Cost-effectiveness of very brief interventions promoting physical activity: an application of the iterative approach in decision making

Economic evaluations are increasingly used in healthcare decision-making. An iterative approach to economic evaluation has been proposed as good practice in which economic evaluations are re-performed as new evidence becomes available throughout the lifecycle of health technology. Decision analytical models play a key role within this process as they provide a structure in which evidence from a range of sources can be synthesised along with Bayesian updating in order to answer the cost-effectiveness problems. This allows the use of the value of information (VoI) methods that help inform further research priority setting. Physical activity (PA) interventions, in general, are considered good value for money however little is known about the cost-effectiveness of very brief interventions (VBIs) in PA promotion. The thesis aims to explore the feasibility of using an iterative approach to decision-making in the context of the cost-effectiveness of VBIs to promote PA. Using VBI as a case study, this thesis explores the practical and methodological issues of applying an iterative approach to economic evaluation and considers potential reasons as to why the framework has not been widely implemented to date. Using VBI as a case study provided the opportunity to examine the challenges involved in undertaking an economic evaluation of very brief PA interventions in real time. This thesis explored the feasibility of applying the iterative process to evaluate the cost-effectiveness of VBIs in PA promotion in a time-constrained setting. A decision analytic model was developed at the outset of the thesis and employed iteratively to handle the evolving evidence base of VBIs in PA promotion. Although there are several merits of applying such a framework in real life economic evaluation, in the case of the VBI study, it was not viable to fully exploit VoI analyses and follow the process iteratively

Cost-effectiveness of physical activity interventions in adolescents: model development and illustration using two exemplar interventions.

OBJECTIVE: To develop a model to assess the long-term costs and health outcomes of physical activity interventions targeting adolescents. DESIGN: A Markov cohort simulation model was constructed with the intention of being capable of estimating long-term costs and health impacts of changes in activity levels during adolescence. The model parameters were informed by published literature and the analysis took a National Health Service perspective over a lifetime horizon. Univariate and probabilistic sensitivity analyses were undertaken. SETTING: School and community. PARTICIPANTS: A hypothetical cohort of adolescents aged 16 years at baseline. INTERVENTIONS: Two exemplar school-based: a comparatively simple, after-school intervention and a more complex multicomponent intervention compared with usual care. PRIMARY AND SECONDARY OUTCOME MEASURES: Incremental cost-effectiveness ratio as measured by cost per quality-adjusted life year gained. RESULTS: The model gave plausible estimates of the long-term effect of changes in physical activity. The use of two exemplar interventions suggests that the model could potentially be used to evaluate a number of different physical activity interventions in adolescents. The key model driver was the degree to which intervention effects were maintained over time. CONCLUSIONS: The model developed here has the potential to assess long-term value for money of physical activity interventions in adolescents. The two applications of the model indicate that complex interventions may not necessarily be the ones considered the most cost-effective when longer-term costs and consequences are taken into account.This report is an independent research commissioned and funded by the Department of Health Policy Research Programme (opportunities within the school environment to shift the distribution of activity intensity in adolescents, PR-R5-0213-25001). The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health. This work was also supported by the Medical Research Council (unit programme number: MC_UU_12015/7). The work was undertaken under the auspices of the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence which is funded by the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust (MR/K023187/1)

Are brief interventions to increase physical activity cost-effective? A systematic review.

OBJECTIVE: To determine whether brief interventions promoting physical activity are cost-effective in primary care or community settings. DESIGN: Systematic review of economic evaluations. METHODS AND DATA SOURCES: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, EconLit, SPORTDiscus, PEDro, the Cochrane library, National Health Service Economic Evaluation Database and the Cost-Effectiveness Analysis Registry up to 20 August 2014. Web of Knowledge was used for cross-reference search. We included studies investigating the cost-effectiveness of brief interventions, as defined by National Institute for Health and Care Excellence, promoting physical activity in primary care or the community. Methodological quality was assessed using Drummond's checklist for economic evaluations. Data were extracted from individual studies fulfilling selection criteria using a standardised pro forma. Comparisons of cost-effectiveness and cost-utility ratios were made between studies. RESULTS: Of 1840 identified publications, 13 studies fulfilled the inclusion criteria describing 14 brief interventions. Studies varied widely in the methods used, such as the perspective of economic analysis, intervention effects and outcome measures. The incremental cost of moving an inactive person to an active state, estimated for eight studies, ranged from £96 to £986. The cost-utility was estimated in nine studies compared with usual care and varied from £57 to £14 002 per quality-adjusted life year; dominant to £6500 per disability-adjusted life year; and £15 873 per life years gained. CONCLUSIONS: Brief interventions promoting physical activity in primary care and the community are likely to be inexpensive compared with usual care. Given the commonly accepted thresholds, they appear to be cost-effective on the whole, although there is notable variation between studies.This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0608-10079).This is the final version of the article. It first appeared from BMJ via http://dx.doi.org/10.1136/bjsports-2015-09465

Comparative analysis of COVID-19 case fatality rate between two waves in Nepal

The first COVID-19 case in Nepal was reported on January 23, 2020. Then infection, then, started to spread gradually, and October marked the most devastating increase in COVID-19 cases of the year 2020. Compared with the October 2020 peak in Nepal, the May 2021 peak of COVID-19 observed 2- and 10-fold rise in new cases and deaths per day, respectively. Given that this surprising increase in the death rate was not observed in other countries, this study analyzed the COVID-19 case fatality rates between the two peaks in Nepal. We found an increase in death rates among younger adults and people without comorbidities

The prevalence of exclusive breastfeeding practice in the first six months of life and its associated factors in Nepal: A systematic review and meta-analysis

Despite the global emphasis on breastfeeding, exclusive breastfeeding (EBF) in the first six months of life still lag behind the global recommendations in low- and middle-income countries, such as Nepal. This systematic review aims to determine the prevalence of EBF in the first six months of life and the associated factors determining EBF practices in Nepal. The databases PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, MIDIRS, DOAJ, and the NepJOL were searched for peer-reviewed literature published up to December 2021. The JBI quality appraisal checklist was used to assess the quality of studies. Analyses were performed by pooling together studies using the random-effect model, and the I2 test was used to assess the heterogeneity of the included studies. A total of 340 records were found, out of which 59 full-text were screened. Finally, 28 studies met the inclusion criteria and were selected for analysis. The pooled prevalence of EBF was 43 % (95 % confidence interval: 34–53). The odds ratio for the type of delivery was 1.59 (1.24–2.05), for ethnic minority groups 1.33 (1.02–1.75) and for first-birth order 1.89 (1.33–2.67). We found a lower prevalence of exclusive breastfeeding practice in Nepal compared to the national target. Multifaceted, effective, evidence-based interventions would encourage individuals in the exclusive breastfeeding journey. Incorporating the BEF counselling component into Nepal’s existing maternal health counselling package may help promote exclusive breastfeeding practice. Further research to explore the reasons for the suboptimal level of EBF practice would help develop the targeted interventions pragmatically

Using discrete choice experiments to elicit preferences for digital wearable health technology for self-management of chronic kidney disease

Objectives: Wearable digital health technologies (DHTs) have the potential to improve chronic kidney disease (CKD) management through patient engagement. This study aimed to investi gate and elicit preferences of individuals with CKD toward wearable DHTs designed to support self-management of their condition. Methods: Using the results of our review of the published literature and after conducting qualitative patient interviews, five-choice attributes were identified and included in a discrete choice experiment. The design consisted of 10-choice tasks, each comprising two hypothetical technologies and one opt-out scenario. We collected data from 113 adult patients with CKD stages 3–5 not on dialysis and analyzed their responses via a latent class model to explore preference heterogeneity. Results: Two patient segments were identified. In all preference segments, the most important attributes were the device appearance, format, and type of information provided. Patients within the largest preference class (70 percent) favored information provided in any format except the audio, while individuals in the other class preferred information in text format. In terms of the style of engagement with the device, both classes wanted a device that provides options rather than telling them what to do. Conclusions: Our analysis indicates that user preferences differ between patient subgroups, supporting the case for offering a different design of the device for different patients’ strata, thus moving away from a one-size-fits-all service provision. Furthermore, we showed how to leverage the information from user preferences early in the R&D process to inform and support the provision of nuanced person-centered wearable DHT

Burden of tuberculosis and hepatitis co-infection among people living with HIV in Nepal: a systematic review and meta-analysis

People living with HIV (PLHIV) are prone to tuberculosis (TB) and hepatitis co-infections, which cause substantial burden on morbidity and mortality. However, data on the burden of HIV co-infection from a specific low- and middle-income country are limited. To address this gap in evidence, a meta-analysis of published literature and country surveillance report was conducted to estimate the burden of TB, hepatitis B (HBV) and hepatitis C (HCV) co-infection among PLHIV in Nepal. Twenty-three studies, including 5900 PLHIV, were included in the meta-analysis. The pooled prevalence of HIV-TB, HIV-HBV and HIV-HCV co-infection was 19% (95% CI, 10-28%), 3% (2-5%) and 19% (4-33%), respectively. Low CD4 cell count (pooled odds ratio [OR] 4.38, 95% CI 1.11-17.25), smoking (3.07, 1.48-6.37) and alcohol drinking (3.12, 1.52-6.43) were significantly correlated with HIV-TB co-infection. The odds of HCV co-infection was greater in PLHIV, who were male (5.39, 1.54-18.89) and drug users (166.26, 15.94-1734.44). PLHIV who were on antiretroviral therapy had a reduced risk of HCV co-infection (0.49, 0.36-0.66) than the general PLHIV population. The burden of TB and hepatitis co-infection among PLHIV in Nepal was high. Regular screening of PLHIV for co-infections and prompt initiation of treatment are essential to reduce the transmission of infection and improve quality of life

Community Health Workers Can Identify and Manage Possible Infections in Neonates and Young Infants: MINI\u2014A Model from Nepal

The mortality rates of infants and children aged less than five years are declining globally and in Nepal but less among neonates. Most deliveries occur at home without skilled attendants, and most neonates may not receive appropriate care through the existing medical systems. So, a community-based pilot programme\u2014 Morang Innovative Neonatal Intervention (MINI) programme\u2014was implemented in Morang district of Nepal to see the feasibility of bringing the management of sick neonates closer to home. The objective of this model was to answer the question: "Can a team of female community health volunteers and paid facility-based community health workers (collectively called CHWs) within the existing heath system correctly follow a set of guidelines to identify possible severe bacterial infection in neonates and young infants and successfully deliver their treatment?" In the MINI model, the CHWs followed an algorithm to classify sick young infants with possible severe bacterial infection (PSBI). Female Community Health Volunteers (FCHVS) were trained to visit homes soon after delivery, record the birth, counsel mothers on essential newborn care, and assess the newborns for danger-signs. Infants classified as having PSBI, during this or subsequent contacts, were treated with co-trimoxazole and referred to facility-based CHWs for seven-day treatment with injection gentamicin. Additional supervisory support was provided for quality of care and intensified monitoring. Of 11,457 livebirths recorded during May 2005-April 2007, 1,526 (13.3%) episodes of PSBI were identified in young infants. Assessment of signs by the FCHVs matched that of more highly-trained facility-based CHWs in over 90% of episodes. Treatment was initiated in 90% of the PSBI episodes; 93% completed a full course of gentamicin. Case fatality in those who received treatment with gentamicin was 1.5% [95% confidence interval (CI) 1.0-2.3] compared to 5.3% (95% CI 2.6-9.7) in episodes that did not receive any treatment. Within the existing government health infrastructure, the CHWs can assess and identify possible infections in neonates and young infants and deliver appropriate treatment with antibiotics. This will result in improvement in the likelihood of survival and address one of the main causes of neonatal mortality

Clinical and cost-effectiveness of individualised (early) patient-directed rehabilitation versus standard rehabilitation after surgical repair of the rotator cuff of the shoulder: protocol for a multi-centre, randomised controlled trial with integrated Quintet Recruitment Intervention (RaCeR 2).

Introduction: Despite the high number of operations and surgical advancement, rehabilitation after rotator cuff repair has not progressed for over 20 years. The traditional cautious approach might be contributing to sub-optimal outcomes. Our aim is to assess whether individualised (early) patient-directed rehabilitation results in less shoulder pain and disability at 12 weeks after surgical repair of full-thickness tears of the rotator cuff compared to current standard (delayed) rehabilitation. Methods and analysis: The rehabilitation after rotator cuff repair (RaCeR 2) study is a pragmatic multi-centre, open label, randomised controlled trial with internal pilot phase. It has a parallel group design with 1:1 allocation ratio, full health economic evaluation, and Quintet Recruitment Intervention. Adults awaiting arthroscopic surgical repair of a full-thickness tear are eligible to participate. Upon completion of surgery, 638 participants will be randomised. The intervention (individualised early patient-directed rehabilitation) includes advice to the patient to remove their sling as soon as they feel able, gradually begin using their arm as they feel able and a specific exercise programme. Sling removal and movement is progressed by the patient over time according to agreed goals and within their own pain and tolerance. The comparator (standard rehabilitation) includes advice to the patient to wear the sling for at least four weeks and only to remove while eating, washing, dressing or performing specific exercises. Progression is according to specific timeframes rather than as the patient feels able. The primary outcome measure is the Shoulder Pain and Disability Index (SPADI) total score at 12-week post-randomisation. The trial timeline is 56 months in total, from September 2022. <br/

Manipulating a qubit through the backaction of sequential partial measurements and real-time feedback

Quantum measurements not only extract information from a system but also alter its state. Although the outcome of the measurement is probabilistic, the backaction imparted on the measured system is accurately described by quantum theory. Therefore, quantum measurements can be exploited for manipulating quantum systems without the need for control fields. We demonstrate measurement-only state manipulation on a nuclear spin qubit in diamond by adaptive partial measurements. We implement the partial measurement via tunable correlation with an electron ancilla qubit and subsequent ancilla readout. We vary the measurement strength to observe controlled wavefunction collapse and find post-selected quantum weak values. By combining a novel quantum non-demolition readout on the ancilla with real-time adaption of the measurement strength we realize steering of the nuclear spin to a target state by measurements alone. Besides being of fundamental interest, adaptive measurements can improve metrology applications and are key to measurement-based quantum computing.Comment: 6 pages, 4 figure