A systematic review and meta-analysis of acute stroke unit care: what's beyond the statistical significance?

BACKGROUND: The benefits of stroke unit care in terms of reducing death, dependency and institutional care were demonstrated in a 2009 Cochrane review carried out by the Stroke Unit Trialists' Collaboration. METHODS: As requested by the Belgian health authorities, a systematic review and meta-analysis of the effect of acute stroke units was performed. Clinical trials mentioned in the original Cochrane review were included. In addition, an electronic database search on Medline, Embase, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro) was conducted to identify trials published since 2006. Trials investigating acute stroke units compared to alternative care were eligible for inclusion. Study quality was appraised according to the criteria recommended by Scottish Intercollegiate Guidelines Network (SIGN) and the GRADE system. In the meta-analysis, dichotomous outcomes were estimated by calculating odds ratios (OR) and continuous outcomes were estimated by calculating standardized mean differences. The weight of a study was calculated based on inverse variance. RESULTS: Evidence from eight trials comparing acute stroke unit and conventional care (general medical ward) were retained for the main synthesis and analysis. The findings from this study were broadly in line with the original Cochrane review: acute stroke units can improve survival and independency, as well as reduce the chance of hospitalization and the length of inpatient stay. The improvement with stroke unit care on mortality was less conclusive and only reached borderline level of significance (OR 0.84, 95% CI 0.70 to 1.00, P = 0.05). This improvement became statistically non-significant (OR 0.87, 95% CI 0.74 to 1.03, P = 0.12) when data from two unpublished trials (Goteborg-Ostra and Svendborg) were added to the analysis. After further also adding two additional trials (Beijing, Stockholm) with very short observation periods (until discharge), the difference between acute stroke units and general medical wards on death remained statistically non-significant (OR 0.86, 95% CI 0.74 to 1.01, P = 0.06). Furthermore, based on figures reported by the clinical trials included in this study, a slightly higher proportion of patients became dependent after receiving care in stroke units than those treated in general medical wards - although the difference was not statistically significant. This result could have an impact on the future demand for healthcare services for individuals that survive a stroke but became dependent on their care-givers. CONCLUSIONS: These findings demonstrate that a well-conducted meta-analysis can produce results that can be of value to policymakers but the choice of inclusion/exclusion criteria and outcomes in this context needs careful consideration. The financing of interventions such as stroke units that increase independency and reduce inpatient stays are worthwhile in a context of an ageing population with increasing care needs. One limitation of this study was the selection of trials published in only four languages: English, French, Dutch and German. This choice was pragmatic in the context of this study, where the objective was to support health authorities in their decision processes.

Cost-effectiveness of stroke unit care followed by early supported discharge.

BACKGROUND AND PURPOSE: Stroke places a significant burden on the economy in England and Wales with the overall societal costs estimated at pound7 billion per annum. There is evidence that both stroke units (SUs) and early supported discharge (ESD) are effective in treating patients with stroke. This study assesses the cost-effectiveness of the combination of these 2 strategies and compares it with the care provided in SU without ESD and in a general medical ward without ESD. The objective of this study was to model the long-term (10 years) cost-effectiveness of SU care followed by ESD. METHODS: The study design was cost-effectiveness modeling. The study took place in SUs in the coverage area of the South London Stroke Register, UK. The modeled population was incident ischemic stroke cases (N=844) observed between 2001 and 2006. SU care followed by ESD was compared with SU care without ESD and general medical ward care without ESD. Main outcome measures were health service and societal costs and cost per quality-adjusted life-year gained. RESULTS: Using the cost-effectiveness threshold of pound30000, as commonly used in the UK, SU care followed by ESD is the cost-effective strategy compared with the other 2 options. The incremental cost-effectiveness ratio of SU care followed by ESD is pound10661 compared with the general medical ward without ESD care and pound17721 compared with the SU without ESD. CONCLUSIONS: SU care followed by ESD is both an effective and a cost-effective strategy with the main gains in years of life saved.

Cost of stroke in the United Kingdom.

INTRODUCTION: this study aims to quantify the annual cost of illness of stroke to the UK economy. METHODS: we estimate the cost of stroke from a societal perspective. Direct care costs include diagnosis, inpatient care and outpatient care. Income loss and social benefit payments to stroke patients are accounted for in the indirect cost calculations. Data from South London Stroke Register and a number of other national sources are used. Sensitivity analysis was carried out to account for the variability in the data used. RESULTS: the treatment of and productivity loss arising from stroke results in total societal costs of pound 8.9 billion a year, with treatment costs accounting for approximately 5% of total UK NHS costs. Direct care accounts for approximately 50% of the total, informal care costs 27% and the indirect costs 24%. Sensitivity analysis did not alter the estimate of total costs significantly for most of the variables except using of differing prevalence rates. CONCLUSIONS: stroke incurs considerable societal costs. Our calculations show a high sensitivity to the underlying prevalence rates used. The findings highlight a need for further economic evaluations to ensure that there is an efficient use of resources devoted to the treatment of this disease.

A report on the status of vaccination in Europe.

Vaccine policy, decision processes and outcomes vary widely across Europe. The objective was to map these factors across 16 European countries by assessing (A) national vaccination strategy and implementation, (B) attributes of healthcare vaccination systems, and (C) outcomes of universal mass vaccination (UMV) as a measure of how successful the vaccination policy is. A. Eleven countries use standardised assessment frameworks to inform vaccine recommendations. Only Sweden horizon scans new technologies, uses standard assessments, systematic literature and health economic reviews, and publishes its decision rationale. Time from European marketing authorisation to UMV implementation varies despite these standard frameworks. Paediatric UMV recommendations (generally government-funded) are relatively comparable, however only influenza vaccine is widely recommended for adults. B. Fourteen countries aim to report annually on national vaccine coverage rates (VCRs), as well as have target VCRs per vaccine across different age groups. Ten countries use either electronic immunisation records or a centralised registry for childhood vaccinations, and seven for other age group vaccinations. C. National VCRs for infant (primary diphtheria tetanus pertussis (DTP)), adolescent (human papillomavirus (HPV)) and older adult (seasonal influenza) UMV programmes found ranges of: 89.1% to 98.2% for DTP-containing vaccines, 5% to 85.9% for HPV vaccination, and 4.3% to 71.6% for influenza vaccine. Regarding reported disease incidence, a wide range was found across countries for measles, mumps and rubella (in children), and hepatitis B and invasive pneumococcal disease (in all ages). These findings reflect an individual approach to vaccination by country. High VCRs can be achieved, particularly for paediatric vaccinations, despite different approaches, targets and reporting systems; these are not replicated in vaccines for other age groups in the same country. Additional measures to improve VCRs across all age groups are needed and could benefit from greater harmonisation in target setting, vaccination data collection and sharing across EU countries.

Participating or not in a cardiac rehabilitation programme: factors influencing a patient's decision.

BACKGROUND: International research indicates that attendance of patients to a proposed cardiac rehabilitation (CR) programme varies between 21% and 75%. Addressing the reasons why cardiac patients are not participating will improve accessibility to CR. The objective of this study was to investigate patient compliance with cardiac rehabilitation and the reasons of refusing or abandoning the programme. METHODS: Twenty hospital centres were recruited to participate. Each centre was asked to recruit patients from three patient groups, namely: percutaneous coronary intervention patients, patients that underwent major cardiac surgery, and patients being admitted because of an acute myocardial infarction and not belonging to the other two groups. Patients were asked to fill out a questionnaire during a follow-up outpatient consultation after the cardiac intervention. RESULTS: In total, 226 patients participated in the survey. Most patients were proposed (86%) and accepted (81% out of proposed) to attend a CR programme. Of those who accepted, 77% completed the programme. The main reasons that led to patients' refusal to participate in a CR programme were distance to the CR centre, patients' belief they could handle their own problems, and lack of time. The main three reasons for not completing an initiated CR programme were other physical problems, patients' belief they could handle their own problems, and the cost of rehabilitation. CONCLUSION: Our findings demonstrate the importance of raising patients' awareness of the benefits of CR. Addressing potential barriers to attend a CR programme should be investigated with patients individually in order to ensure compliance.

Cost-effectiveness of rivaroxaban versus warfarin for stroke prevention in atrial fibrillation in the Belgian healthcare setting.

BACKGROUND: Warfarin, an inexpensive drug that has been available for over half a century, has been the mainstay of anticoagulant therapy for stroke prevention in patients with atrial fibrillation (AF). Recently, rivaroxaban, a novel oral anticoagulant (NOAC) which offers some distinct advantages over warfarin, the standard of care in a world without NOACs, has been introduced and is now recommended by international guidelines. OBJECTIVE: The aim of this study was to evaluate, from a Belgian healthcare payer perspective, the cost-effectiveness of rivaroxaban versus use of warfarin for the treatment of patients with non-valvular AF at moderate to high risk. METHODS: A Markov model was designed and populated with local cost estimates, safety-on-treatment clinical results from the pivotal phase III ROCKET AF trial and utility values obtained from the literature. RESULTS: Rivaroxaban treatment was associated with fewer ischemic strokes and systemic embolisms (0.308 vs. 0.321 events), intracranial bleeds (0.048 vs. 0.063), and myocardial infarctions (0.082 vs. 0.095) per patient compared with warfarin. Over a lifetime time horizon, rivaroxaban led to a reduction of 0.042 life-threatening events per patient, and increases of 0.111 life-years and 0.094 quality-adjusted life-years (QALYs) versus warfarin treatment. This resulted in an incremental cost-effectiveness ratio of €8,809 per QALY or €7,493 per life-year gained. These results are based on valuated data from 2010. Sensitivity analysis indicated that these results were robust and that rivaroxaban is cost-effective compared with warfarin in 87 % of cases should a willingness-to-pay threshold of €35,000/QALY gained be considered. CONCLUSIONS: The present analysis suggests that rivaroxaban is a cost-effective alternative to warfarin therapy for the prevention of stroke in patients with AF in the Belgian healthcare setting.

Ethnic differences in blood pressure monitoring and control in south east London.

BACKGROUND: High blood pressure is the single most important risk factor worldwide for the development of cardiovascular disease, and has been shown to affect some ethnic minority groups disproportionately. AIM: To explore ethnic inequalities in blood pressure monitoring and control. METHOD: Data from Lambeth DataNet was used, based on case records from GP practices in one inner-city London borough. Blood pressure monitoring and control was compared using Quality and Outcomes Framework (QOF) targets for patients with: diabetes, coronary heart disease, stroke, hypertension, and chronic kidney disease. The study controlled for age, sex, social deprivation, and clustering within GP practices. RESULTS: A total of 16 613 patients met the study criteria, with 5962 categorised as black/black British. Blood pressure monitoring was similar across ethnic groups and as good, if not better, for black patients compared to white. However, marked ethnic inequalities in blood pressure control were found, with black patients significantly less likely to achieve QOF targets than their white counterparts (odds ratio [OR] 0.73; 95% confidence interval [CI] = 0.64 to 0.82). Further inequalities were revealed in blood pressure control within disease groups and ethnic subgroups. In particular, blood pressure control was poor in African patients with diabetes (OR 0.63; 95% CI = 0.50 to 0.79) and Caribbean patients with coronary heart disease (OR 0.53; 95% CI = 0.37 to 0.77) when compared with white patients. DISCUSSION: While black patients with chronic conditions are equally likely to have their blood pressure monitored, their blood pressure control is consistently poorer than that of their white counterparts. This may have important implications for cardiovascular risk management in black patients.