2,280 research outputs found
The clinical effectiveness and cost-effectiveness of inhaler devices used in the routine management of chronic asthma in older children: a systematic review and economic evaluation
Background:
This review examines the clinical effectiveness and
cost-effectiveness of hand-held inhalers to deliver
medication for the routine management of chronic
asthma in children aged between 5 and 15 years.
Asthma is a common disease of the airways, with a
prevalence of treated asthma in 5â15-year-olds of
around 12% and an actual prevalence in the community
as high as 23%. Treatment for the condition
is predominantly by inhalation of medication. There
are three main types of inhaler device, pressurised
metered dose, breath actuated, and dry powder, with
the option of the attachment of a spacer to the first
two devices under some prescribed circumstances.
Two recent reviews have examined the clinical and
cost-effectiveness evidence on inhaler devices, but
one was for children aged under 5 years and the
comparison in the second was made between pressurised
metered dose inhalers and other types only.
Objectives:
This review examines the clinical effectiveness and
cost-effectiveness of manual pressurised metered
dose inhalers, breath-actuated metered dose
inhalers, and breath-actuated dry powder inhalers,
with and without spacers as appropriate, to deliver
medication for the routine management of chronic
asthma in children aged between 5 and 15 years.
Methods:
Two previous HTA reviews have compared the
effectiveness of inhaler devices, one focusing on
asthma in children aged under 5 years and the
other on asthma and chronic obstructive airways
disease in all age groups. For the current review, a
literature search was carried out to identify all
evidence relating to the use of inhalers in older
children with chronic asthma. A search of in-vitro
studies undertaken for one of the previous reviews
was also updated.
The data sources used were: 15 electronic bibliographic
databases; the reference lists of one of the
previous HTA reports and other relevant articles;
health services research-related internet resources;
and all sponsor submissions.
Studies were selected according to strict inclusion
and exclusion criteria, and relevant information
concerning effectiveness and patient compliance
and preference was extracted directly on to an
extraction/evidence table. Quality assurance
was monitored.
Economic evaluation was undertaken by reviewing
existing cost-effective evidence. Further economic
modelling was carried out, and tables constructed
to determine device cost-minimisation and
incremental quality-adjusted life-year (QALY)
thresholds between devices.
Results:
Number and quality of studies, and
direction of evidence:
Fourteen randomised controlled studies were
identified relating to the clinical effectiveness of
inhaler devices for delivering ÎČ2-agonists. A further
five were on devices delivering corticosteroids and
one concerned the delivery of cromoglicate.
Overall, there were no differences in clinical
efficacy between inhaler devices, but a pressurised
metered dose inhaler with a spacer would appear
to be more effective than one without. These
findings endorse those of a previous HTA review
but extend them to other inhaler devices.
Seven randomised controlled trials examined the
impact on clinical effectiveness of using a nonchlorofluorocarbon
(CFC) propellant in place of
a CFC propellant in metered dose inhalers, both
pressurised and breath activated, although only one
study considered the latter type. No differences were
found between inhalers containing either propellant.
A further 30 studies of varying quality, from 12 randomised
controlled trials to non-controlled studies,
were identified that concerned the impact of use
by, and preference for, inhaler type, and treatment
adherence in children. Differences between the
studies, and limitations in comparative data between
various inhaler device types, make it difficult to draw
any firm conclusions from this evidence.
Summary of benefits:
No obvious benefits for one inhaler device type
over another for use in children aged 5â15 years
were identified.
Costs and cost per quality-adjusted
life-year:
Two approaches have been taken: cost-minimisation
and QALY threshold. In the QALY threshold
approach, additional QALYs that each device must
produce compared with a cheaper device to achieve
an acceptable cost per QALY were calculated. Using
the cheapest and most expensive devices for delivering
200 ÎŒg of beclometasone per day, assuming no
cost offset for any device, and a threshold of ÂŁ5000,
the largest QALY needed was 0.00807. With such
a small QALY increase, no intervention can be
categorically rejected as not cost-effective.
Conclusions:
Generalisability of findings:
On the available evidence there are no obvious
benefits for one inhaler device over another
when used by children aged 5â15 years with
chronic asthma. However, the evidence, in the
majority of cases, was compiled on children
with mild to moderate asthma and restricted
to a limited number of drugs. Therefore the
findings may not be generalisable to those at
the more severe end of the spectrum of the
disease or to inhaler devices delivering some
of the drugs used in the management of asthma.
Need for further research:
Many of the previous studies are likely to
have been underpowered. Further clinical
trials with a robust methodology, sufficient
power and qualitative components are needed
to demonstrate any differences in clinical
resource use and patientsâ asthma symptoms.
Further studies should also include the
behavioural aspects of patients towards their
medication and its delivery mechanisms.
It is acknowledged that sufficient power may
prove impractical owing to the large numbers
of patients required
Technical and Behavioral Interventions for Medication Adherence through Mobile Health
In this research, we present a novel intervention, Carrot and Stick, to improve the outcome of one of the self-management tasks, medication adherence (MA), among patients with chronic disease(s). Our design incorporates the growing importance of mobile health (m-health) in Health Information Technology (HIT) with the usersâ dependency on mobile phones to facilitate valuable behavioral changes. Drawing on Social Cognitive Theory, Social Exchange Theory, Goal-setting Theory, and peopleâs dependence on smartphones, we develop the functionalities in our intervention, including positive and negative reinforcement, goal-setting, and social connections. The iterative process of our development follows the Design Science Approach.
In the evaluation and validation of our intervention, we not only examine the interventionâs impacts on patients through analytical models and simulation but also demonstrate the possible active support of the intervention from healthcare providers based on the current pay-for-performance (P4P) scheme. Our results suggest that (1) with the help of electronic medication container, appropriate reminder design can reduce the patientsâ chances of forgetting doses, overdosing, and intaking doses at the wrong time, (2) positive reinforcement can help increase the probability of the patient achieving expected MA, while negative reinforcement has a further impact that is added to the increment, (3) our intervention can assist the patient in saving more than $600 per year, and (4) under the current P4P scheme, physicians with the exceptional performance or with bad performance are likely to invest in the intervention to change their patientsâ behaviors, while physicians with good performance are less likely to participate.
Our research is the first to utilize negative reinforcement in intervention design to enhance MA; it is also the first to provide corresponding interventional solutions that are customized according to elements derived from theories. Besides, the focus and understanding of healthcare providersâ involvement in the incentive program can facilitate the adoption, prescription, and implementation of the proposed intervention
The nurse of the Mediterranean
During the First World War Malta did not take an active part in the fighting. Britain was joined in an âententeâ a friendship agreement with France since 1904 and later with Russia in 1907. On the other hand Germany was allied to the Austrian- Hungerian Empire, hence when the Great War started in July 1914 there were France, Britain and Russia on one side and Germany and Austria-Hungary on the other. The British fleet âruled the wavesâ, hence with France and Britain as allies, to be joined later by Italy, the Mediterranean was more or less an allied lake, with Malta in the centre.peer-reviewe
Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP).
BACKGROUND: Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging.
OBJECTIVES: In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes.
METHODS: The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations.
LIMITATIONS: There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states.
CONCLUSION: These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded - and herein recommended - that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments
Pharmacotherapy review: a proposal to improve medication adherence among hypertensive patients
A revisĂŁo da farmacoterapia Ă© uma avaliação estruturada dos medicamentos com o objetivo de proporcionar aos pacientes o alcance dos objetivos terapĂȘuticos por meio da forma adequada de administração dos medicamentos. O objetivo foi analisar a influĂȘncia da revisĂŁo da farmacoterapia, por meio do aprazamento dos medicamentos, na adesĂŁo Ă medicação e no controle da hipertensĂŁo arterial sistĂȘmica. Trata-se de um estudo de intervenção nĂŁo controlado desenvolvido em trĂȘs momentos distintos. No primeiro, realizou-se a coleta de dados sobre o perfil dos pacientes e de suas medicaçÔes e a avaliação da adesĂŁo; no segundo momento, realizou-se a entrega do relatĂłrio da revisĂŁo aos pacientes e na terceira etapa avaliou-se o resultado da adesĂŁo e pressĂŁo arterial. A influĂȘncia da revisĂŁo foi medida por meio de testes estatĂsticos (pharmacotherapy review is a structured assessment of medicines, which aims to obtain a partnership with patients to achieve drug treatment goals and agreement about drug dosage, as well as when and how the drugs should be administered. The objective was to analyze the influence of pharmacotherapy review, by scheduling drug administration to improve medication adherence among antihypertensive patients. This study was an uncontrolled intervention developed in three distinct stages. The first stage included data collection on the profile of patients and their medications, and a preliminary assessment of medication adherence. In the second stage, the review report was delivered to patients. In the third stage, the results of blood pressure and medication adherence were assessed. The influence of the revision was measured through statistical tests (
Aiming Higher: Results From a State Scorecard on Health System Performance, 2009
Ranks states on thirty-eight indicators of healthcare access, prevention and treatment, avoidable hospital use and costs, equity, and healthy lives. Examines trends, including eroding adult insurance coverage, poor care coordination, and rising costs
How do the attitudes and beliefs of healthcare professionals and older people impact on the appropriate use of multi-compartment compliance aids by older people living at home
Compliance with medication regimes is a widely researched topic within the field of healthcare. Older people are considered to be a greater risk of non-compliance due to
multiple morbidities. Multi-compartment compliance aids are frequently issued to older people in an attempt to improve their medicines management.
This thesis aims to determine whether the attitudes and beliefs of both the older people who use MCAs and the healthcare professionals who request their use, influence the use of such devices by older people living in the community.
A preliminary study which investigated the use of MCAs in primary care is described. The findings suggested that over 100,00 people in the UK may be issued with a MCA
despite little evidence for their efficacy.
The literature review undertaken for this thesis concludes that very few studies have been undertaken in this area and those which have are mainly of poor quality. The
results from these studies failed to conclusively support the use of these devices and further rigorous conducted studies are needed.
The main study comprises qualitative, in-depth semi-structured interviews with older people, who are using a MCA and healthcare professionals. The interviews were
analysed using a grounded theory approach.
The study revealed that older people find MCAs easy to use and convenient although a minority of the participants did experience difficulties using the device. Maintaining
independence and remaining in control was important for all the older people and this influenced their attitudes towards using their MCA.
The healthcare professionals concurred with the observation that MCAs were convenient to use and despite a minority stating that MCAs assisted older people to remember to take their medication, the majority acknowledged that this was not the case. The healthcare professionals agreed that the decision to issue a MCA could be seen as paternalistic however there remained a belief that the issue of a MCA would assist the older person take their medication correctly.
The thesis concludes by providing details of a proposed method for undertaking a holistic, patient-centred, multi-disciplinary assessment of older people's medicines
management abilities
Pharmacy Posters - 2019
Pharmacy Posters - 2019https://scholarlycommons.libraryinfo.bhs.org/research_education/1013/thumbnail.jp
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