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1.
Medicine (Baltimore) ; 98(41): e17289, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593081

RESUMO

INTRODUCTION: Fibromyalgia (FM) is a chronic condition characterized by chronic pain, fatigue and loss of function which significantly impairs quality of life. Although treatment of FM remains disputed, some studies point at the efficacy of interdisciplinary therapy. This study aims to analyze the effectiveness, cost-utility and benefits of a multicomponent therapy on quality of life (main variable), functional impact, mood and pain in people suffering from FM that attend primary care centers (PCCs) of the Catalan Institute of Health (ICS). METHODS AND ANALYSIS: A 2-phase, mixed methods study has been designed following Medical Research Council guidance. Phase 1: Pragmatic randomized clinical trial with patients diagnosed with FM that attend one of the 11 PCCs of the ICS Gerència Territorial Terres de l'Ebre. We estimate a total sample of 336 patients. The control group will receive usual clinical care, while the multicomponent therapy group (MT group) will receive usual clinical care plus group therapy (consisting of health education, exercise and cognitive-behavioural therapy) during 12 weeks in 2-hourly weekly sessions. ANALYSIS: the standardized mean response and the standardized effect size will be assessed at 3, 9, and 15 months after the beginning of the study using multiple linear regression models. Utility measurements will be used for the economic analysis. Phase 2: Qualitative socio constructivist study to evaluate the intervention according to the results obtained and the opinions and experiences of participants (patients and professionals). We will use theoretical sampling, with 2 discussion groups of participants in the multicomponent therapy and 2 discussion groups of professionals of different PCCs. A thematic content analysis will be carried out. ETHICS AND DISSEMINATION: This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P18/068). Articles will be published in international, peer-reviewed scientific journals. TRIAL REGISTRATION: Clinical-Trials.gov: NCT04049006.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Terapia por Exercício/métodos , Fibromialgia/terapia , Educação de Pacientes como Assunto/métodos , Atenção Primária à Saúde/métodos , Qualidade de Vida , Adulto , Terapia Cognitivo-Comportamental/economia , Terapia Combinada , Análise Custo-Benefício , Terapia por Exercício/economia , Estudos de Viabilidade , Feminino , Fibromialgia/economia , Fibromialgia/psicologia , Implementação de Plano de Saúde , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde , Cooperação do Paciente , Educação de Pacientes como Assunto/economia , Atenção Primária à Saúde/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa
2.
J Altern Complement Med ; 25(12): 1225-1237, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31556689

RESUMO

Objectives: Falls are common in Parkinson's disease (PD). Exercise interventions can prevent falls. This review aims to (1) explore the existing evidence regarding the cost-effectiveness of exercise-based fall prevention programs for people with PD and (2) discuss the implications of the review findings for future research and clinical practice. Design: Databases AMED Allied and Complementary Medicine, CINAHL, CRD, EBSCO, EMBASE, MEDLINE, PubMed, Scopus, and Web of Science were searched from their inception until June 2019. Randomized and nonrandomized trials that included an economic evaluation of fall prevention programs for people with PD were considered. Quality of the economic evaluation was assessed using the Consensus on Health Economic Criteria list (CHEC-list), and the methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) and Cochrane risk of bias tool. Results: Nine hundred and sixty-five studies were screened to include three studies involving 556 participants. Quality of economic evaluation assessed using CHEC-list was high. The methodological quality was high for two studies and low for one study. Tested interventions included Tai Ji Quan, physiotherapist-led, supervised, weekly and monthly balance, and strengthening exercises. The duration of the interventions ranged from 10 weeks to 6 months, while the intervention frequency ranged from two sessions per week to one session per month. Treatment sessions lasted for 60 min in all three studies. One high economic and methodological quality study comparing Tai Ji Quan with resistance and stretching exercises reported least cost resource use among Tai Ji Quan group (USD 80,441) and greater incremental number of falls prevented. All three tested interventions had an 80% probability of being cost-effective with the corresponding country-specific threshold incremental cost-effectiveness ratio values. Conclusions: The findings provide some evidence for exercise-based intervention as a cost-effective treatment option for preventing falls in PD; however, due to the limited number of available studies, heterogeneity of the interventions, and diversity of assessment settings, a firm conclusion cannot be established. Additional studies evaluating the cost-effectiveness of fall prevention programs involving larger samples and using different treatment parameters in various settings are warranted.


Assuntos
Acidentes por Quedas/prevenção & controle , Terapia por Exercício , Doença de Parkinson/terapia , Idoso , Análise Custo-Benefício , Terapia por Exercício/economia , Terapia por Exercício/métodos , Terapia por Exercício/estatística & dados numéricos , Feminino , Humanos , Masculino , Tai Ji
3.
Artigo em Inglês | MEDLINE | ID: mdl-31200434

RESUMO

This study analyses the effectiveness and cost-effectiveness of a group-based multicomponent physical exercise programme aimed at reducing the risk of falling and frailty in community-dwelling older adults. This is a pretest-posttest non-equivalent control group design, with an intervention group and a comparison group. Participants were evaluated at baseline and after 9 months. The effectiveness analyses showed significant reduction in the risk of falling (-45.5%; p = 0.000) and frailty (-31%; p = 0.000) after the intervention for the participants in the physical exercise programme. Moreover, these participants showed an improvement in limitations in activities of daily living, self-care ability and the use of health resources, physical performance, balance and body mass index. The cost-effectiveness analyses showed that the intervention was cost-saving and more effective than usual care scenario. A novel group-based multicomponent physical exercise programme showed to be more effective and cost-effective than usual care for older adults suffering from risk of falling and frailty.


Assuntos
Acidentes por Quedas/prevenção & controle , Terapia por Exercício/economia , Fragilidade/prevenção & controle , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Análise Custo-Benefício , Exercício , Feminino , Humanos , Vida Independente , Masculino , Equilíbrio Postural , Autocuidado
4.
BMC Musculoskelet Disord ; 20(1): 254, 2019 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-31138256

RESUMO

BACKGROUND: Physical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions. METHODS / DESIGN: Step-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA. DISCUSSION: STEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02653768 (STepped Exercise Program for Knee OsteoArthritis (STEP-KOA)), Registered January 12, 2016.


Assuntos
Terapia por Exercício/métodos , Osteoartrite do Joelho/terapia , Assistência Centrada no Paciente/métodos , Adulto , Análise Custo-Benefício , Terapia por Exercício/economia , Feminino , Humanos , Masculino , Osteoartrite do Joelho/diagnóstico , Assistência Centrada no Paciente/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs , Veteranos , Adulto Jovem
5.
PLoS One ; 14(4): e0214195, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31009470

RESUMO

OBJECTIVE: To assess the cost-effectiveness of acupuncture for pelvic girdle and low back pain (PGLBP) during pregnancy. DESIGN: Pragmatic-open-label randomised controlled trial. SETTING: Five maternity hospitals. POPULATION: Pregnant women with PGLBP. METHOD: 1:1 randomization to standard care or standard care plus acupuncture (5 sessions by an acupuncturist midwife). MAIN OUTCOME MEASURE: Efficacy: proportion of days with self-assessed pain by numerical rating scale (NRS) ≤ 4/10. Cost effectiveness (societal viewpoint, time horizon: pregnancy): incremental cost per days with NRS ≤ 4/10. Indirect non-healthcare costs included daily compensations for sick leave and productivity loss caused by absenteeism or presenteeism. RESULTS: 96 women were allocated to acupuncture and 103 to standard care (total 199). The proportion of days with NRS ≤ 4/10 was greater in the acupuncture group than in the standard care group (61% vs 48%, p = 0.007). The mean Oswestry disability score was lower in the acupuncture group than with standard care alone (33 versus 38, Δ = 5, 95% CI: 0.8 to 9, p = 0.02). Average total costs were higher in the control group (€2947) than in the acupuncture group (€2635, Δ = -€312, 95% CI: -966 to +325), resulting from the higher indirect costs of absenteeism and presenteeism. Acupuncture was a dominant strategy when both healthcare and non-healthcare costs were included. Costs for the health system (employer and out-of-pocket costs excluded) were slightly higher for acupuncture (€1512 versus €1452, Δ = €60, 95% CI: -272 to +470). CONCLUSION: Acupuncture was a dominant strategy when accounting for employer costs. A 100% probability of cost-effectiveness was obtained for a willingness to pay of €100 per days with pain NRS ≤ 4.


Assuntos
Terapia por Acupuntura/métodos , Dor Lombar/terapia , Dor Pélvica/terapia , Complicações na Gravidez/terapia , Terapia por Acupuntura/economia , Adolescente , Adulto , Análise Custo-Benefício , Terapia por Exercício/economia , Feminino , Humanos , Dor Lombar/etiologia , Dor Lombar/fisiopatologia , Dor Pélvica/etiologia , Dor Pélvica/fisiopatologia , Pelve/fisiopatologia , Gravidez , Complicações na Gravidez/fisiopatologia , Qualidade de Vida , Resultado do Tratamento , Adulto Jovem
6.
Breast Cancer Res Treat ; 176(1): 37-52, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30997624

RESUMO

PURPOSE: Treatments for breast cancer can lead to chronic musculoskeletal problems. This study aimed to systematically review the evidence surrounding the cost-effectiveness of exercise and physiotherapy interventions aimed at reducing the risk of physical symptoms and functional limitations due to breast cancer treatment. METHODS: A systematic review of the cost-effectiveness of exercise and physiotherapy interventions during and following treatment for breast cancer was undertaken according to PRISMA guidelines. Literature searches were carried out in Ovid MEDLINE, Ovid Embase, Web of Science, EconLit, CINAHL, PsycINFO, Scopus and the Cochrane Library. Cost-effectiveness evidence was summarised in a descriptive manner and studies were assessed using quality appraisal tools. The review protocol was registered on PROSPERO. RESULTS: A total of 7783 articles were identified and seven were included in the final review. Five studies undertook trial-based economic evaluations, whereas two studies conducted economic evaluation based on decision models. One study was a cost-effectiveness analysis (CEA), three undertook stand-alone cost-utility analyses (CUA) and three studies were combined CEAs and CUAs. Three studies reported favourable cost-effectiveness results for different exercise or physiotherapy interventions. In contrast, four studies found that exercise and physiotherapy interventions were not cost-effective on the basis of quality-adjusted life year outcomes. CONCLUSIONS: The evidence surrounding the cost-effectiveness of exercise and physiotherapy interventions for the treatment of breast cancer remains sparse with contrasting conclusions. Future research should particularly aim to broaden the evidence base by disentangling the contributing effects of frequency, intensity, time and type of exercise and physiotherapy interventions on cost-effectiveness outcomes.


Assuntos
Neoplasias da Mama/epidemiologia , Terapia por Exercício/economia , Modalidades de Fisioterapia/economia , Neoplasias da Mama/terapia , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Anos de Vida Ajustados por Qualidade de Vida
7.
Klin Padiatr ; 231(3): 150-156, 2019 May.
Artigo em Alemão | MEDLINE | ID: mdl-30934088

RESUMO

Regular physical activity is an important requirement for the development and the general health in childhood and adolescence. However, patients during and after treatment for childhood cancer show high levels of physical inactivity, and only a marginal extent of physical activity. In addition to the negative side effects of treatment, this lack of physical activity and exertion has further negative implications for their health, such as decrease in physical performance and health related quality of life. In order to reduce these negative effects and provide access to regular physical activity for children and adolescents with cancer, childhood cancer patients should participate in targeted physical exercise therapy sessions at the treating hospital. Physical activity promotion for children and adolescents with cancer is an effective measure to enhance or preserve functional mobility, physical performance and health related quality of life. Both the behavioral level (person) and the setting (environment) should be taken into account for a sustainable implementation of physical activity promotion in the treatment of childhood cancer. The Leipzig Movement Concept promotes physical activity both during and after treatment for childhood cancer. On the basis of the modular concept, factors influencing physical activity in childhood cancer, alongside requirements for the successful and long-term implementation of physical activity programs and clinical exercise therapy are described. Furthermore financing options, based on Book V § 43 of the German Social Welfare Code, are presented.


Assuntos
Sobreviventes de Câncer/psicologia , Terapia por Exercício , Exercício , Neoplasias/terapia , Qualidade de Vida , Adolescente , Criança , Terapia por Exercício/economia , Terapia por Exercício/métodos , Humanos , Oncologia , Neoplasias/psicologia , Aptidão Física
8.
BMC Musculoskelet Disord ; 20(1): 129, 2019 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-30917806

RESUMO

BACKGROUND: A novel loaded self-managed exercise programme that includes pain education and self-management strategies may result in better outcomes for people with patellofemoral pain (PFP). However, establishing program feasibility is an essential first step before testing efficacy. The purpose of this study was to evaluate the feasibility and acceptability of conducting a definitive RCT which will evaluate the clinical and cost-effectiveness of a loaded self-managed exercise programme for people with PFP compared with usual physiotherapy. METHODS: In a mixed methods, pragmatic, randomised controlled feasibility study, 60 participants with PFP (57% female; mean age 29 years) were recruited from a physiotherapy clinic within a large UK teaching hospital. They were randomly allocated to receive either a loaded self-managed exercise programme (n = 30) or usual physiotherapy (n = 30). Feasibility indicators of process, resources, and management were collected through follow-up of standardised questionnaires six months after recruitment and semi-structured interviews with 20 participants and physiotherapists. RESULTS: Recruitment rate was 5 participants per month; consent rate was 99%; adherence to intervention appointments was 87%; completeness of questionnaire data was 100%; and adherence to intervention delivery was 95%. Three exercise diaries were returned at six months (5%). At six months, 25 questionnaire booklets were returned (9 in the loaded self-managed group, 16 in the usual physiotherapy group), with a total retention rate of 42%. At six months, 56% (5/9) of respondents in the loaded self-managed group and 56% (9/16) in the usual physiotherapy group were classified as 'recovered'. Both groups demonstrated improvements in average pain (VAS), kinesiophobia, pain catastrophizing, general self-efficacy and EQ-5D-5 L from baseline to six months. CONCLUSION: The results of this feasibility study confirm that it is feasible and acceptable to deliver a loaded self-managed exercise programme to adults with PFP in an NHS physiotherapy outpatient setting. However, between group differences in lost to follow up and poor exercise diary completion mean we are uncertain on some feasibility aspects. These methodological issues need addressing prior to conducting a definitive RCT. TRIAL REGISTRATION: ISRCTN 35272486 . Registered 19th December 2016.


Assuntos
Artralgia/reabilitação , Terapia por Exercício/métodos , Manejo da Dor/métodos , Autogestão/métodos , Adulto , Artralgia/diagnóstico , Análise Custo-Benefício , Terapia por Exercício/economia , Terapia por Exercício/educação , Estudos de Viabilidade , Feminino , Humanos , Articulação do Joelho , Masculino , Manejo da Dor/economia , Medição da Dor , Educação de Pacientes como Assunto , Autogestão/economia , Autogestão/educação , Inquéritos e Questionários/estatística & dados numéricos , Resultado do Tratamento , Reino Unido , Adulto Jovem
9.
Trials ; 20(1): 36, 2019 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-30630494

RESUMO

BACKGROUND: Physical rehabilitation is required to enhance functional outcomes and overall recovery following total knee arthroplasty (TKA). However, there are no universally accepted clinical guidelines available to consistently structure rehabilitation for TKA patients. A common method is rehabilitation provided in an outpatient setting, on a one-to-one treatment basis. This method is resource-intensive and outcomes must be compared to less costly alternatives such as home-based rehabilitation. The current study will analyse a novel home-based rehabilitation program. The Maxm skate is a portable, lower-limb, postoperative, rehabilitation exercise device for individual use in a hospital or home-based setting. This study was developed to compare the safety, efficacy and cost-effectiveness of the Maxm Skate rehabilitation program to standard rehabilitative care following TKA. The primary outcome is the range of motion (ROM) achieved by patients who received the Maxm Skate program compared to standard care at three months post TKA. Secondary outcomes include patient-reported outcomes, costs and functional evaluations which will be collected at multiple time-points up to 12 months after TKA. METHODS: This is a single-blinded, randomised controlled trial (RCT) in which 116 eligible participants consented for primary TKA will be randomly allocated to receive either the Maxm Skate rehabilitation program or standard rehabilitative care. Fifty-eight participants per group will provide 90% power (α = 0.05) to detect 10° of difference in ROM between groups at three months after TKA, assuming a within-group standard deviation of 16° and allowing for 5% loss to follow-up. Participants randomised to the Maxm Skate group will use the skate device and accompanying iOS App and sensors to complete rehabilitation exercises, as outlined in the Maxm Skate Rehabilitation Guide. Outcomes will be compared to those receiving standard rehabilitative care. A blinded physiotherapist will evaluate functional outcomes preoperatively and at 2, 4, 6, 12, 26 and 52 weeks after TKA. The functional assessment will include measures of knee ROM, pain, isometric knee strength, balance and knee/thigh circumference. Limited measures will also be assessed at day 2 postoperatively by an alternate, unblinded physiotherapist. Clinical outcome measures will be administered preoperatively and at 6, 12 and 52 weeks postoperatively. An economic evaluation will be conducted and participants will be screened for adverse event occurrences from the time of consent to 12 months postoperatively. DISCUSSION: This RCT will be the first to investigate the safety, efficacy and cost-effectiveness of the home-based Maxm Skate Rehabilitation program, in comparison to standard rehabilitative care following primary TKA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616001081404p . Registered on 11 August 2016.


Assuntos
Artroplastia do Joelho/economia , Artroplastia do Joelho/reabilitação , Terapia por Exercício/economia , Terapia por Exercício/instrumentação , Custos de Cuidados de Saúde , Serviços de Assistência Domiciliar/economia , Articulação do Joelho/cirurgia , Fenômenos Biomecânicos , Análise Custo-Benefício , Desenho de Equipamento , Humanos , Articulação do Joelho/fisiopatologia , Medidas de Resultados Relatados pelo Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Método Simples-Cego , Austrália do Sul , Fatores de Tempo , Resultado do Tratamento
10.
Br J Sports Med ; 53(3): 172-181, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29678893

RESUMO

OBJECTIVE: To investigate the cost-effectiveness of exercise therapy in the treatment of patients with non-specific neck pain and low back pain. DESIGN: Systematic review of economic evaluations. DATA SOURCES: The search was performed in 5 clinical and 3 economic electronic databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included economic evaluations performed alongside randomised controlled trials. Differences in costs and effects were pooled in a meta-analysis, if possible, and incremental cost-utility ratios (ICUR) were descriptively analysed. RESULTS: Twenty-two studies were included. On average, exercise therapy was associated with lower costs and larger effects for quality-adjusted life-year (QALY) in comparison with usual care for subacute and chronic low back pain from a healthcare perspective (based on ICUR). Exercise therapy had similar costs and effect for QALY in comparison with other interventions for neck pain from a societal perspective, and subacute and chronic low back pain from a healthcare perspective. There was limited or inconsistent evidence on the cost-effectiveness of exercise therapy compared with usual care for neck pain and acute low back pain, other interventions for acute low back pain and different types of exercise therapy for neck pain and low back pain. CONCLUSIONS: Exercise therapy seems to be cost-effective compared with usual care for subacute and chronic low back pain. Exercise therapy was not (more) cost-effective compared with other interventions for neck pain and low back pain. The cost-utility estimates are rather uncertain, indicating that more economic evaluations are needed. REGISTRATION: PROSPERO, CRD42017059025.


Assuntos
Análise Custo-Benefício , Terapia por Exercício/economia , Dor Lombar/terapia , Cervicalgia/terapia , Terapia Cognitivo-Comportamental , Humanos , Modalidades de Fisioterapia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
11.
Clin Rehabil ; 33(3): 524-534, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30375234

RESUMO

OBJECTIVE:: To estimate the cost-effectiveness of a strength and balance exercise programme (SUNBEAM) which has been shown to be clinically effective in reducing the rate of falls in residents of aged care facilities. DESIGN:: An economic evaluation was conducted alongside a pragmatic cluster randomized controlled trial that included 16 residential care facilities and 221 participants. Mean participant age was 86 years, 65% were female and 78% relied on a mobility aide. A cost-effectiveness analysis examined the costs of providing the exercise programme and costs of health service use arising from falls in each arm (intervention and usual care) over 12 months. MAIN MEASURES:: Incremental cost-effectiveness ratios were calculated for the cost per fall avoided. Costs were bootstrapped to obtain adjusted confidence intervals for the incremental cost-effectiveness ratios. RESULTS:: Of 63 facilities contacted, 16 met the eligibility criteria and were randomized to the intervention or usual care (1:1). There were 142 falls in the intervention group and 277 in the usual care group. 72 injurious falls occurred in the intervention group versus 157 with usual care. Delivery of the SUNBEAM programme cost $463 per participant. The mean total cost of each fall (regardless of group) was $400.09 and the mean cost of each injurious fall was $708.27. The incremental cost-effectiveness ratio was $22 per fall per person avoided with the mean bootstrapped incremental cost-effectiveness ratio $18 per fall avoided (95% CI: -$380.34 to $417.85). CONCLUSION:: The SUNBEAM programme can be considered cost-effective, relative to other fall-prevention interventions in older adults.


Assuntos
Acidentes por Quedas/economia , Acidentes por Quedas/prevenção & controle , Terapia por Exercício/economia , Idoso de 80 Anos ou mais , Austrália , Análise Custo-Benefício , Feminino , Humanos , Masculino , Serviços Preventivos de Saúde/economia , Avaliação de Programas e Projetos de Saúde , Instituições Residenciais
12.
Heart ; 105(2): 122-129, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30150328

RESUMO

OBJECTIVE: Compare the effects and costs of remotely monitored exercise-based cardiac telerehabilitation (REMOTE-CR) with centre-based programmes (CBexCR) in adults with coronary heart disease (CHD). METHODS: Participants were randomised to receive 12 weeks of telerehabilitation or centre-based rehabilitation. REMOTE-CR provided individualised exercise prescription, real-time exercise monitoring/coaching and theory-based behavioural strategies via a bespoke telerehabilitation platform; CBexCR provided individualised exercise prescription and coaching via established rehabilitation clinics. Outcomes assessed at baseline, 12 and/or 24 weeks included maximal oxygen uptake (V̇O2max, primary) modifiable cardiovascular risk factors, exercise adherence, motivation, health-related quality of life and programme delivery, hospital service utilisation and medication costs. The primary hypothesis was a non-inferior between-group difference in V̇O2max at 12 weeks (inferiority margin=-1.25 mL/kg/min); inferiority margins were not set for secondary outcomes. RESULTS: 162 participants (mean 61±12.7 years, 86% men) were randomised. V̇O2 max was comparable in both groups at 12 weeks and REMOTE-CR was non-inferior to CBexCR (REMOTE-CR-CBexCR adjusted mean difference (AMD)=0.51 (95% CI -0.97 to 1.98) mL/kg/min, p=0.48). REMOTE-CR participants were less sedentary at 24 weeks (AMD=-61.5 (95% CI -117.8 to -5.3) min/day, p=0.03), while CBexCR participants had smaller waist (AMD=1.71 (95% CI 0.09 to 3.34) cm, p=0.04) and hip circumferences (AMD=1.16 (95% CI 0.06 to 2.27) cm, p=0.04) at 12 weeks. No other between-group differences were detected. Per capita programme delivery (NZD1130/GBP573 vs NZD3466/GBP1758) and medication costs (NZD331/GBP168 vs NZD605/GBP307, p=0.02) were lower for REMOTE-CR. Hospital service utilisation costs were not statistically significantly different (NZD3459/GBP1754 vs NZD5464/GBP2771, p=0.20). CONCLUSION: REMOTE-CR is an effective, cost-efficient alternative delivery model that could-as a complement to existing services-improve overall utilisation rates by increasing reach and satisfying unique participant preferences.


Assuntos
Doença das Coronárias/reabilitação , Terapia por Exercício/métodos , Internet , Qualidade de Vida , Centros de Reabilitação , Telemedicina/métodos , Doença das Coronárias/economia , Análise Custo-Benefício , Terapia por Exercício/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Resultado do Tratamento
13.
BMC Musculoskelet Disord ; 19(1): 421, 2018 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-30497420

RESUMO

BACKGROUND: The objective of this study is to analyze the influence of a 14-week periodized circuit training protocol on patients with knee osteoarthritis (OA), in randomized intervention groups, on thigh intermuscular adipose tissue (interMAT), body composition, systemic inflammation, cartilage degradation, and its repercussion on pain, functional performance and quality of life. METHODS: This study presents a protocol for a randomized controlled trial. Sixty selected participants diagnosed with knee OA grades II and III, 40-65 years old and BMI < 30 kg/m2, will be randomly divided into three groups:periodized circuit training, strength training, and educational protocol. The circuit training and strength training protocols consist of 14-week training protocols conducted 3 times a week. The circuit training group will perform selected exercises previously stratified as light, moderate, and intense, arranged progressively in a circuit model, the strength group will perform regular strength exercises, and the educational protocol group will participate in a 14-week protocol with lectures twice a month about healthy lifestyles. Baseline and follow-up evaluations will be conducted for thigh interMAT (computed tomography), body composition (DXA), inflammation (IL-1ß, IL-6, IL-10, TNF-α, leptin, and adiponectin), and joint degradation biomarkers (uCTX-II and sCOMP), performance-based tests (30s Chair Stand Test, 40 m Fast-paced Walk Test and Stair Climb Test), quadriceps and hamstring maximal isometric voluntary contraction (MIVC), and questionnaires (WOMAC and pain catastrophizing scale). Repeated measures ANOVA will be used to compare differences between groups (circuit training X strength training X educational protocol) at the different times of assessment (baseline x follow-up or baseline x during protocol x follow-up) for each of the dependent variables. When significant main effects were found, the pots hoc Bonferroni test will be used to identify statistical differences. A significance level of 5% (p < 0.05) will be adopted. DISCUSSION: This will be the first randomized controlled trial to assess the effects of a circuit training protocol on patients with knee OA on thigh intermuscular adipose tissue (interMAT). Given the prevalence and impact of OA and the widespread availability of this intervention, assessing the efficacy of a low-cost, non-pharmacological, and non-invasive treatment for knee OA patients has the potential for immediate and high clinical impact. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02761590 , registered in May 4, 2016.


Assuntos
Tecido Adiposo/metabolismo , Exercícios em Circuitos/métodos , Terapia por Exercício/métodos , Osteoartrite do Joelho/reabilitação , Dor/reabilitação , Adulto , Biomarcadores/análise , Biomarcadores/metabolismo , Composição Corporal/fisiologia , Cartilagem Articular/metabolismo , Cartilagem Articular/patologia , Cartilagem Articular/fisiopatologia , Catastrofização/diagnóstico , Catastrofização/psicologia , Exercícios em Circuitos/economia , Terapia por Exercício/economia , Feminino , Humanos , Articulação do Joelho/fisiopatologia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/fisiopatologia , Osteoartrite do Joelho/psicologia , Dor/etiologia , Dor/fisiopatologia , Dor/psicologia , Medição da Dor , Músculo Quadríceps/metabolismo , Músculo Quadríceps/fisiopatologia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Inquéritos e Questionários , Resultado do Tratamento
14.
BMC Cardiovasc Disord ; 18(1): 225, 2018 12 06.
Artigo em Inglês | MEDLINE | ID: mdl-30522438

RESUMO

BACKGROUND: Physical activity programs (PAP) in patients with cardiovascular disease require evidence of cost-utility. To assess improvement in health-related quality of life (QoL) and reduction of health care consumption of patients following PAP, a randomized trial was used. METHODS: Patients from a health insurance company who had experienced coronary artery disease or moderate heart failure were invited to participate (N = 1891). Positive responders (N = 50) were randomly assigned to a progressively autonomous physical activity (PAPA) program or to a standard supervised physical activity (SPA) program. The SPA group had two supervised sessions per week over 5 months. PAPA group had one session per week and support to aid habit formation (written tips, exercise program, phone call). To measure health-related quality of life EQ-5D utility score were used, before intervention, 6 months (T6) and 1 year later. Health care costs were provided from reimbursement databases. RESULTS: Mobility, usual activities and discomfort improved significantly in both group (T6). One year later, EQ-5D utility score was improved in the PAPA group only. Total health care consumption in the intervention group decreased, from a mean of 4097 euros per year before intervention to 2877 euros per year after (p = 0.05), compared to a health care consumption of 4087 euros and 4180 euros per year, in the total population of patients (N = 1891) from the health insurance company. The incremental cost effectiveness ratio was 10,928 euros per QALYs. CONCLUSION: A physical activity program is cost-effective in providing a better quality of life and reducing health care consumption in cardiovascular patients. TRIAL REGISTRATION: ISRCTN77313697 , retrospectively registered on 20 November 2015.


Assuntos
Reabilitação Cardíaca/economia , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/terapia , Terapia por Exercício/economia , Custos de Cuidados de Saúde , Qualidade de Vida , Idoso , Reabilitação Cardíaca/métodos , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/fisiopatologia , Análise Custo-Benefício , Terapia por Exercício/métodos , Feminino , França , Recursos em Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento
15.
BMC Public Health ; 18(1): 1376, 2018 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-30558592

RESUMO

BACKGROUND: Registered healthcare workers worldwide have a high prevalence of work-related musculoskeletal disorders, particularly of the back. Multidisciplinary interventions among these workers have improved fear avoidance beliefs, but not low back pain (LBP) and related sickness absences, cost-effectiveness studies are scarce. Our purpose was to investigate the effectiveness and cost-effectiveness of three intervention-arms (combined neuromuscular exercise and back care counselling or either alone) compared with non-treatment. METHODS: We randomly assigned female healthcare workers with recurrent non-specific LBP to one of four study-arms: Combined neuromuscular exercise and back care counseling; Exercise; Counseling; and no intervention Control. We assessed the effectiveness of the interventions on intensity of LBP, pain interfering with work and fear avoidance beliefs against the Control, and calculated the incremental cost-effectiveness ratios for sickness absence and QALY. RESULTS: We conducted three sub-studies in consecutive years of 2011, 2012, and 2013 to reach an adequate sample size. All together 219 women were randomized within each sub-study, of whom 74 and 68% had adequate questionnaire data at 6 and 12 months, respectively. No adverse events occurred. Compliance rates varied between intervention-arms. After 12 months, the Combined-arm showed reduced intensity of LBP (p = 0.006; effect size 0.70, confidence interval 0.23 to 1.17) and pain interfering with work (p = 0.011) compared with the Control-arm. Work-related fear of pain was reduced in both the Combined- (p = 0.003) and Exercise-arm (p = 0.002). Physical activity-related fear was reduced only in the Exercise-arm (p = 0.008). During the study period (0-12 months) mean total costs were lowest in the Combined-arm (€476 vs. €1062-€1992, p < 0.001) as were the mean number of sickness absence days (0.15 vs. 2.29-4.17, p = 0.025). None of the intervention-arms was cost-effective for sickness absence. There was 85% probability of exercise-arm being cost-effective if willing to pay €3550 for QALY gained. CONCLUSIONS: Exercise once a week for 6 months combined with five sessions of back care counseling after working hours in real-life settings effectively reduced the intensity of LBP, work interference due to LBP, and fear of pain, but was not cost-effective. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01465698 November 7, 2011 (prospective).


Assuntos
Aconselhamento/economia , Terapia por Exercício/economia , Pessoal de Saúde/psicologia , Dor Lombar/terapia , Adulto , Análise Custo-Benefício , Medo , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Recidiva , Licença Médica/economia , Licença Médica/estatística & dados numéricos , Inquéritos e Questionários , Resultado do Tratamento
16.
Chiropr Man Therap ; 26: 46, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30473764

RESUMO

Background: Spinal pain is a common and disabling condition with considerable socioeconomic burden. Spine pain management in the United States has gathered increased scrutiny amidst concerns of overutilization of costly and potentially harmful interventions and diagnostic tests. Conservative interventions such as spinal manipulation, exercise and self-management may provide value for the care of spinal pain, but little is known regarding the cost-effectiveness of these interventions in the U.S. Our primary objective for this project is to estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management for spinal pain using an individual patient data meta-analysis approach. Methods/design: We will estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management using cost and clinical outcome data collected in eight randomized clinical trials performed in the U.S. Cost-effectiveness will be assessed from both societal and healthcare perspectives using QALYs, pain intensity, and disability as effectiveness measures. The eight randomized clinical trials used similar methods and included different combinations of spinal manipulation, exercise therapy, or self-management for spinal pain. They also collected similar clinical outcome, healthcare utilization, and work productivity data. A two-stage approach to individual patient data meta-analysis will be conducted. Discussion: This project capitalizes on a unique opportunity to combine clinical and economic data collected in a several clinical trials that used similar methods. The findings will provide important information on the value of spinal manipulation, exercise therapy, and self-management for spinal pain management in the U.S.


Assuntos
Dor nas Costas/economia , Dor nas Costas/terapia , Terapia por Exercício/economia , Manipulação da Coluna/economia , Cervicalgia/economia , Cervicalgia/terapia , Autogestão/economia , Adolescente , Adulto , Idoso , Criança , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto/economia , Adulto Jovem
17.
BMC Geriatr ; 18(1): 267, 2018 11 06.
Artigo em Inglês | MEDLINE | ID: mdl-30400832

RESUMO

BACKGROUND: The Lifestyle-Integrated Functional Exercise (LiFE) program is effective in improving strength, balance, and physical activity (PA) while simultaneously reducing falls in older people by incorporating exercise activities in recurring daily tasks. However, implementing the original LiFE program includes substantial resource requirements. Therefore, as part of the LiFE-is-LiFE project, a group format (gLiFE) of the LiFE program has been developed, which will be tested regarding its noninferiority to the individually delivered LiFE in terms of PA-adjusted fall incidence and overall cost-effectiveness. METHODS: In a multi-centre, single-blinded noninferiority trial, an envisaged sample of N = 300 participants (> 70 years; faller and/or confirmed falls risk; community-dwelling) will be randomized in either LiFE or gLiFE. Both groups will undergo the same strength and balance activities as well as PA promotion activities and habitualization strategies as described in the LiFE programme, however, based on different approaches of delivery: During the 6-month intervention phase, LiFE participants will receive seven home visits and two telephone calls; in gLiFE, the program will be delivered in seven group sessions and also two telephone calls. Main outcomes are a) fall incidence per PA and b) incremental cost-effectiveness ratio comparing costs and quality-adjusted life years between the two interventions. Secondary outcomes include PA behaviour, motor performance, health status, psychosocial status, program evaluation, and adherence. Measurements will be conducted at baseline, 6-month and 12-month follow-up; evaluation of intervention sessions and assessment of psychosocial variables related to execution and habitualization of LiFE activities will be made during the intervention period as well. DISCUSSION: Compared to LiFE, we expect gLiFE to (a) reduce falls per PA by a similar rate; (b) be more cost-effective; (c) comparably enhance physical performance in terms of strength and balance as well as PA. By investigating the economic and societal benefit, this study will be of high practical relevance as noninferiority of gLiFE would facilitate large-scale implementation due to lower resource usage. This would result in better reach and increased accessibility, which is important for subjects with a history of falls and/or being at risk of falls. TRIAL REGISTRATION: ClinicalTrials.gov NCT03462654 . Registered on March 12, 2018.


Assuntos
Acidentes por Quedas/prevenção & controle , Terapia por Exercício/métodos , Exercício/psicologia , Vida Independente , Estilo de Vida , Atividade Motora/fisiologia , Anos de Vida Ajustados por Qualidade de Vida , Acidentes por Quedas/economia , Acidentes por Quedas/estatística & dados numéricos , Idoso , Análise Custo-Benefício , Terapia por Exercício/economia , Feminino , Humanos , Masculino , Método Simples-Cego
18.
Ont Health Technol Assess Ser ; 18(8): 1-110, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30443280

RESUMO

Background: Osteoarthritis is a chronic disorder and the most common form of arthritis. The joints most commonly affected are the hip and knee. The progression of osteoarthritis results in the breakdown of tissues and cartilage and the loss of joint function, causing symptoms such as pain, stiffness, reduced physical function, and limited movement. Although there is no cure for osteoarthritis, treatment options are available to manage symptoms and optimize quality of life. Clinical guidelines recommend education, exercise, and weight loss (when necessary) as the first line of treatment. Methods: We conducted a health technology assessment, which included an evaluation of the effectiveness, safety, and cost-effectiveness of a structured education and neuromuscular exercise program for the management of hip and/or knee osteoarthritis. We also assessed the budget impact of publicly funding such a program, and we spoke with people with osteoarthritis to gain an understanding of their preferences and values. We performed a systematic review of the clinical and economic literature published between January 1, 2008, and October 4, 2017. We also performed a grey literature search of health technology assessment websites. We assessed the risk of bias of each study, and we assessed the quality of the body of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group criteria. To evaluate the cost-effectiveness of a structured education and neuromuscular exercise program for adults with knee osteoarthritis, we conducted a cost-utility analysis from the perspective of the Ontario Ministry of Health and Long-Term Care. We also estimated the budget impact of publicly funding such a program in Ontario over the next 5 years. To contextualize the potential value of this type of program as a treatment option, we spoke with people with hip and/or knee osteoarthritis. Results: Ten studies met our inclusion criteria for the clinical evidence review. Compared with usual care, a structured education and neuromuscular exercise program showed statistically significant short-term improvements in pain (GRADE low) and physical function (GRADE moderate), as well as statistically significant long-term improvements in performing activities of daily living (GRADE moderate) and in quality of life (GRADE moderate). The short-term improvements in pain and physical function appeared to be sustained into the medium term. Compared with patient education, a structured education and neuromuscular exercise program showed statistically significant short-term improvements in pain (GRADE low) and physical function (GRADE low) and sustained long-term improvement in physical function.Our primary economic evaluation showed that, compared with usual care, a group-based structured education and neuromuscular exercise program consisting of two educational sessions and 24 exercise sessions for the management of knee osteoarthritis was associated with an incremental cost of $719 (95% confidence interval [CI]: $410-$1,118) and an incremental quality-adjusted survival of 0.03 quality-adjusted life-years (QALYs) (95% CI: -0.006 to 0.06), resulting in an incremental cost-effectiveness ratio (ICER) of $23,967 per QALY gained. The budget impact of publicly funding a group-based structured education and neuromuscular exercise program consisting of two educational sessions and 24 exercise sessions would range from $21.4 million to $91.6 million per year over the next 5 years. The budget impact of publicly funding a program consisting of two educational sessions and 12 exercise sessions would range from $12.4 million to $53.2 million per year over the next 5 years.People with hip and/or knee osteoarthritis with whom we spoke reported on the negative impact of osteoarthritis on their physical functioning and quality of life. Those with experience of a structured education and neuromuscular exercise program reported favourably on the program, stating they felt that participation in the program had strengthened their muscles and reduced the negative impact of their symptoms. The cost of such programs was reported as a barrier to access. Conclusions: There is moderate-quality evidence that, compared with usual care, a structured education and neuromuscular exercise program improves physical function, quality of life, and the ability to perform activities of daily living. There is low-quality evidence that, compared with usual care, this type of program improves pain. Low-quality evidence suggests that, compared with patient education, a structured education and neuromuscular exercise program improves pain and physical function.A group-based structured education and neuromuscular exercise program may be cost-effective for the nonsurgical management of knee osteoarthritis. Publicly funding a group-based structured education and neuromuscular exercise program for hip and/or knee osteoarthritis in Ontario would lead to additional costs to the health system of $21.4 million to $91.6 million per year over the next 5 years. If the program could be delivered with a smaller number of 12 exercise sessions, the budget impact would be reduced to between $12.4 million and $53.2 million over the next 5 years.Structured education and neuromuscular exercise programs are perceived favourably by people with hip and/or knee osteoarthritis. However, the cost of such programs may be a barrier to access.


Assuntos
Terapia por Exercício/métodos , Osteoartrite do Joelho/terapia , Atividades Cotidianas , Artralgia/terapia , Análise Custo-Benefício , Terapia por Exercício/efeitos adversos , Terapia por Exercício/economia , Humanos , Ontário , Qualidade de Vida , Avaliação da Tecnologia Biomédica
19.
Contemp Clin Trials ; 75: 1-8, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30342254

RESUMO

BACKGROUND: Exercise training is a promising approach for managing multiple sclerosis (MS), but existing research has not focused on black individuals with MS. This is important as black individuals with MS may experience a more aggressive disease course, increased comorbidities, and have a poorer prognosis with disease modifying therapies. MATERIALS AND METHODS: Thirty-two black adults with mild-to-moderate MS related disability participated in a patient-informed, three-month, home-based, racially tailored, exercise program. The exercise program, Project GEMS, was modified for black persons with MS through patient feedback. The feasibility of the modified exercise program was measured through the four domains of process (e.g., recruitment and retention), resources (e.g., communication and monetary costs), management (e.g., of data management and safety reporting), and scientific outcomes (e.g., safety, burden, adherence, experience, and treatment effect). RESULTS: This exercise program was feasible, safe, and well received based on data analysis and formative evaluation. Twenty-four participants completed post-assessment (75%; two dropped out, six did not return follow-up assessments). The exercise program cost a total of $3726.57 (personnel costs = $2128.74 USD, $20.87 USD per/h; exercise program costs = $1597.83 USD, mean cost per person = $46.93). Participants were adherent with 70% of the 48 exercise sessions via self-reported exercise logs. There was a significant and large increase (t = -5.1, p < .001, d = -1.0) in exercise behavior as measured by the Godin Leisure-Time Exercise Questionnaire. CONCLUSION: The results support the feasibility, acceptability, safety, and efficacy of this intervention for increasing exercise behavior among black adults with mild-to-moderate MS.


Assuntos
Afro-Americanos , Terapia por Exercício/métodos , Esclerose Múltipla/reabilitação , Cooperação do Paciente , Adulto , Custos e Análise de Custo , Terapia por Exercício/economia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Seleção de Pacientes , Treinamento de Resistência/economia , Treinamento de Resistência/métodos , Autocuidado , Resultado do Tratamento
20.
BMC Cancer ; 18(1): 1031, 2018 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-30352568

RESUMO

BACKGROUND: Androgen deprivation therapy (ADT) is commonly used to treat prostate cancer. However, side effects of ADT often lead to reduced quality of life and physical function. Existing evidence demonstrates that exercise can ameliorate multiple treatment-related side effects for men on ADT, yet adherence rates are often low. The method of exercise delivery (e.g., supervised group in-centre vs. individual home-based) may be important from clinical and economic perspectives; however, few studies have compared different delivery models. Additionally, long-term exercise adherence and an understanding of predictors of adherence are critical to achieving sustained benefits, but such data are lacking. The primary aim of this multi-centre phase III non-inferiority randomized controlled trial is to determine whether a home-based delivery model is non-inferior to a group-based delivery model in terms of benefits in fatigue and fitness in this population. Two other key aims include examining cost-effectiveness and long-term adherence. METHODS: Men diagnosed with prostate cancer of any stage, starting or continuing on ADT for at least 6 months, fluent in English, and living close to a study centre are eligible. Participants complete five assessments over 12 months (baseline and every 3 months during the 6-month intervention and 6-month follow-up phases), including a fitness assessment and self-report questionnaires. Biological outcomes are collected at baseline, 6, and 12 months. A total of 200 participants will be randomized in a 1:1 fashion to supervised group training or home-based training supported by smartphones, health coaches, and Fitbit technology. Participants are asked to complete 4 to 5 exercise sessions per week, incorporating aerobic, resistance and flexibility training. Outcomes include fatigue, quality of life, fitness measures, body composition, biological outcomes, and program adherence. Cost information will be obtained using patient diary-based self-report and utilities via the EQ-5D. DISCUSSION: To disseminate publicly funded exercise programs widely, clinical efficacy and cost-effectiveness have to be demonstrated. The goals of this trial are to provide these data along with an increased understanding of adherence to exercise among men with prostate cancer receiving ADT. TRIAL REGISTRATION: The trial has been registered at clinicaltrials.gov (Registration # NCT02834416 ). Registration date was June 2, 2016.


Assuntos
Terapia por Exercício , Neoplasias da Próstata/terapia , Antagonistas de Androgênios/uso terapêutico , Ensaios Clínicos Fase III como Assunto , Análise Custo-Benefício , Terapia por Exercício/economia , Terapia por Exercício/métodos , Humanos , Masculino , Neoplasias da Próstata/tratamento farmacológico , Neoplasias da Próstata/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
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