Evaluating stroke rehabilitation provision in Thailand: analysis of real-world data, economic evaluation and value of implementation

Stroke is the second largest cause of death in Thailand and many stroke survivors suffer from disability after their stroke. The ministry of public health (MOPH) Thailand published a service plan strategy for improvement in service delivery and has endorsed new rehabilitation guidelines and policy in 2019, which recommended to provide an intensive inpatient-based rehabilitation programme to eligible stroke patients. However, there is currently limited evidence at national level regarding service provision, patients’ health outcomes, as well as cost-effectiveness and value of implementation of the new rehabilitation policy. Heath technology assessment (HTA) has received increased attention in the policy decision making process in the past decades in Thailand for assisting policy makers to enhance the allocation of resources. Economic evaluation and value of implementation of new interventions are useful tools to inform evidence-based decision making to maximise the use of cost-effective technology into real-world practice. This study aims to assess the current situation, impact on stroke service delivery, and to evaluate the implications of the endorsement of the new policy of rehabilitation services and estimate cost-effectiveness and value of implementation of this new rehabilitation strategy. A multi-methods approach was utilised, including primary data collection in the form of a hospital survey, the analysis of routinely collected real-world data, a systematic literature review, and an economic evaluation and value of implementation analyses. It is essential to consider a provider’s capacity and service delivery in relation to the new service plan strategy. In Chapter 2, this thesis assessed the availability of stroke services and hospital facilities at different hospital levels in Thailand. In Chapter 3, national administrative stroke data, covering about 75% of the Thai population, were analysed to examine the extent to which the stroke service plan improvement affects health resource utilisation, costs, and health outcomes of stroke patients. Chapter 2 presents results from a hospital survey of tertiary hospitals across Thailand, which are categorised into advanced-level, standard-level and mid-level hospitals. Findings confirm that hospitals at all levels are likely to have shown improvement in service delivery, achieving the goals set by the service plan strategy in terms of setting up stroke units with essential supportive features for acute stroke treatment. However, some challenges remain in order to improve quality of care. These include establishing health information systems to record clinical measurements and health outcome measures, e.g. the Barthel index score, during the post-acute phase. This should be done to ensure continuity of care between hospitals, health regions and at national level. Using national administrative stroke data, stroke services were evaluated in terms of resource utilisation, costs and health outcomes in Chapter 3. Resource use was measured and costs estimated using a two-part model to address issues of zero-cost observations. Parametric survival analysis was used to assess health outcomes, namely all-cause mortality and recurrent stroke events. Though the Thai MOPH attempted to enhance the quality of stroke care by improving treatment during the acute phase, treatment and services during the post acute phase still present challenges. Findings revealed a low proportion of stroke survivors accessed rehabilitation services. But patients who received rehabilitation incurred lower mean annual medical cost and had a 15% decrease in the risk of mortality. A systematic review of economic evaluations of rehabilitation interventions was performed in Chapter 4 to review and assess existing economic models of rehabilitation services to identify an appropriate rehabilitation model for a Thai context. The findings showed that the majority of new rehabilitation interventions/services were likely to be cost-saving or cost-effective. However, these studies were moderately heterogeneous in their economic evaluation components. Most importantly, only direct-medical costs, especially costs related to the new intervention, were considered, while costs due to lost productivity, including informal care costs, were rarely considered. Based on results from the systematic review, an economic evaluation and value of implementation analysis of the new rehabilitation policy were performed to assess whether this initiative presents value for money for the Thai MOPH. Findings showed that inpatient rehabilitation was cost-saving from a provider perspective. It was not cost-effective when adopting a societal perspective. Only when direct non-medical costs were reduced by 20% in sensitivity analyses, the intervention was found to be cost-effective at a willingness to pay threshold of 160,000 Baht. At the current level of rehabilitation implementation, the benefits of new the rehabilitation policy is of value to The Thai MOPH which means it is worth implementing. The expected value of perfect implementation, as net monetary benefit (NMB), is approximately 23,359 Baht per person or 7.9 billion Baht over five years from a provider perspective. From a societal perspective, if non-medical costs were reduced by 25%, the rehabilitation programme would be worth implementing. Further, at the current cost of rehabilitation implementation, the actual level of implementation that would need to be achieved should be at least 69% of eligible patients over five years, so that the NMB to the Thai MOPH would be greater than the implementation costs. Finally, healthcare intervention that have been shown to be cost-effective will be beneficial to patients and the wider healthcare system if these are offered and used in clinical practice. This thesis shows the potential of how evidence generated from real-world data can complement existing evidence from the literature to generate new knowledge to support Thai decision makers in designing the implementation strategies to ensure continuity in stroke care along the stroke care pathway

Real-world safety of intravitreal bevacizumab and ranibizumab treatments for retinal diseases in Thailand: a prospective observational study

Background: There is very limited evidence examining serious systemic adverse events (SSAEs) and post-injection endophthalmitis of intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) treatments in Thailand and low- and middle-income countries. Moreover, findings from the existing trials might have limited generalizability to certain populations and rare SSAEs. Objectives: This prospective observational study aimed to assess and compare the safety profiles of IVB and IVR in patients with retinal diseases in Thailand. Methods: Between 2013 and 2015, 6354 patients eligible for IVB or IVR were recruited from eight hospitals. Main outcomes measures were prevalence and risk of SSAEs, mortality, and endophthalmitis during the 6-month follow-up period. Results: In the IVB and IVR groups, 94 and 6% of patients participated, respectively. The rates of outcomes in the IVB group were slightly greater than in the IVR group. All-cause mortality rates in the IVB and IVR groups were 1.10 and 0.53%, respectively. Prevalence rates of endophthalmitis and non-fatal strokes in the IVB group were 0.04% of 16,421 injections and 0.27% of 5975 patients, respectively, whereas none of these events were identified in the IVR group. There were no differences between the two groups in the risks of mortality, arteriothrombotic events (ATE), and non-fatal heart failure (HF). Adjustment for potential confounding factors and selection bias using multivariable models for time-to-event outcomes and propensity scores did not alter the results. Conclusions: The rates of SAEs in both groups were low. The IVB and IVR treatments were not associated with significant risks of mortality, ATE, and non-fatal HF. Trial Registration: Thai Clinical Trial Registry identifier TCTR20141002001

Availability of stroke services and hospital facilities at different hospital levels in Thailand: A cross-sectional survey study

No abstract available

Stroke resource utilisation and all-cause mortality in Thailand: a national health insurance database study 2017-2020

No abstract available

A real-world study of effectiveness of intravitreal bevacizumab and ranibizumab injection for treating retinal diseases in Thailand

Abstract Background To evaluate the effectiveness of intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) in actual practice for treating patients with retinal diseases in Thailand. Methods A prospective, multi-centre, observational study was conducted among eight hospitals in their ophthalmology outpatient departments. Participants consisted of patients who had previously not received any IVB or IVR treatment between 2013 and 2014. The primary outcome measurement was the change in best-corrected visual acuity (BCVA) at the end of the follow-up period compared to baseline. Results There were 1629 treatment-naïve patients for the pro re nata (PRN) treatment pattern and 226 treatment-naive patients for the three-injections (3Inj) treatment pattern. BCVA improvements were found in 35% of the PRN group and 47% of the 3Inj group; however, it was not clinically meaningful between the IVB and IVR groups (P-value = 0.568 for PRN, P-value = 0.103 for 3Inj). A multivariable logistic regression (using the propensity score) showed that positive factors associated with vision improvement for the PRN pattern were the number of drug injections, having retinal vein occlusion, and under 60 years of age, while good BCVA at baseline was a negative predictive factor. For the 3Inj pattern, under 60 years of age and baseline BCVA were statistically significant predictors. Nonetheless, diabetes mellitus (DM) without other comorbidities was a statistically significant predictor of low response to vision improvement compared to DM with other comorbidities. Conclusions This study was the first observational, prospective study to evaluate the real-life effectiveness of IVB and IVR in Thailand. The majority of participants who used IVB or IVR showed improvements in BCVA after treatment. Further evaluation such as long-term follow-ups and subsequent comparison of effectiveness between IVB and IVR should be investigated due to the limited sample of IVR patients. Trial registration Thai Clinical Trial Registry TCTR20141002001. Registered 02 October 2014 (retrospectively registered)