Cost-effectiveness of asthma control: an economic appraisal of the GOAL study

<i>Background</i>: The Gaining Optimal Asthma ControL (GOAL) study has shown the superiority of a combination of salmeterol/fluticasone propionate (SFC) compared with fluticasone propionate alone (FP) in terms of improving guideline defined asthma control. <i>Methods</i>: Clinical and economic data were taken from the GOAL study, supplemented with data on health related quality of life, in order to estimate the cost per quality adjusted life year (QALY) results for each of three strata (previously corticosteroid-free, low- and moderate-dose corticosteroid users). A series of statistical models of trial outcomes was used to construct cost effectiveness estimates across the strata of the multinational GOAL study including adjustment to the UK experience. Uncertainty was handled using the non-parametric bootstrap. Cost-effectiveness was compared with other treatments for chronic conditions. <i>Result</i>: Salmeterol/fluticasone propionate improved the proportion of patients achieving totally and well-controlled weeks resulting in a similar QALY gain across the three strata of GOAL. Additional costs of treatment were greatest in stratum 1 and least in stratum 3, with some of the costs offset by reduced health care resource use. Cost-effectiveness by stratum was £7600 (95% CI: £4800–10 700) per QALY gained for stratum 3; £11 000 (£8600–14 600) per QALY gained for stratum 2; and £13 700 (£11 000–18 300) per QALY gained for stratum 1. <i>Conclusion</i>: The GOAL study previously demonstrated the improvement in total control associated with the use of SFC compared with FP alone. This study suggests that this improvement in control is associated with cost-per-QALY figures that compare favourably with other uses of scarce health care resources

Diagnostic and Prognostic Utility of Procalcitonin in Patients Presenting to the Emergency Department with Dyspnea

Background Among patients in the emergency department, dyspnea is a common complaint and can pose a diagnostic challenge. Biomarkers are used increasingly to improve diagnostic accuracy and aid with prognostication in dyspneic patients. The purpose of this study was to examine the clinical utility of serum procalcitonin (PCT) for the diagnosis of pneumonia in patients presenting to the emergency department with dyspnea. A secondary objective was to evaluate the prognostic value of PCT for death to 1 year. Methods This study pooled the patient populations of 2 prospective cohorts that previously enrolled patients presenting to 2 urban emergency departments with dyspnea. A total of 453 patients had serum samples available for biomarker analysis. Clinician certainty for the diagnosis of acutely decompensated heart failure was reviewed. Discrimination, calibration, and net reclassification improvement for the diagnosis of pneumonia as well as fatal outcomes were considered. The main outcome was accuracy of PCT for diagnostic categorization of pneumonia. The prognostic value of PCT for survival to 1 year was a secondary outcome. Results Pneumonia alone was diagnosed in 30 patients (6.6%), heart failure without pneumonia in 212 patients (47%), and both diagnoses in 30 patients (6.6%). Procalcitonin concentrations were higher in subjects with pneumonia (0.38 vs 0.06 ng/mL; P < .001). Area under the receiver operating characteristic curve for the diagnosis of pneumonia based on PCT was 0.84 (95% confidence interval [CI], 0.77-0.91; P < .001). Across all levels of clinician-based estimates of heart failure, PCT was sensitive and specific; notably, in patients judged with diagnostic uncertainty (n = 70), a PCT value of 0.10 ng/mL had the optimal balance of sensitivity and specificity (80% and 77%, respectively) for pneumonia. Adding PCT results to variables predictive of pneumonia resulted in a net reclassification improvement of 0.54 (95% CI, 0.24-0.83; P < .001) for both up- and down-reclassifying events. In adjusted analyses, elevated PCT was a predictor of 1-year mortality (hazard ratio 1.8; 95% CI, 1.4-2.3; P < .001) and was additive when elevated in conjunction with natriuretic peptides for this application. Conclusion In emergency department patients with acute dyspnea, PCT is an accurate diagnostic marker for pneumonia and adds independent prognostic information for 1-year mortality

Crafting knowledge exchange in the social science agenda

To any social science researcher the term “Knowledge Exchange” is a key buzzword in the academic community and wider society. In an article by Contandriopoulos, Lemire, Denis, and Tremblay (2010, p. 456) it was pointed out that knowledge exchange “rests on an implicit commonsense notion that this ‘knowledge’ must be evidence based”. This evidence, based within a social science context, relies upon two strands: theoretical data and empirical data. When examining the notion of Knowledge Exchange it becomes apparent that the concept has deep and meaningful connotations. These connotations have been driven by the involvements of the public and private sectors. Moreover, work carried out by Benneworth and Cunha (2015, p. 509) concludes that higher education institutions’ involvement in knowledge exchange “remains dynamic and influenced by universities” own strategic choices and relationships’. Traditionally, universities have had two key missions: to teach undergraduate/postgraduate students and to undertake research. Striukova and Rayna (2015, p. 488) have recently observed that universities now have a third mission, “knowledge exchange”, and that knowledge exchange plays a vital “integral part of the mix, without which the other two missions cannot run successfully.” Knowledge exchange is also a fundamental feature of “sustainable communities” (Powell, 2013) through the partnerships between HEIs and communities by which they serve. This is a point we will return to

Global oral cholera vaccine use, 2013-2018

Vaccination is a key intervention to prevent and control cholera in conjunction with water, sanitation and hygiene activities. An oral cholera vaccine (OCV) stockpile was established by the World Health Organization (WHO) in 2013. We reviewed its use from July 2013 to all of 2018 in order to assess its role in cholera control. We computed information related to OCV deployments and campaigns conducted including setting, target population, timelines, delivery strategy, reported adverse events, coverage achieved, and costs. In 2013-2018, a total of 83,509,941 OCV doses have been requested by 24 countries, of which 55,409,160 were approved and 36,066,010 eventually shipped in 83 deployments, resulting in 104 vaccination campaigns in 22 countries. OCVs had in general high uptake (mean administrative coverage 1st dose campaign at 90.3%; 2nd dose campaign at 88.2%; mean survey-estimated two-dose coverage at 69.9%, at least one dose at 84.6%) No serious adverse events were reported. Campaigns were organized quickly (five days median duration). In emergency settings, the longest delay was from the occurrence of the emergency to requesting OCV (median: 26days). The mean cost of administering one dose of vaccine was 2.98 USD. The OCV stockpile is an important public health resource. OCVs were generally well accepted by the population and their use demonstrated to be safe and feasible in all settings. OCV was an inexpensive intervention, although timing was a limiting factor for emergency use. The dynamic created by the establishment of the OCV stockpile has played a role in the increased use of the vaccine by setting in motion a virtuous cycle by which better monitoring and evaluation leads to better campaign organization, better cholera control, and more requests being generated. Further work is needed to improve timeliness of response and contextualize strategies for OCV delivery in the various settings

Challenges and priorities for pediatric critical care clinician-researchers in low- and middle-income countries

IntroductionThere is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high.Materials and methodsTo inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis.ResultsThe majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation.ConclusionLMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success

Global Impact of COVID-19 on Stroke Care

BACKGROUND: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide. AIMS: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy (MT), stroke, and intracranial hemorrhage (ICH) hospitalizations over a 3-month period at the height of the pandemic (March 1 to May 31, 2020) compared with two control 3-month periods (immediately preceding and one year prior). METHODS: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers. RESULTS: The hospitalization volumes for any stroke, ICH, and MT were 26,699, 4,002, and 5,191 in the 3 months immediately before versus 21,576, 3,540, and 4,533 during the first 3 pandemic months, representing declines of 19.2% (95%CI,-19.7 to -18.7), 11.5% (95%CI,-12.6 to -10.6), and 12.7% (95%CI,-13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/MT centers. High-volume COVID-19 centers (-20.5%) had greater declines in MT volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p \u3c 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions. CONCLUSION: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, MT procedures, and ICH admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/MT volumes

"How do pilates trained physiotherapists utilize and value pilates exercise for MSK conditions? A qualitative study"

Background Pilates is a popular exercise therapy approach offering numerous benefits, including muscular strength, flexibility, control, and core stability. Pilates has been widely utilized in the prevention and rehabilitation of a variety of musculoskeletal disorders. Objectives The aim of this study was to explore the experiences and opinions of Pilates trained NHS and private practice physiotherapists in the UK, regarding the perceived benefits, risks, delivery and rationale for this exercise method. Methods This qualitative study used a self‐designed electronic survey to retrieve the views of 30 physiotherapists, who had undertaken formal Pilates Instruction training, recruited by a purposive and snowball sampling method. Questions were either multiple choice or open‐ended, examined via thematic analysis. Results Physiotherapists identified the most important benefits of Pilates as reduction in fear‐avoidance, improving bodily awareness and increasing muscular strength. Exercises that promote general movement were highlighted as being particularly useful, with a majority recommending daily practice for optimum benefit. Participants recognized lack of core strength as a key indicator, whereas others criticized excessive focus on this principle. Conclusions Physiotherapists identified a range of inter‐linked benefits and recognized that Pilates is hugely modifiable. Individualizing exercises can further encourage participation and negate the restriction of some health conditions. NHS and Private Practice Therapists utilize Pilates in a similar way, although rationales for its use may differ, as the justification for Pilates exercise may be evolving. Pilates appears a valuable methodology in the NHS, which can help patients engage with activity

Cardiovascular disease, chronic kidney disease, and diabetes mortality burden of cardiometabolic risk factors from 1980 to 2010: A comparative risk assessment

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