Interventions for hyperhidrosis in secondary care : a systematic review and value-of-information analysis

Background: Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. The management of hyperhidrosis is uncertain and variable. Objective: To establish the expected value of undertaking additional research to determine the most effective interventions for the management of refractory primary hyperhidrosis in secondary care. Methods: A systematic review and economic model, including a value-of-information (VOI) analysis. Treatments to be prescribed by dermatologists and minor surgical treatments for hyperhidrosis of the hands, feet and axillae were reviewed; as endoscopic thoracic sympathectomy (ETS) is incontestably an end-of-line treatment, it was not reviewed further. Fifteen databases (e.g. CENTRAL, PubMed and PsycINFO), conference proceedings and trial registers were searched from inception to July 2016. Systematic review methods were followed. Pairwise meta-analyses were conducted for comparisons between botulinum toxin (BTX) injections and placebo for axillary hyperhidrosis, but otherwise, owing to evidence limitations, data were synthesised narratively. A decision-analytic model assessed the cost-effectiveness and VOI of five treatments (iontophoresis, medication, BTX, curettage, ETS) in 64 different sequences for axillary hyperhidrosis only. Results and conclusions: Fifty studies were included in the effectiveness review: 32 randomised controlled trials (RCTs), 17 non-RCTs and one large prospective case series. Most studies were small, rated as having a high risk of bias and poorly reported. The interventions assessed in the review were iontophoresis, BTX, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland (e.g. laser, microwave). There is moderate-quality evidence of a large statistically significant effect of BTX on axillary hyperhidrosis symptoms, compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was of low or very low quality. For axillary hyperhidrosis cost-effectiveness results indicated that iontophoresis, BTX, medication, curettage and ETS was the most cost-effective sequence (probability 0.8), with an incremental cost-effectiveness ratio of £9304 per quality-adjusted life-year. Uncertainty associated with study bias was not reflected in the economic results. Patients and clinicians attending an end-of-project workshop were satisfied with the sequence of treatments for axillary hyperhidrosis identified as being cost-effective. All patient advisors considered that the Hyperhidrosis Quality of Life Index was superior to other tools commonly used in hyperhidrosis research for assessing quality of life. Limitations: The evidence for the clinical effectiveness and safety of second-line treatments for primary hyperhidrosis is limited. This meant that there was insufficient evidence to draw conclusions for most interventions assessed and the cost-effectiveness analysis was restricted to hyperhidrosis of the axilla. Future work: Based on anecdotal evidence and inference from evidence for the axillae, participants agreed that a trial of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis would be most useful. The VOI analysis indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear that such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses

Acceso al servicio de atención prenatal para las mujeres de la Zona de Monteverde hasta el momento del parto

Abstract Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community. The purpose of this analysis is to conduct a retrospective, exploratory study of access and utilization of health care services from the prenatal period through parturition in the Monteverde Community. Initial interviews indicated that although universal health care is available to all women in the Monteverde zone through the CAJA, many women were not satisfied with the services they received and still others chose private physicians for care. A quantitative survey tool was utilized to assess the satisfaction of women with clinic services. In-depth semi-structured qualitative interviews were also conducted. The research group focused on women of childbearing age. Women were questioned about clinic utilization, satisfaction with services, and suggestions for improvements. The results of our study show that, overall, 67% of women are satisfied with women\u27s health services at the clinic. Women also reported their largest concern with the clinic is the quality of care and the experience of the doctors. Of those surveyed, 47% either disagreed or strongly disagreed that they were satisfied with the doctors at the clinic. The study also highlighted the need for additional services such as a birthing center, a laboratory, specialty services, and H1V/A1DS testing. While limitations to the current study exist, the findings warrant further investigation into the access and utilization of services at the Clínica Monteverde. Abstract Spanish Retrospectivo, estudio exploratorio del acceso y utilización de los servicios de salud para mujeres embarazadas en la comunidad de Monteverde. El propósito de este análisis es conducir un estudio exploratorio y retrospectivo del acceso y la utilización de los servicios de salud desde el periodo prenatal hasta el momento del parto en la zona de Monteverde. Las entrevistas iníciales indicaron que a pesar que los servicios de salud universal están disponibles para todas en la zona de Monteverde a través de la Caja, muchas mujeres no están satisfechas con los servicios que reciben y otras escogen a médicos privados para su atención medica. Una herramienta de medición cuantitativa fue utilizada para valorar la satisfacción de las mujeres con los servicios de la clínica. Para profundizar también se realizaron entrevistas cualitativas estructuradas. El grupo de investigación se enfoco en mujeres en edad reproductiva. A las mujeres se les pregunto acerca de la utilización de la clínica, la satisfacción con los servicios, y sugerencias para mejorar. Los resultados de nuestro estudio mostraron que el 67% de las mujeres están satisfechas con los servicios de salud para las mujeres en la clínica. Las mujeres reportaron, además, que están preocupadas con la calidad de la atención y la experiencia de los doctores. De las entrevistadas el 47% estaban en desacuerdo o en fuerte desacuerdo con los médicos de la clínica. El estudio, además, señalo la necesidad de tener servicios adicionales como un centro de nacimiento, un laboratorio, servicios especiales, y pruebas de diversas enfermedades venéreas. A pesar de las limitaciones de este estudio, los hallazgos son una garantía de más investigaciones en el acceso a la utilización de los servicios en la Clínica de Monteverde.https://digitalcommons.usf.edu/community_health/1080/thumbnail.jp

Acceso y utilización de servicios de salud desde el periodo prenatal hasta el parto por mujeres en la comunidad de Monteverde Fase I [Power Point]

Abstract Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community. Abstract Spanish Retrospectiva, estudio exploratorio y uso de servicios del cuidado de la salud para mujeres embarazadas en la comunidad de Monteverde.https://digitalcommons.usf.edu/community_health/1083/thumbnail.jp

Women’s access and utilization of health care services from the pre-natal period through parturition in the Monteverde Zone phase II

Abstract Follow up study of access and utilization of health care services for pregnant women in the Monteverde Community. Following the initial exploratory study entitled Women\u27s Access and Utilization of Health Care Services from Pre-natal Period through Parturition in the Monteverde, Zone, this phase of research focused on two areas which had been targeted for follow\u27 up. Using semi-structured interviews and reassessing the original data, the topics of standard of care during pregnancy and birth histories were examined. This included a brief historical review of obstetric care and medical transportation from The Monteverde area. Three medical personnel and four additional women who had children within the last 12 years were interviewed for a total of 17 interviews. Many women (50%, n =36) chose to have their care with private providers. However, all the women in our study delivered their children in public hospitals provided by the CAJA. The results of the study showed that like their predecessors, women from Monteverde often choose to wait near the hospital before their delivery (57%) rather than risking having to make the difficult trip to the closest hospital during labor. The average wait time before delivery was 10.86 days among seven women for whom this data was available. The choice of hospital was made for three primary reasons: proximity of the facility, family or friends nearby and because of the hospital\u27s reputation. Births occur frequently in transit as the local ambulance service reported that one worker alone had 14 deliveries over 17 year’s time. Despite these hardships, the majority (88%) of reported birth weights in our study was healthy and the district of Puntarenas has an infant mortality rate consistent with the rest of Costa Rica. Abstract Spanish Estudio de seguimiento de acceso y utilización de los servicios de salud para mujeres embarazadas en la comunidad de Monteverde.https://digitalcommons.usf.edu/community_health/1015/thumbnail.jp

Acceso y utilización de servicios de salud desde el periodo prenatal hasta el parto por mujeres en la comunidad de Monteverde Fase I [Power Point]

Abstract Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community. Abstract Spanish Retrospectiva, estudio exploratorio y uso de servicios del cuidado de la salud para mujeres embarazadas en la comunidad de Monteverde.https://digitalcommons.usf.edu/community_health/1083/thumbnail.jp

Acceso y utilización a los servicios de salud para las mujeres en los periodos prenatales hasta el momento de los partos en la zona de Monteverde Segunda Fase

Abstract Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community. Following the initial exploratory study entitled Women\u27s Access and Utilization of Health Care Services from Pre-natal Period through Parturition in the Monteverde, Zone, this phase of research focused on two areas which had been targeted for follow\u27 up. Using semi-structured interviews and reassessing the original data, the topics of standard of care during pregnancy and birth histories were examined. This included a brief historical review of obstetric care and medical transportation from The Monteverde area. Three medical personnel and four additional women who had children within the last 12 years were interviewed for a total of 17 interviews. Many women (50%, n =36) chose to have their care with private providers. However, all the women in our study delivered their children in public hospitals provided by the CAJA. The results of the study showed that like their predecessors, women from Monteverde often choose to wait near the hospital before their delivery (57%) rather than risking having to make the difficult trip to the closest hospital during labor. The average wait time before delivery was 10.86 days among seven women for whom this data was available. The choice of hospital was made for three primary reasons: proximity of the facility, family or friends nearby and because of the hospital\u27s reputation. Births occur frequently in transit as the local ambulance service reported that one worker alone had 14 deliveries over 17 year’s time. Despite these hardships, the majority (88%) of reported birth weights in our study was healthy and the district of Puntarenas has an infant mortality rate consistent with the rest of Costa Rica. Abstract Spanish Retrospectivo, estudio exploratorio de acceso y uso de servicios de cuidados de salud para mujeres embarazadas en la comunidad de Monteverde. Siguiendo al estudio exploratorio inicial titulado “Acceso al servicio de atención prenatal para las mujeres de la zona de Monteverde hasta el momento del parto” esta fase de la investigación se concentro en dos áreas que se habían planteado como objetivos para su seguimiento. Usando entrevistadas semiestructuradas y revalorando los datos, los tópicos normales de la atención durante el embarazo y las historias de nacimientos fueron examinados. Esto incluía una breve revisión histórica de la atención obstétrica y la transportación medica desde el area de Monteverde. Tres miembros del personal medico y otras cuatro mujeres quienes tuvieron hijos en los últimos doce años fueron entrevistadas para un total de 17 entrevistas. Muchas mujeres (50%, n=36) decidieron buscar atención privada. Sin embargo, todas las mujeres en nuestro estudio dieron a luz a sus hijos en los Hospitales provistos por la CAJA: Los resultados del estudio mostraron que al igual que sus predecesoras las mujeres de Monteverde a menudoescogieron esperar cerca del Hospital antes del parto (57%) en lugar de arriesgar hacer un viaje difícil al hospital mas cercano durante la labor de parto. El promedio de espera antes del nacimiento era de 10,86 dias entre siete mujeres para quienes los datos estaban disponibles. La escogencia del Hospital era hecha basada en tres razones primordiales: la cercanía al mismo, familiares o amigos cerca y la reputación que estos tienen. Los partos ocurren con frecuencia en transito puesto que el servicio de la ambulancia local reporto que un solo trabajador atendió los mismos por catorce veces en 17 años. A pesar de estas dificultades la mayoría (88%) de los pesos reportados al nacimiento en nuestro estudio eran saludables yla provincia de Puntarenas tiene una tasa de mortalidad infantil consistente con el resto de Costa Rica.https://digitalcommons.usf.edu/community_health/1081/thumbnail.jp

Women’s access and organization of health care services from pre-natal period through parturition in the Monteverde community Phase I [Power Point]

Abstract Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community Abstract Spanish Retrospectiva, estudio exploratorio del acceso y el uso de servicios de cuidados de la salud para mujeres embarazadas en la comunidad de Monteverdehttps://digitalcommons.usf.edu/community_health/1082/thumbnail.jp

Women’s access and organization of health care services from pre-natal period through parturition in the Monteverde community Phase I [Power Point]

Abstract Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community Abstract Spanish Retrospectiva, estudio exploratorio del acceso y el uso de servicios de cuidados de la salud para mujeres embarazadas en la comunidad de Monteverdehttps://digitalcommons.usf.edu/community_health/1082/thumbnail.jp

Women’s access and utilization of health care services from pre-natal period through parturition in the Monteverde Zone

Abstract Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community. The purpose of this analysis is to conduct a retrospective, exploratory study of access and utilization of health care services from the prenatal period through parturition in the Monteverde Community. Initial interviews indicated that although universal health care is available to all women in the Monteverde zone through the CAJA, many women were not satisfied with the services they received and still others chose private physicians for care. A quantitative survey tool was utilized to assess the satisfaction of women with clinic services. In-depth semi-structured qualitative interviews were also conducted. The research group focused on women of childbearing age. Women were questioned about clinic utilization, satisfaction with services, and suggestions for improvements. The results of our study show that, overall, 67% of women are satisfied with women\u27s health services at the clinic. Women also reported their largest concern with the clinic is the quality of care and the experience of the doctors. Of those surveyed, 47% either disagreed or strongly disagreed that they were satisfied with the doctors at the clinic. The study also highlighted the need for additional services such as a birthing center, a laboratory, specialty services, and H1V/A1DS testing. While limitations to the current study exist, the findings warrant further investigation into the access and utilization of services at the Clínica Monteverde. Abstract Spanish Retrospectivo, estudio exploratorio del acceso y uso de los servicios de atenció de la salud para mujeres embarazadas en la comunidad de Monteverde.https://digitalcommons.usf.edu/community_health/1014/thumbnail.jp