Objectives Stroke is a leading cause for disability and morbidity associated with increased economic burden due to treatment and post-stroke care (PSC). The aim of our study is to provide information ...on resource consumption for PSC, to identify relevant cost drivers, and to discuss potential information gaps. Methods A systematic literature review on economic studies reporting PSC-associated data was performed in PubMed/MEDLINE, Scopus/Elsevier and Cochrane databases, Google Scholar and gray literature ranging from January 2000 to August 2016. Results for post-stroke interventions (treatment and care) were systematically extracted and summarized in evidence tables reporting study characteristics and economic outcomes. Economic results were converted to 2015 US Dollars, and the total cost of PSC per patient month (PM) was calculated. Results We included 42 studies. Overall PSC costs (inpatient/outpatient) were highest in the USA ($4850/PM) and lowest in Australia ($752/PM). Studies assessing only outpatient care reported the highest cost in the United Kingdom ($883/PM), and the lowest in Malaysia ($192/PM). Fifteen different segments of specific services utilization were described, in which rehabilitation and nursing care were identified as the major contributors. Conclusion The highest PSC costs were observed in the USA, with rehabilitation services being the main cost driver. Due to diversity in reporting, it was not possible to conduct a detailed cost analysis addressing different segments of services. Further approaches should benefit from the advantages of administrative and claims data, focusing on inpatient/outpatient PSC cost and its predictors, assuring appropriate resource allocation.
Abstract Models—mathematical frameworks that facilitate estimation of the consequences of health care decisions—have become essential tools for health technology assessment. Evolution of the methods ...since the first ISPOR Modeling Task Force reported in 2003 has led to a new Task Force, jointly convened with the Society for Medical Decision Making, and this series of seven articles presents the updated recommendations for best practices in conceptualizing models; implementing state-transition approaches, discrete event simulations, or dynamic transmission models; and dealing with uncertainty and validating and reporting models transparently. This overview article introduces the work of the Task Force, provides all the recommendations, and discusses some quandaries that require further elucidation. The audience for these articles includes those who build models, stakeholders who utilize their results, and, indeed, anyone concerned with the use of models to support decision making.
For the evaluation of infectious-diseases interventions, the transmissible nature of such diseases plays a central role. Agent-based models (ABM) allow for dynamic transmission modeling but ...publications are limited. We aim to provide an overview of important characteristics of ABM for decision-analytic modeling of infectious diseases. A case study of dengue epidemics illustrates model characteristics, conceptualization, calibration and model analysis. First, major characteristics of ABM are outlined and discussed based on ISPOR and ISPOR-SMDM Good Practice guidelines. Second, in our case study, we modeled a dengue outbreak in Cebu City (Philippines) to assess the impact interventions to control the relative growth of the mosquito population. Model outcomes include prevalence and incidence of infected persons. The modular ABM simulates persons and mosquitoes over an annual time horizon considering daily time steps. The model was calibrated and validated. ABM is a dynamic, individual-level modeling approach that is capable to reproduce direct and indirect effects of interventions for infectious diseases. The ability to replicate emerging behavior and to include human behavior or the behavior of other agents is a distinguishing modeling characteristic (e.g., compared to Markov models). Modeling behavior may, however, require extensive calibration and validation. The analyzed hypothetical effectiveness of dengue interventions showed that a reduced human-mosquito ratio of 1:2.5 during rainy seasons leads already to a substantial decrease of infected persons. ABM can support decision-analyses for infectious diseases including disease dynamics, emerging behavior, and providing a high level of reusability due to modularity.
Morawetz, D, Blank, C, Koller, A, Arvandi, M, Siebert, U, and Schobersberger, W. Sex-related differences after a single bout of maximal eccentric exercise in response to acute effects: a systematic ...review and meta-analysis. J Strength Cond Res 34(9): 2697-2707, 2020-The most prominent effects after unaccustomed eccentric exercise are muscle damage, muscle soreness, strength loss, and higher concentrations of muscle proteins in the plasma. The aim of this systematic review is to evaluate sex-related differences in these acute effects. A systematic literature search in MEDLINE following the PRISMA guidelines was performed. Inclusion criteria were the difference in absolute outcomes between sexes in eccentric muscle strength, strength loss after eccentric exercise, blood concentrations of creatine kinase (CK), and delayed onset muscle soreness (DOMS). Results for maximal eccentric torque and CK data were pooled using a random-effect meta-analysis. A meta-regression was conducted to explain heterogeneity. Based on the 23 included trials, men showed significantly higher absolute eccentric strength. No sex-related differences were detected when normalizing strength for body mass, cross-sectional area of the muscle, or fat-free mass. Women displayed a tendency toward greater relative strength loss immediately after exercise. The absolute CK concentrations of men were significantly higher after exercise-induced muscle damage. No significant difference was found between sexes in DOMS. Untrained men and women display similar responses in all measures of relative muscle strength and DOMS. Apart from the enzymatic activity after exercise and the levels of absolute eccentric torque, there is no evidence for sex-related differences immediately after eccentric exercise. Therefore, eccentric training might have the same impact on men and women. One potential sex difference with practical relevance would be the possible difference in fatigue pattern immediately after eccentric exercise.
Personalized medicine has the potential to allow patients to receive drugs specific to their individual disease, and to increase the efficiency of the healthcare system. There is currently no ...comprehensive overview of personalized medicine, and this research aims to provide an overview of the concept and definition of personalized medicine in nine European countries.
A targeted literature review of selected health databases and grey literature was conducted to collate information regarding the definition, process, use, funding, impact and challenges associated with personalized medicine. In-depth qualitative interviews were carried out with experts with health technology assessment, clinical provisioning, payer, academic, economic and industry experience, and with patient organizations.
We identified a wide range of definitions of personalized medicine, with most studies referring to the use of diagnostics and individual biological information such as genetics and biomarkers. Few studies mentioned patients' needs, beliefs, behaviour, values, wishes, utilities, environment and circumstances, and there was little evidence in the literature for formal incorporation of patient preferences into the evaluation of new medicines. Most interviewees described approaches to stratification and segmentation of patients based on genetic markers or diagnostics, and few mentioned health-related quality of life.
The published literature on personalized medicine is predominantly focused on patient stratification according to individual biological information. Although these approaches are important, incorporation of environmental factors and patients' preferences in decision making is also needed. In future, personalized medicine should move from treating diseases to managing patients, taking into account all individual factors.
Women with inherited mutations in the BRCA1 or BRCA2 genes have increased lifetime risks for developing breast and/or ovarian cancer and may develop these cancers around the age of 30 years. ...Therefore, prevention of breast and ovarian cancer in these women may need to start relatively early in life. In this study we systematically evaluate the long-term effectiveness and cost effectiveness of different prevention strategies for breast and ovarian cancer in women with BRCA-1/2 mutation in Germany.
A decision-analytic Markov model simulating lifetime breast and ovarian cancer development in BRCA-1/2 carriers was developed. Different strategies including intensified surveillance (IS), prophylactic bilateral mastectomy (PBM), and prophylactic bilateral salpingo-oophorectomy (PBSO) alone or in combination at different ages were evaluated. German clinical, epidemiological, and economic (in 2022 Euro) data were used. Outcomes included cancer incidences, mortality, life years (LYs), quality-adjusted life years (QALYs), and discounted incremental cost-effectiveness ratios (ICER). We adopted the German health-care system perspective and discounted costs and health effects with 3% annually.
All intervention strategies are more effective and less costly than IS alone. Prevention with PBM plus PBSO at age 30 maximizes life expectancy with 6.3 LYs gained, whereas PBM at age 30 with delayed PBSO at age 35 improves quality of life with 11.1 QALYs gained, when compared to IS alone. A further delay of PBSO was associated with lower effectiveness. Both strategies are cost effective with ICERs significantly below 10,000 EUR/LYG or QALY.
Based on our results, PBM at age 30 plus PBSO between age 30 and 40 prolongs life and is cost effective in women with BRCA-1/2 mutations in Germany. Serial preventive surgeries with delayed PBSO potentially improve quality of life for women. However, delaying PBM and/or PBSO further may lead to increased mortality and reduced QALYs.
Cisitu is a small-scale gold mining village in Indonesia. Mercury (Hg) is used to extract gold from ore, heavily polluting air, soil, fish and rice paddy fields with Hg. Rice in Cisitu is burdened ...with mercury. The main staple food of the inhabitants of Cisitu is this polluted rice. Villagers were concerned that the severe diseases they observed in the community might be related to their mining activities, including high mercury exposure. Case report of the medical examinations and the mercury levels in urine and hair of 18 people with neurological symptoms. Typical signs and symptoms of chronic mercury intoxication were found (excessive salivation, sleep disturbances, tremor, ataxia, dysdiadochokinesia, pathological coordination tests, gray to bluish discoloration of the oral cavity and proteinuria). Mercury levels in urine were increased in eight patients (>7µg Hg/L urine). All 18 people had increased hair levels (>1µg Hg/g hair). 15 patients exhibited several, and sometimes numerous, symptoms in addition to having moderately to highly elevated levels of mercury in their specimens. These patients were classified as intoxicated. The situation in Cisitu is special, with rice paddy fields being irrigated with mercury-contaminated water and villagers consuming only local food, especially mercury-contaminated rice. Severe neurological symptoms and increased levels of mercury in urine and hair support are possibly caused by exposure to inorganic mercury in air, and the consumption of mercury-contaminated fish and rice. The mercury exposure needs to be reduced and treatment provided. Further research is needed to test the hypothesis that mercury-contaminated rice from small-scale gold mining areas might cause mercury intoxication.
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•Severely mercury polluted gold mining area in Indonesia.•Mercury contaminated rice and fish.•Series of 18 case reports with severe, impressive clinical symptoms.•First ever observed clinical intoxication due to mercury contaminated rice.
In patients with multivessel coronary artery disease who are undergoing percutaneous coronary intervention (PCI), coronary angiography is the standard method for guiding the placement of the stent. ...It is unclear whether routine measurement of fractional flow reserve (FFR; the ratio of maximal blood flow in a stenotic artery to normal maximal flow), in addition to angiography, improves outcomes.
In 20 medical centers in the United States and Europe, we randomly assigned 1005 patients with multivessel coronary artery disease to undergo PCI with implantation of drug-eluting stents guided by angiography alone or guided by FFR measurements in addition to angiography. Before randomization, lesions requiring PCI were identified on the basis of their angiographic appearance. Patients assigned to angiography-guided PCI underwent stenting of all indicated lesions, whereas those assigned to FFR-guided PCI underwent stenting of indicated lesions only if the FFR was 0.80 or less. The primary end point was the rate of death, nonfatal myocardial infarction, and repeat revascularization at 1 year.
The mean (+/-SD) number of indicated lesions per patient was 2.7+/-0.9 in the angiography group and 2.8+/-1.0 in the FFR group (P=0.34). The number of stents used per patient was 2.7+/-1.2 and 1.9+/-1.3, respectively (P<0.001). The 1-year event rate was 18.3% (91 patients) in the angiography group and 13.2% (67 patients) in the FFR group (P=0.02). Seventy-eight percent of the patients in the angiography group were free from angina at 1 year, as compared with 81% of patients in the FFR group (P=0.20).
Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents significantly reduces the rate of the composite end point of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. (ClinicalTrials.gov number, NCT00267774.)
Abstract State-transition modeling is an intuitive, flexible, and transparent approach of computer-based decision-analytic modeling including both Markov model cohort simulation and individual-based ...(first-order Monte Carlo) microsimulation. Conceptualizing a decision problem in terms of a set of (health) states and transitions among these states, state-transition modeling is one of the most widespread modeling techniques in clinical decision analysis, health technology assessment, and health-economic evaluation. State-transition models have been used in many different populations and diseases, and their applications range from personalized health care strategies to public health programs. Most frequently, state-transition models are used in the evaluation of risk factor interventions, screening, diagnostic procedures, treatment strategies, and disease management programs. The goal of this article was to provide consensus-based guidelines for the application of state-transition models in the context of health care. We structured the best practice recommendations in the following sections: choice of model type (cohort vs. individual-level model), model structure, model parameters, analysis, reporting, and communication. In each of these sections, we give a brief description, address the issues that are of particular relevance to the application of state-transition models, give specific examples from the literature, and provide best practice recommendations for state-transition modeling. These recommendations are directed both to modelers and to users of modeling results such as clinicians, clinical guideline developers, manufacturers, or policymakers.
Background:
Ethical and legal issues are increasingly being reported by health caregivers; however, little is known about the nature of these issues in geriatric care. These issues can improve work ...and care conditions in healthcare, and consequently, the health and welfare of older people.
Aim:
This literature review aims to identify research focusing on ethical and legal issues in geriatric care, in order to give nurses and other health care workers an overview of existing grievances and possible solutions to take care of old patients in a both ethical and legally correct way.
Methods:
Using a systematic approach based on Aveyard, a search of the PubMed, CINAHL, and Ethicshare databases was conducted to find out the articles published on ethical and legal issues in geriatric care.
Ethical considerations:
The approval for the study was obtained from UMIT-The Health and Life Sciences University, Austria.
Results:
Only 50 articles were included for systematic analysis reporting ethical and legal issues in the geriatric care. The results presented in this article showed that the main ethical issues were related to the older people’s autonomy, respect for their needs, wishes and values, and respect for their decision-making. The main legal issues were related to patients’ rights, advance directives, elderly rights, treatment nutrition dilemma, and autonomy.
Conclusion:
Further education for professional caregivers, elderly people, and their families is needed on following topics: care planning, directive and living wills, and caregiver-family member relationships to guide and support the elderly people within their decision-making processes and during the end-of-life care.
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