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Sathyanarayanan A. The use of routinely collected healthcare records for outcome assessment in clinical trials: a UK perspective. Curr Med Res Opin 2024; 40:887-892. [PMID: 38511976 DOI: 10.1080/03007995.2024.2333441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 03/15/2024] [Indexed: 03/22/2024]
Abstract
The use of routinely collected electronic healthcare records (EHR) for outcome assessment in clinical trials has been described as a 'disruptive' new technique more than a decade ago. Despite this potential, significant methodological issues and regulatory barriers have hampered the progress in this area. This article discusses the key considerations that trialists should take into account when incorporating EHR into their trials. These include considerations of the clinical relevance of the outcome, data timeliness and quality, ethical and regulatory issues, and some practical considerations for clinical trials units. In addition, this article describes the benefits of using EHR which include cost, reduced trial burden for participants and staff, follow up efficiencies, and improved health economic evaluation procedures. We also describe the major regulatory and start up costs of using EHR in clinical trials. This article focuses on the UK specific EHR landscape in clinical trials and would help researchers and trials units considering the use of this method of outcome data collection in their next trial. If the issues described are mitigated, this method will be a formidable tool for conducting pragmatic clinical trials.
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Lai X, Yuan Y, Wang H, Zhang R, Qiao Q, Feng X, Jin A, Li H, Li J, Si L, Gao P, Jan S, Fang H, Wu Y. Cost-Effectiveness of Salt Substitute and Salt Supply Restriction in Eldercare Facilities: The DECIDE-Salt Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2355564. [PMID: 38345818 PMCID: PMC10862151 DOI: 10.1001/jamanetworkopen.2023.55564] [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: 07/31/2023] [Accepted: 12/15/2023] [Indexed: 02/15/2024] Open
Abstract
Importance Salt substitution has been reported to be a cost-saving sodium reduction strategy that has not yet been replicated in different contexts. Objective To estimate the cost-effectiveness of sodium reduction strategies within the DECIDE-Salt trial. Design, Setting, and Participants The DECIDE-Salt trial cluster randomized in a 1:1:1:1 ratio 48 eldercare facilities in China into 4 groups for evaluation of 2 sodium reduction strategies for 2 years: 1 with both strategies, 2 with either strategy, and 1 with neither strategy. The trial was conducted from September 25, 2017, through October 24, 2020. Interventions The 2 intervention strategies were replacing regular salt with salt substitute and progressively restricting salt supply to kitchens. Main Outcomes and Measures The main outcomes included per-participant costs of intervention implementation and medical treatments for hypertension and major adverse cardiovascular events (MACEs) against mean reductions in systolic blood pressure, hypertension prevalence, MACE incidence, and mortality. The incremental cost-utility ratio was then assessed as the additional mean cost per quality-adjusted life-year gained. Analyses were conducted separately for each strategy, comparing groups assigned and not assigned the test strategy. Disease outcomes followed the intention-to-treat principle and adopted different models as appropriate. One-way and probabilistic sensitivity analyses were conducted to explore uncertainty, and data analyses were performed between August 13, 2022, and April 5, 2023. Results A total of 1612 participants (1230 males [76.3%]) with a mean (SD) age of 71.0 (9.5) years were enrolled. Replacing regular salt with salt substitute reduced mean systolic blood pressure by 7.14 (95% CI, 3.79-10.48) mm Hg, hypertension prevalence by 5.09 (95% CI, 0.37-9.80) percentage points, and cumulative MACEs by 2.27 (95% CI, 0.09-4.45) percentage points. At the end of the 2-year intervention, the mean cost was $25.95 less for the salt substitute group than the regular salt group due to substantial savings in health care costs for MACEs (mean [SD], $72.88 [$9.11] vs $111.18 [$13.90], respectively). Sensitivity analysis showed robust cost savings. By contrast, the salt restriction strategy did not show significant results. If the salt substitution strategy were rolled out to all eldercare facilities in China, 48 101 MACEs and 107 857 hypertension cases were estimated to be averted and $54 982 278 saved in the first 2 years. Conclusions and Relevance The findings of this cluster randomized clinical trial indicate that salt substitution may be a cost-saving strategy for hypertension control and cardiovascular disease prevention for residents of eldercare facilities in China. The substantial health benefit savings in preventing MACEs and moderate operating costs offer strong evidence to support the Chinese government and other countries in planning or implementing sodium intake reduction and salt substitute campaigns. Trial Registration ClinicalTrials.gov Identifier: NCT03290716.
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Affiliation(s)
- Xiaozhen Lai
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Yifang Yuan
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
| | - Hongxia Wang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Inner Mongolia, China
| | - Ruijuan Zhang
- Department of Public Health, Xi’an Jiaotong University, Shaanxi, China
| | - Qianku Qiao
- Yangcheng Ophthalmic Hospital, Shanxi, China
| | | | - Aoming Jin
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
- Now with China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huijuan Li
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | - Jiayu Li
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | - Lei Si
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Pei Gao
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
| | - Stephen Jan
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Hai Fang
- China Center for Health Development Studies, Peking University, Beijing, China
- Peking University Health Science Center-Chinese Center for Disease Control and Prevention Joint Research Center for Vaccine Economics, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
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Hancock SL, Thayabaranathan T, Cameron J, Stolwyk R, Lawrence M, Johnson L, Hillier S, Hackett M, Cadilhac DA. Comparisons between group- and individual-based interventions to support recovery from stroke and ischaemic heart disease in the community: a scoping review. Disabil Rehabil 2024:1-10. [PMID: 38279793 DOI: 10.1080/09638288.2024.2305300] [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: 07/29/2023] [Accepted: 12/27/2023] [Indexed: 01/29/2024]
Abstract
PURPOSE To map and summarise available literature on the effectiveness or other benefits of group- and individual-based interventions provided for adults living with stroke or ischaemic heart disease (IHD) in the community. MATERIAL AND METHODS The review was conducted based on JBI methodology and reported using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Articles were retrieved from: Medline, PsychInfo, Embase, Scopus, and CINAHL from 2002-2022. Extracted data from eligible studies included type of health outcomes (e.g., impairments), retention and adherence, social connectedness, and the costs associated with group- and individual-based interventions. RESULTS After screening, five articles (representing 4 unique studies) comparing a group- and individual-based intervention were included (total sample size n = 87). Three types of interventions were assessed: exercise (3/5), communication (1/5), and occupational therapy (1/5). Effectiveness of group- and individual-based interventions at improving health outcomes (i.e. physical ability, communication, motivation, and quality of life) is unclear. Currently there is insufficient evidence to guide clinical practice. CONCLUSIONS There is limited evidence comparing interventions delivered in a group and individual modality for adults living with stroke or IHD. Adequately powered studies are needed to determine if mode of delivery is equivalent or more cost effective.
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Affiliation(s)
- Shaun L Hancock
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Tharshanah Thayabaranathan
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Jan Cameron
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Rene Stolwyk
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Victoria, Australia
| | - Maggie Lawrence
- School of Health and Life Sciences, Department of Nursing and Community Health, Glasgow Caledonian University, Scotland
| | - Liam Johnson
- School of Behavioural and Health Sciences, Australian Catholic University, Victoria, Australia
- Physiotherapy Department, Melbourne School of Health Sciences, University of Melbourne, Victoria, Australia
| | - Susan Hillier
- Allied Health and Human Performance, University of South Australia, Australia
| | - Maree Hackett
- Mental Health, The George Institute for Global Health, New South Wales, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
- Stroke theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
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Proudfoot C, Gautam R, Cristino J, Agrawal R, Thakur L, Tolley K. Model parameters influencing the cost-effectiveness of sacubitril/valsartan in heart failure: evidence from a systematic literature review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:453-467. [PMID: 35790595 PMCID: PMC10060315 DOI: 10.1007/s10198-022-01485-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To summarize cost-effectiveness (CE) evidence of sacubitril/valsartan for the treatment of heart failure (HF) patients with reduced ejection fraction (HFrEF). The impact of different modeling approaches and parameters on the CE results is also described. METHODS We conducted a systematic literature review using multiple databases: Embase®; MEDLINE®; MEDLINE®-In Process; NIHR CRD database including DARE, NHS EED, and HTA databases; and the Cost Effectiveness Analysis registry. We also reviewed HTA countries' websites to identify CE reports of sacubitril/valsartan, published up to 25-July-2021. Articles published in English as full-texts, conference-abstracts, or HTA reports were included. RESULTS We included 44 CE models [39 from 37 publications (22 full-texts; 15 conference-abstracts) and 5 HTAs; Europe, n = 20; North and South Americas, n = 14; Asia and Australia, n = 10]. Most models adopted a Markov structure with constant transition probabilities of events (n = 27) or a mix of Markov and regression-based models (n = 16), with variations in structural assumptions and chosen parameters. Study authors concluded sacubitril/valsartan to be a cost-effective therapy in 37/41 models in chronic HFrEF patients and 2/3 models in hospitalized patients stabilized after an acute decompensation for HF. CE models showing sacubitril/valsartan not to be a cost-effective treatment generally modeled a shorter time horizon. Effect of sacubitril/valsartan on cardiovascular and all-cause mortality, cost, duration of effect and time horizon was the main model drivers. CONCLUSIONS Most evidence indicated sacubitril/valsartan is cost-effective in HFrEF. The use of a lifetime horizon is recommended in future models as HF is a chronic disease. Data on the CE of sacubitril/valsartan in the inpatient setting were limited and further research is warranted.
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Affiliation(s)
| | - Raju Gautam
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | | | | | | | - Keith Tolley
- Tolley Health Economics Ltd., Unit 5, 11-13 Eagle Parade, Buxton, SK17 6EQ, Derbyshire, UK.
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Chen YY, Liu SH, Nurmatov U, van Schayck OC, Kuo IC. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2023; 3:CD001211. [PMID: 36912752 PMCID: PMC10014114 DOI: 10.1002/14651858.cd001211.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self-limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022. OBJECTIVES To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www. CLINICALTRIALS gov), and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments. DATA COLLECTION AND ANALYSIS Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random-effects meta-analyses using RevMan Web. MAIN RESULTS We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non-FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention-to-treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost-effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non-FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty. AUTHORS' CONCLUSIONS The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance.
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Affiliation(s)
- Yu-Yen Chen
- Department of Ophthalmology, Taichung Veterans General Hospital, Taichung, Taiwan
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Su-Hsun Liu
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ulugbek Nurmatov
- Division of Population Medicine, School of Medicine, the National Centre for Population Health and Wellbeing Research, Cardiff University, Cardiff, UK
| | - Onno Cp van Schayck
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, Netherlands
| | - Irene C Kuo
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Amaro-Gahete FJ, Jurado J, Cisneros A, Corres P, Marmol-Perez A, Osuna-Prieto FJ, Fernández-Escabias M, Salcedo E, Hermán-Sánchez N, Gahete MD, Aparicio VA, González-Callejas C, Mirón Pozo B, R. Ruiz J, Nestares T, Carneiro-Barrera A. Multidisciplinary Prehabilitation and Postoperative Rehabilitation for Avoiding Complications in Patients Undergoing Resection of Colon Cancer: Rationale, Design, and Methodology of the ONCOFIT Study. Nutrients 2022; 14:4647. [PMID: 36364908 PMCID: PMC9656780 DOI: 10.3390/nu14214647] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/24/2022] [Accepted: 10/31/2022] [Indexed: 08/25/2023] Open
Abstract
ONCOFIT is a randomized clinical trial with a two-arm parallel design aimed at determining the influence of a multidisciplinary Prehabilitation and Postoperative Program (PPP) on post-surgery complications in patients undergoing resection of colon cancer. This intervention will include supervised physical exercise, dietary behavior change, and psychological support comparing its influence to the standard care. Primary and secondary endpoints will be assessed at baseline, at preoperative conditions, at the end of the PPP intervention (after 12 weeks) and 1-year post-surgery, and will include: post-surgery complications (primary endpoint); prolonged hospital length of stay; readmissions and emergency department call within 1-year after surgery; functional capacity; patient reported outcome measures targeted; anthropometry and body composition; clinical/tumor parameters; physical activity levels and sedentariness; dietary habits; other unhealthy habits; sleep quality; and fecal microbiota diversity and composition. Considering the feasibility of the present intervention in a real-life scenario, ONCOFIT will contribute to the standardization of a cost-effective strategy for preventing and improving health-related consequences in patients undergoing resection of colon cancer with an important clinical and economic impact, not only in the scientific community, but also in clinical practice.
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Affiliation(s)
- Francisco J. Amaro-Gahete
- PROFITH (PROmoting FITness and Health through Physical Activity) Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, 18007 Granada, Spain
- Department of Physiology, Faculty of Medicine, EFFECTS-262 Research Group, University of Granada, 18016 Granada, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Javier Jurado
- Service of Surgery, Hospital Universitario Clínico San Cecilio, 18016 Granada, Spain
| | - Andrea Cisneros
- Service of Surgery, Hospital Universitario Clínico San Cecilio, 18016 Granada, Spain
| | - Pablo Corres
- Department of Physical Education and Sport, Faculty of Education and Sport-Physical Activity and Sport Sciences Section, University of the Basque Country (UPV/EHU), 01007 Vitoria-Gasteiz, Spain
| | - Andres Marmol-Perez
- PROFITH (PROmoting FITness and Health through Physical Activity) Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, 18007 Granada, Spain
| | - Francisco J. Osuna-Prieto
- PROFITH (PROmoting FITness and Health through Physical Activity) Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, 18007 Granada, Spain
- Department of Analytical Chemistry, University of Granada, 18071 Granada, Spain
| | - Manuel Fernández-Escabias
- PROFITH (PROmoting FITness and Health through Physical Activity) Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, 18007 Granada, Spain
| | - Estela Salcedo
- Service of Clinical Psychology, Hospital Universitario Clínico San Cecilio, 18016 Granada, Spain
| | - Natalia Hermán-Sánchez
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Maimónides Biomedical Research Institute of Córdoba, 14004 Córdoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Córdoba, 14004 Córdoba, Spain
- Reina Sofía University Hospital, 14004 Córdoba, Spain
| | - Manuel D. Gahete
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Maimónides Biomedical Research Institute of Córdoba, 14004 Córdoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Córdoba, 14004 Córdoba, Spain
- Reina Sofía University Hospital, 14004 Córdoba, Spain
| | - Virginia A. Aparicio
- Department of Physiology, Faculty of Pharmacy, University of Granada, 18016 Granada, Spain
- Centro de Investigación Biomédica (CIBM), Instituto de Nutrición y Tecnología de los Alimentos “José Mataix” (INYTA), Universidad de Granada, 18016 Granada, Spain
| | | | - Benito Mirón Pozo
- Service of Surgery, Hospital Universitario Clínico San Cecilio, 18016 Granada, Spain
| | - Jonatan R. Ruiz
- PROFITH (PROmoting FITness and Health through Physical Activity) Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, 18007 Granada, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Instituto de Investigación Biosanitaria, ibs.Granada, 18016 Granada, Spain
| | - Teresa Nestares
- Department of Physiology, Faculty of Pharmacy, University of Granada, 18016 Granada, Spain
- Centro de Investigación Biomédica (CIBM), Instituto de Nutrición y Tecnología de los Alimentos “José Mataix” (INYTA), Universidad de Granada, 18016 Granada, Spain
| | - Almudena Carneiro-Barrera
- PROFITH (PROmoting FITness and Health through Physical Activity) Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, 18007 Granada, Spain
- Department of Psychology, Universidad Loyola Andalucía, 41007 Seville, Spain
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Shen C, Tannenbaum D, Horn R, Rogers J, Eng C, Zhou S, Johnson B, Kopetz S, Morris V, Overman M, Parseghian C, Chang GJ, Lopez-Olivo MA, Kanwal R, Ellis LM, Dasari A. Overall Survival in Phase 3 Clinical Trials and the Surveillance, Epidemiology, and End Results Database in Patients With Metastatic Colorectal Cancer, 1986-2016: A Systematic Review. JAMA Netw Open 2022; 5:e2213588. [PMID: 35608860 PMCID: PMC9131746 DOI: 10.1001/jamanetworkopen.2022.13588] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/02/2022] [Indexed: 01/15/2023] Open
Abstract
Importance Phase 3 trials for patients with metastatic colorectal cancer (mCRC) have been conducted with varying designs and often with surrogate end points for overall survival (OS). Objectives To critically examine the factors associated with clinically relevant improvement in OS (defined as ≥2 months) in these trials and to evaluate their association with outcomes reflected in Surveillance, Epidemiology, and End Results (SEER) registry data. Evidence Review Medline, EMBASE, Cochrane, Web of Science, ClinicalTrials.gov, EU Clinical Trials Register, and the International Clinical Trials Registry Platform were searched for phase 3 trials of systemic therapy for patients with mCRC by decade (1986-1996, 1997-2006, and 2007-2016), excluding early or pilot studies, studies that did not involve an anticancer drug, studies on cancer screening and prevention, reports of pooled data from multiple trials, and studies with nonpharmaceutical approaches. The association of drug development with OS outside the clinical trial setting was evaluated using data from the SEER registry, including adult patients with a primary cancer site in the colon or rectum, including adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma; a distant stage; and receipt of chemotherapy as first-line therapy. Kaplan-Meier curves and log-rank tests were used to assess OS. Findings The literature search identified 150 phase III clinical trials with 77 494 total enrollments, and 67 126 patients with mCRC were identified from the SEER database. Significant increases in survival were noted over time, best reflected in the experimental arm of first-line therapy (OS increased by 5.7 months per 10 years; 95% CI, 4.7-6.6 months; progression-free survival increased by 1.4 months per 10 years; 95% CI, 0.7-2.1 months). Although 69 of 148 trials (46.6%) met their predefined primary end point (including 20 of 44 trials [45.5%] with OS as the primary end point), only 35 of 132 trials (26.5%) resulted in improvement in OS by 2 months or more (including 13 of 42 trials [31.0%] with OS as the primary end point). Multivariable logistic regression showed that third-line therapies or later (odds ratio, 0.57; 95% CI, 0.51-0.63) and funding by pharmaceutical companies (odds ratio, 0.57; 95% CI, 0.54-0.60) were less often associated with improvement in OS. Furthermore, there was a decrease in the novelty of targets and agents over time, with trials that evaluated regimens composed entirely of previously approved drugs for mCRC increasing from 28% to 50%. Data from the SEER database showed that median OS increased from 12 months (95% CI, 12-13 months) (1986-1996) to 21 months (95% CI, 21-22 months) (2007-2015) (P < .001), but the 5-year OS continued to be low at 12.2% in 2011. Conclusions and Relevance In this systematic review, OS for patients with mCRC appeared to improve significantly in trials, translating into meaningful benefits outside the clinical trial setting; however, these advances, although significant cumulatively, are largely incremental individually. These data should be a call to aim for larger gains from future trials with novel drugs, building on the increasing understanding of the biology of mCRC and sophisticated translational research tools.
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Affiliation(s)
- Chan Shen
- Division of Health Outcomes Research and Quality, Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania
- Division of Health Services and Behavioral Research, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Daniel Tannenbaum
- Department of Internal Medicine, The University of Texas Health Sciences Center at Houston, Houston
| | - Robert Horn
- Department of Internal Medicine, The University of Texas Health Sciences Center at Houston, Houston
| | - Jane Rogers
- Department of Pharmacy Clinical Programs, the University of Texas MD Anderson Cancer Center, Houston
| | - Cathy Eng
- Division of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Benny Johnson
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Van Morris
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Michael Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Christine Parseghian
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - George J. Chang
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Maria A. Lopez-Olivo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Raghav Kanwal
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Lee M. Ellis
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Arvind Dasari
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
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8
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Cyr MP, Dostie R, Camden C, Dumoulin C, Bessette P, Pina A, Gotlieb WH, Lapointe-Milot K, Mayrand MH, Morin M. Improvements following multimodal pelvic floor physical therapy in gynecological cancer survivors suffering from pain during sexual intercourse: Results from a one-year follow-up mixed-method study. PLoS One 2022; 17:e0262844. [PMID: 35077479 PMCID: PMC8789131 DOI: 10.1371/journal.pone.0262844] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/06/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A large proportion of gynecological cancer survivors suffer from pain during sexual intercourse, also known as dyspareunia. Following a multimodal pelvic floor physical therapy (PFPT) treatment, a reduction in pain and improvement in psychosexual outcomes were found in the short term, but no study thus far has examined whether these changes are sustained over time. PURPOSE To examine the improvements in pain, sexual functioning, sexual distress, body image concerns, pain anxiety, pain catastrophizing, painful intercourse self-efficacy, depressive symptoms and pelvic floor disorder symptoms in gynecological cancer survivors with dyspareunia after PFPT, and to explore women's perceptions of treatment effects at one-year follow-up. METHODS This mixed-method study included 31 gynecological cancer survivors affected by dyspareunia. The women completed a 12-week PFPT treatment comprising education, manual therapy and pelvic floor muscle exercises. Quantitative data were collected using validated questionnaires at baseline, post-treatment and one-year follow-up. As for qualitative data, semi-structured interviews were conducted at one-year follow-up to better understand women's perception and experience of treatment effects. RESULTS Significant improvements were found from baseline to one-year follow-up on all quantitative outcomes (P ≤ 0.028). Moreover, no changes were found from post-treatment to one-year follow-up, supporting that the improvements were sustained at follow-up. Qualitative data highlighted that reduction in pain, improvement in sexual functioning and reduction in urinary symptoms were the most meaningful effects perceived by participants. Women expressed that these effects resulted from positive biological, psychological and social changes attributable to multimodal PFPT. Adherence was also perceived to influence treatment outcomes. CONCLUSIONS Findings suggest that the short-term improvements following multimodal PFPT are sustained and meaningful for gynecological cancer survivors with dyspareunia one year after treatment.
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Affiliation(s)
- Marie-Pierre Cyr
- Faculty of Medicine and Health Sciences, School of Rehabilitation, University of Sherbrooke, Sherbrooke, Quebec, Canada
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Rosalie Dostie
- Faculty of Medicine and Health Sciences, School of Rehabilitation, University of Sherbrooke, Sherbrooke, Quebec, Canada
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Chantal Camden
- Faculty of Medicine and Health Sciences, School of Rehabilitation, University of Sherbrooke, Sherbrooke, Quebec, Canada
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Chantale Dumoulin
- Faculty of Medicine, School of Rehabilitation, University of Montreal, Montreal, Quebec, Canada
- Research Center of the Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada
| | - Paul Bessette
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Faculty of Medicine and Health Sciences, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Annick Pina
- Faculty of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
- Research Center of the Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Walter Henry Gotlieb
- Faculty of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
- Lady Davis Institute of the Jewish General Hospital, Montreal, Quebec, Canada
| | - Korine Lapointe-Milot
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Faculty of Medicine and Health Sciences, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marie-Hélène Mayrand
- Research Center of the Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
- Faculty of Medicine, Departments of Obstetrics and Gynecology and Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Mélanie Morin
- Faculty of Medicine and Health Sciences, School of Rehabilitation, University of Sherbrooke, Sherbrooke, Quebec, Canada
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
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9
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Ray S, Neogi SB, Singh R, Devasenapathy N, Zodpey S. Is IV iron sucrose a cost-effective option for treatment of severe anaemia in pregnancy as compared with oral iron? Health Policy Plan 2021; 35:1339-1346. [PMID: 33230561 DOI: 10.1093/heapol/czaa110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2020] [Indexed: 11/12/2022] Open
Abstract
Anaemia in pregnancy is a public health concern because it is strongly associated with maternal and perinatal morbidity and mortality. An open label randomized controlled trial (RCT) was conducted in India across four government medical colleges, comparing intravenous (IV) iron sucrose and oral iron for the treatment of anaemia in pregnancy. This RCT failed to demonstrate superiority of IV iron sucrose compared with oral iron therapy in reducing adverse clinical (maternal and foetal/neonatal) outcomes in moderate-to-severe anaemia in pregnancy. However, IV iron sucrose seemed to reduce the need for blood transfusion among women with severe anaemia. The study objective was to conduct a cost-effectiveness analysis of IV iron sucrose over oral therapy for treatment of severe anaemia in pregnancy, alongside the RCT, to inform policy. The outcome of interest in our study was a 'safe delivery' defined by the absence of composite maternal and foetal/neonatal adverse clinical outcomes. Incremental cost-effectiveness ratio (ICER) was calculated from a limited societal perspective. IV iron sucrose was found to be more costly but more effective than the oral therapy for treatment of severe anaemia. The ICER was calculated at INR 31 951 (USD 445.2) per safe delivery. We considered a threshold of half the gross national income for decision-making. Considering this threshold of India (INR 57 230, USD 797.4), IV iron-sucrose remained cost-effective in 67% of the iterations in the model. At the current ICER, for every 32 severely anaemic pregnant woman treated with IV iron sucrose one additional pregnant woman will have a safe delivery. Such analyses can complement the national strategy to support evidence-based action.
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Affiliation(s)
- Shomik Ray
- Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot Number 47, Sector 44, Gurgaon 122002, India
| | - Sutapa B Neogi
- Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot Number 47, Sector 44, Gurgaon 122002, India
| | - Ranjana Singh
- Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot Number 47, Sector 44, Gurgaon 122002, India
| | - Niveditha Devasenapathy
- Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot Number 47, Sector 44, Gurgaon 122002, India
| | - Sanjay Zodpey
- Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot Number 47, Sector 44, Gurgaon 122002, India
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10
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Abstract
In the era of evidence-based medicine, healthcare professionals are bombarded with plenty of trials and articles of which randomized control trial is considered as the epitome of all in terms of level of evidence. It is very crucial to learn the skill of balancing knowledge of randomized control trial and to avoid misinterpretation of trial result in clinical practice. There are various methods and steps to critically appraise the randomized control trial, but those are overly complex to interpret. There should be more simplified and pragmatic approach for analysis of randomized controlled trial. In this article, we like to summarize few of the practical points under 5 headings: "5 'Rs' of critical analysis of randomized control trial" which encompass Right Question, Right Population, Right Study Design, Right Data, and Right Interpretation. This article gives us insight that analysis of randomized control trial should not only based on statistical findings or results but also on systematically reviewing its core question, relevant population selection, robustness of study design, and right interpretation of outcome. How to cite this article: Nimavat BD, Zirpe KG, Gurav SK. Critical Analysis of a Randomized Controlled Trial. Indian J Crit Care Med 2020;24(Suppl 4):S215-S222.
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Affiliation(s)
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Sushma K Gurav
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
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11
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Sehested TSG, Bjerre J, Ku S, Chang A, Jahansouz A, Owens DK, Hlatky MA, Goldhaber-Fiebert JD. Cost-effectiveness of Canakinumab for Prevention of Recurrent Cardiovascular Events. JAMA Cardiol 2020; 4:128-135. [PMID: 30649147 DOI: 10.1001/jamacardio.2018.4566] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In the Canakinumab Anti-inflammatory Thrombosis Outcome Study (CANTOS) trial, the anti-inflammatory monoclonal antibody canakinumab significantly reduced the risk of recurrent cardiovascular events in patients with previous myocardial infarction (MI) and high-sensitivity C-reactive protein (hs-CRP) levels of 2 mg/L or greater. Objective To estimate the cost-effectiveness of adding canakinumab to standard of care for the secondary prevention of major cardiovascular events over a range of potential prices. Design, Setting, and Participants A state-transition Markov model was constructed to estimate costs and outcomes over a lifetime horizon by projecting rates of recurrent MI, coronary revascularization, infection, and lung cancer with and without canakinumab treatment. We used a US health care sector perspective, and the base case used the current US market price of canakinumab of $73 000 per year. A hypothetical cohort of patients after MI aged 61 years with an hs-CRP level of 2 mg/L or greater was constructed. Interventions Canakinumab, 150 mg, administered every 3 months plus standard of care compared with standard of care alone. Main Outcomes and Measures Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually. Results Adding canakinumab to standard of care increased life expectancy from 11.31 to 11.36 years, QALYs from 9.37 to 9.50, and costs from $242 000 to $1 074 000, yielding an incremental cost-effectiveness ratio of $6.4 million per QALY gained. The price would have to be reduced by more than 98% (to $1150 per year or less) to meet the $100 000 per QALY willingness-to-pay threshold. These results were generally robust across alternative assumptions, eg, substantially lower health-related quality of life after recurrent cardiovascular events, lower infection rates while receiving canakinumab, and reduced all-cause mortality while receiving canakinumab. Including a potential beneficial effect of canakinumab on lung cancer incidence improved the incremental cost-effectiveness ratio to $3.5 million per QALY gained. A strategy of continuing canakinumab selectively in patients with reduction in hs-CRP levels to less than 2 mg/L would have a cost-effectiveness ratio of $819 000 per QALY gained. Conclusions and Relevance Canakinumab is not cost-effective at current US prices for prevention of recurrent cardiovascular events in patients with a prior MI. Substantial price reductions would be needed for canakinumab to be considered cost-effective.
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Affiliation(s)
- Thomas S G Sehested
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Jenny Bjerre
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Seul Ku
- Department of Medicine, Stanford University, Stanford, California
| | - Andrew Chang
- Department of Medicine, Stanford University, Stanford, California
| | - Alison Jahansouz
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Douglas K Owens
- VA Palo Alto Health Care System, Palo Alto, California.,Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Mark A Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.,Department of Medicine, Stanford University, Stanford, California
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
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Interdisciplinary Weight Loss and Lifestyle Intervention for Obstructive Sleep Apnoea in Adults: Rationale, Design and Methodology of the INTERAPNEA Study. Nutrients 2019; 11:nu11092227. [PMID: 31540168 PMCID: PMC6770131 DOI: 10.3390/nu11092227] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 12/12/2022] Open
Abstract
Obesity is a major risk factor for obstructive sleep apnoea (OSA), the most common sleep-disordered breathing related to neurocognitive and metabolic syndromes, type II diabetes, and cardiovascular diseases. Although strongly recommended for this condition, there are no studies on the effectiveness of an interdisciplinary weight loss and lifestyle intervention including nutrition, exercise, sleep hygiene, and smoking and alcohol cessation. INTERAPNEA is a randomised controlled trial with a two-arm parallel design aimed at determining the effects of an interdisciplinary tailored weight loss and lifestyle intervention on OSA outcomes. The study will include 84 males aged 18–65 with a body mass index of ≥25 kg/m2 and severe to moderate OSA randomly assigned to usual care (i.e., continuous positive airway pressure), or interdisciplinary weight loss and lifestyle intervention combined with usual care. Outcomes will be measured at baseline, intervention end-point, and six-month post-intervention, including apnoea-hypopnoea index (primary outcome), other neurophysical and cardiorespiratory polysomnographic outcomes, sleep quality, daily functioning and mood, body weight and composition, physical fitness, blood biomarkers, health-related quality of life, and cost-effectiveness. INTERAPNEA may serve to establish a cost-effective treatment not only for the improvement of OSA and its vast and severe comorbidities, but also for a potential remission of this condition.
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13
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Affiliation(s)
- Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
| | - Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Duke University Medical Center, Durham, North Carolina
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14
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Ulrich LR, Petersen JJ, Mergenthal K, Berghold A, Pregartner G, Holle R, Siebenhofer A. Cost-effectiveness analysis of case management for optimized antithrombotic treatment in German general practices compared to usual care - results from the PICANT trial. HEALTH ECONOMICS REVIEW 2019; 9:4. [PMID: 30729350 PMCID: PMC6734317 DOI: 10.1186/s13561-019-0221-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/27/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND By performing case management, general practitioners and health care assistants can provide additional benefits to their chronically ill patients. However, the economic effects of such case management interventions often remain unclear although how to manage the burden of chronic disease is a key question for policy-makers. This analysis aimed to compare the cost-effectiveness of 24 months of primary care case management for patients with a long-term indication for oral anticoagulation therapy with usual care. METHODS This analysis is part of the cluster-randomized controlled Primary Care Management for Optimized Antithrombotic Treatment (PICANT) trial. A sample of 680 patients with German statutory health insurance was initially considered for the cost analysis (92% of all participants at baseline). Costs included all disease-related direct health care costs from the payer's perspective (German statutory health insurers) plus case management costs for the intervention group. A-Quality Adjusted Life Year (QALY) measurement (EQ-5D-3 L instrument) was used to evaluate utility, and incremental cost-effectiveness ratio (ICER) to assess cost-effectiveness. Mean differences were calculated and displayed with 95%-confidence intervals (CI) from non-parametric bootstrapping (1000 replicates). RESULTS N = 505 patients (505/680, 74%) were included in the cost analysis (complete case analysis with a follow-up after 12 and 24 months as well as information on cost and QALY). After two years, the mean difference of direct health care costs per patient (€115, 95% CI [- 201; 406]) and QALYs (0.03, 95% CI [- 0.04; 0.11]) in the two groups was small and not significant. The costs of case management in the intervention group caused mean total costs per patient in this group to rise significantly (mean difference €503, 95% CI [188; 794]). The ICER was €16,767 per QALY. Regardless of the willingness of insurers to pay per QALY, the probability of the intervention being cost-effective never rose above 70%. CONCLUSIONS A primary care case management for patients with a long-term indication for oral anticoagulation therapy improved QALYs compared to usual care, but was more costly. However, the results may help professionals and policy-makers allocate scarce health care resources in such a way that the overall quality of care is improved at moderate costs, particularly for chronically ill patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN41847489 .
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Affiliation(s)
- Lisa R. Ulrich
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
| | - Juliana J. Petersen
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Rolf Holle
- Helmholtz Zentrum München - German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Andrea Siebenhofer
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
- Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
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15
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Haji Ali Afzali H, Bojke L, Karnon J. Model Structuring for Economic Evaluations of New Health Technologies. PHARMACOECONOMICS 2018; 36:1309-1319. [PMID: 30030816 DOI: 10.1007/s40273-018-0693-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
In countries such as Australia, the UK and Canada, decisions on whether to fund new health technologies are commonly informed by decision analytic models. While the impact of making inappropriate structural choices/assumptions on model predictions is well noted, there is a lack of clarity about the definition of key structural aspects, the process of developing model structure (including the development of conceptual models) and uncertainty associated with the structuring process (structural uncertainty) in guidelines developed by national funding bodies. This forms the focus of this article. Building on the reports of good modelling practice, and recognising the fundamental role of model structuring within the model development process, we specified key structural choices and provided ideas about model structuring for the future direction. This will help to further standardise guidelines developed by national funding bodies, with potential impact on transparency, comprehensiveness and consistency of model structuring. We argue that the process of model structuring and structural sensitivity analysis should be documented in a more systematic and transparent way in submissions to national funding bodies. Within the decision-making process, the development of conceptual models and presentation of all key structural choices would mean that national funding bodies could be more confident of maximising value for money when making public funding decisions.
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Affiliation(s)
- Hossein Haji Ali Afzali
- Health Economics and Policy Unit, School of Public Health, The University of Adelaide, Level 9, Adelaide Health and Medical Sciences Building, Corner of North Terrace and George Street, Adelaide, SA, 5005, Australia.
| | - Laura Bojke
- Centre for Health Economics, University of York, Heslington, York, Y010 5DD, UK
| | - Jonathan Karnon
- Health Economics and Policy Unit, School of Public Health, The University of Adelaide, Level 9, Adelaide Health and Medical Sciences Building, Corner of North Terrace and George Street, Adelaide, SA, 5005, Australia
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16
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Seidl A, Danner M, Wagner CJ, Sandmann FG, Sroczynski G, Stürzlinger H, Zsifkovits J, Schwalm A, Lhachimi SK, Siebert U, Gerber-Grote A. Estimation of Input Costs for a Markov Model in a German Health Economic Evaluation of Newer Antidepressants. MDM Policy Pract 2018; 3:2381468317751923. [PMID: 30288435 PMCID: PMC6132834 DOI: 10.1177/2381468317751923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 11/13/2017] [Indexed: 11/17/2022] Open
Abstract
Background: Estimating input costs for Markov models in health
economic evaluations requires health state–specific costing. This is a challenge
in mental illnesses such as depression, as interventions are not clearly related
to health states. We present a hybrid approach to health state–specific cost
estimation for a German health economic evaluation of antidepressants.
Methods: Costs were determined from the perspective of the
community of persons insured by statutory health insurance (“SHI insuree
perspective”) and included costs for outpatient care, inpatient care, drugs, and
psychotherapy. In an additional step, costs for rehabilitation and productivity
losses were calculated from the societal perspective. We collected resource use
data in a stepwise hierarchical approach using SHI claims data, where available,
followed by data from clinical guidelines and expert surveys. Bottom-up and
top-down costing approaches were combined. Results: Depending on
the drug strategy and health state, the average input costs varied per patient
per 8-week Markov cycle. The highest costs occurred for agomelatine in the
health state first-line treatment (FT) (“FT relapse”) with €506 from the SHI
insuree perspective and €724 from the societal perspective. From both
perspectives, the lowest costs (excluding placebo) were €55 for selective
serotonin reuptake inhibitors in the health state “FT remission.”
Conclusion: To estimate costs in health economic evaluations of
treatments for depression, it can be necessary to link different data sources
and costing approaches systematically to meet the requirements of the
decision-analytic model. As this can increase complexity, the corresponding
calculations should be presented transparently. The approach presented could
provide useful input for future models.
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Affiliation(s)
- Astrid Seidl
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Marion Danner
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Christoph J Wagner
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Frank G Sandmann
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Gaby Sroczynski
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Heidi Stürzlinger
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Johannes Zsifkovits
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Anja Schwalm
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Stefan K Lhachimi
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Uwe Siebert
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
| | - Andreas Gerber-Grote
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany (A Seidl, A Schwalm).,Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany (MD, CJW).,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK (FGS).,Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology (UMIT), Tirol, Austria (GS, US).,Gesundheit Österreich GmbH, Vienna, Austria (HS, JZ).,Research Group Evidence-Based Public Health, Leibniz-Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany (SKL).,Institute for Public Health and Nursing, Health Sciences Bremen, University of Bremen, Bremen, Germany (SKL).,School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland (AG)
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Wu Q, Gilbert H, Nazareth I, Sutton S, Morris R, Petersen I, Galton S, Parrott S. Cost-effectiveness of personal tailored risk information and taster sessions to increase the uptake of the NHS stop smoking services: the Start2quit randomized controlled trial. Addiction 2018; 113:708-718. [PMID: 29105871 PMCID: PMC5873401 DOI: 10.1111/add.14086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/08/2017] [Accepted: 10/24/2017] [Indexed: 11/30/2022]
Abstract
AIMS To assess the cost-effectiveness of a two-component intervention designed to increase attendance at the NHS Stop Smoking Services (SSSs) in England. DESIGN Cost-effectiveness analysis alongside a randomized controlled trial (Start2quit). SETTING NHS SSS and general practices in England. PARTICIPANTS The study comprised 4384 smokers aged 16 years or more identified from medical records in 99 participating practices, who were motivated to quit and had not attended the SSS in the previous 12 months. INTERVENTION AND COMPARATOR Intervention was a personalized and tailored letter sent from the general practitioner (GP) and a personal invitation and appointment to attend a taster session providing information about SSS. Control was a standard generic letter from the GP advertising SSS and asking smokers to contact the service to make an appointment. MEASUREMENTS Costs measured from an NHS/personal social services perspective, estimated health gains in quality-adjusted life-years (QALYs) measured with EQ-5D and incremental cost per QALY gained during both 6 months and a life-time horizon. FINDINGS During the trial period, the adjusted mean difference in costs was £92 [95% confidence interval (CI) = -£32 to -£216) and the adjusted mean difference in QALY gains was 0.002 (95% CI = -0.001 to 0.004). This generates an incremental cost per QALY gained of £59 401. The probability that the tailored letter and taster session is more cost-effective than the generic letter at 6 months is never above 50%. In contrast, the discounted life-time health-care cost was lower in the intervention group, while the life-time QALY gains were significantly higher. The probability that the intervention is more cost-effective is more than 83% using a £20 000-30 000 per QALY-gained decision-making threshold. CONCLUSIONS An intervention designed to increase attendance at the NHS Stop Smoking Services (tailored letter and taster session in the services) appears less likely to be cost-effective than a generic letter in the short term, but is likely to become more cost-effective than the generic letter during the long term.
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Affiliation(s)
- Qi Wu
- Department of Health SciencesUniversity of YorkYorkUK
| | - Hazel Gilbert
- Research Department of Primary Care and Population HealthUCLLondonUK
| | - Irwin Nazareth
- Research Department of Primary Care and Population HealthUCLLondonUK
| | - Stephen Sutton
- Institute of Public HealthUniversity of CambridgeCambridgeUK
| | - Richard Morris
- Research Department of Primary Care and Population HealthUCLLondonUK
| | - Irene Petersen
- Research Department of Primary Care and Population HealthUCLLondonUK
| | - Simon Galton
- Smokefree Camden (Public Health)NHS CamdenLondonUK
| | - Steve Parrott
- Department of Health SciencesUniversity of YorkYorkUK
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Gilbert H, Sutton S, Morris R, Petersen I, Wu Q, Parrott S, Galton S, Kale D, Magee MS, Gardner L, Nazareth I. Start2quit: a randomised clinical controlled trial to evaluate the effectiveness and cost-effectiveness of using personal tailored risk information and taster sessions to increase the uptake of the NHS Stop Smoking Services. Health Technol Assess 2018; 21:1-206. [PMID: 28121288 DOI: 10.3310/hta21030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The NHS Stop Smoking Services (SSSs) offer help to smokers who want to quit. However, the proportion of smokers attending the SSSs is low and current figures show a continuing downward trend. This research addressed the problem of how to motivate more smokers to accept help to quit. OBJECTIVES To assess the relative effectiveness, and cost-effectiveness, of an intervention consisting of proactive recruitment by a brief computer-tailored personal risk letter and an invitation to a 'Come and Try it' taster session to provide information about the SSSs, compared with a standard generic letter advertising the service, in terms of attendance at the SSSs of at least one session and validated 7-day point prevalent abstinence at the 6-month follow-up. DESIGN Randomised controlled trial of a complex intervention with follow-up 6 months after the date of randomisation. SETTING SSSs and general practices in England. PARTICIPANTS All smokers aged ≥ 16 years identified from medical records in participating practices who were motivated to quit and who had not attended the SSS in the previous 12 months. Participants were randomised in the ratio 3 : 2 (intervention to control) by a computer program. INTERVENTIONS Intervention - brief personalised and tailored letter sent from the general practitioner using information obtained from the screening questionnaire and from medical records, and an invitation to attend a taster session, run by the local SSS. Control - standard generic letter from the general practice advertising the local SSS and the therapies available, and asking the smoker to contact the service to make an appointment. MAIN OUTCOME MEASURES (1) Proportion of people attending the first session of a 6-week course over a period of 6 months from the receipt of the invitation letter, measured by records of attendance at the SSSs; (2) 7-day point prevalent abstinence at the 6-month follow-up, validated by salivary cotinine analysis; and (3) cost-effectiveness of the intervention. RESULTS Eighteen SSSs and 99 practices within the SSS areas participated; 4384 participants were randomised to the intervention (n = 2636) or control (n = 1748). One participant withdrew and 4383 were analysed. The proportion of people attending the first session of a SSS course was significantly higher in the intervention group than in the control group [17.4% vs. 9.0%; unadjusted odds ratio (OR) 2.12, 95% confidence interval (CI) 1.75 to 2.57; p < 0.001]. The validated 7-day point prevalent abstinence at the 6-month follow-up was significantly higher in the intervention group than in the control group (9.0% vs. 5.6%; unadjusted OR 1.68, 95% CI 1.32 to 2.15; p < 0.001), as was the validated 3-month prolonged abstinence and all other periods of abstinence measured by self-report. Using the National Institute for Health and Care Excellence decision-making threshold range of £20,000-30,000 per quality-adjusted life-year gained, the probability that the intervention was more cost-effective than the control was up to 27% at 6 months and > 86% over a lifetime horizon. LIMITATIONS Participating SSSs may not be representative of all SSSs in England. Recruitment was low, at 4%. CONCLUSIONS The Start2quit trial added to evidence that a proactive approach with an intensive intervention to deliver personalised risk information and offer a no-commitment introductory session can be successful in reaching more smokers and increasing the uptake of the SSS and quit rates. The intervention appears less likely to be cost-effective in the short term, but is highly likely to be cost-effective over a lifetime horizon. FUTURE WORK Further research could assess the separate effects of these components. TRIAL REGISTRATION Current Controlled Trials ISRCTN76561916. FUNDING DETAILS 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. 21, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hazel Gilbert
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Stephen Sutton
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Richard Morris
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Qi Wu
- Department of Health Sciences, University of York, York, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Simon Galton
- Smokefree Camden (Public Health), NHS Camden, London, UK
| | - Dimitra Kale
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Molly Sweeney Magee
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Leanne Gardner
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, London, UK
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Siedner MJ, Bwana MB, Moosa MYS, Paul M, Pillay S, McCluskey S, Aturinda I, Ard K, Muyindike W, Moodley P, Brijkumar J, Rautenberg T, George G, Johnson B, Gandhi RT, Sunpath H, Marconi VC. The REVAMP trial to evaluate HIV resistance testing in sub-Saharan Africa: a case study in clinical trial design in resource limited settings to optimize effectiveness and cost effectiveness estimates. HIV CLINICAL TRIALS 2017; 18:149-155. [PMID: 28720039 DOI: 10.1080/15284336.2017.1349028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND In sub-Saharan Africa, rates of sustained HIV virologic suppression remain below international goals. HIV resistance testing, while common in resource-rich settings, has not gained traction due to concerns about cost and sustainability. OBJECTIVE We designed a randomized clinical trial to determine the feasibility, effectiveness, and cost-effectiveness of routine HIV resistance testing in sub-Saharan Africa. APPROACH We describe challenges common to intervention studies in resource-limited settings, and strategies used to address them, including: (1) optimizing generalizability and cost-effectiveness estimates to promote transition from study results to policy; (2) minimizing bias due to patient attrition; and (3) addressing ethical issues related to enrollment of pregnant women. METHODS The study randomizes people in Uganda and South Africa with virologic failure on first-line therapy to standard of care virologic monitoring or immediate resistance testing. To strengthen external validity, study procedures are conducted within publicly supported laboratory and clinical facilities using local staff. To optimize cost estimates, we collect primary data on quality of life and medical resource utilization. To minimize losses from observation, we collect locally relevant contact information, including Whatsapp account details, for field-based tracking of missing participants. Finally, pregnant women are followed with an adapted protocol which includes an increased visit frequency to minimize risk to them and their fetuses. CONCLUSIONS REVAMP is a pragammatic randomized clinical trial designed to test the effectiveness and cost-effectiveness of HIV resistance testing versus standard of care in sub-Saharan Africa. We anticipate the results will directly inform HIV policy in sub-Saharan Africa to optimize care for HIV-infected patients.
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Affiliation(s)
- Mark J Siedner
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Mwebesa B Bwana
- b Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | | | - Michelle Paul
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Selvan Pillay
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Suzanne McCluskey
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Isaac Aturinda
- b Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Kevin Ard
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Winnie Muyindike
- b Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | | | - Jaysingh Brijkumar
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Tamlyn Rautenberg
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Gavin George
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Brent Johnson
- e Department of Biostatistics and Computational Biology , University of Rochester , Rochester , NY , USA
| | - Rajesh T Gandhi
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Henry Sunpath
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
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Munteanu SE, Landorf KB, McClelland JA, Roddy E, Cicuttini FM, Shiell A, Auhl M, Allan JJ, Buldt AK, Menz HB. Shoe-stiffening inserts for first metatarsophalangeal joint osteoarthritis (the SIMPLE trial): study protocol for a randomised controlled trial. Trials 2017; 18:198. [PMID: 28449699 PMCID: PMC5408786 DOI: 10.1186/s13063-017-1936-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 04/11/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND This article describes the design of a parallel-group, participant- and assessor-blinded randomised controlled trial comparing the effectiveness of shoe-stiffening inserts versus sham shoe insert(s) for reducing pain associated with first metatarsophalangeal joint (MTPJ) osteoarthritis (OA). METHODS Ninety participants with first MTPJ OA will be randomised to receive full-length shoe-stiffening insert(s) (Carbon Fibre Spring Plate, Paris Orthotics, Vancouver, BC, Canada) plus rehabilitation therapy or sham shoe insert(s) plus rehabilitation therapy. Outcome measures will be obtained at baseline, 4, 12, 24 and 52 weeks; the primary endpoint for assessing effectiveness being 12 weeks. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire (FHSQ). Secondary outcome measures will include the function domain of the FHSQ, severity of first MTPJ pain (using a 100-mm Visual Analogue Scale), global change in symptoms (using a 15-point Likert scale), health status (using the Short-Form-12® Version 2.0 and EuroQol (EQ-5D-5L™) questionnaires), use of rescue medication and co-interventions, self-reported adverse events and physical activity levels (using the Incidental and Planned Activity Questionnaire). Data will be analysed using the intention-to-treat principle. Economic analysis (cost-effectiveness and cost-utility) will also be performed. In addition, the kinematic effects of the interventions will be examined at 1 week using a three-dimensional motion analysis system and multisegment foot model. DISCUSSION This study will determine whether shoe-stiffening inserts are a cost-effective intervention for relieving pain associated with first MTPJ OA. The biomechanical analysis will provide useful insights into the mechanism of action of the shoe-stiffening inserts. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, identifier: ACTRN12616000552482 . Registered on 28 April 2016.
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Affiliation(s)
- Shannon E. Munteanu
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
| | - Karl B. Landorf
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- Allied Health Department, Melbourne Health, 300 Grattan Street, Parkville, VIC 3050 Australia
| | - Jodie A. McClelland
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
| | - Edward Roddy
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG UK
| | - Flavia M. Cicuttini
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004 Australia
| | - Alan Shiell
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
| | - Maria Auhl
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
| | - Jamie J. Allan
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
| | - Andrew K. Buldt
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
| | - Hylton B. Menz
- Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
- La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC 3086 Australia
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Allen KD, Bierma-Zeinstra SMA, Foster NE, Golightly YM, Hawker G. OARSI Clinical Trials Recommendations: Design and conduct of implementation trials of interventions for osteoarthritis. Osteoarthritis Cartilage 2015; 23:826-38. [PMID: 25952353 DOI: 10.1016/j.joca.2015.02.772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 02/02/2023]
Abstract
Rigorous implementation research is important for testing strategies to improve the delivery of effective osteoarthritis (OA) interventions. The objective of this manuscript is to describe principles of implementation research, including conceptual frameworks, study designs and methodology, with specific recommendations for randomized clinical trials of OA treatment and management. This manuscript includes a comprehensive review of prior research and recommendations for implementation trials. The review of literature included identification of seminal articles on implementation research methods, as well as examples of previous exemplar studies using these methods. In addition to a comprehensive summary of this literature, this manuscript provides key recommendations for OA implementation trials. This review concluded that to date there have been relatively few implementation trials of OA interventions, but this is an emerging area of research. Future OA clinical trials should routinely consider incorporation of implementation aims to enhance translation of findings.
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Affiliation(s)
- K D Allen
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA; Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; Health Services Research and Development, Department of Veterans Affairs Medical Center, Durham, NC, USA.
| | - S M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC - University Medical Center Rotterdam, The Netherlands; Department of Orthopaedic Surgery, Erasmus MC - University Medical Center Rotterdam, The Netherlands.
| | - N E Foster
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK.
| | - Y M Golightly
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA; Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.
| | - G Hawker
- Department of Medicine, University of Toronto, Canada; Women's College Research Institute, Women's College Hospital, University of Toronto, Canada.
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Goldstein TR, Fersch-Podrat RK, Rivera M, Axelson DA, Merranko J, Yu H, Brent DA, Birmaher B. Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial. J Child Adolesc Psychopharmacol 2015; 25:140-9. [PMID: 25010702 PMCID: PMC4367513 DOI: 10.1089/cap.2013.0145] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to conduct a pilot randomized trial of dialectical behavior therapy (DBT) versus psychosocial treatment as usual (TAU) for adolescents diagnosed with bipolar disorder (BP). METHODS We recruited participants 12-18 years of age with a primary BP diagnosis (I, II, or operationalized not otherwise specified [NOS] criteria) from a pediatric specialty clinic. Eligible patients were assigned using a 2:1 randomization structure to either DBT (n=14) or psychosocial TAU (n=6). All patients received medication management from a study-affiliated psychiatrist. DBT included 36 sessions (18 individual, 18 family skills training) over 1 year. TAU was an eclectic psychotherapy approach consisting of psychoeducational, supportive, and cognitive behavioral techniques. An independent evaluator, blind to treatment condition, assessed outcomes including affective symptoms, suicidal ideation and behavior, nonsuicidal self-injurious behavior, and emotional dysregulation, quarterly over 1 year. RESULTS Adolescents receiving DBT attended significantly more therapy sessions over 1 year than did adolescents receiving TAU, possibly reflecting greater engagement and retention; both treatments were rated as highly acceptable by adolescents and parents. As compared with adolescents receiving TAU, adolescents receiving DBT demonstrated significantly less severe depressive symptoms over follow-up, and were nearly three times more likely to demonstrate improvement in suicidal ideation. Models indicate a large effect size, for more weeks being euthymic, over follow-up among adolescents receiving DBT. Although there were no between-group differences in manic symptoms or emotional dysregulation with treatment, adolescents receiving DBT, but not those receiving TAU, evidenced improvement from pre- to posttreatment in both manic symptoms and emotional dysregulation. CONCLUSIONS DBT may offer promise as an adjunct to pharmacotherapy in the treatment of depressive symptoms and suicidal ideation for adolescents with BP. The DBT focus on commitment to treatment may be important for the treatment of early-onset BP. Larger controlled trials are needed to establish the efficacy of this approach, examine impact on suicidal behavior, and demonstrate cost effectiveness.
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Affiliation(s)
- Tina R. Goldstein
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rachael K. Fersch-Podrat
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Maribel Rivera
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - John Merranko
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Haifeng Yu
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David A. Brent
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Scudeler TL, Rezende PC, Hueb W. The cost–effectiveness of strategies in coronary artery disease. Expert Rev Pharmacoecon Outcomes Res 2014; 14:805-13. [DOI: 10.1586/14737167.2014.957681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Erder MH, Xie J, Signorovitch JE, Chen KS, Hodgkins P, Lu M, Wu EQ, Sikirica V. Cost effectiveness of guanfacine extended-release versus atomoxetine for the treatment of attention-deficit/hyperactivity disorder: application of a matching-adjusted indirect comparison. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2012; 10:381-395. [PMID: 23113551 DOI: 10.1007/bf03261873] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND About 7% of children and adolescents are diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the US. Patients with ADHD who are intolerant of or do not have an optimal response to stimulants often use non-stimulants as alternative therapies. Guanfacine extended-release (GXR) and atomoxetine (ATX) are the only non-stimulants approved by the US Food and Drug Administration for once-daily use in the treatment of children and adolescents with ADHD in the US. ATX has been on the market since 2002 while GXR was recently approved in 2009. To date, there is no comparative effectiveness or cost-effectiveness study comparing the two drugs. OBJECTIVES The aim of this study was to assess the cost effectiveness of GXR versus ATX for the treatment of ADHD in children and adolescents, using the comparative efficacy results from a matching-adjusted indirect comparison (MAIC). METHODS The MAIC method was used to compare the efficacy between GXR (target dose and lower doses) and ATX (target dose) in the absence of head-to-head clinical trials. Individual patients in the GXR trials were weighted such that the summary baseline characteristics and the efficacy of the placebo arm of the GXR trials matched exactly with those from published ATX trials. After weighting, the efficacy (i.e. change in the ADHD rating scale, fourth edition [ADHD-RS-IV] total score from baseline) was compared between each GXR dosing group and the ATX group. The results from the MAIC analyses were used to populate a 1-year Markov model that is used to compare the cost effectiveness of GXR versus ATX from a US third-party payer perspective. Effectiveness outcomes for each treatment group were estimated as the proportion of responders, defined as patients with ≥25% reduction in ADHD-RS-IV total score from baseline, and average quality-adjusted life years (QALYs). Utilities associated with response/non-response and disutilities due to adverse events were applied in the model. Costs included drug and medical service costs and were inflated to 2011 US dollars ($US). Incremental cost/QALY and incremental cost/responder were estimated. Univariate sensitivity analyses were conducted by varying all model parameters, including costs, utilities, and response rate. RESULTS The target dose of GXR was 0.12 mg/kg/day. In match-adjusted populations with balanced baseline characteristics, patients receiving GXR at the dose of 0.09-0.12(p = 0.0016) [DOSAGE ERROR CORRECTED] and 0.075-0.09 mg/kg/day (p = 0.0248) had better efficacy, while those receiving GXR at the dose of 0.046-0.075 mg/kg/day had comparable efficacy (p = 0.0699), compared with patients receiving ATX at the target dose of 1.2 mg/kg/day. In the base case of the cost-effectiveness analysis (CEA), GXR had incremental cost-effectiveness ratios of $US10 637/QALY and $US853/responder, compared with ATX (incremental costs: $US74; incremental effectiveness: 0.007 QALYs and 86 responders per 1000 patients treated). Results of all univariate sensitivity analyses showed that the model results were robust to changes in model inputs. CONCLUSIONS To our knowledge, this is the first application of the novel comparative efficacy method of MAIC to a CEA model. The MAIC results indicate that GXR (0.075-0.12 mg/kg/day) was more effective than ATX (1.2 mg/kg/day) in the trial population. The CEA results indicate that GXR is cost effective compared with ATX for the treatment of ADHD in children and adolescents.
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Vieira RD, Hueb W, Hlatky M, Favarato D, Rezende PC, Garzillo CL, Lima EG, Soares PR, Hueb AC, Pereira AC, Ramires JAF, Filho RK. Cost-Effectiveness Analysis for Surgical, Angioplasty, or Medical Therapeutics for Coronary Artery Disease: 5-Year Follow-Up of Medicine, Angioplasty, or Surgery Study (MASS) II Trial. Circulation 2012; 126:S145-50. [DOI: 10.1161/circulationaha.111.084442] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Scott IA, Glasziou PP. Improving the effectiveness of clinical medicine: the need for better science. Med J Aust 2012; 196:304-8. [PMID: 22432658 DOI: 10.5694/mja11.10364] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 08/29/2011] [Indexed: 11/17/2022]
Abstract
Effective clinical practice is predicated on valid and relevant clinical science - a commodity in increasingly short supply. The pre-eminent place of clinical research has become tainted by methodological shortcomings, commercial influences and neglect of the needs of patients and clinicians. Researchers need to be more proactive in evaluating clinical interventions in terms of patient-important benefit, wide applicability and comparative effectiveness, and in adopting study designs and reporting standards that ensure accurate and transparent research outputs. Funders of research need to be more supportive of applied clinical research that rigorously evaluates effectiveness of new treatments and synthesis existing knowledge into clinically useful systematic reviews. Several strategies for improving the state of the science are possible but their implementation requires collective action of all those undertaking and reporting clinical research.
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Affiliation(s)
- Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
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Kim SY, Park JY. The Utilization of Western and Oriental Medical Services by Outpatients with Musculoskeletal System Disorders and Its Related Factors. ACTA ACUST UNITED AC 2012. [DOI: 10.12811/kshsm.2012.6.1.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Petrou S, Gray A. Economic evaluation alongside randomised controlled trials: design, conduct, analysis, and reporting. BMJ 2011; 342:d1548. [PMID: 21474510 PMCID: PMC3230107 DOI: 10.1136/bmj.d1548] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2011] [Indexed: 11/03/2022]
Affiliation(s)
- Stavros Petrou
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK.
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Schreyögg J, Weller J, Stargardt T, Herrmann K, Bluemel C, Dechow T, Glatting G, Krause BJ, Mottaghy F, Reske SN, Buck AK. Cost-Effectiveness of Hybrid PET/CT for Staging of Non–Small Cell Lung Cancer. J Nucl Med 2010; 51:1668-75. [DOI: 10.2967/jnumed.109.072090] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Fillit H, Cummings J, Neumann P, McLaughlin T, Salavtore P, Leibman C. Novel approaches to incorporating pharmacoeconomic studies into phase III clinical trials for Alzheimer's disease. J Nutr Health Aging 2010; 14:640-7. [PMID: 20922340 DOI: 10.1007/s12603-010-0310-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The societal and individual costs of Alzheimer's disease are significant, worldwide. As the world ages, these costs are increasing rapidly, while health systems face finite budgets. As a result, many regulators and payers will require or at least consider phase III cost-effectiveness data (in addition to safety and efficacy data) for drug approval and reimbursement, increasing the risks and costs of drug development. Incorporating pharmacoeconomic studies in phase III clinical trials for Alzheimer's disease presents a number of challenges. We propose several specific suggestions to improve the design of pharmacoeconomic studies in phase III clinical trials. We propose that acute episodes of care are key outcome measures for pharmacoeconomic studies. To improve the possibility of detecting a pharmacoeconomic impact in phase III, we suggest several strategies including; study designs for enrichment of pharmacoeconomic outcomes that include co-morbidity of patients; reducing variability of care that can affect pharmacoeconomic outcomes through standardized care management; employing administrative claims data to better capture meaningful pharmacoeconomic data; and extending clinical trials in open label follow-up periods in which pharmacoeconomic data are captured electronically by administrative claims. Specific aspects of power analysis for pharmacoeconomic studies are presented. The particular pharmacoeconomic challenges caused by the use of biomarkers in clinical trials, the increasing use of multinational studies, and the pharmacoeconomic challenges presented by biologicals in development for Alzheimer's disease are discussed. In summary, since we are entering an era in which pharmacoeconomic studies will be essential in drug development for supporting regulatory approval, payor reimbursement and integration of new therapies into clinical care, we must consider the design and incorporation of pharmacoeconomic studies in phase III clinical trials more seriously and more creatively.
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Affiliation(s)
- H Fillit
- The Alzheimer's Drug Discovery Foundation, NY, NY, USA
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Bodrogi J, Kaló Z. Principles of pharmacoeconomics and their impact on strategic imperatives of pharmaceutical research and development. Br J Pharmacol 2010; 159:1367-73. [PMID: 20132213 DOI: 10.1111/j.1476-5381.2009.00550.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The importance of evidence-based health policy is widely acknowledged among health care professionals, patients and politicians. Health care resources available for medical procedures, including pharmaceuticals, are limited all over the world. Economic evaluations help to alleviate the burden of scarce resources by improving the allocative efficiency of health care financing. Reimbursement of new medicines is subject to their cost-effectiveness and affordability in more and more countries. There are three major approaches to calculate the cost-effectiveness of new pharmaceuticals. Economic analyses alongside pivotal clinical trials are often inconclusive due to the suboptimal collection of economic data and protocol-driven costs. The major limitation of observational naturalistic economic evaluations is the selection bias and that they can be conducted only after registration and reimbursement. Economic modelling is routinely used to predict the cost-effectiveness of new pharmaceuticals for reimbursement purposes. Accuracy of cost-effectiveness estimates depends on the quality of input variables; validity of surrogate end points; and appropriateness of modelling assumptions, including model structure, time horizon and sophistication of the model to differentiate clinically and economically meaningful outcomes. These economic evaluation methods are not mutually exclusive; in practice, economic analyses often combine data collection alongside clinical trials or observational studies with modelling. The need for pharmacoeconomic evidence has fundamentally changed the strategic imperatives of research and development (R&D). Therefore, professionals in pharmaceutical R&D have to be familiar with the principles of pharmacoeconomics, including the selection of health policy-relevant comparators, analytical techniques, measurement of health gain by quality-adjusted life-years and strategic pricing of pharmaceuticals.
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Affiliation(s)
- József Bodrogi
- Health Economics Research Centre, Faculty of Social Sciences, Eötvös Loránd University, Budapest, Hungary
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Kim MY, Park JK, Koh SB, Kim CB. Factors Influencing Utilization of Medical Care Among Osteoarthritis Patients in Korea: Using 2005 Korean National Health and Nutrition Survey Data. J Prev Med Public Health 2010; 43:513-22. [DOI: 10.3961/jpmph.2010.43.6.513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Min Young Kim
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Korea
| | - Jong Ku Park
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Korea
| | - Sang Baek Koh
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Korea
| | - Chun-Bae Kim
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Korea
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Khairy P, Hosn JA, Broberg C, Cook S, Earing M, Gersony D, Kay J, Landzberg MJ, Nickolaus MJ, Opotowsky S, Valente AM, Warnes C, Webb G, Gurvitz MZ. Multicenter research in adult congenital heart disease. Int J Cardiol 2008; 129:155-9. [DOI: 10.1016/j.ijcard.2008.03.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Revised: 01/24/2008] [Accepted: 03/01/2008] [Indexed: 11/29/2022]
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Abstract
Electronic monitoring of the fetal heart rate during labor (EFM), originally designed to assess fetal stress and allow the early detection of the compromised fetus, has instead led to increasing maternal morbidity without decreasing fetal morbidity. The unintended consequences of this technologic advance have led to the creation of a pseudodisease and unwarranted intervention in response to its detection. Is it ethical to introduce a new technology without adequate assessment of its possible consequences? Are we about to repeat this (error resulting from the introduction of EFM?) There is increasing interest in monitoring the function of the newborn brain, to enable the early detection of subclinical seizures. The monitor may also be used for assessing brain function in older children and adults who are comatose or paralyzed and cannot appropriately respond to stimuli. Use of this amplitude-integrated electroencephalography (aEEG) in the newborn for detection of seizures and other brain abnormalities is not dissimilar to the use of electronic fetal heart rate monitoring. Whether seizures or subclinical seizures themselves cause harm to the developing nervous system is unclear. The effectiveness of medications for treatment of seizures in the newborn has not been established. Therefore, the consequences of introducing automated EEG for the detection of subclinical neonatal seizures are likely to be similar to the results of the introduction of EFM: creation of another pseudodisease, followed by unwarranted intervention, and increased legal liability. What are the ethics of continued approval and introduction of unevaluated technology? What is the wisdom of its use? Beware of the unintended consequences.
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Affiliation(s)
- John M Freeman
- Department of Neurology and the Berman Institute of Bioethics, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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