Fighting healthcare rocketing costs with value-based medicine: the case of stroke management

Application of health technology assessment: a new need for an ethical neonatology

New health technologies are constantly developing. However, their impacts on health and implications for health systems are not always clear. Faced with this situation, in the last 45 years, Health Technology Assessment (HTA) has taken an important role in the decision-making process related to the implementation of technologies in healthcare systems. According to the Core Model® EUnetHTA, a "full HTA" should cover nine domains: health problems and current use of technology, description and technical characteristics, safety, clinical effectiveness, costs and economic evaluation, ethical analysis, organizational aspects, patients and social aspects, legal aspects. In all domains of a HTA, the approach is evidence-based and uses epidemiological data, systematic reviews to gather the best level of proofs regarding clinical efficacy and safety of interventions and comparators and organizational and economic models. One exception is the ethical analysis, that uses value-based approach. Although in Neonatal Intensive Care Units (NICUs) there are highly advanced technological environments, HTA has not yet been widely used in this field for determining the "value" of the diagnostic and therapeutic procedures. An example of diagnostic tool used in NICUs is the near-infrared spectroscopy (NIRS), a noninvasive device that enables real-time monitoring of the condition of peripheral tissues in critically ill newborns. The availability of this diagnostic tool could improve the choice of the most appropriate treatment to the clinical situation of the newborn. The expected benefit of NIRS motivates the need of a full HTA.    Conclusion: HTA is still little used in Neonatal Critical Care, but it may be the appropriate tool to determine the "value" of technologies used in this field. The implementation of clinical trials and HTA may help in an evidence-based evaluation of new technologies for the neonatal critical care. This could facilitate the rapid introduction of the best health technologies into clinical practice. What is Known: • Health Technology Assessment (HTA) has taken an important role in the decision-making process related to the implementation of technologies in healthcare systems • The centrality of ethics in HTA has been known. In fact, ethics is everywhere in HTA, and value judgments permeate all levels of HTA What is New: • HTA is still little used in Neonatal Critical Care, but it may be the appropriate tool to determine the "value" of technologies used in this field • The implementation of clinical trials and HTA may help in an evidence-based evaluation of new technologies for the neonatal critical care and in introduction of the best and ethically acceptable health technologies into clinical practice.

Caregiving experiences of informal caregivers of adult stroke patients during the COVID-19 pandemic: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to identify, appraise, and synthesize the best available qualitative evidence on the caregiving experiences of informal caregivers of adult stroke patients during the COVID-19 pandemic.

INTRODUCTION

The functional and health outcomes of stroke patients are directly impacted by the mental and physical well-being of the patient's informal caregiver, which have been negatively affected by COVID-19 due to a lack of caregiver education and competency in caring for stroke patients. Therefore, improvement of the informal caregiver experience preserves the stroke survivor-caregiver relationship and the care goals of stroke patients.

INCLUSION CRITERIA

This review will consider qualitative studies focusing on the experiences of informal caregivers of adult stroke patients during COVID-19. Only informal caregivers will be included, defined as individuals of any age, gender, or culture who provide care, typically unpaid, to someone with whom they have a personal relationship (ie, family or friend). Studies conducted in inpatient settings, rehabilitation settings, community care settings, or home care settings will be considered.

METHODS

The databases to be searched include MEDLINE, CINAHL, Embase, Web of Science, and PsycINFO. Sources of unpublished studies and gray literature will include ProQuest Dissertations and Theses, MedNar, and the American Heart Association. Studies published from 2019 to the present will be considered and data synthesis will be conducted using the meta-aggregation approach. Confidence in the findings will be assessed using the ConQual approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022326666.

Liposomal Bupivacaine Injection in Nuss Procedure Allows Narcotic Avoidance and Improved Outcomes

Background: The Nuss procedure has provided a minimally invasive surgical solution for pectus excavatum with excellent long-term outcomes. However, opioid avoidance, cost reduction, and length of stay (LOS) still offer room for improvement. The focus of this study is to identify the impact of Bupivacaine liposome injectable suspension (Exparel) on outcomes. Methods: A retrospective review at a Pediatric specialty hospital from October 1, 2014 to December 31, 2019 was performed. All patients underwent a Nuss procedure (n = 19) for pectus excavatum. The cohort comprised a control group that did not use liposomal Bupivacaine (Standard, n = 9) and an interventional group that received liposomal Bupivacaine (n = 10). Nonparametric Wilcoxon rank-sum tests and chi-squared or Fisher's exact tests were used to assess significance (P < .05). Results: Overall, the entire population was 68.4% male and had an average age of 15 years. There was a significant difference between the Standard and Liposomal Bupivacaine groups for total cost ($60,746 versus $13,289), total Morphine Milligram Equivalents (MME) (282 versus 76.8 MME) and Epidural Catheter usage (100% versus 0%). There was also a significant difference between groups for LOS (5.00 days versus 3.00 days) and Foley catheter usage (100% versus 20%). Conclusions: There is a significant impact of liposomal Bupivacaine usage on epidural catheter avoidance and opioid administration correlating with a significantly decreased total cost and decreased LOS. While more study is necessary, liposomal Bupivacaine for Nuss procedure offers improvement of postoperative patient outcomes and drastic cost savings.

Patient-Reported Experience Measures in Stroke Care: A Systematic Review

BACKGROUND AND PURPOSE

Patient-reported experience measures (PREMs) assess patients' perception of health care. We aimed to identify all reported PREMs for stroke care and critically appraise psychometric properties of PREMs validated for patients with stroke.

METHODS

Studies on the development, validation, or utilization of PREMs for adult patients with stroke were systematically identified. The Consensus-Based Standards for the Selection of Health Measurement Instruments criteria were used to appraise psychometric performance.

RESULTS

We included 18 studies, examining 13 PREMs. Two PREMs had been developed for stroke care: Consumer Quality Index: Cerebrovascular Accident and Riksstroke. Consumer Quality Index: Cerebrovascular Accident was given a positive psychometric assessment, but its length and limited language applicability impede clinical implementation. Riksstroke was appraised as doubtful. Eleven PREMs were generic. The psychometric performance of 5 generic PREMS, validated for patients with stroke, received conflicting assessments. Six generic PREMs had not been validated in patients with stroke and were therefore not assessed for instrument performance.

CONCLUSIONS

Thirteen PREMs have been published for use in stroke care. The stroke-specific Consumer Quality Index: Cerebrovascular Accident has favorable psychometric performance but lacks practical feasibility. Other PREMs have inadequate or unknown psychometric properties. This indicates the need for developing stroke-specific PREMs to support quality improvement and enhance patient-centered care.