Evaluation of health outcomes in osteoarthritis patients after total knee replacement: a two-year follow-up

10.1186/1477-7525-8-87Health and Quality of Life Outcomes8

A review of health utilities across conditions common in paediatric and adult populations

<p>Abstract</p> <p>Background</p> <p>Cost-utility analyses are commonly used in economic evaluations of interventions or conditions that have an impact on health-related quality of life. However, evaluating utilities in children presents several challenges since young children may not have the cognitive ability to complete measurement tasks and thus utility values must be estimated by proxy assessors. Another solution is to use utilities derived from an adult population. To better inform the future conduct of cost-utility analyses in paediatric populations, we reviewed the published literature reporting utilities among children and adults across selected conditions common to paediatric and adult populations.</p> <p>Methods</p> <p>An electronic search of Ovid MEDLINE, EMBASE, and the Cochrane Library up to November 2008 was conducted to identify studies presenting utility values derived from the Health Utilities Index (HUI) or EuroQoL-5Dimensions (EQ-5D) questionnaires or using time trade off (TTO) or standard gamble (SG) techniques in children and/or adult populations from randomized controlled trials, comparative or non-comparative observational studies, or cross-sectional studies. The search was targeted to four chronic diseases/conditions common to both children and adults and known to have a negative impact on health-related quality of life (HRQoL).</p> <p>Results</p> <p>After screening 951 citations identified from the literature search, 77 unique studies included in our review evaluated utilities in patients with asthma (n = 25), cancer (n = 23), diabetes mellitus (n = 11), skin diseases (n = 19) or chronic diseases (n = 2), with some studies evaluating multiple conditions. Utility values were estimated using HUI (n = 33), EQ-5D (n = 26), TTO (n = 12), and SG (n = 14), with some studies applying more than one technique to estimate utility values. 21% of studies evaluated utilities in children, of those the majority being in the area of oncology. No utility values for children were reported in skin diseases. Although few studies provided comparative information on utility values between children and adults, results seem to indicate that utilities may be similar in adolescents and young adults with asthma and acne. Differences in results were observed depending on methods and proxies.</p> <p>Conclusions</p> <p>This review highlights the need to conduct future research regarding measurement of utilities in children.</p

Should Endovascular Repair Be Reimbursed for Low Risk Abdominal Aortic Aneurysm Patients? Evidence from Ontario, Canada

Background. This paper presents unpublished clinical and economic data associated with open surgical repair (OSR) in low risk (LR) patients and how it compares with EVAR and OSR in high risk (HR) patients with an AAA > 5.5 cm. Design. Data from a 1-year prospective observational study was used to compare EVAR in HR patients versus OSR in HR and LR patients. Results. Between 2003 and 2005, 140 patients were treated with EVAR and 195 with OSR (HR: 52; LR: 143). The 1-year mortality rate with EVAR was statistically lower than HR OSR patients and comparable to LR OSR patients. One-year health-related quality of life was lower in the EVAR patients compared to OSR patients. EVAR was cost-effective compared to OSR HR but not when compared to OSR LR patients. Conclusions. Despite a similar clinical effectiveness, these results suggest that, at the current price, EVAR is more expensive than open repair for low risk patients

A prospective, double-blind, randomized, controlled clinical trial comparing standard wound care with adjunctive hyperbaric oxygen therapy (HBOT) to standard wound care only for the treatment of chronic, non-healing ulcers of the lower limb in patients with diabetes mellitus: a study protocol

<p>Abstract</p> <p>Background</p> <p>It has been suggested that the use of adjunctive hyperbaric oxygen therapy improves the healing of diabetic foot ulcers, and decreases the risk of lower extremity amputations. A limited number of studies have used a double blind approach to evaluate the efficacy of hyperbaric oxygen therapy in the treatment of diabetic ulcers. The primary aim of this study is to assess the efficacy of hyperbaric oxygen therapy plus standard wound care compared with standard wound care alone in preventing the need for major amputation in patients with diabetes mellitus and chronic ulcers of the lower limb.</p> <p>Methods/Design</p> <p>One hundred and eighteen (59 patients per arm) patients with non-healing diabetic ulcers of the lower limb, referred to the Judy Dan Research and Treatment Centre are being recruited if they are at least 18 years of age, have either Type 1 or 2 diabetes with a Wagner grading of foot lesions 2, 3 or 4 on lower limb not healing for at least 4 weeks. Patients receive hyperbaric oxygen therapy every day for 6 weeks during the treatment phase and are provided ongoing wound care and weekly assessments. Patients are required to return to the study centre every week for an additional 6 weeks of follow-up for wound evaluation and management. The primary outcome is freedom from having, or meeting the criteria for, a major amputation (below knee amputation, or metatarsal level) up to 12 weeks after randomization. The decision to amputate is made by a vascular surgeon. Other outcomes include wound healing, effectiveness, safety, healthcare resource utilization, quality of life, and cost-effectiveness. The study will run for a total of about 3 years.</p> <p>Discussion</p> <p>The results of this study will provide detailed information on the efficacy of hyperbaric oxygen therapy for the treatment of non-healing ulcers of the lower limb. This will be the first double-blind randomized controlled trial for this health technology which evaluates the efficacy of hyperbaric oxygen therapy in prevention of amputations in diabetic patients.</p> <p>Trial registration</p> <p>ClinicalTrials.gov Identifier: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00621608">NCT00621608</a></p

Interprofessional Teams for Chronic Disease Management

Research Question: “Is there reliable scientific evidence to support team-based management of chronic disease and, if so, given the NL context (in terms of geography, demography, fiscal resources and health system capacities) what is the most effective and efficient way to organize, implement, and sustain team-based care for individuals with diabetes and chronic obstructive pulmonary disease (COPD) so as to derive the best possible outcomes for patients, providers, and the health system?” Findings: As we worked through the many challenges of synthesizing the evidence on team-based chronic disease management, the project team concluded, in consultation with our subject experts, that we are unable to answer this CHRSP question as formulated. As our report will show, the high-level research evidence on both the clinical and cost-effectiveness of team-based Chronic Disease Management is simply not available at this time. In short, the question itself is ahead of the published literature. We are hopeful that, as research in this subject area advances, we may be in a better position to provide some guidance on this question in future

The annual institutional long-term care needs in the St. John's Region

The St. John's region has approximately 1400 long-term care (LTC) beds in nursing homes and personal care homes. Despite this there are concerns that excessive numbers of acute care beds are occupied by clients awaiting long-term care placement that the waiting list for placement is too long, and that there is a mismatch between needs of clients and level of care provided in nursing homes. -- Actual placement within the long-term care (LTC) sector is influenced by services that are currently available, the desires/demands of clients as well as their needs. Accordingly, relating needs to utilization will assist in rational planning for LTC services to accommodate the expected growth in need as the population ages. -- The primary objective of this study was to determine the current status of the long-term care sector in the region. This analysis determined the needs of the clients entering the long-term care sector using validated scoring systems. It identified: -- the needs of the clients awaiting institutional placement; -- the proportion of acute care beds occupied while awaiting placement; -- the annual demands on the long-term care sector; -- appropriateness of client placement; -- time to placement. -- The availability of home support, the need for professional care provided in a nursing home (NH) and degree of disability was estimated for the 426 clients entering the LTC sector in 1995/96. Using validated assessment tools, the needs of these clients were compared to the actual placement. 4% of clients had no measurable disability and another 8% may have managed with home support. 20% of the clients recommended for NH care did not have a clinical indication for NH placement. Thus, the development of minimal criteria for placement in supervised care and in NH care may help maximize the utilization of the current number of beds. -- The median time to placement in a private personal care home was 8 days, whereas average wait for government-subsidized, level 1 supervised care in a NH was 302 days. There is a need for supervised care in the city aimed at clients who have disability, but who do not have need for NH level of care. The median time to placement of clients requiring nursing home placement (levels 2/3) was 96 days. A target time for placement should be developed. -- 139 LTC clients awaiting placement from an acute care hospital bed had an average wait of 97 days, and occupied less than 4% of the acute care beds. -- The annual incidence of clients requiring placement in a supervised environment was 110/426, and the incidence of those requiring the professional care available in a nursing home was 316/426, as determined by the assessment panel. Using objective criteria the former rate was 108/426 and the latter 268/426. -- The actual annual rate of placement in both supervised and nursing home care was commensurate with the demand when mortality and client wishes were taken into account. In fact there was no increase in the waiting list after 1 year of follow-up. -- We conclude that minimal criteria should be developed for admission to institutional long-term care. The current system is providing reasonable access to nursing homes, without excess blocking of acute care beds or increasing size of waiting lists. Restructuring of the long-term care system requires study of the needs and outcomes of current residents

The introduction of an unrestricted reimbursement policy for atypical antipsychotic medications in Newfoundland and Labrador: the impact on hospital utilization by patients with schizophrenia

Objectives: To measure total days of hospitalization, length of stay (LOS) and readmission risk for patients with schizophrenia following the introduction of an unrestricted reimbursement policy for costly atypical antipsychotic medications. -- Methods: A province-wide, observational, retrospective hospital chart review, using a before and after design, was used to identify all hospital admissions and quantify data on risk factors associated with LOS and readmission for acute episodes of schizophrenia. Three time periods were studied: 1) 1995/96 at the beginning of restricted access to atypical agents; 2) 1998 at the last year of restricted access; and 3) 2000 the second year of open access. Multivariable Cox proportional hazards and logistic regression models were used to identify risk factors influencing LOS and readmission within one year of discharge respectively. Retrospective administrative prescription claims provided data on the use of and expenditure for atypical agents before and after the policy change. -- Results: Total days hospitalization for schizophrenia in 1995/96 was 15,089, 16,318 in 1998 and 15,691 in 2000. There were 57 (18.2%) fewer patients admitted to hospital and 98 (16.7%) fewer admissions during the period of open access (2000) when compared to baseline (1995/96). However, median LOS in 2000 was significantly longer than in 1995/96 (22.0 vs. 15.0 days, P<0.001). Being admitted in 2000 compared to baseline was a significant predictor of increased LOS (HR: 3.04, CI=1.57-5.86, P=0.0009); independent of requiring ECT (HR: 2.49, CI=1.69-3.66, P<0/001); seclusion (HR: 1.87, CI=1.41-2.50, P<0.001); thought disorder (HR: 1.41, CI=1.11-1.81, P=0.006); suicidal ideation on admission (HR: 0.70, CI=0.57-0.86, P=0.0007) and discharging against medical advice (HR: 0.38; CI=0.27-0.54, P<0.001). No change m the number of readmissions was observed over the study period. -- Expenditures for atypical agents were $217,273 in 1995/96,$1.3 million in 1998, and 3.8 million in 2000, a 17.5 fold increase. -- Conclusions: The unrestricted reimbursement policy for atypical antipsychotic medications was associated with a large increase in government expenditure for these drugs, which was not associated with a decrease in hospital utilization in the province by schizophrenia sufferers. Although a decrease in hospital admissions occurred, this was negated by an increase in LOS