Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis

Global consensus statement on simulation-based practice in healthcare

ABSTRACT

Simulation plays a pivotal role in addressing universal healthcare challenges, reducing education inequities, and improving mortality, morbidity and patient experiences. It enhances healthcare processes and systems, contributing significantly to the development of a safety culture within organizations. It has proven to be cost-effective and successful in enhancing team performance, fostering workforce resilience and improving patient outcomes.Through an international collaborative effort, an iterative consultation process was conducted with 50 societies operating across 67 countries within six continents. This process revealed common healthcare challenges and simulation practices worldwide. The intended audience for this statement includes policymakers, healthcare organization leaders, health education institutions, and simulation practitioners. It aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

KEY RECOMMENDATIONS

Advocating for the benefits that simulation provides to patients, staff and organizations is crucial, as well as promoting its adoption and integration into daily learning and practice throughout the healthcare spectrum. Low-cost, high-impact simulation methods should be leveraged to expand global accessibility and integrate into system improvement processes as well as undergraduate and postgraduate curricula. Support at institutional and governmental level is essential, necessitating a unified and concerted approach in terms of political, strategic and financial commitment.It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognized standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification.We must endeavor to provide equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, firmly upholding the principles of equity, diversity and inclusion. This should be complemented with a renewed emphasis on research and scholarship in this field.

CALL FOR ACTION

We urge policymakers and leaders to formally acknowledge and embrace the benefits of simulation in healthcare practice and education. This includes a commitment to sustained support and a mandate for the application of simulation within education, training, and clinical environments.We advocate for healthcare systems and education institutions to commit themselves to the goal of high-quality healthcare and improved patient outcomes. This commitment should encompass the promotion and resource support of simulation-based learning opportunities for individuals and interprofessional teams throughout all stages and levels of a caregiver's career, in alignment with best practice standards.We call upon simulation practitioners to champion healthcare simulation as an indispensable learning tool, adhere to best practice standards, maintain a commitment to lifelong learning, and persist in their fervent advocacy for patient safety.This statement, the result of an international collaborative effort, aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

Global consensus statement on simulation-based practice in healthcare

Simulation plays a pivotal role in addressing universal healthcare challenges, reducing education inequities, and improving mortality, morbidity and patient experiences. It enhances healthcare processes and systems, contributing significantly to the development of a safety culture within organizations. It has proven to be cost-effective and successful in enhancing team performance, fostering workforce resilience and improving patient outcomes.Through an international collaborative effort, an iterative consultation process was conducted with 50 societies operating across 67 countries within six continents. This process revealed common healthcare challenges and simulation practices worldwide. The intended audience for this statement includes policymakers, healthcare organization leaders, health education institutions, and simulation practitioners. It aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.Key recommendations Advocating for the benefits that simulation provides to patients, staff and organizations is crucial, as well as promoting its adoption and integration into daily learning and practice throughout the healthcare spectrum. Low-cost, high-impact simulation methods should be leveraged to expand global accessibility and integrate into system improvement processes as well as undergraduate and postgraduate curricula. Support at institutional and governmental level is essential, necessitating a unified and concerted approach in terms of political, strategic and financial commitment.It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognized standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification.We must endeavor to provide equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, firmly upholding the principles of equity, diversity and inclusion. This should be complemented with a renewed emphasis on research and scholarship in this field.Call for action We urge policymakers and leaders to formally acknowledge and embrace the benefits of simulation in healthcare practice and education. This includes a commitment to sustained support and a mandate for the application of simulation within education, training, and clinical environments.We advocate for healthcare systems and education institutions to commit themselves to the goal of high-quality healthcare and improved patient outcomes. This commitment should encompass the promotion and resource support of simulation-based learning opportunities for individuals and interprofessional teams throughout all stages and levels of a caregiver's career, in alignment with best practice standards.We call upon simulation practitioners to champion healthcare simulation as an indispensable learning tool, adhere to best practice standards, maintain a commitment to lifelong learning, and persist in their fervent advocacy for patient safety.This statement, the result of an international collaborative effort, aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke

BACKGROUND

Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS.

METHODS AND RESULTS

We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case.

CONCLUSIONS

Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.

Cost-effectiveness of quality improvement intervention to reduce time between CT-detection and ureteroscopic laser fragmentation in acute symptomatic ureteric stones management

OBJECTIVE

To prospectively assess clinical and cost effectiveness of emergency ureteroscopic laser fragmentation of urinary stones causing symptoms or obstruction.

PATIENTS AND METHODS

100 consecutive patients with an average (median) age 55.6 (57.5) years and average (median) stone size of 8.2 mm (± 7 mm) between October 2018 and December 2021 who underwent emergency ureteroscopy and laser fragmentation formed the study cohort as part of a clinical service quality improvement. Primary outcome was single procedure stone-free rate and cost-effectiveness. The secondary outcomes were complications, re-admission and re-intervention. A decision analysis model was constructed to compare the cost-effectiveness of emergency ureteroscopy with laser fragmentation (EUL) and emergency temporary stenting followed by delayed ureteroscopy with laser fragmentation (DUL) using our results and success rates for modelling.

RESULTS

Single procedure stone-free rates (SFR) for EUL and DUL were 85%. The re-intervention rate, re-admission and complication rates of the study cohort (EUL) were 9%, 18%, and 4%, respectively, compared to 15%, 20%, and 5%, respectively for the control cohort (DUL). The decision analysis modelling demonstrated that the EUL treatment option was more cost-efficient, averting £2868 (€3260) per patient for the UK health sector. Total cost of delayed intervention was £7783 (€8847) for DUL in contrast to £4915 (€5580) for EUL.

CONCLUSIONS

Implementation of quality improvement project based on a reduction in CT detection-to-laser fragmentation time interval in acute ureteric obstruction or symptoms caused by stones had similar clinical effectiveness compared to delayed ureteroscopic management, but more cost-effective.

Powerful medical education improves health care quality and return on investment

INTRODUCTION

Powerful medical education (PME) involves the use of new technologies informed by the science of expertise that are embedded in laboratories and organizations that value evidence-based education and support innovation. This contrasts with traditional medical education that relies on a dated apprenticeship model that yields uneven results. PME involves an amalgam of features, conditions and assumptions, and contextual variables that comprise an approach to developing clinical competence grounded in education impact metrics including efficiency and cost-effectiveness.

METHODS

This article is a narrative review based on SANRA criteria and informed by realist review principles. The review addresses the PME model with an emphasis on mastery learning and deliberate practice principles drawn from the new science of expertise. Pub Med, Scopus, and Web of Science search terms include medical education, the science of expertise, mastery learning, translational outcomes, cost effectiveness, and return on investment. Literature coverage is comprehensive with selective citations.

RESULTS

PME is described as an integrated set of twelve features embedded in a group of seven conditions and assumptions and four context variables. PME is illustrated via case examples that demonstrate improved ventilator patient management learning outcomes compared to traditional clinical education and mastery learning of breaking bad news communication skills. Evidence also shows that PME of physicians and other health care providers can have translational, downstream effects on patient care practices, patient outcomes, and return on investment. Several translational health care quality improvements that derive from PME include reduced infections; better communication among physicians, patients, and families; exceptional birth outcomes; more effective patient education; and return on investment.

CONCLUSIONS

The article concludes with challenges to hospitals, health systems, and medical education organizations that are responsible for producing physicians who are expected to deliver safe, effective, and cost-conscious health care.

Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review

BACKGROUND

Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT.

METHODS

A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality.

RESULTS

Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%).

CONCLUSIONS

A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.