences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by -0.28 (95% CI: -0.55, -0.06). The cost-utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £-13.11 (95% CI: -81.09 to 54.85) and an incremental quality adjusted life year (QALY) of -0.003 (95% CI: -0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm. Conclusion: Implementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective.


Assuntos
Nível de Saúde , Osteoartrite/diagnóstico , Atenção Primária à Saúde/economia , Encaminhamento e Consulta/economia , Autogestão/métodos , Análise Custo-Benefício , Humanos , Perda de Seguimento , Osteoartrite/economia , Qualidade de Vida , Inquéritos e Questionários
19.
Int J Health Policy Manag ; 7(11): 1040-1052, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30624877

RESUMO

BACKGROUND: Ghana is implementing activities towards universal health coverage (UHC) as well as the attainment of the health-related Sustainable Development Goals (SDGs) by the health sector by the year 2030. Aside lack of empirical forecast of the required healthcare facilities to achieve these mandates, health workforce deficits are also a major threat. We therefore modelled the needed healthcare facilities in Ghana and translated it into year-by-year staffing requirements based on established staffing standards. METHODS: Two levels of modelling were used. First, a predictive model based on Markov processes was used to estimate the future healthcare facilities needed in Ghana. Second, the projected healthcare facilities were translated into aggregate staffing requirements using staffing standards developed by Ghana's Ministry of Health (MoH). RESULTS: The forecast shows a need to expand the number/capacity of healthcare facilities in order to attain UHC. All things being equal, the requisite healthcare infrastructure for UHC would be attainable from 2023. The forecast also shows wide variations in staffing-need-availability rate, ranging from 15% to 94% (average being 68%) across the various staff types. Thus, there are serious shortages of staff which are worse amongst specialists. CONCLUSION: Ghana needs to expand and/or increase the number of healthcare facilities to facilitate the attainment of UHC. Also, only about 68% of the health workforce (HWF) requirements are employed and available for service delivery, leaving serious shortages of the essential health professionals. Immediate recruitment of unemployed but qualified health workers is therefore imperative. Also, addressing health worker productivity, equitable distribution of existing workers, and attrition may be the immediate steps to take whilst a long-term commitment to comprehensively address HWF challenges, including recruitments, expansion and streamlining of HWF training, is pursued.


Assuntos
Atenção à Saúde , Instalações de Saúde , Pessoal de Saúde , Necessidades e Demandas de Serviços de Saúde , Mão de Obra em Saúde , Setor Público , Países em Desenvolvimento , Previsões , Gana , Órgãos Governamentais , Política de Saúde , Humanos , Atenção Primária à Saúde , Desenvolvimento Sustentável , Cobertura Universal do Seguro de Saúde
20.
BMC Musculoskelet Disord ; 18(1): 183, 2017 05 10.
Artigo em Inglês | MEDLINE | ID: mdl-28486957

RESUMO

BACKGROUND: The primary purpose of this study is to assess the existing evidence on the cost-effectiveness of surgical interventions for the management of knee and hip osteoarthritis by systematically reviewing published economic evaluation studies. METHODS: A systematic review was conducted for the period 2004 to 2016. Electronic databases were searched to identify both trial and model based economic evaluation studies that evaluated surgical interventions for knee and hip osteoarthritis. RESULTS: A total of 23 studies met the inclusion criteria and an assessment of these studies showed that total knee arthroplasty (TKA), and total hip arthroplasty (THA) showed evidence of cost-effectiveness and improvement in quality of life of the patients when compared to non-operative and non-surgical procedures. On the other hand, even though delaying TKA and THA may lead to some cost savings in the short-run, the results from the study showed that this was not a cost-effective option. CONCLUSIONS: TKA and THA are cost-effective and should be recommended for the management of patients with end stage/severe knee and hip OA. However, there needs to be additional studies to assess the cost-effectiveness of other surgical interventions in order for definite conclusions to be reached.


Assuntos
Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Análise Custo-Benefício , Osteoartrite do Quadril/economia , Osteoartrite do Joelho/economia , Análise Custo-Benefício/métodos , Gerenciamento Clínico , Humanos , Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/cirurgia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...