Background
Evidence-informed oral health policies (OHP) can be instrumental in ending the neglect of oral health globally. When appropriately developed and implemented, OHP can improve the efficiency ...of healthcare systems and the quality of health outcomes. However, more than half of the countries in the World Health Organization (WHO) African region do not have an oral health policy or even the existence of a policy in need of additional and more national-specific OHP as part of non-communicable diseases and universal health coverage agendas. The objective of this protocol's study is to determine the barriers to and facilitators for the creation, dissemination, implementation, monitoring, and evaluation of OHP in the WHO Africa region.
Methods
We will conduct a systematic search in Global Health, Embase, PubMed, PAIS, ABI/Inform, Web of Science, Academic Search Complete, Scopus, databases that index gray literature, and the WHO policy repositories. We will include qualitative, quantitative, or mixed-methods research studies and OHP documents published since January 1, 2002, which address stakeholders' perceptions and experiences regarding barriers to and facilitators for the creation, dissemination, implementation, monitoring, and evaluation of OHP in countries part of the WHO African region. We will produce descriptive statistics (frequencies and proportions) for quantitative data and conduct descriptive content analysis for qualitative data.
Discussion
To effectively establish evidence-based OHP in the WHO African region, it is crucial to recognize existing challenges and opportunities for progress. The findings of this review will be relevant for Chief Dental Officers at ministries of health, administrators of dental schools, or academic institutions in the WHO African region and will inform a stakeholder dialogue meeting in Kenya in November of 2023.
Registration
Open Science Framework:
https://doi.org/10.17605/OSF.IO/9KMWR
To advance oral health policies (OHPs) in the World Health Organization (WHO) African region, barriers to and facilitators for creating, disseminating, implementing, monitoring and evaluating OHPs in ...the region were examined.
Global Health, Embase, PubMed, Public Affairs Information Service Index, ABI/Inform, Web of Science, Academic Search Complete, Scopus, Dissertations Global, Google Scholar, WHO's Institutional Repository for Information Sharing (IRIS), the WHO Noncommunicable Diseases Document Repository and the Regional African Index Medicus and African Journals Online were searched. Technical officers at the WHO Regional Office for Africa were contacted. Research studies and policy documents reporting barriers to and facilitators for OHP in the 47 Member States in the WHO African region published between January 2002 and March 2024 in English, French or Portuguese were included. Frequencies were used to summarize quantitative data, and descriptive content analysis was used to code and classify barrier and facilitator statements.
Eighty-eight reports, including 55 research articles and 33 policy documents, were included. The vast majority of the research articles and policy documents were country-specific, but they were lacking for most countries. Frequently mentioned barriers across policy at all stages included financial constraints, a limited and poorly organized workforce, deprioritization of oral health, the absence of health information systems, inadequate integration of oral health services within the overarching health system and limited oral health literacy. Facilitators included a renewed commitment to establishing national OHPs, recognition of a need to diversify the oral health workforce, and an increased understanding of the influence of social determinants of health among oral health care providers.
Most countries lack a country-specific body of evidence to assist policymakers in anticipating barriers to and facilitators for OHPs. The barriers and facilitators relevant to disparate subnational, national, and regional conditions and circumstances must be considered to advance the creation, dissemination, implementation, monitoring and evaluation of OHPs in the WHO African region.
Background: Evidence-informed oral health policies (OHP) can be instrumental in ending the neglect of oral health globally. When appropriately developed and implemented, OHP can improve the ...efficiency of healthcare systems and the quality of health outcomes. However, more than half of the countries in the World Health Organization (WHO) African region did not have an oral health policy or even the existence of a policy in need of additional and more national-specific OHP as part of non-communicable diseases and universal health coverage agendas. The objective of this protocol's study is to determine the barriers to and facilitators for the creation, dissemination, implementation, monitoring, and evaluation of OHP in the WHO Africa region.
Methods: We will conduct a systematic search in Global Health, Embase, PubMed, PAIS, ABI/Inform, Web of Science, Academic Search Complete, Scopus, databases that index gray literature, and the WHO policy repositories. We will include qualitative, quantitative, or mixed-methods research studies and OHP documents published since January 1, 2002, which address stakeholders' perceptions and experiences regarding barriers to and facilitators for the creation, dissemination, implementation, monitoring, and evaluation of OHP in countries part of the WHO African region. We will produce descriptive statistics (frequencies and proportions) for quantitative data and conduct descriptive content analysis for qualitative data.
Discussion: To effectively establish evidence-based OHP in the WHO African region, it is crucial to recognize existing challenges and opportunities for progress. The findings of this review will be relevant for Chief Dental Officers at ministries of health, administrators of dental schools, or academic institutions in the WHO African region and will inform a stakeholder dialogue meeting in Kenya in November of 2023.
Registration: Open Science Framework:
https://doi.org/10.17605/OSF.IO/9KMWR
Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value.
To systematically review economic evaluations of QI interventions designed to ...reduce readmissions.
Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016).
Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs.
Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs.
Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P = .006).
Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.
Although quality improvement (QI) interventions can reduce central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI), their economic value is ...uncertain.
To systematically review economic evaluations of QI interventions designed to prevent CLABSI and/or CRBSI in acute care hospitals.
A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, Worldcat, prior systematic reviews (January 2004 to July 2016), and IDWeek conference abstracts (2013-2016), was conducted from 2013 to 2016. We included English-language studies of any design that evaluated organizational or structural changes to prevent CLABSI or CRBSI, and reported program and infection-related costs. Dual reviewers assessed study design, effectiveness, costs, and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net savings. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter-days per study per year.
Of 505 articles, 15 unique studies were eligible, together representing data from 113 hospitals. Thirteen studies compared Agency for Healthcare Research and Quality-recommended practices with usual care, including 7 testing insertion checklists. Eleven studies were based on uncontrolled before-after designs, 1 on a randomized controlled trial, 1 on a time-series analysis, and 2 on modeled estimates. Overall, the weighted mean IRR was 0.43 (95% CI, 0.35-0.51) and incremental net savings were $1.85 million (95% CI, $1.30 million to $2.40 million) per hospital over 3 years (2015 US dollars). Each $100 000-increase in program cost was associated with $315 000 greater savings (95% CI, $166 000-$464 000; P < .001). Infections and net costs declined when hospitals already used checklists or had baseline infection rates of 1.7 to 3.7 per 1000 catheter-days. Study quality was not associated with effectiveness or costs.
Interventions related to central venous catheters were, on average, associated with 57% fewer bloodstream infections and substantial savings to hospitals. Larger initial investments may be associated with greater savings. Although checklists are now widely used and infections have started to decline, additional improvements and savings can occur at hospitals that have not yet attained very low infection rates.
Quality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control ...among adults with type 1 or type 2 diabetes.
We used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLit, Centre for Reviews and Dissemination, New York Academy of Medicine's Grey Literature Report, and WorldCat (January 2004 to August 2016). We extracted data regarding intervention, study design, change in HbA
, time horizon, perspective, incremental net cost (studies lasting ≤3 years), incremental cost-effectiveness ratio (ICER) (studies lasting ≥20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA
and incremental net cost.
Of 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA
declined by 0.26% (95% CI 0.17-0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting ≤3 years, incremental net costs were $116 (95% CI -$612 to $843) per patient annually. Long-term ICERs were $100,000-$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000-$99,999/QALY in 1 RCT, $0-$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias.
Diverse multifaceted QI interventions that lower HbA
appear to be a fair-to-good value relative to usual care, depending on society's willingness to pay for improvements in health.
Abstract
Aim
The aim was to determine whether specialist‐led habit training using Habit Training with Biofeedback (HTBF) is more effective than specialist‐led habit training alone (HT) for chronic ...constipation and whether outcomes of interventions are improved by stratification to HTBF or HT based on diagnosis (functional defaecation disorder vs. no functional defaecation disorder) by radio‐physiological investigations (INVEST).
Method
This was a parallel three‐arm randomized single‐blinded controlled trial, permitting two randomized comparisons: HTBF versus HT alone; INVEST‐ versus no‐INVEST‐guided intervention. The inclusion criteria were age 18–70 years; attending specialist hospitals in England; self‐reported constipation for >6 months; refractory to basic treatment. The main exclusions were secondary constipation and previous experience of the trial interventions. The primary outcome was the mean change in Patient Assessment of Constipation Quality of Life score at 6 months on intention to treat. The secondary outcomes were validated disease‐specific and psychological questionnaires and cost‐effectiveness (based on EQ‐5D‐5L).
Results
In all, 182 patients were randomized 3:3:2 (target 384): HT
n
= 68; HTBF
n
= 68; INVEST‐guided treatment
n
= 46. All interventions had similar reductions (improvement) in the primary outcome at 6 months (approximately −0.8 points of a 4‐point scale) with no statistically significant difference between HT and HTBF (−0.03 points; 95% CI −0.33 to 0.27;
P
= 0.85) or INVEST versus no‐INVEST (0.22; −0.11 to 0.55;
P
= 0.19). Secondary outcomes showed a benefit for all interventions with no evidence of greater cost‐effectiveness of HTBF or INVEST compared with HT.
Conclusion
The results of the study at 6 months were inconclusive. However, with the caveat of under‐recruitment and further attrition at 6 months, a simple, cheaper approach to intervention may be as clinically effective and more cost‐effective than more complex and invasive approaches.
Background
Chronic constipation affects 1–2% of adults and significantly affects quality of life. Beyond the use of laxatives and other basic measures, there is uncertainty about management, ...including the value of specialist investigations, equipment-intensive therapies using biofeedback, transanal irrigation and surgery.
Objectives
(1) To determine whether or not standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback is more clinically effective than standardised specialist-led habit training alone, and whether or not outcomes of such specialist-led interventions are improved by stratification to habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or habit training alone based on prior knowledge of anorectal and colonic pathophysiology using standardised radiophysiological investigations; (2) to compare the impact of transanal irrigation initiated with low-volume and high-volume systems on patient disease-specific quality of life; and (3) to determine the clinical efficacy of laparoscopic ventral mesh rectopexy compared with controls at short-term follow-up.
Design
The Chronic Constipation Treatment Pathway (CapaCiTY) research programme was a programme of national recruitment with a standardised methodological framework (i.e. eligibility, baseline phenotyping and standardised outcomes) for three randomised trials: a parallel three-group trial, permitting two randomised comparisons (CapaCiTY trial 1), a parallel two-group trial (CapaCiTY trial 2) and a stepped-wedge (individual-level) three-group trial (CapaCiTY trial 3).
Setting
Specialist hospital centres across England, with a mix of urban and rural referral bases.
Participants
The main inclusion criteria were as follows: age 18–70 years, participant self-reported problematic constipation, symptom onset > 6 months before recruitment, symptoms meeting the American College of Gastroenterology’s constipation definition and constipation that failed treatment to a minimum basic standard. The main exclusion criteria were secondary constipation and previous experience of study interventions.
Interventions
CapaCiTY trial 1: group 1 – standardised specialist-led habit training alone (
n
= 68); group 2 – standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (
n
= 68); and group 3 – standardised radiophysiological investigations-guided treatment (
n
= 46) (allocation ratio 3 : 3 : 2, respectively). CapaCiTY trial 2: transanal irrigation initiated with low-volume (group 1,
n
= 30) or high-volume (group 2,
n
= 35) systems (allocation ratio 1 : 1). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy performed immediately (
n
= 9) and after 12 weeks’ (
n
= 10) and after 24 weeks’ (
n
= 9) waiting time (allocation ratio 1 : 1 : 1, respectively).
Main outcome measures
The main outcome measures were standardised outcomes for all three trials. The primary clinical outcome was mean change in Patient Assessment of Constipation Quality of Life score at the 6-month, 3-month or 24-week follow-up. The secondary clinical outcomes were a range of validated disease-specific and psychological scoring instrument scores. For cost-effectiveness, quality-adjusted life-year estimates were determined from individual participant-level cost data and EuroQol-5 Dimensions, five-level version, data. Participant experience was investigated through interviews and qualitative analysis.
Results
A total of 275 participants were recruited. Baseline phenotyping demonstrated high levels of symptom burden and psychological morbidity. CapaCiTY trial 1: all interventions (standardised specialist-led habit training alone, standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback and standardised radiophysiological investigations-guided habit training alone or habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback) led to similar reductions in the Patient Assessment of Constipation Quality of Life score (approximately –0.8 points), with no statistically significant difference between habit training alone and habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (–0.03 points, 95% confidence interval –0.33 to 0.27 points;
p
= 0.8445) or between standardised radiophysiological investigations and no standardised radiophysiological investigations (0.22 points, 95% confidence interval –0.11 to 0.55 points;
p
= 0.1871). Secondary outcomes reflected similar levels of benefit for all interventions. There was no evidence of greater cost-effectiveness of habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or stratification by standardised radiophysiological investigations compared with habit training alone (with the probability that habit training alone is cost-effective at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year gain;
p
= 0.83). Participants reported mixed experiences and similar satisfaction in all groups in the qualitative interviews. CapaCiTY trial 2: at 3 months, there was a modest reduction in the Patient Assessment of Constipation Quality of Life score, from a mean of 2.4 to 2.2 points (i.e. a reduction of 0.2 points), in the low-volume transanal irrigation group compared with a larger mean reduction of 0.6 points in the high-volume transanal irrigation group (difference –0.37 points, 95% confidence interval –0.89 to 0.15 points). The majority of participants preferred high-volume transanal irrigation, with substantial crossover to high-volume transanal irrigation during follow-up. Compared with low-volume transanal irrigation, high-volume transanal irrigation had similar costs (median difference –£8, 95% confidence interval –£240 to £221) and resulted in significantly higher quality of life (0.093 quality-adjusted life-years, 95% confidence interval 0.016 to 0.175 quality-adjusted life-years). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy resulted in a substantial short-term mean reduction in the Patient Assessment of Constipation Quality of Life score (–1.09 points, 95% confidence interval –1.76 to –0.41 points) and beneficial changes in all other outcomes; however, significant increases in cost (£5012, 95% confidence interval £4446 to £5322) resulted in only modest increases in quality of life (0.043 quality-adjusted life-years, 95% confidence interval –0.005 to 0.093 quality-adjusted life-years), with an incremental cost-effectiveness ratio of £115,512 per quality-adjusted life-year.
Conclusions
Excluding poor recruitment and underpowering of clinical effectiveness analyses, several themes emerge: (1) all interventions studied have beneficial effects on symptoms and disease-specific quality of life in the short term; (2) a simpler, cheaper approach to nurse-led behavioural interventions appears to be at least as clinically effective as and more cost-effective than more complex and invasive approaches (including prior investigation); (3) high-volume transanal irrigation is preferred by participants and has better clinical effectiveness than low-volume transanal irrigation systems; and (4) laparoscopic ventral mesh rectopexy in highly selected participants confers a very significant short-term reduction in symptoms, with low levels of harm but little effect on general quality of life.
Limitations
All three trials significantly under-recruited CapaCiTY trial 1,
n
= 182 (target 394); CapaCiTY trial 2,
n
= 65 (target 300); and CapaCiTY trial 3,
n
= 28 (target 114). The numbers analysed were further limited by loss before primary outcome.
Trial registration
Current Controlled Trials ISRCTN11791740, ISRCTN11093872 and ISRCTN11747152.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in
Programme Grants for Applied Research
; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.
PDF
