Integrating patient preferences in efficiency frontier analyses using the analytical hierarchy process

OBJECTIVES: In comparative effectiveness research and economic evaluations, benefits of technologies are measured using multiple outcomes measures. Information lacks however about the importance of these endpoints for patients. We propose a new methodology to integrate patient weighted outcomes in a cost-efficiency frontier. We illustrate this methodology by means of an efficiency frontier analysis of five alternative treatments of patients with equinovarus deformity poststroke. METHODS: The Analytic Hierarchy Process (AHP) is a technique for multi-criteria analysis. The AHP supported 140 patients to prioritize the outcome measures of treatments of equinovarus deformity poststroke, and 10 professionals to prioritize the treatments regarding the outcome measures. These outcome measures include functional outcomes, risk and side effects, comfort, daily effort, cosmetics, and impact of the treatment. Sensitivity analysis is based on bootstrapping of the participants’ priorities. Relative costs include the device related costs and the care related costs of the treatments. RESULTS: The overall effectiveness of soft-tissue surgery (.41) is ranked first, followed by orthopedic footwear (.18), ankle-footorthosis (.15), surface electrostimulation (.14), and finally implanted electrostimulation (.12). Implanted electrostimulation (.35) and soft-tissue surgery (.34) are considered to be most expensive, followed by surface electrostimulation (.26), orthopedic footwear (.03) and ankle-foot orthosis (.02). Based on these priorities of the treatments’ overall effectiveness and costs, an efficiency frontier was drawn that includes decision uncertainty. CONCLUSIONS: The results suggest that the cost-effectiveness of implanted electrostimulation and surface electrostimulation are unfavourable. This new methodology for efficiency frontier analysis allows decision makers to integrate the outcomes about the diverse values and costs of health care technology, and can be applied broadly. It is particularly suitable in the field of early technology assessment, since the AHP supports a systematic estimation of priors about the effectiveness of alternative treatments

Early detection and efficient therapy of cardiac angiosarcoma due to routine transesophageal echocardiography after cerebrovascular stroke

Primary malignant cardiac tumors (cardiac angiosarcomas) are exceedingly rare. Since there are initially nonspecific or missing symptoms, these tumors are usually diagnosed only in an advanced, often incurable stage, after the large tumor mass elicits hemodynamic obstructive symptoms. A 59-year-old female presented with symptoms of cerebral ischemia. A computed tomography (CT) scan showed changes suggestive of stroke. Transesophageal echocardiography revealed an inhomogeneous, medium-echogenic, floating mass at the roof of the left atrium near the mouth of the right upper pulmonary vein, indicative of a thrombus. At surgery, a solitary tumor was completely enucleated. Histologically, cardiac angiosarcoma was diagnosed. The patient received adjuvant chemotherapy and was free of symptoms and recurrence of disease at 14 months follow-up. Due to the fortuitous appearance of clinical signs indicative of stroke, cardiac angiosarcoma was diagnosed and effectively treated at an early, nonmetastatic, and therefore potentially curable stage. Although cardiac angiosarcoma is a rare disease, it should be taken into consideration as a potential cause of cerebral embolic disease

Analysing the attributes of Comprehensive Cancer Centres and Cancer Centres across Europe to identify key hallmarks.

There is a persistent variation in cancer outcomes among and within European countries suggesting (among other causes) inequalities in access to or delivery of high-quality cancer care. European policy (EU Cancer Mission and Europe's Beating Cancer Plan) is currently moving towards a mission-oriented approach addressing these inequalities. In this study, we used the quantitative and qualitative data of the Organisation of European Cancer Institutes' Accreditation and Designation Programme, relating to 40 large European cancer centres, to describe their current compliance with quality standards, to identify the hallmarks common to all centres and to show the distinctive features of Comprehensive Cancer Centres. All Comprehensive Cancer Centres and Cancer Centres accredited by the Organisation of European Cancer Institutes show good compliance with quality standards related to care, multidisciplinarity and patient centredness. However, Comprehensive Cancer Centres on average showed significantly better scores on indicators related to the volume, quality and integration of translational research, such as high-impact publications, clinical trial activity (especially in phase I and phase IIa trials) and filing more patents as early indicators of innovation. However, irrespective of their size, centres show significant variability regarding effective governance when functioning as entities within larger hospitals

Drosophila melanogaster as a Model Organism of Brain Diseases

Drosophila melanogaster has been utilized to model human brain diseases. In most of these invertebrate transgenic models, some aspects of human disease are reproduced. Although investigation of rodent models has been of significant impact, invertebrate models offer a wide variety of experimental tools that can potentially address some of the outstanding questions underlying neurological disease. This review considers what has been gleaned from invertebrate models of neurodegenerative diseases, including Alzheimer’s disease, Parkinson’s disease, metabolic diseases such as Leigh disease, Niemann-Pick disease and ceroid lipofuscinoses, tumor syndromes such as neurofibromatosis and tuberous sclerosis, epilepsy as well as CNS injury. It is to be expected that genetic tools in Drosophila will reveal new pathways and interactions, which hopefully will result in molecular based therapy approaches

A time-resolved proteomic and prognostic map of COVID-19

COVID-19 is highly variable in its clinical presentation, ranging from asymptomatic infection to severe organ damage and death. We characterized the time-dependent progression of the disease in 139 COVID-19 inpatients by measuring 86 accredited diagnostic parameters, such as blood cell counts and enzyme activities, as well as untargeted plasma proteomes at 687 sampling points. We report an initial spike in a systemic inflammatory response, which is gradually alleviated and followed by a protein signature indicative of tissue repair, metabolic reconstitution, and immunomodulation. We identify prognostic marker signatures for devising risk-adapted treatment strategies and use machine learning to classify therapeutic needs. We show that the machine learning models based on the proteome are transferable to an independent cohort. Our study presents a map linking routinely used clinical diagnostic parameters to plasma proteomes and their dynamics in an infectious disease

Clinical and virological characteristics of hospitalised COVID-19 patients in a German tertiary care centre during the first wave of the SARS-CoV-2 pandemic: a prospective observational study

Purpose: Adequate patient allocation is pivotal for optimal resource management in strained healthcare systems, and requires detailed knowledge of clinical and virological disease trajectories. The purpose of this work was to identify risk factors associated with need for invasive mechanical ventilation (IMV), to analyse viral kinetics in patients with and without IMV and to provide a comprehensive description of clinical course. Methods: A cohort of 168 hospitalised adult COVID-19 patients enrolled in a prospective observational study at a large European tertiary care centre was analysed. Results: Forty-four per cent (71/161) of patients required invasive mechanical ventilation (IMV). Shorter duration of symptoms before admission (aOR 1.22 per day less, 95% CI 1.10-1.37, p < 0.01) and history of hypertension (aOR 5.55, 95% CI 2.00-16.82, p < 0.01) were associated with need for IMV. Patients on IMV had higher maximal concentrations, slower decline rates, and longer shedding of SARS-CoV-2 than non-IMV patients (33 days, IQR 26-46.75, vs 18 days, IQR 16-46.75, respectively, p < 0.01). Median duration of hospitalisation was 9 days (IQR 6-15.5) for non-IMV and 49.5 days (IQR 36.8-82.5) for IMV patients. Conclusions: Our results indicate a short duration of symptoms before admission as a risk factor for severe disease that merits further investigation and different viral load kinetics in severely affected patients. Median duration of hospitalisation of IMV patients was longer than described for acute respiratory distress syndrome unrelated to COVID-19

Gezamenlijke besluitvorming (shared decision making): patiënt- en behandelaarsbehoeften in balans

Diverse technologische ontwikkelingen zijn waarneembaar binnen de gezondheidszorg. Schattingen van het ministerie van VWS gaan er vanuit dat van de totale groei in de zorg circa 75% door technologische innovaties wordt veroorzaakt. Er bestaat derhalve een sterke wens om deze technologieën op een goed onderbouwde manier te evalueren op effectiviteit en doelmatigheid. Daarbij wordt ook de wens van de potentiële gebruiker steeds belangrijker. Er is al langer een trend zichtbaar dat de traditionele arts-patiëntrelatie verandert naar een arts-cliëntrelatie, waarin de arts meer een rol inneemt als voorlichter en de patiënt de beslissing neemt. Het consumentenperspectief wordt daarin vooral aangehangen. In deze bijdrage wordt als stelling genomen dat een eenzijdig consumentenperspectief (net zomin als een eenzijdig medisch perspectief) geen goede mogelijkheden biedt om de wensen van de cliënt in een medische beslissing mee te nemen. Gestreefd moet worden naar een gezamenlijk besluitvormingsproces tussen behandelaar en hulpvrager. Deze "shared decision making" is binnen een aantal andere medische specialismen reeds ingevoerd (o.a. borstkankerbehandeling) en zou binnen de (dwarslaesie-)revalidatiegeneeskunde ook een waardevolle plaats kunnen innemen