Differences in care-seeking behavior for acute chest pain in the United States and Japan

Economic Evaluations Comparing Deep Brain Stimulation to Best Medical Therapy for Movement Disorders: A Meta-Analysis

BACKGROUND

Movement disorders (Parkinson's disease, essential tremor, primary dystonia) are a debilitating group of conditions that are progressive in nature. The mainstay of treatment is best medical therapy; however, a number of surgical therapies are available, including deep brain stimulation. Economic evaluations are an important aspect of evidence to inform decision makers regarding funding allocated to these therapies.

OBJECTIVE

This systematic review and meta-analysis evaluated the cost effectiveness of including deep brain stimulation compared with best medical therapy for movement disorder indications in the adult population.

METHODS

Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials were queried. Only economic evaluations reporting incremental cost-effectiveness ratios for including deep brain stimulation versus best medical therapy for movement disorders were included. Studies were reviewed in duplicate for inclusion and data abstraction. Data were harmonized using the Consumer Price Index and Purchasing Power Parity to standardize values to 2022 US dollars. For inclusion in meta-analyses, studies were required to have sufficient data available to calculate an estimate of the incremental net benefit. Meta-analyses of pooled incremental net benefit based on the time horizon were performed. The study was registered at PROSPERO (CRD42022335436).

RESULTS

There were 2190 studies reviewed, with 14 economic evaluations included following a title/abstract and full-text review. Only studies considering Parkinson's disease were available for the meta-analysis. Quality of the identified studies was low, with moderate transferability to the American Healthcare System, and certainty of evidence was low. However, studies with a longer time horizon (15 years to lifetime) were found to have significant positive incremental net benefit (indicating cost effectiveness) for including deep brain stimulation with a mean difference of US$40,504.81 (95% confidence interval 2422.42-78,587.19).

CONCLUSIONS

Deep brain stimulation was cost effective for Parkinson's disease when considered over the course of the patient's remaining life after implantation.

TRIAL REGISTRATION

Clinical Trial Registration: PROSPERO (CRD42022335436).

Perceptions of chest pain and healthcare seeking behavior for chest pain in northern Tanzania: A community-based survey

Background

Little is known about community perceptions of chest pain and healthcare seeking behavior for chest pain in sub-Saharan Africa.

Methods

A two-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household healthcare decision-makers from randomly selected households were asked to list all possible causes of chest pain in an adult and asked where they would go if an adult household member had chest pain.

Results

Of 718 respondents, 485 (67.5%) were females. The most commonly cited causes of chest pain were weather and exercise, identified by 342 (47.6%) and 318 (44.3%) respondents. Two (0.3%) respondents identified ‘heart attack’ as a possible cause of chest pain. A hospital was selected as the preferred healthcare facility for an adult with chest pain by 277 (38.6%) respondents. Females were less likely to prefer a hospital than males (OR 0.65, 95% CI 0.47–0.90, p = 0.008).

Conclusions

There is little community awareness of cardiac causes of chest pain in northern Tanzania, and most adults reported that they would not present to a hospital for this symptom. There is an urgent need for educational interventions to address this knowledge deficit and guide appropriate care-seeking behavior.

Responses to hypothetical health scenarios overestimate healthcare utilization for common infectious syndromes: a cross-sectional survey, South Africa, 2012

BACKGROUND

Asking people how they would seek healthcare in a hypothetical situation can be an efficient way to estimate healthcare utilization, but it is unclear how intended healthcare use corresponds to actual healthcare use.

METHODS

We performed a cross-sectional survey between August and September 2012 among households in Soweto and Klerksdorp, South Africa, to compare healthcare seeking behaviors intended for hypothetical common infectious syndromes (pneumonia, influenza-like illness [ILI], chronic respiratory illness, meningitis in persons of any age, and diarrhea in a child < 5 years old) with the self-reported healthcare use among patients with those syndromes.

RESULTS

For most syndromes, the proportion of respondents who intended to seek healthcare at any facility or provider (99-100%) in a hypothetical scenario exceeded the proportion that did seek care (78-100%). More people intended to seek care for a child < 5 years old with diarrhea (186/188 [99%]) than actually did seek care (32/41 [78%], P < 0.01). Although most people faced with hypothetical scenarios intended to seek care with licensed medical providers such as hospitals and clinics (97-100%), patients who were ill reported lower use of licensed medical providers (55-95%).

CONCLUSIONS

People overestimated their intended healthcare utilization, especially with licensed medical providers, compared with reported healthcare utilization among patients with these illnesses. Studies that measure intended healthcare utilization should consider that actual use of healthcare facilities may be lower than intended use.

The association between ethnicity and delay in seeking medical care for chest pain: a systematic review

BACKGROUND

Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide, and chest pain is one of the most common symptoms of ACSs. A rapid response to chest pain by patients and appropriate management by health professionals are vital to improve survival rates.People from different ethnic groups are likely to have different perceptions of chest pain, its severity and the need for urgent treatment. These differences in perception may contribute to differences in response to chests pain and precipitate unique coping strategies. Delay in seeking medical care for chest pain in the general population has been well documented; however, limited studies have focused on delay times within ethnic groups. There is little research to date as to whether ethnicity is associated with the time taken to seek medical care for chest pain. Consequently, addressing this gap in knowledge will play a crucial role in improving the health outcomes of culturally and linguistically diverse (CALD) patients suffering from chest pain and for developing appropriate clinical practice and public awareness for these populations.

OBJECTIVES

The current review aimed to determine if there is an association between ethnicity and delay in seeking medical care for chest pain among CALD populations.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Patients from different ethnic minority groups presenting to emergency departments (EDs) with chest pain.

TYPES OF EXPOSURE

The current review will examine studies that evaluate the association between ethnicity and delay in seeking medical care for chest pain among CALD populations.

TYPES OF STUDIES

The current review will consider quantitative studies including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies.

OUTCOMES

The current review will consider studies that measure delay time as the main outcome. The time will be measured as the interval between the time of symptom onset and time to reach an ED.

SEARCH STRATEGY

A comprehensive search was undertaken for relevant published and unpublished studies written in English with no date restriction. All searches were conducted in October 2014. We searched the following databases: MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, ProQuest (health databases only), Informit, Sociological Abstracts, Scopus and Web of Science. The search for unpublished studies included a wide range of 'gray literature' sources including national libraries, digital theses repositories and clinical trial registries. We also targeted specific health research, specialist cardiac, migrant health, and emergency medicine organizational websites and/or conferences. We also checked the reference lists of included studies and contacted authors when further details about reported data was required to make a decision about eligibility.

METHODOLOGICAL QUALITY

Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to being included in the review. Validity was assessed using standardized critical appraisal instruments from the Joanna Briggs Institute. Adjudication was produced by the third reviewer.

DATA EXTRACTION

Data were extracted from included articles by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

The extracted data were synthesized into a narrative summary. Meta-analysis could not be performed due to the heterogeneity of study protocols and methods used to measure outcomes.

RESULTS

A total of 10 studies, with a total of 1,511,382 participants, investigating the association between ethnicity and delay met the inclusion criteria. Delay times varied across ethnic groups, including Black, Hispanic, Asian, South Asian, Southeast Asian and Chinese. Seven studies reported delay in hours and ranged from 1.90 to 3.10 h. Delay times were longer among CALD populations than the majority population. The other three studies reported delay time in categories of time (e.g. <1, <4 and <6 h) and found larger proportions of later presentations to the EDs among ethnic groups compared with the majority groups.

CONCLUSION

There is evidence of an association between ethnicity and time taken in seeking medical care for chest pain, with patients from some ethnic minorities (e.g. Black, Asian, Hispanic and South Asian) taking longer than those of the majority population. Health promotions and health campaigns focusing on these populations are indicated.

Public Response to Chest Pain in Jordan

Background: Chest pain is one of the main and most frequent manifestations of myocardial infarction (MI). Increased level of public awareness on the optimal response to chest pain due to MI attacks is crucial for minimizing its complications and mortality rate.

Aims: The first aim of this investigation was to assess the level of public awareness on their response to acute chest pain. The second aim was to obtain information about self-reported risk factors for coronary heart disease and acute myocardial infarction.

Settings and design: This survey was conducted in various regions of Jordan during the period of July–September 2004. A total of 4194 adults (out of 4500), 2086 males (49.7%) and 2108 females (50.3%) resident in Jordan were included in the sample. The response rate was 92.3%.

Methods: Each individual of the sample who agreed voluntarily to participate in the investigation was asked to report in a questionnaire his/her possible risk factors for MI. Moreover, each person of the sample was asked “What do you do when you suffer from a severe and crushing chest pain that persists for longer than 15 min and radiates to jaws, neck or left shoulder, with sweating and paleness of the face?” The person was asked to choose one option out of 11.

Statistical analysis: The frequency and percentage were determined for each investigated parameter.

Results and conclusion: The highest percentage of respondents had good response by selecting the option “I go to a doctor” while the lowest percentage of respondents showed poor response by choosing the option “I use an antacid”. The remainder of responses was distributed among other options. Excellent awareness was reported by 47% of the sample. Differences in the type of responses were detected when the results were analyzed according to gender, type of job, level of education and ethnicity. Approximately half of the interviewed individuals of the sample had 2–4 clustering risk factors for developing acute MI attacks. Individuals in more than half of the sample had family history of hypertension and diabetes mellitus.

It is concluded that although the type of response to chest pain in Jordan is good–excellent, more improvement is recommended since the risk to MI is relatively high. Community education campaigns may participate in increasing public health education on the optimal response to chest pain of myocardial origin.

Response to a cardiac event in relation to cardiac knowledge and risk perception in a Lebanese sample: a cross sectional survey

BACKGROUND

Heart disease is the leading cause of morbidity and mortality in many countries, including Lebanon. The continuing advances in the treatment of heart disease have improved patient outcomes significantly over the years. Nevertheless, prompt treatment remains essential to treatment success, which depends on the person's early recognition of cardiac symptoms and quick seeking of care.

OBJECTIVE

The purpose of the study was to examine the relationship between knowledge of symptoms of heart disease, perceived cardiac risk and the potential response to a heart attack in a sample of Lebanese adults.

DESIGN

A cross sectional descriptive survey design was used. A convenience sample of 399 adult hospital visitors who did not have heart disease were interviewed in two major referral hospitals in Beirut.

MEASURES

The Illness Perception Questionnaire and the Behavioral Risk Factor Surveillance System were used; in addition an open-ended question was asked to elicit what the visitor would do in case he/she experienced cardiac symptoms.

RESULTS

While most participants (94%) correctly recognized major symptoms of heart disease (like chest pain and dyspnea), they also reported irrelevant symptoms to be associated with heart disease (like irritability by 68% and muscle cramps by 52%). Only 21% of participants reported that they would seek emergency care as their first response if they were experiencing a heart attack. Knowledge of symptoms and perceived cardiac risk were not associated with the response to a heart attack. Being single was the only significant predictor of choosing the appropriate response when experiencing a cardiac event.

CONCLUSION

The findings suggest lack of adequate knowledge of cardiac symptoms and a high potential for inappropriate responses when symptoms occur. Public health heart health campaigns are needed to raise awareness about heart disease in Lebanon.

Trajectory of prehospital delay in patients with acute myocardial infarction in the Japanese health care system

OBJECTIVE

The purpose of this study was to understand the trajectory of prehospital delay in patients with acute myocardial infarction (AMI) in the Japanese health care system, which offers patients a choice between seeking treatment in a neighborhood clinic/small hospital (clinic group) or a large hospital with comprehensive cardiac services, including a cardiac catheterization laboratory (hospital group).

METHODS

In this cross sectional study, 155 consecutive patients admitted with AMI to one of 5 urban hospitals in Japan were interviewed within 7 days after admission.

RESULTS

The median total prehospital delay time in the clinic group (n=84) was significantly longer than the hospital group (n=71) (6 h and 48 min vs 2 h and 9 min, p<.001). Patients with severe chest pain were significantly less likely to seek treatment at a clinic/small hospital than at a large hospital compared to patients with mild or moderate symptoms (OR 0.85, 95% CI: 0.75, 0.97). Patients who did not interpret their symptoms as cardiac in origin were significantly more likely to seek treatment at a clinic/small hospital than at a large hospital compared to patients who interpreted their symptoms as cardiac in origin (OR 3.32, 95% CI: 1.56, 7.10). After controlling for demographic and medical history, patients in the clinic group were 3.69 times (95% CI: 1.28, 10.66) less likely to receive any reperfusion therapy compared to patients in the hospital group.

CONCLUSIONS

Findings support the need for public education in Japan that focuses on the appropriate response to AMI symptoms. Moreover, regional AMI networks need to be instituted to provide for early transfer for PCI from clinic/small hospitals to tertiary centers.

Global patterns of health care for acute coronary syndromes

PURPOSE OF REVIEW

Despite similar guidelines, remarkable global differences exist in the management of acute coronary syndromes. This review describes recent insights in global patterns of patient baseline characteristics, treatment strategies, medication use, and outcome in acute coronary syndromes.

RECENT FINDINGS

Results from recent registries and randomized clinical trials suggest that the arrival of many novel medications and treatment options for acute coronary syndromes has led to interregional heterogeneity in the management and treatment of patients with acute coronary syndromes. These differences in health care and adherence to national and international guidelines appear to be influenced by geographical, social, cultural, and economic factors, resulting in regional variation in hospital characteristics, physician attitude, access to resources or advanced cardiovascular care, access to the literature, and the availability of drugs.

SUMMARY

Significant differences in diagnosis and treatment of acute coronary syndrome patients can be observed globally, despite similar guidelines based on the same randomized clinical trials. Guidelines are not adapted promptly worldwide, influencing outcome and health care expenditure.

A decision chart for assessing and improving the transferability of economic evaluation results between countries

OBJECTIVE

To develop a user-friendly tool for managing the transfer of economic evaluation results.

METHODS

Factors that may influence the transfer of health economic study results were systematically identified and the way they impact on transferability was investigated. A transferability decision chart was developed that includes: knock-out criteria; a checklist based on the transferability factors; and methods for improving transferability and for assessing the uncertainty of transferred results. This approach was tested on various international cost-effectiveness studies in the areas of interventional cardiology, vaccination and screening.

RESULTS

The transfer of study results is possible pending the outcomes of the transferability check and necessary adjustments. Transferability factors can be grouped into areas of methodological, healthcare system and population characteristics. Different levels of effort are required for analysis of factors, ranging from very low (e.g. discount rate) to very high (e.g. practice variation). The impact of differences of most transferability factors can be estimated via the key health economic determinants: capacity utilisation, effectiveness, productivity loss and returns to scale. Depending on the outcomes of the transferability check a correction of the study results for inflation and for differences related to currencies or purchasing power might be sufficient. Otherwise, modelling-based adjustments might be necessary, requiring the (re-)building and sometimes structural modification of the study model. For determination of the most essential adjustments, a univariate sensitivity analysis seems appropriate. If not all relevant study parameters can be substituted with country-specific ones, multivariate or probabilistic sensitivity analysis seems to be a promising way to quantify the uncertainty associated with a transfer. If study results cannot be transferred, the transfer of study models or designs should be investigated as this can significantly save time when conducting a new study.

CONCLUSIONS

Our transferability decision chart is a transparent and user-friendly tool for assessing and improving the transferability of economic evaluation results. A state of the art description of the methodology in a study, providing detailed components for calculation, is not only essential for determining its transferability but also for improving it via modelling adjustments.