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Lv W, Wang A, Wang Q, Wang R, Xu Q, Wu S, Han Y, Jiang Y, Lin J, Jing J, Li H, Wang Y, Meng X. One-year direct and indirect costs of ischaemic stroke in China. Stroke Vasc Neurol 2024; 9:380-389. [PMID: 37788911 PMCID: PMC11420908 DOI: 10.1136/svn-2023-002296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 08/09/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND This is the first real-world study to estimate the direct costs and indirect costs of first-ever ischaemic stroke with 1-year follow-up in China, based on a nationally representative sample. METHODS Patients were chosen from 20 geographically diverse sites from the nationally representative database China National Stroke Registry-III (CNSR-III). The inclusion criteria were surviving patients who were hospitalised with first-ever ischaemic stroke from February 2017 to February 2018 (the index event); aged 18-80 during the index event; no history of other stroke types. The primary endpoints were direct medical costs, direct non-medical costs, indirect costs and total cost (ie, the sum of all cost components). Patient characteristics and clinical data were extracted from CNSR-III. Stroke-related in-hospital direct medical costs were collected from hospital electronic medical records. The patient survey collected data related to out-of-hospital direct medical costs, direct non-medical costs and indirect costs. The secondary objective was to explore clinical factors associated with cost outcomes through univariate analysis and multiple regression. RESULTS The study enrolled 520 patients. The total cost was 57 567.48 CNY, with 26 612.67 CNY direct medical costs, 2 787.56 CNY direct non-medical costs and 28 167.25 CNY indirect costs. Univariate analysis showed that longer lengths of stay during the index event, higher National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale scores were associated with higher costs in all categories. Conversely, EuroQol 5 Dimension utility scores were associated with decreased costs except direct non-medical costs. Multiple regressions showed that higher admission NIHSS scores were independently associated with higher direct medical costs, indirect costs and total cost. Higher 3-month utilities were associated with lower total cost. CONCLUSION This real-world study showed substantial 1-year economic burden following first-ever ischaemic stroke in China, and that indirect costs are a non-negligible driver of costs.
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Affiliation(s)
- Wei Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qianyi Wang
- School of Basic Medical Science, Capital Medical University, Beijing, China
| | - Ruimin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qin Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuqing Wu
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yi Han
- Health Economic Research Institute, Sun Yat-Sen University, Guangzhou, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Hassan A, Benlamri R, Diner T, Cristofaro K, Dillistone L, Khallouki H, Ahghari M, Littlefield S, Siddiqui R, MacDonald R, Savage DW. An App for Navigating Patient Transportation and Acute Stroke Care in Northwestern Ontario Using Machine Learning: Retrospective Study. JMIR Form Res 2024; 8:e54009. [PMID: 39088821 PMCID: PMC11327622 DOI: 10.2196/54009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 04/29/2024] [Accepted: 05/16/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND A coordinated care system helps provide timely access to treatment for suspected acute stroke. In Northwestern Ontario (NWO), Canada, communities are widespread with several hospitals offering various diagnostic equipment and services. Thus, resources are limited, and health care providers must often transfer patients with stroke to different hospital locations to ensure the most appropriate care access within recommended time frames. However, health care providers frequently situated temporarily (locum) in NWO or providing care remotely from other areas of Ontario may lack sufficient information and experience in the region to access care for a patient with a time-sensitive condition. Suboptimal decision-making may lead to multiple transfers before definitive stroke care is obtained, resulting in poor outcomes and additional health care system costs. OBJECTIVE We aimed to develop a tool to inform and assist NWO health care providers in determining the best transfer options for patients with stroke to provide the most efficient care access. We aimed to develop an app using a comprehensive geomapping navigation and estimation system based on machine learning algorithms. This app uses key stroke-related timelines including the last time the patient was known to be well, patient location, treatment options, and imaging availability at different health care facilities. METHODS Using historical data (2008-2020), an accurate prediction model using machine learning methods was developed and incorporated into a mobile app. These data contained parameters regarding air (Ornge) and land medical transport (3 services), which were preprocessed and cleaned. For cases in which Ornge air services and land ambulance medical transport were both involved in a patient transport process, data were merged and time intervals of the transport journey were determined. The data were distributed for training (35%), testing (35%), and validation (30%) of the prediction model. RESULTS In total, 70,623 records were collected in the data set from Ornge and land medical transport services to develop a prediction model. Various learning models were analyzed; all learning models perform better than the simple average of all points in predicting output variables. The decision tree model provided more accurate results than the other models. The decision tree model performed remarkably well, with the values from testing, validation, and the model within a close range. This model was used to develop the "NWO Navigate Stroke" system. The system provides accurate results and demonstrates that a mobile app can be a significant tool for health care providers navigating stroke care in NWO, potentially impacting patient care and outcomes. CONCLUSIONS The NWO Navigate Stroke system uses a data-driven, reliable, accurate prediction model while considering all variations and is simultaneously linked to all required acute stroke management pathways and tools. It was tested using historical data, and the next step will to involve usability testing with end users.
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Affiliation(s)
- Ayman Hassan
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON, Canada
- Northern Ontario School of Medicine University, Thunder Bay, ON, Canada
| | | | - Trina Diner
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | - Keli Cristofaro
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | | | | | | | | | - Rabail Siddiqui
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON, Canada
| | | | - David W Savage
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
- Northern Ontario School of Medicine University, Thunder Bay, ON, Canada
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Razavilar N, Tran DT, Dukelow SP, Round J. Utilization of early supported discharge and outpatient rehabilitation services following inpatient stroke rehabilitation. Arch Public Health 2024; 82:80. [PMID: 38816872 PMCID: PMC11137928 DOI: 10.1186/s13690-024-01300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Studies examining factors associated with patient referral to early supported discharge (ESD)/outpatient rehabilitation (OPR) programs and utilization of ESD/OPR services after discharge from inpatient stroke rehabilitation (IPR) are scarce. Accordingly, we examined utilization of ESD/OPR services following discharge from IPR and patient factors associated with service utilization. METHODS Stroke patients discharged from IPR facilities in Alberta between April 2014 and March 2016 were included and followed for one year for ESD/OPR service utilization. Multivariable linear and negative binomial regressions were used to examine association of patients' factors with ESD/OPR use. RESULTS We included 752 patients (34.4% of 2,187 patients discharged from IPR) who had 40,772 ESD/OPR visits during one year of follow-up in the analysis. Mean and median ESD/OPR visits were 54.2 and 36 visits, respectively. Unadjusted ESD/OPR visits were lower in females and patients aged ≥ 60 years but were similar between urban and rural areas. After adjustment for patient factors, patients in urban areas and discharged home after IPR were associated with 83.5% and 61.9%, respectively, increase in ESD/OPR visits, while having a right-body stroke was associated with 23.5% increase. Older patients used ESD/OPR less than their younger counterparts (1.4% decrease per one year of older age). Available factors explained 12.3% of variation in ESD/OPR use. CONCLUSION ESD/OPR utilization after IPR in Alberta was low and varied across age and geographic locations. Factors associated with use of ESD/OPR were identified but they could not fully explain variation of ESD/OPR use.
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Affiliation(s)
| | - Dat T Tran
- Institute of Health Economics, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Sean P Dukelow
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Jeff Round
- Institute of Health Economics, Edmonton, AB, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Baker WL, Sharma M, Cohen A, Ouwens M, Christoph MJ, Koch B, Moore TE, Frady G, Coleman CI. Using 30-day modified rankin scale score to predict 90-day score in patients with intracranial hemorrhage: Derivation and validation of prediction model. PLoS One 2024; 19:e0303757. [PMID: 38771834 PMCID: PMC11108121 DOI: 10.1371/journal.pone.0303757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/30/2024] [Indexed: 05/23/2024] Open
Abstract
Whether 30-day modified Rankin Scale (mRS) scores can predict 90-day scores is unclear. This study derived and validated a model to predict ordinal 90-day mRS score in an intracerebral hemorrhage (ICH) population using 30-day mRS values and routinely available baseline variables. Adults enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 (ATACH-2) trial between May 2011 and September 2015 with acute ICH, who were alive at 30 days and had mRS scores reported at both 30 and 90 days were included in this post-hoc analysis. A proportional odds regression model for predicting ordinal 90-day mRS scores was developed and internally validated using bootstrapping. Variables in the model included: mRS score at 30 days, age (years), hematoma volume (cm3), hematoma location (deep [basal ganglia, thalamus], lobar, or infratentorial), presence of intraventricular hemorrhage (IVH), baseline Glasgow Coma Scale (GCS) score, and National Institutes of Health Stroke Scale (NIHSS) score at randomization. We assessed model fit, calibration, discrimination, and agreement (ordinal, dichotomized functional independence), and EuroQol-5D ([EQ-5D] utility weighted) between predicted and observed 90-day mRS. A total of 898/1000 participants were included. Following bootstrap internal validation, our model (calibration slope = 0.967) had an optimism-corrected c-index of 0.884 (95% CI = 0.873-0.896) and R2 = 0.712 for 90-day mRS score. The weighted ĸ for agreement between observed and predicted ordinal 90-day mRS score was 0.811 (95% CI = 0.787-0.834). Agreement between observed and predicted functional independence (mRS score of 0-2) at 90 days was 74.3% (95% CI = 69.9-78.7%). The mean ± SD absolute difference between predicted and observed EQ-5D-weighted mRS score was negligible (0.005 ± 0.145). This tool allows practitioners and researchers to utilize clinically available information along with the mRS score 30 days after ICH to reliably predict the mRS score at 90 days.
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Affiliation(s)
- William L. Baker
- University of Connecticut School of Pharmacy, Storrs, CT, United States of America
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, United States of America
| | - Mukul Sharma
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander Cohen
- Guy’s and St. Thomas’ Hospitals, King’s College London, London, United Kingdom
| | - Mario Ouwens
- Medical and Payer Evidence, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom
| | - Mary J. Christoph
- AstraZeneca Pharmaceuticals, Wilmington, DE, United States of America
| | - Bruce Koch
- AstraZeneca Pharmaceuticals, Wilmington, DE, United States of America
| | - Timothy E. Moore
- Statistical Consulting Services, Center for Open Research Resources & Equipment, University of Connecticut, Storrs, CT, United States of America
| | - Garrett Frady
- Department of Statistics, University of Connecticut, Storrs, CT, United States of America
| | - Craig I. Coleman
- University of Connecticut School of Pharmacy, Storrs, CT, United States of America
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, United States of America
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Pinckaers FME, Grutters JPC, Huijberts I, Gabrio A, Boogaarts HD, Postma AA, van Oostenbrugge RJ, van Zwam WH, Evers SMAA. Cost and Utility Estimates per Modified Rankin Scale Score up to 2 Years Post Stroke: Data to Inform Economic Evaluations From a Societal Perspective. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:441-448. [PMID: 38244981 DOI: 10.1016/j.jval.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/22/2023] [Accepted: 01/02/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Model-based health economic evaluations of ischemic stroke are in need of cost- and utility estimates related to relevant outcome measures. This study aims to describe societal cost- and utility estimates per modified Rankin Scale (mRS)-score at different time points within 2 years post stroke. METHODS Included patients had a stroke between 3 months and 2.5 years ago. mRS and EQ-5D-5L were scored during a telephone interview. Based on the interview date, records were categorized into a time point: 3 months (3M; 3-6 months), 1 year (Y1; 6-18 months), or 2 years (Y2; 18-30 months). Patients completed a questionnaire on healthcare utilization and productivity losses in the previous 3 months. Initial stroke hospitalization costs were assessed. Mean costs and utilities per mRS and time point were derived with multiple imputation nested in bootstrapping. Cost at 3 months post stroke were estimated separately for endovascular treatment (EVT)-/non-EVT-patients. RESULTS 1106 patients were included from 18 Dutch centers. At each time point, higher mRS-scores were associated with increasing average costs and decreasing average utility. Mean societal costs at 3M ranged from €11 943 (mRS 1, no EVT) to €55 957 (mRS 5, no EVT). For Y1, mean costs in the previous 3 months ranged from €885 (mRS 0) to €23 215 (mRS 5), and from €1655 (mRS 0) to €22 904 (mRS 5) for Y2. Mean utilities ranged from 0.07 to 0.96, depending on mRS and time point. CONCLUSIONS The mRS-score is a major determinant of costs and utilities at different post-stroke time points. Our estimates may be used to inform future model-based health economic evaluations.
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Affiliation(s)
- Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | | | - Ilse Huijberts
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Andrea Gabrio
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | | | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands; Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Silvia M A A Evers
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Health Services Research, Maastricht University, Maastricht, The Netherlands; Centre of Economic Evaluation and Machine Learning, Trimbos Institute, Utrecht, The Netherlands
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6
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Irish J, Sharma A, Labbe D, Arsenault S, White K, Sakakibara BM. Stroke virtual rehabilitation in rural communities: exploring the perceptions of stroke survivors, caregivers, clinicians, and health administrators. Disabil Rehabil 2024:1-8. [PMID: 38493294 DOI: 10.1080/09638288.2024.2328308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 03/02/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Rural-dwelling stroke survivors have unmet rehabilitation needs after returning to community-living. Virtual rehabilitation, defined as the use of technology to provide rehabilitation services from a distance, could be a viable and timely solution to address this need, especially within the COVID-19 pandemic context. There is still a minimal understanding of virtual rehabilitation delivery within rural contexts. This study sought to explore the perceptions of rural stakeholders about virtual stroke rehabilitation. METHODS Following an interpretive description approach, 17 qualitative interviews were conducted with stroke survivors (n = 5), caregivers (n = 2), clinicians (n = 7), and health administrators (n = 3), and analyzed to understand their experiences and perceptions of virtual stroke rehabilitation. RESULTS We identified three overarching themes from the participant responses (1) The Root of the (Rural) Problem considered how systemic inequities impact stroke survivors' and caregivers' access to stroke recovery services; (2) Common Benefits, Different Challenges identified the unique benefits and challenges of delivering virtual rehabilitation within rural contexts; and (3) Ingredients for Success described important considerations for implementing virtual rehabilitation. CONCLUSION Virtual rehabilitation is generally accepted by all stakeholders as a supplement to in-person services. Addressing the unique barriers faced by rural clinicians and stroke survivors is necessary to provide successful virtual rehabilitation.
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Affiliation(s)
- Jessica Irish
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Annu Sharma
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Delphine Labbe
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Disability and Human Development Department, University of IL at Chicago, Chicago, IL, USA
| | - Sacha Arsenault
- Stroke Services British Columbia, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Katie White
- Stroke Services British Columbia, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Brodie M Sakakibara
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Chronic Disease Prevention and Management, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
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Adjetey C, Davis JC, Falck RS, Best JR, Dao E, Bennett K, Tai D, McGuire K, Eng JJ, Hsiung GYR, Middleton LE, Hall PA, Hu M, Sakakibara BM, Liu-Ambrose T. Economic Evaluation of Exercise or Cognitive and Social Enrichment Activities for Improved Cognition After Stroke. JAMA Netw Open 2023; 6:e2345687. [PMID: 38032638 PMCID: PMC10690466 DOI: 10.1001/jamanetworkopen.2023.45687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Importance Cognitive impairment is prevalent in survivors of stroke, affecting approximately 30% of individuals. Physical exercise and cognitive and social enrichment activities can enhance cognitive function in patients with chronic stroke, but their cost-effectiveness compared with a balance and tone program is uncertain. Objective To conduct a cost-effectiveness and cost-utility analysis of multicomponent exercise or cognitive and social enrichment activities compared with a balance and tone program. Design, Setting, and Participants This economic evaluation used a Canadian health care systems perspective and the Vitality study, a randomized clinical trial aimed at improving cognition after stroke with a 6-month intervention and a subsequent 6-month follow-up (ie, 12 months). The economic evaluation covered the duration of the Vitality trial, between June 6, 2014, and February 26, 2019. Participants were community-dwelling adults aged 55 years and older who experienced a stroke at least 12 months prior to study enrollment in the Vancouver metropolitan area, British Columbia, Canada. Data were analyzed from June 1, 2022, to March 31, 2023. Interventions Participants were randomly assigned to twice-weekly classes for 1 of the 3 groups: multicomponent exercise program, cognitive and social enrichment activities program, or a balance and tone program (control). Main Outcomes and Measures The primary measures for the economic evaluation included cost-effectiveness (incremental costs per mean change in cognitive function, evaluated using the Alzheimer Disease Assessment Scale-Cognitive-Plus), cost-utility (incremental cost per quality-adjusted life-year gained), intervention costs, and health care costs. Since cognitive benefits 6 months after intervention cessation were not observed in the primary randomized clinical trial, an economic evaluation at 12 months was not performed. Results Among 120 participants (mean [SD] age, 71 [9] years; 74 [62%] male), 34 were randomized to the multicomponent exercise program, 34 were randomized to the social and cognitive enrichment activities program, and 52 were randomized to the balance and tone control program. At the end of the 6-month intervention, the cost per mean change in Alzheimer Disease Assessment Scale-Cognitive-Plus score demonstrated that exercise was more effective and costlier compared with the control group in terms of cognitive improvement with an incremental cost-effectiveness ratio of CAD -$8823. The cost per quality-adjusted life-year gained for both interventions was negligible, with exercise less costly (mean [SD] incremental cost, CAD -$32 [$258]) and cognitive and social enrichment more costly than the control group (mean [SD] incremental cost, CAD $1018 [$378]). The balance and tone program had the lowest delivery cost (CAD $777), and the exercise group had the lowest health care resource utilization (mean [SD] $1261 [$1188]) per person. Conclusions and Relevance The findings of this economic evaluation suggest that exercise demonstrated potential for cost-effectiveness to improve cognitive function in older adults with chronic stroke during a 6-month intervention.
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Affiliation(s)
- Cassandra Adjetey
- Faculty of Management, University of British Columbia, Kelowna, Canada
- Applied Health Economics Lab, University of British Columbia, Kelowna, Canada
| | - Jennifer C. Davis
- Faculty of Management, University of British Columbia, Kelowna, Canada
- Applied Health Economics Lab, University of British Columbia, Kelowna, Canada
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Ryan S. Falck
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - John R. Best
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Elizabeth Dao
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Kim Bennett
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Daria Tai
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Katherine McGuire
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Janice J. Eng
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Ging-Yuek Robin Hsiung
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Laura E. Middleton
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Canada
- Schlegel–UW Research Institute for Aging, Waterloo, Canada
| | - Peter A. Hall
- School of Public Health Sciences, University of Waterloo, Waterloo, Canada
| | - Min Hu
- Department of Economics, Philosophy and Political Science, University of British Columbia, Kelowna, Canada
| | - Brodie M. Sakakibara
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada
- Centre for Chronic Disease Prevention and Management, Southern Medical Program, The University of British Columbia, Kelowna, Canada
| | - Teresa Liu-Ambrose
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
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8
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Vyas MV, Fang J, de Oliveira C, Austin PC, Yu AYX, Kapral MK. Attributable Costs of Stroke in Ontario, Canada and Their Variation by Stroke Type and Social Determinants of Health. Stroke 2023; 54:2824-2831. [PMID: 37823307 DOI: 10.1161/strokeaha.123.043369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/14/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Estimates of attributable costs of stroke are scarce, as most prior studies do not account for the baseline health care costs in people at risk of stroke. We estimated the attributable costs of stroke in a universal health care setting and their variation across stroke types and several social determinants of health. METHODS We undertook a population-based administrative database-derived matched retrospective cohort study in Ontario, Canada. Community-dwelling adults aged ≥40 years with a stroke between 2003 and 2018 were matched (1:1) on demographics and comorbidities with controls without stroke. Using a difference-in-differences approach, we estimated the mean 1-year direct health care costs attributable to stroke from a public health care payer perspective, accounting for censoring with a weighted available sample estimator. We described health sector-specific costs and reported variation across stroke type and social determinants of health. RESULTS The mean 1-year attributable costs of stroke were Canadian dollars 33 522 (95% CI, $33 231-$33 813), with higher costs for intracerebral hemorrhage ($40 244; $39 193-$41 294) than ischemic stroke ($32 547; $32 252-$32 843). Most of these costs were incurred in acute care hospitals ($15 693) and rehabilitation facilities ($7215). Compared with all patients with stroke, the mean attributable costs were higher among immigrants ($40 554; $39 316-$41 793), those aged <65 years ($35 175; $34 533-$35 818), and those residing in low-income neighborhoods ($34 687; $34 054-$35 320) and lower among rural residents ($29 047; $28 362-$29 731). CONCLUSIONS Our findings of high attributable costs of stroke, especially in immigrants, younger patients, and residents of low-income neighborhoods, can be used to evaluate potential health care cost savings associated with different primary stroke prevention strategies.
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Affiliation(s)
- Manav V Vyas
- Division of Neurology, Department of Medicine (M.V.V., A.Y.X.Y.), University of Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- Division of Neurology, Li Ka Shing Knowledge Institute, St. Michael's Hospital-Unity Health Toronto, Canada (M.V.V.)
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Claire de Oliveira
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- Health Economics, Centre for Addictions and Mental Health, Toronto, Canada (C.d.O.)
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Amy Y X Yu
- Division of Neurology, Department of Medicine (M.V.V., A.Y.X.Y.), University of Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada (A.Y.X.Y.)
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- Division of General Internal Medicine, Department of Medicine (M.K.K.), University of Toronto, Canada
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
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9
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Andrushko JW, Rinat S, Greeley B, Larssen BC, Jones CB, Rubino C, Denyer R, Ferris JK, Campbell KL, Neva JL, Boyd LA. Improved processing speed and decreased functional connectivity in individuals with chronic stroke after paired exercise and motor training. Sci Rep 2023; 13:13652. [PMID: 37608062 PMCID: PMC10444837 DOI: 10.1038/s41598-023-40605-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023] Open
Abstract
After stroke, impaired motor performance is linked to an increased demand for cognitive resources. Aerobic exercise improves cognitive function in neurologically intact populations and may be effective in altering cognitive function post-stroke. We sought to determine if high-intensity aerobic exercise paired with motor training in individuals with chronic stroke alters cognitive-motor function and functional connectivity between the dorsolateral prefrontal cortex (DLPFC), a key region for cognitive-motor processes, and the sensorimotor network. Twenty-five participants with chronic stroke were randomly assigned to exercise (n = 14; 66 ± 11 years; 4 females), or control (n = 11; 68 ± 8 years; 2 females) groups. Both groups performed 5-days of paretic upper limb motor training after either high-intensity aerobic exercise (3 intervals of 3 min each, total exercise duration of 23-min) or watching a documentary (control). Resting-state fMRI, and trail making test part A (TMT-A) and B were recorded pre- and post-intervention. Both groups showed implicit motor sequence learning (p < 0.001); there was no added benefit of exercise for implicit motor sequence learning (p = 0.738). The exercise group experienced greater overall cognitive-motor improvements measured with the TMT-A. Regardless of group, the changes in task score, and dwell time during TMT-A were correlated with a decrease in DLPFC-sensorimotor network functional connectivity (task score: p = 0.025; dwell time: p = 0.043), which is thought to reflect a reduction in the cognitive demand and increased automaticity. Aerobic exercise may improve cognitive-motor processing speed post-stroke.
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Affiliation(s)
- Justin W Andrushko
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Shie Rinat
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Brian Greeley
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Beverley C Larssen
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Christina B Jones
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Cristina Rubino
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Ronan Denyer
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Graduate Program in Neuroscience, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Jennifer K Ferris
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Kristin L Campbell
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Jason L Neva
- Faculty of Medicine, School of Kinesiology and Physical Activity Sciences, University of Montreal, Montreal, QC, H3T 1J4, Canada
- Research Center of the Montreal Geriatrics Institute (CRIUGM), Montreal, QC, Canada
| | - Lara A Boyd
- Brain Behaviour Laboratory, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada.
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada.
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10
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Ye Z, Zhou T, Zhang M, Zhou J, Xie F, Hill MD, Smith EE, Busse JW, Zhang Y, Liu Y, Wang X, Ma Z, An Z. Cost-effectiveness of endovascular thrombectomy with alteplase versus endovascular thrombectomy alone for acute ischemic stroke secondary to large vessel occlusion. CMAJ Open 2023; 11:E443-E450. [PMID: 37192770 DOI: 10.9778/cmajo.20220096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Recent randomized trials have suggested that endovascular thrombectomy (EVT) alone may provide similar functional outcomes as the current standard of care, EVT combined with intravenous alteplase treatment, for acute ischemic stroke secondary to large vessel occlusion. We conducted an economic evaluation of these 2 therapeutic options. METHODS We constructed a decision analytic model with a hypothetical cohort of 1000 patients to assess the cost-effectiveness of EVT with intravenous alteplase treatment versus EVT alone for acute ischemic stroke secondary to large vessel occlusion from both the societal and public health care payer perspectives. We used studies and data published in 2009-2021 for model inputs, and acquired cost data for Canada and China, representing high- and middle-income countries, respectively. We calculated incremental cost-effectiveness ratios (ICERs) using a lifetime horizon and accounted for uncertainty using 1-way and probabilistic sensitivity analyses. All costs are reported in 2021 Canadian dollars. RESULTS In Canada, the difference in quality-adjusted life-years (QALYs) gained between EVT with alteplase and EVT alone was 0.10 from both the societal and health care payer perspectives. The difference in cost was $2847 from a societal perspective and $2767 from the payer perspective. In China, the difference in QALYs gained was 0.07 from both perspectives, and the difference in cost was $1550 from the societal perspective and $1607 from the payer perspective. One-way sensitivity analyses showed that the distributions of modified Rankin Scale scores at 90 days after stroke were the most influential factor on ICERs. For Canada, compared to EVT alone, the probability that EVT with alteplase would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained was 58.7% from a societal perspective and 58.4% from a payer perspective. The corresponding values for at a willingness-to-pay threshold of $47 185 (3 times the Chinese gross domestic product per capita in 2021) were 65.2% and 67.4%. INTERPRETATION For patients with acute ischemic stroke due to large vessel occlusion eligible for immediate treatment with both EVT alone and EVT with intravenous alteplase treatment, it is uncertain whether EVT with alteplase is cost-effective compared to EVT alone in Canada and China.
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Affiliation(s)
- Zhikang Ye
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ting Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Mengmeng Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Junwen Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Feng Xie
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Michael D Hill
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Eric E Smith
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Jason W Busse
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Yi Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ying Liu
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Xin Wang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuo Ma
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuoling An
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont.
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11
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Gagnon MA, Batcho CS, Bird ML, Labbé B, Best KL. Feasibility of a remotely supervised home-based group eHealth Fitness and Mobility Exercise program for stroke: French-Canadian version preliminary study. Top Stroke Rehabil 2023; 30:169-179. [PMID: 34994303 DOI: 10.1080/10749357.2021.2012008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The numerous barriers to community-based physical activity programs have been exacerbated by the COVID-19 pandemic, especially among individuals with disabilities. eHealth programs may provide an alternative approach to address the physical activity needs of stroke survivors, but little is known about their feasibility or acceptance. OBJECTIVE The aims of this study were to 1) evaluate the feasibility of a remotely supervised home-based group eHealth program called Fitness and Mobility Exercise (FAME@home); 2) explore the influence of FAME@home on physical condition, mobility, self-efficacy, depression and anxiety; and 3) describe participants' satisfaction and experiences. METHODS A pre-post pilot study was used to recruit stroke survivors (>1 y post stroke) to complete a 12-week (2 days/week) eHealth program in small groups (n = 3). Feasibility indicators were assessed for process (e.g. inclusion criteria), resources (e.g. ability to use technology), management (e.g. major challenges), and treatment (e.g. influence on clinical outcomes and adverse events). RESULTS Nine participants were recruited with a mean (SD) of 60 (13) years of age and 7 (4) years post-stroke; eight completed the program. FAME@home was feasible for indicators of process, management, and treatment. Minor considerations to improve resources were suggested (i.e. support for technology use). There were statistically significant improvements in mobility after completion of FAME@home and 100% of the participants reported satisfaction. No adverse events occurred. CONCLUSION FAME@home was feasible to deliver as a remotely supervised group exercise program to community-dwelling stroke survivors, with high levels of retention and adherence. FAME@home improved accessibility to exercise and facilitated engagement by having a class schedule and social interaction.
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Affiliation(s)
- Marie-Andrée Gagnon
- Department of Rehabilitation, Faculty of Medicine Université Laval, Quebec City, Canada.,Center for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Quebec City, Canada
| | - Charles Sèbiyo Batcho
- Department of Rehabilitation, Faculty of Medicine Université Laval, Quebec City, Canada.,Center for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Quebec City, Canada
| | - Marie-Louise Bird
- University of Tasmania, Launceston Tasmania, Australia.,University of British Columbia, Vancouver, BC, Canada
| | | | - Krista L Best
- Department of Rehabilitation, Faculty of Medicine Université Laval, Quebec City, Canada.,Center for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Quebec City, Canada
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12
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Szeto SG, Wan H, Alavinia M, Dukelow S, MacNeill H. Effect of mobile application types on stroke rehabilitation: a systematic review. J Neuroeng Rehabil 2023; 20:12. [PMID: 36694257 PMCID: PMC9872745 DOI: 10.1186/s12984-023-01124-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/07/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Stroke is a significant contributor of worldwide disability and morbidity with substantial economic consequences. Rehabilitation is a vital component of stroke recovery, but inpatient stroke rehabilitation programs can struggle to meet the recommended hours of therapy per day outlined by the Canadian Stroke Best Practices and American Heart Association. Mobile applications (apps) are an emerging technology which may help bridge this deficit, however this area is understudied. The purpose of this study is to review the effect of mobile apps for stroke rehabilitation on stroke impairments and functional outcomes. Specifically, this paper will delve into the impact of varying mobile app types on stroke rehabilitation. METHODS This systematic review included 29 studies: 11 randomized control trials and 18 quasi-experimental studies. Data extrapolation mapped 5 mobile app types (therapy apps, education apps, rehab videos, reminders, and a combination of rehab videos with reminders) to stroke deficits (motor paresis, aphasia, neglect), adherence to exercise, activities of daily living (ADLs), quality of life, secondary stroke prevention, and depression and anxiety. RESULTS There were multiple studies supporting the use of therapy apps for motor paresis or aphasia, rehab videos for exercise adherence, and reminders for exercise adherence. For permutations involving other app types with stroke deficits or functional outcomes (adherence to exercise, ADLs, quality of life, secondary stroke prevention, depression and anxiety), the results were either non-significant or limited by a paucity of studies. CONCLUSION Mobile apps demonstrate potential to assist with stroke recovery and augment face to face rehabilitation, however, development of a mobile app should be carefully planned when targeting specific stroke deficits or functional outcomes. This study found that mobile app types which mimicked principles of effective face-to-face therapy (massed practice, task-specific practice, goal-oriented practice, multisensory stimulation, rhythmic cueing, feedback, social interaction, and constraint-induced therapy) and education (interactivity, feedback, repetition, practice exercises, social learning) had the greatest benefits. Protocol registration PROPSERO (ID CRD42021186534). Registered 21 February 2021.
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Affiliation(s)
- Stephen G. Szeto
- grid.17063.330000 0001 2157 2938Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428UHN Toronto Rehab Institute, 550 University Avenue, Toronto, ON M5G 2A2 Canada
| | - Hoyee Wan
- grid.17063.330000 0001 2157 2938Division of Plastic, Reconstructive, and Aesthetic Surgery, University of Toronto, Toronto, Canada
| | - Mohammad Alavinia
- grid.17063.330000 0001 2157 2938Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
| | - Sean Dukelow
- grid.22072.350000 0004 1936 7697Division of Physical Medicine & Rehabilitation, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Heather MacNeill
- grid.17063.330000 0001 2157 2938Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada ,grid.492573.e0000 0004 6477 6457Physical Medicine & Rehabilitation, Hennick Bridgepoint Hospital, Sinai Health System, Toronto, Canada
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13
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Length of Stay and Home Discharge for Patients with Inpatient Stroke Rehabilitation. Neurol Sci 2023; 50:28-36. [PMID: 34666861 DOI: 10.1017/cjn.2021.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine temporal trends and geographic variations and predict inpatient rehabilitation (IPR) length of stay (LOS) and home discharge for stroke patients. METHODS Patients aged ≥18 years who were admitted to an IPR facility in Alberta, Canada, between 04/2014 and 03/2018 (years 2014-2017) were included. Predictors of LOS and home discharge were examined using 2014-2016 data and validated using 2017 data. Multivariable linear regression (MLR), multivariable negative binomial (MNB), and multivariable quantile regressions (MQR) were used to examine LOS, and logistic regression was used for home discharge. RESULTS We included 2686 rehabilitation admissions between 2014 and 2017. The mean LOS decreased (2014: 71 days; 2017: 62.1 days; p = 0.003) during the study period and was shortest in Edmonton (59.1 days) compared to Calgary (66 days) or other localities (70.8 days; p < 0.001). Three-quarters of patients were discharged home and this proportion remained unchanged between 2014 and 2017. Calgary patients were more likely to be discharged home than those in Edmonton (OR = 0.62; p = 0.019) or other localities (OR = 0.39; p = 0.011). The MLR and MNB models provided accurate prediction for the mean LOS (predicted = 59.9 and 60.8 days, respectively, vs. actual = 62.1 days; both p > 0.5), while the MQR model did so for the median LOS (predicted = 44.3 days vs. actual = 44 days; p = 0.09). The logistic regression resulted in 82.4% of correct prediction, a sensitivity of 91.6%, and a specificity of 50.7% for home discharge. CONCLUSIONS Rehabilitation LOS decreased while the proportion of home discharge remained unchanged during the study period. Both varied across health zones. Identifiable statistical models provided accurate prediction with a separate patient cohort.
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Kiflen M, Le A, Mao S, Lali R, Narula S, Xie F, Paré G. Cost-Effectiveness of Polygenic Risk Scores to Guide Statin Therapy for Cardiovascular Disease Prevention. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2022; 15:e003423. [PMID: 35904973 DOI: 10.1161/circgen.121.003423] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atherosclerotic cardiovascular diseases (CVDs) are leading causes of death despite effective therapies and result in unnecessary morbidity and mortality throughout the world. We aimed to investigate the cost-effectiveness of polygenic risk scores (PRS) to guide statin therapy for Canadians with intermediate CVD risk and model its economic outlook. METHODS This cost-utility analysis was conducted using UK Biobank prospective cohort study participants, with recruitment from 2006 to 2010, and at least 10 years of follow-up. We included nonrelated white British-descent participants (n=96 116) at intermediate CVD risk with no prior lipid lowering medication or statin-indicated conditions. A coronary artery disease PRS was used to inform decision to use statins. The effects of statin therapy with and without PRS, as well as CVD events were modelled to determine the incremental cost-effectiveness ratio from a Canadian public health care perspective. We discounted future costs and quality-adjusted life-years by 1.5% annually. RESULTS The optimal economic strategy was when intermediate risk individuals with a PRS in the top 70% are eligible for statins while the lowest 1% are excluded. Base-case analysis at a genotyping cost of $70 produced an incremental cost-effectiveness ratio of $172 906 (143 685 USD) per quality-adjusted life-year. In the probabilistic sensitivity analysis, the intervention has approximately a 50% probability of being cost-effective at $179 100 (148 749 USD) per quality-adjusted life-year. At a $0 genotyping cost, representing individuals with existing genotyping information, PRS-guided strategies dominated standard care when 12% of the lowest PRS individuals were withheld from statins. With improved PRS predictive performance and lower genotyping costs, the incremental cost-effectiveness ratio demonstrates possible cost-effectiveness under thresholds of $150 000 and possibly $50 000 per quality-adjusted life-year. CONCLUSIONS This study suggests that using PRS alongside existing guidelines might be cost-effective for CVD. Stronger predictiveness combined with decreased cost of PRS could further improve cost-effectiveness, providing an economic basis for its inclusion into clinical care.
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Affiliation(s)
- Michel Kiflen
- Department of Medicine, University of Toronto, Toronto (M.K.).,Population Health Research Institute (M.K., A.L., S.M., R.L., S.N., G.P.), McMaster University, Hamilton, Ontario, Canada
| | - Ann Le
- Population Health Research Institute (M.K., A.L., S.M., R.L., S.N., G.P.), McMaster University, Hamilton, Ontario, Canada.,Department of Medical Sciences (A.L.), McMaster University, Hamilton, Ontario, Canada
| | - Shihong Mao
- Population Health Research Institute (M.K., A.L., S.M., R.L., S.N., G.P.), McMaster University, Hamilton, Ontario, Canada
| | - Ricky Lali
- Population Health Research Institute (M.K., A.L., S.M., R.L., S.N., G.P.), McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact (R.L., S.N., F.X., G.P.), McMaster University, Hamilton, Ontario, Canada
| | - Sukrit Narula
- Population Health Research Institute (M.K., A.L., S.M., R.L., S.N., G.P.), McMaster University, Hamilton, Ontario, Canada.,Department of Internal Medicine, Yale University, New Haven, CT (S.N.)
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact (R.L., S.N., F.X., G.P.), McMaster University, Hamilton, Ontario, Canada
| | - Guillaume Paré
- Population Health Research Institute (M.K., A.L., S.M., R.L., S.N., G.P.), McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact (R.L., S.N., F.X., G.P.), McMaster University, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada.,Thrombosis & Atherosclerosis Research Institute (G.P.), McMaster University, Hamilton, Ontario, Canada.,McMaster University, Hamilton, Ontario, Canada (G.P.)
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15
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Nozoe M, Noguchi M, Kubo H, Kanai M, Shimada S. Association between the coexistence of premorbid sarcopenia, frailty, and disability and functional outcome in older patients with acute stroke. Geriatr Gerontol Int 2022; 22:642-647. [PMID: 35848637 DOI: 10.1111/ggi.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 11/29/2022]
Abstract
AIM To investigate the effects of coexisting conditions such as premorbid sarcopenia, frailty, and disability on functional outcomes in older patients with acute stroke. METHODS This prospective cohort study included older patients (aged ≥65 years) hospitalized for acute stroke at a single neurosurgical hospital. Premorbid sarcopenia, frailty, and disability were diagnosed using the strength, assistance with walking, rising from a chair, climbing stairs, and falls (SARC-F) questionnaire, frailty index, and modified Rankin Scale (mRS) on admission. The primary outcome was the mRS score 3 months after stroke, and a poor outcome was defined as mRS ≥4. RESULTS This study included 317 older patients with acute stroke (median [interquartile range] age: 76 [12] years). Premorbid sarcopenia, frailty, and disability (mRS = 2 or 3) were identified in 59 (19%), 27 (9%), and 54 (17%) patients, respectively. Two coexisting conditions were observed in 26 patients (8%), and three were observed in 18 patients (6%). Adjusted logistic regression analysis revealed that coexisting conditions were independently associated with poor outcomes (one condition, adjusted OR: 3.20 [95%CI: 0.98-10.45]; two conditions, adjusted OR: 6.57 [95%CI: 1.74-24.87]; three conditions, adjusted OR: 12.70 [95%CI: 2.65-60.91]). CONCLUSIONS The coexistence of premorbid sarcopenia, frailty, and disability was associated with poor functional outcomes in older patients with acute stroke. Geriatr Gerontol Int 2022; ••: ••-••.
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan
| | - Madoka Noguchi
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Hiroki Kubo
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Masashi Kanai
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan
| | - Shinichi Shimada
- Department of Neurosurgery, Itami Kousei Neurosurgical Hospital, Itami, Japan
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16
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Neurologic Complications in HHT with Pulmonary Arteriovenous Malformations: Systematic Review. Neurol Sci 2022:1-12. [PMID: 35686303 DOI: 10.1017/cjn.2022.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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17
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Navi BB, Audebert HJ, Alexandrov AW, Cadilhac DA, Grotta JC. Mobile Stroke Units: Evidence, Gaps, and Next Steps. Stroke 2022; 53:2103-2113. [PMID: 35331008 DOI: 10.1161/strokeaha.121.037376] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mobile stroke units (MSUs) are specialized ambulances equipped with the personnel, equipment, and imaging capability to diagnose and treat acute stroke in the prehospital setting. Over the past decade, MSUs have proliferated throughout the world, particularly in European and US cities, culminating in the formation of an international consortium. Randomized trials have demonstrated that MSUs increase stroke thrombolysis rates and reduce onset-to-treatment times but until recently it was uncertain if these advantages would translate into better patient outcomes. In 2021, 2 pivotal, large, controlled clinical trials, B_PROUD and BEST-MSU, demonstrated that as compared with conventional emergency care, treatment aboard MSUs was safe and led to improved functional outcomes in patients with stroke. Further, the observed benefit of MSUs appeared to be primarily driven by the higher frequency of ultra-early thrombolysis within the golden hour. Nevertheless, questions remain regarding the cost-effectiveness of MSUs, their utility in nonurban settings, and optimal infrastructure. In addition, in much of the world, MSUs are currently not reimbursed by insurers nor accepted as standard care by regulatory bodies. As MSUs are now established as one of the few proven acute stroke interventions with an effect size that is comparable to that of intravenous thrombolysis and stroke units, stroke leaders and organizations should work with emergency medical services, governments, and community stakeholders to determine how MSUs might benefit individual communities, and their optimal organization and financing. Future research to explore the effect of MSUs on intracranial hemorrhage and thrombectomy outcomes, cost-effectiveness, and novel models including the use of rendezvous transports, helicopters, and advanced neuroimaging is ongoing. Recommended next steps for MSUs include reimbursement by insurers, integration with ambulance networks, recognition by program accreditors, and inclusion in registries that monitor care quality.
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Affiliation(s)
- Babak B Navi
- Department of Neurology and Brain and Mind Research Institute, Weill Cornell Medicine and NewYork-Presbyterian Hospital' New York (B.B.N.)
| | - Heinrich J Audebert
- Department of Neurology, Center for Stroke Research, Charite-Universitatsmedizin, Berlin, Germany (H.J.A.)
| | | | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia (D.A.C.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston
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18
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Andrushko JW, Gould L, Renshaw DW, Forrester S, Kelly ME, Linassi G, Mickleborough M, Oates A, Hunter G, Borowsky R, Farthing JP. Ipsilesional Motor Cortex Activation with High-force Unimanual Handgrip Contractions of the Less-affected Limb in Participants with Stroke. Neuroscience 2021; 483:82-94. [PMID: 34920023 DOI: 10.1016/j.neuroscience.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 11/27/2022]
Abstract
Stroke is a leading cause of severe disability that often presents with unilateral motor impairment. Conventional rehabilitation approaches focus on motor practice of the affected limb and aim to suppress brain activity in the contralesional hemisphere. Conversely, exercise of the less-affected limb promotes contralesional brain activity which is typically viewed as contraindicated in stroke recovery due to the interhemispheric inhibitory influence onto the ipsilesional hemisphere. Yet, high-force unimanual handgrip contractions are known to increase ipsilateral brain activation in control participants, and it remains to be determined if high-force contractions with the less-affected limb would promote ipsilateral brain activation in participants with stroke (i.e., the ipsilesional hemisphere). Therefore, this study aimed to determine how parametric increases in handgrip force during repeated contractions with the less-affected limb impacts brain activity bilaterally in participants with stroke and in a cohort of neurologically intact controls. Participants performed repeated submaximal contractions at 25%, 50%, and 75% of their maximum voluntary contraction during separate functional magnetic resonance imaging brain scans. Brain activation during the tasks was quantified as the present change from resting levels. In this study, higher force contractions were found to increase brain activation in the ipsilesional (stroke)/ipsilateral (controls) hemisphere in both groups (p = .002), but no between group differences were observed. These data suggest that high-force exercise with the less-affected limb may promote ipsilesional cortical plasticity to promote motor recovery of the affected-limb in participants with stroke.
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Affiliation(s)
- Justin W Andrushko
- College of Kinesiology, University of Saskatchewan, Saskatchewan, Canada
| | - Layla Gould
- Department of Surgery, Division of Neurosurgery, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Doug W Renshaw
- College of Kinesiology, University of Saskatchewan, Saskatchewan, Canada
| | - Shannon Forrester
- College of Kinesiology, University of Saskatchewan, Saskatchewan, Canada
| | - Michael E Kelly
- Department of Surgery, Division of Neurosurgery, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Gary Linassi
- Department of Physical Medicine and Rehabilitation, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Marla Mickleborough
- Department of Psychology, College of Arts and Science, University of Saskatchewan, Saskatchewan, Canada
| | - Alison Oates
- College of Kinesiology, University of Saskatchewan, Saskatchewan, Canada
| | - Gary Hunter
- Department of Medicine, Division of Neurology, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Ron Borowsky
- Department of Psychology, College of Arts and Science, University of Saskatchewan, Saskatchewan, Canada
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19
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Treatment Efficacy Analysis in Acute Ischemic Stroke Patients Using In Silico Modeling Based on Machine Learning: A Proof-of-Principle. Biomedicines 2021; 9:biomedicines9101357. [PMID: 34680474 PMCID: PMC8533087 DOI: 10.3390/biomedicines9101357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 01/08/2023] Open
Abstract
Interventional neuroradiology is characterized by engineering- and experience-driven device development with design improvements every few months. However, clinical validation of these new devices requires lengthy and expensive randomized controlled trials. This contribution proposes a machine learning-based in silico study design to evaluate new devices more quickly with a small sample size. Acute diffusion- and perfusion-weighted MRI, segmented one-week follow-up imaging, and clinical variables were available for 90 acute ischemic stroke patients. Three treatment option-specific random forest models were trained to predict the one-week follow-up lesion segmentation for (1) patients successfully recanalized using intra-arterial mechanical thrombectomy, (2) patients successfully recanalized using intravenous thrombolysis, and (3) non-recanalizing patients as an analogue for conservative treatment for each patient in the sample, independent of the true group membership. A repeated-measures analysis of the three predicted follow-up lesions for each patient revealed significantly larger lesions for the non-recanalizing group compared to the successful intravenous thrombolysis treatment group, which in turn showed significantly larger lesions compared to the successful mechanical thrombectomy treatment group (p < 0.001). A groupwise comparison of the true follow-up lesions for the three treatment options showed the same trend but did not reach statistical significance (p = 0.19). We conclude that the proposed machine learning-based in silico trial design leads to clinically feasible results and can support new efficacy studies by providing additional power and potential early intermediate results.
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20
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Sangarapillai T, Hajizadeh M, Daskalopoulou SS, Dasgupta K. Cost-Comparison Analysis of a Physician-Delivered Step-Count Prescription Strategy. CJC Open 2021; 3:1043-1050. [PMID: 34505044 PMCID: PMC8413227 DOI: 10.1016/j.cjco.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background Increments of 1000 steps/d predict cardiovascular disease (CVD) event reductions. In adults with type 2 diabetes and/or hypertension, our Step Monitoring to Improve Arterial Health (SMARTER) trial demonstrated a physician-delivered step-count prescription strategy to increase steps by more than this amount over 1 year, compared to usual care. In the present analysis, we aimed to determine the costs of the intervention compared to usual care, incorporating 1-year intervention costs and projected savings from lower CVD hospitalizations over the subsequent 5 years. Methods We considered Canadians aged 55 to 74 years with type 2 diabetes and/or hypertension. Using time estimates from our trial, we computed nursing costs corresponding to patient support time over 1 year, and pedometer costs for an anticipated 50% of patients without a smartphone. We estimated the number of CVD hospitalizations, the reduction expected with a mean 1000 steps/d increase, and the associated savings. We calculated the net cost (savings), the proportion of patients with their own device required for cost neutrality, and costs (savings) if all patients needed to be provided with a device. Results At an average intervention cost of $51.28/patient, the total cost would be $168 million. With an estimated 8875 CVD events prevented, $208 million would be saved. This savings would result in ~$40 million in net savings with 50% device ownership, cost neutrality with 25% device ownership, and ~$42 million in net costs if all patients required the healthcare system to provide a device. Conclusions At current levels of smartphone ownership, adoption of the SMARTER strategy is cost-saving to cost-neutral from the healthcare system perspective.
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Affiliation(s)
- Tarsan Sangarapillai
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Kaberi Dasgupta
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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21
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Strilciuc S, Grad DA, Radu C, Chira D, Stan A, Ungureanu M, Gheorghe A, Muresanu FD. The economic burden of stroke: a systematic review of cost of illness studies. J Med Life 2021; 14:606-619. [PMID: 35027963 PMCID: PMC8742896 DOI: 10.25122/jml-2021-0361] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/23/2021] [Indexed: 01/02/2023] Open
Abstract
Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.
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Affiliation(s)
- Stefan Strilciuc
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Diana Alecsandra Grad
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Constantin Radu
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Diana Chira
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Adina Stan
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Marius Ungureanu
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
- Center for Health Workforce Research and Policy, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Adrian Gheorghe
- Department of Infectious Disease Epidemiology, Global Health and Development Group, Imperial College London, London, United Kingdom
| | - Fior-Dafin Muresanu
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
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22
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Investing in Endovascular Thrombectomy Programs: Saving Lives, Saving Money. Can J Neurol Sci 2021; 49:625-626. [PMID: 34425931 DOI: 10.1017/cjn.2021.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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23
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Rutkowski NA, Sabri E, Yang C. Post-stroke fatigue: A factor associated with inability to return to work in patients <60 years-A 1-year follow-up. PLoS One 2021; 16:e0255538. [PMID: 34347804 PMCID: PMC8336834 DOI: 10.1371/journal.pone.0255538] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/17/2021] [Indexed: 11/21/2022] Open
Abstract
This study investigated the association between post-stroke fatigue and inability to return to work/drive in young patients aged <60 years with first stroke who were employed prior to infarct while controlling for stroke severity, age, extent of disability, cognitive function, and depression. The Fatigue Severity Scale (FSS) was used to evaluate post-stroke fatigue in this 1-year prospective cohort study. Follow-ups were completed at 3, 6, and 12 months post rehabilitation discharge. A total of 112 patients were recruited, 7 were excluded, due to loss to follow-up (n = 6) and being palliative (n = 1), resulting in 105 participants (71% male, average age 49 ±10.63 years). Stroke patients receiving both inpatient and outpatient rehabilitation were consecutively recruited. Persistent fatigue remained associated with inability to return to work when controlling for other factors at 3 months (adjusted OR = 18, 95% CI: 2.9, 110.3, p = 0.002), 6 months (adjusted OR = 29.81, 95% CI: 1.7, 532.8, p = 0.021), and 12 months (adjusted OR = 31.6, 95% CI: 1.8, 545.0, p = 0.018). No association was found between persistent fatigue and return to driving. Fatigue at admission was associated with inability to return to work at 3 months but not return to drive. Persistent fatigue was found to be associated with inability to resume work but not driving. It may be beneficial to routinely screen post-stroke fatigue in rehabilitation and educate stroke survivors and employers on the impacts of post-stroke fatigue on return to work.
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Affiliation(s)
- Nicole Anna Rutkowski
- Faculty of Social Sciences, School of Psychology, University of Ottawa, Ottawa, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Christine Yang
- Department of Physical Medicine and Rehabilitation, Elisabeth Bruyère Hospital, Ottawa, Canada
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24
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Hoang MT, Kåreholt I, von Euler M, Jönsson L, von Koch L, Eriksdotter M, Garcia-Ptacek S. Costs of Inpatient Rehabilitation for Ischemic Stroke in Patients with Dementia: A Cohort Swedish Register-Based Study. J Alzheimers Dis 2021; 73:967-979. [PMID: 31884465 PMCID: PMC7081100 DOI: 10.3233/jad-190749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Stroke and dementia are frequent comorbidities. Dementia possibly increases total costs of stroke care, especially cost of institutionalization and informal medical care. However, stroke rehabilitation costs in dementia patients are understudied. OBJECTIVE To estimate inpatient stroke rehabilitation costs for Swedish dementia patients in comparison with non-dementia patients. METHODS A longitudinal cohort study with linked data from the Swedish Dementia Register and the Swedish Stroke Register was conducted. Patients diagnosed with dementia who suffered a first ischemic stroke between 2010 and 2014 (n = 138) were compared with non-dementia patients (n = 935). Cost analyses were conducted from a Swedish health care perspective. The difference of rehabilitation costs between the two groups was examined via simple linear regression (before and after matching by propensity scores of dementia) and multiple linear regression. RESULTS Mean inpatient rehabilitation costs for dementia and non-dementia patients were SEK 103,693/$11,932 and SEK 130,057/$14,966, respectively (median SEK 92,183/$10,607 and SEK 106,365/$12,239) (p = 0.001). Dementia patients suffered from more comorbidities and experienced lower functioning, compared to non-dementia patients. The inpatient rehabilitation cost for patients with known dementia was 0.84 times the cost in non-dementia individuals. CONCLUSION Dementia diagnosis was significantly associated with lower inpatient stroke rehabilitation costs. This might be explained by physicians' beliefs on the limited effectiveness of rehabilitation in dementia patients. Further research on cost-effectiveness of stroke rehabilitation and patients' satisfaction with stroke rehabilitation is necessary.
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Affiliation(s)
- Minh Tuan Hoang
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Ingemar Kåreholt
- Aging Research Center (ARC), Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Institute of Gerontology, School of Health and Welfare, Aging Research Network - Jönköping (ARN-J), Jönköping University, Jönköping, Sweden
| | - Mia von Euler
- Karolinska Institutet, Departments of Clinical Science and Education, Södersjukhuset, and Medicine, Solna, Stockholm, Sweden.,Department of Clinical Pharmacology, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Linus Jönsson
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Lena von Koch
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Eriksdotter
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Aging Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Garcia-Ptacek
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Section for Neurology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
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25
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Tyagi S, Koh GCH, Luo N, Tan KB, Hoenig H, Matchar DB, Yoong J, Chan A, Lee KE, Venketasubramanian N, Menon E, Chan KM, De Silva DA, Yap P, Tan BY, Chew E, Young SH, Ng YS, Tu TM, Ang YH, Kong KH, Singh R, Merchant RA, Chang HM, Yeo TT, Ning C, Cheong A, Ng YL, Tan CS. Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore. BMC FAMILY PRACTICE 2021; 22:74. [PMID: 33853544 PMCID: PMC8048235 DOI: 10.1186/s12875-021-01405-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/22/2021] [Indexed: 11/10/2022]
Abstract
Background Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke. Method Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0–3 months (early) and 4–12 months (late) post-stroke. Results For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits. Conclusion We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01405-z.
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Affiliation(s)
- Shilpa Tyagi
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore.
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - Kelvin Bryan Tan
- Policy Research & Economics Office, Ministry of Health, Singapore, Singapore
| | - Helen Hoenig
- Physical Medicine and Rehabilitation Service, Durham VA Medical Centre, Durham, NC, USA
| | - David B Matchar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Joanne Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - Angelique Chan
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Kim En Lee
- Lee Kim En Neurology Pte Ltd, Singapore, Singapore
| | | | - Edward Menon
- St. Andrew's Community Hospital, Singapore, Singapore
| | | | - Deidre Anne De Silva
- National Neuroscience Institute, Singapore General Hospital Campus, Singapore, Singapore
| | - Philip Yap
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | | | - Effie Chew
- Department of Rehabilitation Medicine, National University Hospital, Singapore, Singapore
| | - Sherry H Young
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore, Singapore
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Neurology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yan Hoon Ang
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Keng He Kong
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Rajinder Singh
- Department of Neurology, National Neuroscience Institute, Neurology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Reshma A Merchant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui Meng Chang
- National Neuroscience Institute, Singapore General Hospital Campus, Singapore, Singapore
| | - Tseng Tsai Yeo
- Department of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Chou Ning
- Department of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Angela Cheong
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - Yu Li Ng
- Policy Research & Economics Office, Ministry of Health, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
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A Prospective Economic Evaluation of Rapid Endovascular Therapy for Acute Ischemic Stroke. Can J Neurol Sci 2021; 48:791-798. [PMID: 33431075 DOI: 10.1017/cjn.2021.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient's lifetime. METHODS Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis. RESULTS The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (-$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care. CONCLUSIONS Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient's lifetime.Clinical Trial Registration: NCT01778335.
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Minet LR, Peterson E, von Koch L, Ytterberg C. Healthcare Utilization After Stroke: A 1-Year Prospective Study. J Am Med Dir Assoc 2020; 21:1684-1688. [DOI: 10.1016/j.jamda.2020.04.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 02/25/2020] [Accepted: 04/28/2020] [Indexed: 11/15/2022]
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New View on the Canadian Burden of Stroke: Productivity Loss in Adults Who Return to Work. Can J Neurol Sci 2020; 48:421-424. [PMID: 32878653 DOI: 10.1017/cjn.2020.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
An often overlooked facet of the indirect costs affecting working-age stroke survivors is the challenges experienced by those who return to work. This study quantified the productivity loss in 20 stroke survivors who returned to work which amounted to 53.0 missed work days and an average indirect cost of $10,298 (CAD) in the year following a stroke. Despite the quantified productivity loss, 75% of patients reported no significant disability and a high proportion were self-employed compared to the Canadian population, indicating that socioeconomic factors may be driving patient decisions to return to work.
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Freitas-Andrade M, Raman-Nair J, Lacoste B. Structural and Functional Remodeling of the Brain Vasculature Following Stroke. Front Physiol 2020; 11:948. [PMID: 32848875 PMCID: PMC7433746 DOI: 10.3389/fphys.2020.00948] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022] Open
Abstract
Maintenance of cerebral blood vessel integrity and regulation of cerebral blood flow ensure proper brain function. The adult human brain represents only a small portion of the body mass, yet about a quarter of the cardiac output is dedicated to energy consumption by brain cells at rest. Due to a low capacity to store energy, brain health is heavily reliant on a steady supply of oxygen and nutrients from the bloodstream, and is thus particularly vulnerable to stroke. Stroke is a leading cause of disability and mortality worldwide. By transiently or permanently limiting tissue perfusion, stroke alters vascular integrity and function, compromising brain homeostasis and leading to widespread consequences from early-onset motor deficits to long-term cognitive decline. While numerous lines of investigation have been undertaken to develop new pharmacological therapies for stroke, only few advances have been made and most clinical trials have failed. Overall, our understanding of the acute and chronic vascular responses to stroke is insufficient, yet a better comprehension of cerebrovascular remodeling following stroke is an essential prerequisite for developing novel therapeutic options. In this review, we present a comprehensive update on post-stroke cerebrovascular remodeling, an important and growing field in neuroscience, by discussing cellular and molecular mechanisms involved, sex differences, limitations of preclinical research design and future directions.
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Affiliation(s)
| | - Joanna Raman-Nair
- Neuroscience Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Baptiste Lacoste
- Neuroscience Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Brain and Mind Research Institute, University of Ottawa, Ottawa, ON, Canada
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Daou BJ, Yost ML, Syrjamaki JD, Fearer KJ, Koduri S, Burke JF, Gemmete JJ, Chaudhary N, Thompson BG, Pandey AS. Drivers of variation in 90-day episode payments after mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg 2020; 13:519-523. [PMID: 32737204 DOI: 10.1136/neurintsurg-2020-016389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although mechanical thrombectomy for acute ischemic stroke from a large vessel occlusion is now the standard of care, little is known about cost variations in stroke patients following thrombectomy and factors that influence these variations. METHODS We evaluated claims data for 2016 to 2018 for thrombectomy-performing hospitals within Michigan through a registry that includes detailed episode payment information for both Medicare and privately insured patients. We aimed to analyze price-standardized and risk-adjusted 90-day episode payments in patients who underwent thrombectomy. Hospitals were grouped into three payment terciles for comparison. Statistical analysis was carried out using unpaired t-test, Chi-square, and ANOVA tests. RESULTS 1076 thrombectomy cases treated at 16 centers were analyzed. The average 90-day episode payment by hospital ranged from $53 046 to $81,767, with a mean of $65 357. A $20 467 difference (35.1%) existed between the high and low payment hospital terciles (P<0.0001), highlighting a significant payment variation across hospital terciles. The primary drivers of payment variation were related to post-discharge care which accounted for 38% of the payment variation (P=0.0058, inter-tercile range $11,977-$19,703) and readmissions accounting for 26% (P=0.016, inter-tercile range $3,315-$7,992). This was followed by professional payments representing 20% of the variation (P<0.0001, inter-tercile range $7525-$9,922), while index hospitalization payment was responsible for only 16% of the 90-day episode payment variation (P=0.10, inter-tercile range $35,432-$41,099). CONCLUSIONS There is a wide variation in 90-day episode payments for patients undergoing mechanical thrombectomy across centers. The main drivers of payment variation are related to differences in post-discharge care and readmissions.
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Affiliation(s)
- Badih J Daou
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica L Yost
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Kelsey J Fearer
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - James F Burke
- Neurology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Radiology and Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | | | - Aditya S Pandey
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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Signal NEJ, McLaren R, Rashid U, Vandal A, King M, Almesfer F, Henderson J, Taylor D. Haptic Nudges Increase Affected Upper Limb Movement During Inpatient Stroke Rehabilitation: Multiple-Period Randomized Crossover Study. JMIR Mhealth Uhealth 2020; 8:e17036. [PMID: 32723718 PMCID: PMC7424469 DOI: 10.2196/17036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/15/2020] [Accepted: 05/13/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND As many as 80% of stroke survivors experience upper limb (UL) disability. The strong relationships between disability, lost productivity, and ongoing health care costs mean reducing disability after stroke is critical at both individual and society levels. Unfortunately, the amount of UL-focused rehabilitation received by people with stroke is extremely low. Activity monitoring and promotion using wearable devices offer a potential technology-based solution to address this gap. Commonly, wearable devices are used to deliver a haptic nudge to the wearer with the aim of promoting a particular behavior. However, little is known about the effectiveness of haptic nudging in promoting behaviors in patient populations. OBJECTIVE This study aimed to estimate the effect of haptic nudging delivered via a wrist-worn wearable device on UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. METHODS A multiple-period randomized crossover design was used to measure the association of UL movement with the occurrence of haptic nudge reminders to move the affected UL in 20 people with stroke undertaking inpatient rehabilitation. UL movement was observed and classified using movement taxonomy across 72 one-minute observation periods from 7:00 AM to 7:00 PM on a single weekday. On 36 occasions, a haptic nudge to move the affected UL was provided just before the observation period. On the other 36 occasions, no haptic nudge was given. The timing of the haptic nudge was randomized across the observation period for each participant. Statistical analysis was performed using mixed logistic regression. The effect of a haptic nudge was evaluated from the intention-to-treat dataset as the ratio of the odds of affected UL movement during the observation period following a "Planned Nudge" to the odds of affected limb movement during the observation period following "No Nudge." RESULTS The primary intention-to-treat analysis showed the odds ratio (OR) of affected UL movement following a haptic nudge was 1.44 (95% CI 1.28-1.63, P<.001). The secondary analysis revealed an increased odds of affected UL movement following a Planned Nudge was predominantly due to increased odds of spontaneous affected UL movement (OR 2.03, 95% CI 1.65-2.51, P<.001) rather than affected UL movement in conjunction with unaffected UL movement (OR 1.13, 95% CI 0.99-1.29, P=.07). CONCLUSIONS Haptic nudging delivered via a wrist-worn wearable device increases affected UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. The promoted movement appears to be specific to the instructions given. TRIAL REGISTRATION Australia New Zealand Clinical Trials Registry 12616000654459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370687&isReview=true.
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Affiliation(s)
| | - Ruth McLaren
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Usman Rashid
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Alain Vandal
- Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Marcus King
- Callaghan Innovation, Christchurch, New Zealand
| | | | - Jeanette Henderson
- Assessment, Treatment and Rehabilitation Department, Waitakere Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Denise Taylor
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
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Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G. Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. Health Technol Assess 2020; 24:1-184. [PMID: 31944175 PMCID: PMC6983910 DOI: 10.3310/hta24050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants. OBJECTIVES The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring. DATA SOURCES MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018. REVIEW METHODS A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment. RESULTS One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX. LIMITATIONS The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution. CONCLUSIONS All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42018109216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven J Edwards
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | | | - Tracey Jhita
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Kayleigh Kew
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Peter Cain
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Gemma Marceniuk
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
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Sharma M, Hart RG, Connolly SJ, Bosch J, Shestakovska O, Ng KKH, Catanese L, Keltai K, Aboyans V, Alings M, Ha JW, Varigos J, Tonkin A, O'Donnell M, Bhatt DL, Fox K, Maggioni A, Berkowitz SD, Bruns NC, Yusuf S, Eikelboom JW. Stroke Outcomes in the COMPASS Trial. Circulation 2019; 139:1134-1145. [PMID: 30667279 DOI: 10.1161/circulationaha.118.035864] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Strokes were significantly reduced by the combination of rivaroxaban plus aspirin in comparison with aspirin in the COMPASS trial (Cardiovascular Outcomes for People Using Anticoagulation Strategies). We present detailed analyses of stroke by type, predictors, and antithrombotic effects in key subgroups. METHODS Participants had stable coronary artery or peripheral artery disease and were randomly assigned to receive aspirin 100 mg once daily (n=9126), rivaroxaban 5 mg twice daily (n=9117), or rivaroxaban 2.5 mg twice daily plus aspirin (n=9152). Patients who required anticoagulation or had a stroke within 1 month, previous lacunar stroke, or intracerebral hemorrhage were excluded. RESULTS During a mean follow-up of 23 months, fewer patients had strokes in the rivaroxaban plus aspirin group than in the aspirin group (83 [0.9% per year] versus 142 [1.6% per year]; hazard ratio [HR], 0.58; 95% CI, 0.44-0.76; P<0.0001). Ischemic/uncertain strokes were reduced by nearly half (68 [0.7% per year] versus 132 [1.4% per year]; HR, 0.51; 95% CI, 0.38-0.68; P<0.0001) by the combination in comparison with aspirin. No significant difference was noted in the occurrence of stroke in the rivaroxaban alone group in comparison with aspirin: annualized rate of 0.7% (HR, 0.82; 95% CI, 0.65-1.05). The occurrence of fatal and disabling stroke (modified Rankin Scale, 3-6) was decreased by the combination (32 [0.3% per year] versus 55 [0.6% per year]; HR, 0.58; 95% CI, 0.37-0.89; P=0.01). Independent predictors of stroke were prior stroke, hypertension, systolic blood pressure at baseline, age, diabetes mellitus, and Asian ethnicity. Prior stroke was the strongest predictor of incident stroke (HR, 3.63; 95% CI, 2.65-4.97; P<0.0001) and was associated with a 3.4% per year rate of stroke recurrence on aspirin. The effect of the combination in comparison with aspirin was consistent across subgroups with high stroke risk, including those with prior stroke. CONCLUSIONS Low-dose rivaroxaban plus aspirin is an important new antithrombotic option for primary and secondary stroke prevention in patients with clinical atherosclerosis. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01776424.
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Affiliation(s)
- Mukul Sharma
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | - Robert G Hart
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | - Stuart J Connolly
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | - Jackie Bosch
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | - Olga Shestakovska
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | - Kelvin K H Ng
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | - Luciana Catanese
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | | | | | - Marco Alings
- Amphia Ziekenhuis and Werkgroep Cardiologische centra Nederland, Utrecht, Nederlands (M.A.)
| | - Jong-Won Ha
- Yonsei University College of Medicine, Seoul, Korea (J.-W.H.)
| | - John Varigos
- Monash University, Clayton, Melbourne, Australia (J.V., A.T.)
| | - Andrew Tonkin
- Monash University, Clayton, Melbourne, Australia (J.V., A.T.)
| | | | | | - Keith Fox
- University of Edinburgh, Scotland (K.F.)
| | - Aldo Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy (A.M.)
| | | | | | - Salim Yusuf
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
| | - John W Eikelboom
- McMaster University/Population Health Research Institute, Hamilton, Canada (M.S., R.G.H., S.J.C., J.B., O.S., K.K.H.N., L.C., S.Y., J.W.E.)
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Rauch B. Patient and care-giver productivity loss and indirect costs associated with cardiovascular events in Europe: A wake-up call for primary prevention. Eur J Prev Cardiol 2019; 26:1556-1558. [DOI: 10.1177/2047487319856718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Tarride JE, Luong T, Goodall G, Burke N, Blackhouse G. A Canadian cost-effectiveness analysis of SAPIEN 3 transcatheter aortic valve implantation compared with surgery, in intermediate and high-risk severe aortic stenosis patients. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:477-486. [PMID: 31551658 PMCID: PMC6677373 DOI: 10.2147/ceor.s208107] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/16/2019] [Indexed: 12/31/2022] Open
Abstract
Background and objectives: The treatment of severe aortic stenosis requires replacement of the defective native valve. Traditionally, this has been done via surgery, but in the last 10 years, transcatheter techniques have emerged. Transcatheter aortic valve implantation (TAVI) is a less invasive option compared to surgical aortic valve replacement (SAVR), and this study evaluates the cost-effectiveness of TAVI versus SAVR in intermediate and high surgical risk patients in Canada. Methods: A Markov model was used to project the costs and quality-adjusted life years (QALYs) gained for TAVI using the SAPIEN 3 valve and SAVR over a 15-year time horizon. The PARTNER I and II studies were used to populate the model in terms of survival, clinical event rates and quality of life over time. The costs of TAVI with SAPIEN 3 and SAVR as well as the costs associated with events included in the model were derived from Canadian administrative and literature data. Costs were expressed in 2018 Canadian dollars and all future costs and QALYs were discounted at a rate of 1.5% annually. Probabilistic and one-way sensitivity analyses were conducted. Results: The incremental cost-effectiveness ratios of TAVI using the SAPIEN 3 valve compared to surgery were $28,154 per QALY gained in intermediate risk patients and $17,237 per QALY gained in high-risk patients. The results of the probabilistic analyses indicated that at willingness-to-pay threshold of $50,000 per QALY gained, the probability of TAVI to be cost-effective was greater than 0.9 in both intermediate-risk and high-risk patients. Sensitivity analyses showed the results were most sensitive to the time horizon used. Conclusion: TAVI using the SAPIEN 3 valve is highly likely to be cost-effective in Canadian patients with severe aortic stenosis who are at intermediate and high surgical risk.
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Affiliation(s)
- Jean-Eric Tarride
- McMaster Chair in Health Technology Management, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton ON, Canada.,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Trinh Luong
- Edwards Lifesciences (Canada) Inc ., Mississauga, ON, Canada
| | | | - Natasha Burke
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Gordon Blackhouse
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton ON, Canada.,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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Selection of anterior circulation acute stroke patients for mechanical thrombectomy. J Neurol 2019; 266:2620-2628. [PMID: 31270665 DOI: 10.1007/s00415-019-09454-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/07/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The use of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) patients has increased with a parallel burden in procedural costs. We tested whether a new prognostic score could identify patients who are unlikely to benefit from MT. METHODS Patients from our endovascular stroke registry were assessed for imaging and clinical outcome measures and randomly divided into two subsets for derivation and validation. We created a new prognostic score based on clinical and radiological prognostic factors of poor outcome (mRS score ≥ 3) from the derivation cohort. Receiver operating characteristics curve analysis was used to assess the discrimination ability of the score. The score was then validated and compared to the MR PREDICTS score. RESULTS The derivation/validation included 270/116 patients, respectively. After multivariate logistic regression analysis, pre stroke mRS, age, admission glycaemia, admission NIHSS, collateral flow, Clot Burden Score, Alberta Stroke Program Early CT score were used to create a new prognostic scoring system called Tor Vergata Stroke Score (TVSS). TVSS revealed a good prognostic accuracy with an AUC of 0.825 [95% CI 0.77-0.88] in the derivation cohort and an AUC of 0.820 [95% CI 0.74-0.90] in the validation cohort. When compared to the MR PREDICTS in the validation cohort, TVSS demonstrated higher prediction ability which was, however, not statistically significant (0.80 vs 0.78; P = 0.26). CONCLUSIONS TVSS is a reliable tool for selection of AIS candidates for MT and optimization of transfer to comprehensive stroke centers.
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Al Hamarneh YN, Johnston K, Marra CA, Tsuyuki RT. Pharmacist prescribing and care improves cardiovascular risk, but is it cost-effective? A cost-effectiveness analysis of the R xEACH study. Can Pharm J (Ott) 2019; 152:257-266. [PMID: 31320960 PMCID: PMC6610508 DOI: 10.1177/1715163519851822] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The RxEACH randomized trial demonstrated that community pharmacist prescribing and care reduced the risk for cardiovascular (CV) events by 21% compared to usual care. OBJECTIVE To evaluate the economic impact of pharmacist prescribing and care for CV risk reduction in a Canadian setting. METHODS A Markov cost-effectiveness model was developed to extrapolate potential differences in long-term CV outcomes, using different risk assessment equations. The mean change in CV risk for the 2 groups of RxEACH was extrapolated over 30 years, with costs and health outcomes discounted at 1.5% per year. The model incorporated health outcomes, costs and quality of life to estimate overall cost-effectiveness. It was assumed that the intervention would be 50% effective after 10 years. Individual-level results were scaled up to population level based on published statistics (29.2% of Canadian adults are at high risk for CV events). Costs considered included direct medical costs as well as the costs associated with implementing the pharmacist intervention. Uncertainty was explored via probabilistic sensitivity analysis. RESULTS It is estimated that the Canadian health care system would save more than $4.4 billion over 30 years if the pharmacist intervention were delivered to 15% of the eligible population. Pharmacist care would be associated with a gain of 576,689 quality-adjusted life years and avoid more than 8.9 million CV events. The intervention is economically dominant (i.e., it is both more effective and reduces costs when compared to usual care). CONCLUSION Across a range of 1-way and probabilistic sensitivity analyses of key parameters and assumptions, pharmacist prescribing and care are both more effective and cost-saving compared to usual care. Canadians need and deserve such care.
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Affiliation(s)
| | - Karissa Johnston
- Faculty of Medicine and Dentistry (Al Hamarneh,
Tsuyuki), University of Alberta, Edmonton, Alberta
- Broadstreet Health Economics & Outcomes Research
(Johnston), Vancouver, British Columbia
- the School of Pharmacy (Marra), University of Otago,
Dunedin, New Zealand
| | - Carlo A. Marra
- Faculty of Medicine and Dentistry (Al Hamarneh,
Tsuyuki), University of Alberta, Edmonton, Alberta
- Broadstreet Health Economics & Outcomes Research
(Johnston), Vancouver, British Columbia
- the School of Pharmacy (Marra), University of Otago,
Dunedin, New Zealand
| | - Ross T. Tsuyuki
- Faculty of Medicine and Dentistry (Al Hamarneh,
Tsuyuki), University of Alberta, Edmonton, Alberta
- Broadstreet Health Economics & Outcomes Research
(Johnston), Vancouver, British Columbia
- the School of Pharmacy (Marra), University of Otago,
Dunedin, New Zealand
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Janzen S, Mirkowski M, McIntyre A, Mehta S, Iruthayarajah J, Teasell R. Referral patterns of stroke rehabilitation inpatients to a model system of outpatient services in Ontario, Canada: a 7-year retrospective analysis. BMC Health Serv Res 2019; 19:399. [PMID: 31221167 PMCID: PMC6585046 DOI: 10.1186/s12913-019-4236-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/10/2019] [Indexed: 11/20/2022] Open
Abstract
Background While several studies have tracked the care paths of patients in the early phases of stroke recovery, studies examining the transition from inpatient to outpatient rehabilitation are lacking. Examining this transition allows for improved understanding and refinement of the process whereby patients are referred and admitted to programs. The objective of this study was to examine the referral patterns of stroke rehabilitation inpatients to outpatient stroke therapy services, their demographics, and clinical profile. Methods This study examined patients who: (1) were admitted to an inpatient stroke rehabilitation unit between January 1, 2009 and March 1, 2016, (2) had a stroke diagnosis, (3) had an inpatient length of stay of > 1 day, and (4) lived within the geographical boundaries of the South West Local Health Integration Network which allowed them access to both hospital-based and home-based stroke rehabilitation outpatient programs. Patient data was collected from the National Rehabilitation Reporting System, as well as three hospital outpatient administrative databases. These databases were cross-referenced to determine each patient’s pathway. Those referred to an outpatient therapy program, and those who attended the outpatient programs, were compared to those who were not, and did not, respectively. Results 1497 inpatients were included in the analysis. Upon discharge, 1037 (69.3%) of patients had an outpatient clinic, follow-up appointment scheduled; of those, 902 (87.0%) patients attended at least one outpatient clinic visit. 891 (59.5%) were referred to one of the interdisciplinary outpatient stroke rehabilitation programs; of those, an outpatient therapy program was attended by 80.9% of patients (n = 721). Of those receiving outpatient therapy services, the number of patients attending the in-hospital versus home-based program were equal, 360 and 361 individuals, respectively. Conclusion This study allows for a better understanding of the transition between inpatient and outpatient stroke care. There is a paucity of this type of information in stroke rehabilitation literature to date. This study acts as a starting point in improving rehabilitation planning across the continuum of care.
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Affiliation(s)
- Shannon Janzen
- Parkwood Institute Research, Lawson Health Research Institute, Parkwood Institute, London, Ontario, Canada
| | - Magdalena Mirkowski
- Parkwood Institute Research, Lawson Health Research Institute, Parkwood Institute, London, Ontario, Canada
| | - Amanda McIntyre
- Parkwood Institute Research, Lawson Health Research Institute, Parkwood Institute, London, Ontario, Canada
| | - Swati Mehta
- Parkwood Institute Research, Lawson Health Research Institute, Parkwood Institute, London, Ontario, Canada
| | - Jerome Iruthayarajah
- Parkwood Institute Research, Lawson Health Research Institute, Parkwood Institute, London, Ontario, Canada
| | - Robert Teasell
- Parkwood Institute Research, Lawson Health Research Institute, Parkwood Institute, London, Ontario, Canada. .,Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. .,St. Joseph's Health Care London, Physical Medicine and Rehabilitation, Parkwood Institute, London, Ontario, Canada.
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Increased Sensorimotor Cortex Activation With Decreased Motor Performance During Functional Upper Extremity Tasks Poststroke. J Neurol Phys Ther 2019; 43:141-150. [PMID: 31136449 DOI: 10.1097/npt.0000000000000277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Current literature has focused on identifying neuroplastic changes associated with stroke through tasks and in positions that are not representative of functional rehabilitation. Emerging technologies such as functional near-infrared spectroscopy (fNIRS) provide new methods of expanding the area of neuroplasticity within rehabilitation. This study determined the differences in sensorimotor cortex activation during unrestrained reaching and gripping after stroke. METHODS Eleven individuals with chronic stroke and 11 neurologically healthy individuals completed reaching and gripping tasks under 3 conditions using their (1) stronger, (2) weaker, and (3) both arms together. Performance and sensorimotor cortex activation using fNIRS were collected. Group and arm differences were calculated using mixed analysis of covariance (covariate: age). Pairwise comparisons were used for post hoc analyses. Partial Pearson correlations between performance and activation were assessed for each task, group, and hemisphere. RESULTS Larger sensorimotor activations in the ipsilesional hemisphere were found for the stroke compared with healthy group for reaching and gripping conditions despite poorer performance. Significant correlations were observed between gripping performance (with the weaker arm and both arms simultaneously) and sensorimotor activation for the stroke group only. DISCUSSION AND CONCLUSIONS Stroke leads to significantly larger sensorimotor activation during functional reaching and gripping despite poorer performance. This may indicate an increased sense of effort, decreased efficiency, or increased difficulty after stroke. fNIRS can be used for assessing differences in brain activation during movements in functional positions after stroke. This can be a promising tool for investigating possible neuroplastic changes associated with functional rehabilitation interventions in the stroke population.Video Abstract available for more insights from the authors (see Video Abstract, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A269).
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Jaber AF, Sabata D, Radel JD. Self-perceived occupational performance of community-dwelling adults living with stroke. The Canadian Journal of Occupational Therapy 2019; 85:378-385. [DOI: 10.1177/0008417418821704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Stroke has long-term consequences for functional performance of daily activities. Evaluating client-perceived occupational performance provides insight for designing stroke-specific programs supporting home and community participation. Purpose. This study describes the personal characteristics and self-perceived occupational performance in community-dwelling adults with stroke. Method. A retrospective chart review was undertaken of 25 stroke survivors who sought services at a community-based centre. The outcome measures were the Canadian Occupational Performance Measure (COPM) to evaluate self-perceived occupational performance and the Montreal Cognitive Assessment (MoCA) to screen for cognitive impairment. The analysis used descriptive statistics. Findings. Mean participant age was 64 years, and most participants were Caucasian males (72%). The mean cognitive function score was 22.1 on MoCA, and the mean COPM performance and satisfaction subscores were 4.1 and 3.9, respectively. The top three challenging daily activities were driving, seeking employment, and functional mobility. Implications. Stroke-specific community programs should emphasize the diverse performance concerns important to stroke survivors.
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Sauvé-Schenk KML, Egan MY, Dubouloz-Wilner CJ, Kristjansson E. Influence of low income on return to participation following stroke. Disabil Rehabil 2019; 42:2726-2734. [PMID: 30763524 DOI: 10.1080/09638288.2019.1570355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Low income is known to influence participation post stroke, but the process by which this occurs is poorly understood.Methods: A qualitative multiple case study approach, focusing on the experience of returning to participation in personal projects among eight low-income francophone stroke survivors living in eastern Ontario (Canada). Data included semi-structured interviews with the stroke survivors and with their care partners, participant observations, assessment measures, and chart reviews.Results: Healthcare professionals inconsistently gave the stroke survivors needed information and assistance to access entitlements during discharge planning. Income support programs were difficult to access and once obtained, were not completely adequate to support essential necessities (food, medication) in addition to other goods and services related to valued activities. Housing was an important monthly expense that limited available monies for personal projects. Only in instances where participants were assisted with housing by informal networks were there adequate funds to pursue personal projects.Conclusion: This case study demonstrated that even in a universal healthcare system, post-stroke participation for those with low incomes was severely restricted. Changes at the clinical level and at the public policy level could facilitate participation.Implications for rehabilitationIncome influenced the experience of return to participation for the low-income stroke survivors by limiting their ability to afford housing, goods, and services.The macro environment, which regulates the healthcare and social service systems, was the strongest influence on return to participation for low income stroke survivors.Findings point to actions at the clinical and policy levels to help address this inequity.
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Affiliation(s)
| | - Mary Y Egan
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.,Bruyère; Research Institute, Ottawa, ON, Canada
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The prevalence of disability among people with cancer, cardiovascular disease, chronic respiratory disease and/or diabetes: a systematic review. INT J EVID-BASED HEA 2019; 16:154-166. [PMID: 29608458 DOI: 10.1097/xeb.0000000000000138] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD), cancer, diabetes and chronic respiratory disease are noncommunicable diseases (NCDs) that cause extensive social and economic burden worldwide, particularly in low-income and middle-income countries. There is growing recognition of the importance of the disabilities that individuals experience as a consequence of these NCDs. OBJECTIVES This systematic review examined the prevalence of disabilities associated with cancer, CVD, chronic respiratory disease and diabetes. METHODS A comprehensive literature search was conducted in PubMed, CINAHL, Embase, Web of Science, PsycINFO, CIRRIE, WHO database, LILACS and AIM. Studies were included if their samples were representative of people with at least one of these four conditions and if prevalence estimates of disability were provided. As random sampling was not feasible in the majority of cases, studies were included where they offered evidence that their sample was representative of the general population being investigated. RESULTS A total of 105 articles were included in the review. Most studies were conducted in high-income countries. The prevalence of difficulties with activities of daily living (i.e. eating, bathing, dressing) was reported to be 10.4-34.5% amongst cancer survivors, 21.1-64.1% in those with CVD, 7.4-49.8% in those with chronic respiratory disease and 12.2-54.5% for those with diabetes. The prevalence of a range of other physical, cognitive and psychological impairments (systemic or structural) was additionally described for each disease. CONCLUSION Substantial proportions of people with cancer, CVD, chronic respiratory disease or diabetes experience some form of disability - although there was great variance in prevalence and definitions. The findings of this review support the evidence base of global impact associated with NCD, indicate frequency measures for specific disabilities and inabilities associated with each NCD and provide direction for future systematic reviews. WHAT IS KNOWN ABOUT THE TOPIC WHAT THIS ARTICLE ADDS.
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Tyagi S, Koh GCH, Nan L, Tan KB, Hoenig H, Matchar DB, Yoong J, Finkelstein EA, Lee KE, Venketasubramanian N, Menon E, Chan KM, De Silva DA, Yap P, Tan BY, Chew E, Young SH, Ng YS, Tu TM, Ang YH, Kong KH, Singh R, Merchant RA, Chang HM, Yeo TT, Ning C, Cheong A, Ng YL, Tan CS. Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors. BMC Health Serv Res 2018; 18:881. [PMID: 30466417 PMCID: PMC6251229 DOI: 10.1186/s12913-018-3696-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 11/08/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors. METHODS Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke. RESULTS Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter. CONCLUSION Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.
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Affiliation(s)
- Shilpa Tyagi
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549 Singapore
| | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549 Singapore
| | - Luo Nan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549 Singapore
| | - Kelvin Bryan Tan
- Policy Research & Economics Office, Ministry of Health, Singapore, Singapore
| | - Helen Hoenig
- Physical Medicine and Rehabilitation Service, Durham VA Medical Centre, Durham, USA
| | - David B. Matchar
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Joanne Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549 Singapore
| | - Eric A. Finkelstein
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Kim En Lee
- Lee Kim En Neurology Pte Ltd, Singapore, Singapore
| | | | - Edward Menon
- St. Andrew’s Community Hospital, Singapore, Singapore
| | | | - Deidre Anne De Silva
- National Neuroscience Institute, Singapore General Hospital campus, Singapore, Singapore
| | - Philip Yap
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | | | - Effie Chew
- Department of Rehabilitation Medicine, National University Hospital, Singapore, Singapore
| | - Sherry H. Young
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore, Singapore
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Neurology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yan Hoon Ang
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Keng Hee Kong
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Rajinder Singh
- Department of Neurology, National Neuroscience Institute, Neurology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Reshma A. Merchant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui Meng Chang
- National Neuroscience Institute, Singapore General Hospital campus, Singapore, Singapore
| | - Tseng Tsai Yeo
- Department of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Chou Ning
- Department of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Angela Cheong
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549 Singapore
| | - Yu Li Ng
- Policy Research & Economics Office, Ministry of Health, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549 Singapore
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Larivière S, Vos de Wael R, Paquola C, Hong SJ, Mišić B, Bernasconi N, Bernasconi A, Bonilha L, Bernhardt BC. Microstructure-Informed Connectomics: Enriching Large-Scale Descriptions of Healthy and Diseased Brains. Brain Connect 2018; 9:113-127. [PMID: 30079754 DOI: 10.1089/brain.2018.0587] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Rapid advances in neuroimaging and network science have produced powerful tools and measures to appreciate human brain organization at multiple spatial and temporal scales. It is now possible to obtain increasingly meaningful representations of whole-brain structural and functional brain networks and to formally assess macroscale principles of network topology. In addition to its utility in characterizing healthy brain organization, individual variability, and life span-related changes, there is high promise of network neuroscience for the conceptualization and, ultimately, management of brain disorders. In the current review, we argue for a science of the human brain that, while strongly embracing macroscale connectomics, also recommends awareness of brain properties derived from meso- and microscale resolutions. Such features include MRI markers of tissue microstructure, local functional properties, as well as information from nonimaging domains, including cellular, genetic, or chemical data. Integrating these measures with connectome models promises to better define the individual elements that constitute large-scale networks, and clarify the notion of connection strength among them. By enriching the description of large-scale networks, this approach may improve our understanding of fundamental principles of healthy brain organization. Notably, it may also better define the substrate of prevalent brain disorders, including stroke, autism, as well as drug-resistant epilepsies that are each characterized by intriguing interactions between local anomalies and network-level perturbations.
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Affiliation(s)
- Sara Larivière
- 1 Multimodal Imaging and Connectome Analysis Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Reinder Vos de Wael
- 1 Multimodal Imaging and Connectome Analysis Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Casey Paquola
- 1 Multimodal Imaging and Connectome Analysis Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Seok-Jun Hong
- 1 Multimodal Imaging and Connectome Analysis Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada.,2 NeuroImaging of Epilepsy Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Bratislav Mišić
- 3 Network Neuroscience Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Neda Bernasconi
- 2 NeuroImaging of Epilepsy Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Andrea Bernasconi
- 2 NeuroImaging of Epilepsy Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Leonardo Bonilha
- 4 Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Boris C Bernhardt
- 1 Multimodal Imaging and Connectome Analysis Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
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Yan C, Zheng Y, Hill MD, Mann B, Jeerakathil T, Kamal N, Amlani S, Chuck AW. Health Technology Optimization Analysis: Conceptual Approach and Illustrative Application. MDM Policy Pract 2018; 3:2381468318774804. [PMID: 30288446 PMCID: PMC6157433 DOI: 10.1177/2381468318774804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/06/2018] [Indexed: 01/19/2023] Open
Abstract
We present a conceptual approach to determine the optimal solution to delivering
a health technology, consistent with the objective of maximizing patient
outcomes subject to resources available to a publicly funded health system. The
article addresses two key policy questions: 1) adding system values through
appropriate planning of health services delivery and 2) considering the tradeoff
between patient outcomes and costs to the health system through appropriate use
of health technologies for conditions with time-dependent treatment outcomes. We
develop a health technology optimization framework that considers geographical
variation and searches for the best delivery method through a pairwise
comparison of all possible strategies, factoring in controlled variables
including disease epidemiology, time or distance to hospitals, available medical
services, treatment eligibility, treatment efficacy, and costs. Taking
variations of these factors into account would help support a more efficient
allocation of health resources. Drawing identified strategies together then
creates a map of optimal strategies. We apply the proposed method to a
policy-relevant health technology assessment of endovascular therapy (EVT) for
treating acute ischemic stroke. The best strategy for providing EVT relies on
the geographical location of stroke onset and the decision maker’s preference
for either patient outcomes or economic efficiency. The proposed method produced
an optimization map showing the optimal strategy for EVT delivery, which
maximizes patient outcomes while minimizing health system costs. In the
illustrative case study, there were no tradeoffs between health outcomes and
costs, meaning that the delivery strategies that were clinically optimal for
patients were also the most cost-effective. In conclusion, the health technology
optimization approach is a useful tool for informing implementation decisions
and coordinating the delivery of complex health services such as EVT.
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Affiliation(s)
- Charles Yan
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Yufei Zheng
- Institute of Health Economics, Edmonton, Alberta, Canada
| | | | - Balraj Mann
- Cardiovascular Health & Stroke SCN, Alberta Health Services, Alberta, Canada
| | | | | | - Shy Amlani
- Alberta Health Services, Edmonton, Alberta, Canada
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Weitz JI, Earl KM, Leblanc K, Semchuk W, Jamali F. Establishing Therapeutic Equivalence of Complex Pharmaceuticals: The Case of Dabigatran. Can J Cardiol 2018; 34:1116-1119. [DOI: 10.1016/j.cjca.2018.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/15/2018] [Accepted: 05/22/2018] [Indexed: 10/14/2022] Open
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Li W, Liu J, Chen JR, Zhu YM, Gao X, Ni Y, Lin B, Li H, Qiao SG, Wang C, Zhang HL, Ao GZ. Neuroprotective Effects of DTIO, A Novel Analog of Nec-1, in Acute and Chronic Stages After Ischemic Stroke. Neuroscience 2018; 390:12-29. [PMID: 30076999 DOI: 10.1016/j.neuroscience.2018.07.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/20/2018] [Accepted: 07/24/2018] [Indexed: 02/04/2023]
Abstract
Receptor-interacting protein 1 kinase (RIP1K) plays a key role in necroptosis. Necrostatin-1 (Nec-1), a specific inhibitor of RIP1K, provides neuroprotection against ischemic brain injury, associating with inhibition of inflammation. Recently, our group synthesized a novel analog of Nec-1, 5-(3',5'-dimethoxybenzal)-2-thio-imidazole-4-ketone (DTIO). The present study investigated the effect of DTIO on ischemic stroke-induced brain injury in both acute and chronic phase and its underlying mechanism. In vivo, DTIO treatment reduced infarct volume and improved neurological deficits in the acute phase after permanent middle cerebral artery occlusion (pMCAO) and it also attenuated brain atrophy and promoted brain functional recovery in the chronic phase post-cerebral ischemia/reperfusion (I/R). In vitro, DTIO treatment decreased lactate dehydrogenase (LDH) leakage and necrotic cell death in the oxygen and glucose deprivation (OGD) or oxygen and glucose deprivation and reoxygenation (OGD/R)-induced neuronal or astrocytic cell injury. Simultaneously, DTIO suppressed the production and release of inflammatory cytokines, and reduced the formation of glial scar. Homology modeling analysis illustrated that DTIO had an ability of binding to RIP1K. Furthermore, immunoprecipitation analysis showed that DTIO inhibited the phosphorylation of RIP1K and decreased the interaction between the RIP1K and RIP3K. In addition, knockdown of RIP1K had neuroprotective effects and inhibited the release of proinflammatory cytokines, but didn't have a significant effect on DTIO-mediated neuroprotection. In conclusion, DTIO has protective effects on acute ischemic stroke and promotes functional recovery during chronic phase, associating with protecting ischemic neurons and astrocytes, inhibiting inflammation, and lessening the glial scar formation via inhibiting of the RIP1K.
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Affiliation(s)
- Wei Li
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Jin Liu
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Jie-Ru Chen
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Yong-Ming Zhu
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Xue Gao
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Yong Ni
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Bo Lin
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Huanqiu Li
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
| | - Shi-Gang Qiao
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China; Department of Anesthesiology and Perioperative Medicine, Suzhou Science and Technology Town Hospital, and Institute of Clinical Medicine, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, Jiangsu 215153, China
| | - Chen Wang
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China; Department of Anesthesiology and Perioperative Medicine, Suzhou Science and Technology Town Hospital, and Institute of Clinical Medicine, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, Jiangsu 215153, China
| | - Hui-Ling Zhang
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China.
| | - Gui-Zhen Ao
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Laboratory of Cerebrovascular Pharmacology, College of Pharmaceutical Science, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, China
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Lechtman E, Balki I, Thomas K, Chen K, Moody AR, Tyrrell PN. Cost-effectiveness of magnetic resonance carotid plaque imaging for primary stroke prevention in Canada. Br J Radiol 2017; 91:20170518. [PMID: 29076745 DOI: 10.1259/bjr.20170518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Magnetic resonance of the carotid arteries provides important insight into plaque composition and vulnerability in addition to the traditional measure of stenosis. The purpose of this study was to evaluate the cost-effectiveness of MR imaging as a first-line modality to assess carotid disease and guide management for high-risk patients with <50% stenosis. METHODS Using TreeAge Pro, a cost-effectiveness simulation was conducted comparing two strategies: (a) standard of care first-line carotid duplex ultrasound (DUS) with regular follow-up, vs (b) first-line MR assessment of stenosis and intraplaque haemorrhage (MRIPH) in which patients with IPH received annual DUS surveillance and immediate carotid endarterectomy in case of plaque progression. RESULTS For patients aged 70 years old, using a first-line MRIPH strategy resulted in a 16.8% relative risk reduction in strokes compared to DUS (0.080 vs 0.097 strokes per patient per lifetime), and an increased quality-adjusted-life years (12.23 vs 12.20) at an increased cost of $897.33 over a patient's lifetime ($5784.53 vs $4887.20 average total cost per patient per lifetime). The incremental cost-effectiveness ratio was $29,744 per quality-adjusted-life years. MRIPH remained cost-effective below a willingness-to-pay threshold of $50,000 for 91.8% of sensitivity analyses. CONCLUSION MRIPH was found to be a cost-effective first-line tool to identify asymptomatic patients at high risk for stroke requiring annual surveillance and prompt management. Advances in Knowledge: Using MR imaging as a fist-line method to detect the presence of IPH provides clinically useful and cost-effective information that allows for enhanced risk evaluation and primary stroke prevention.
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Affiliation(s)
- Eli Lechtman
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Indranil Balki
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Kiersten Thomas
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Kevin Chen
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Alan R Moody
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Pascal N Tyrrell
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada.,2 Department of Statistical Sciences,University of Toronto , University of Toronto , Toronto, ON , Canada
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49
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Systematic Review of the Cost and Cost-Effectiveness of Rapid Endovascular Therapy for Acute Ischemic Stroke. Stroke 2017; 48:2519-2526. [DOI: 10.1161/strokeaha.117.017199] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/04/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
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50
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Tarride JE, Dolovich L, Blackhouse G, Guertin JR, Burke N, Manja V, Grinvalds A, Lim T, Healey JS, Sandhu RK. Screening for atrial fibrillation in Canadian pharmacies: an economic evaluation. CMAJ Open 2017; 5:E653-E661. [PMID: 28835370 PMCID: PMC5621947 DOI: 10.9778/cmajo.20170042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Screening for undiagnosed atrial fibrillation may lead to treatment with oral anticoagulation therapy, which can decrease the risk of ischemic stroke. The objective of this study was to conduct an economic evaluation of the Program for the Identification of 'Actionable' Atrial Fibrillation in the Pharmacy Setting (PIAAF-Pharmacy), which screened 1145 participants aged 65 years or more at 30 community pharmacies in Ontario and Alberta between October 2014 and April 2015. METHODS We used a 2-part decision model to evaluate the short- and long-term costs and quality-adjusted life-years (QALYs) of a pharmacy screening program for atrial fibrillation compared to no screening. Data from the PIAAF-Pharmacy study were used for the short-term model, and the relevant literature was used to extrapolate the benefits of the PIAAF-Pharmacy study in the long-term model. Costs and QALYs were calculated from a payer perspective over a lifetime horizon and were discounted at 1.5%/year. RESULTS Screening for atrial fibrillation in pharmacies was associated with higher costs ($26) and more QALYs (0.0035) compared to no screening, yielding an incremental cost per QALY gained of $7480. Univariate and probabilistic sensitivity analyses confirmed that screening for atrial fibrillation in a pharmacy setting was a cost-effective strategy. INTERPRETATION Our results support screening for atrial fibrillation in Canadian pharmacies. Given this finding, efforts should be made by provincial governments and pharmacies to implement such programs in Canada. The addition of atrial fibrillation screening alongside screening and management of other cardiovascular conditions may help to reduce the burden of stroke.
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Affiliation(s)
- Jean-Eric Tarride
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Lisa Dolovich
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Gordon Blackhouse
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Jason Robert Guertin
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Natasha Burke
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Veena Manja
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Alex Grinvalds
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Ting Lim
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Jeff S Healey
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
| | - Roopinder K Sandhu
- Affiliations: Departments of Health Research Methods, Evidence, and Impact (Tarride, Blackhouse, Burke, Dolovich) and Family Medicine (Dolovich), and Population Health Research Institute (Grinvalds, Lim, Healey), McMaster University; Programs for Assessment of Technology in Health (Tarride, Blackhouse, Burke, Dolovich), Research Institute of St. Joe's Hamilton, Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich), University of Toronto, Toronto, Ont.; Département de médecine sociale et préventive (Guertin), Université Laval; Centre de recherche du Centre hospitalier universitaire de Québec - Université Laval, Axe Santé des populations et pratiques optimales en santé (Guertin), Hôpital du Saint-Sacrement, Québec, Que.; Department of Internal Medicine (Manja), State University of New York at Buffalo; VA Western New York Healthcare System at Buffalo (Manja), Buffalo, NY; Division of Cardiology (Sandhu), University of Alberta, Edmonton, Alta
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