Search

Aims To systematically review the evidence on the costs and cost-effectiveness of self-management support interventions for people with diabetes. Background Self-management support is the provision of education and supportive interventions to increase patients' skills and confidence in managing their health problems, potentially leading to improvements in HbA1c levels in people with diabetes. Methods Randomized controlled trials, observational studies or economic modelling studies were eligible for inclusion in the review. The target population was adults with diabetes. Interventions had to have a substantial component of self-management support and be compared with routine care. Study quality was evaluated using the Consensus on Health Economic Criteria and International Society of Pharmacoeconomic Outcomes Research questionnaires. A narrative review approach was used. Results A total of 16 costing and 21 cost-effectiveness studies of a range of self-management support interventions were identified. There was reasonably consistent evidence across 22 studies evaluating education self-management support programmes suggesting these interventions are cost-effective or superior to usual care. Telemedicine-type interventions were more expensive than usual care and potentially not cost-effective. There was insufficient evidence regarding the other types of self-management interventions, including pharmacist-led and behavioural interventions. The identified studies were predominantly of poor quality, with outcomes based on short-term follow-up data and study designs at high risk of bias. Conclusions Self-management support education programmes may be cost-effective. There was limited evidence regarding other formats of self-management support interventions. The poor quality of many of the studies undermines the evidence base regarding the economic efficiency of self-management support interventions for people with diabetes. [ABSTRACT FROM AUTHOR]

Summary: Background: Multimorbidity is defined as two or more co-existing chronic conditions in an individual and is common in general practice. It is associated with poorer outcomes for patients. This study aimed to establish the prevalence of multimorbidity in patients with chronic respiratory disease in general practice and to describe its impact on health service use. Methods: Cross-sectional study based in general practice in Dublin. Drug and disease code searches were performed to identify adult patients with a diagnosis of chronic respiratory disease. Medical records were reviewed for chronic respiratory diagnosis, other chronic conditions, demographic characteristics, General Practitioner (GP) and practice nurse utilisation rates, and numbers of medications. Results: In a general practice population of 16,946 patients 3.9% had chronic respiratory disease and 60% of these had one or more co-existing chronic condition(s). GP and practice nurse utilisation rates, and number of medications were significantly higher among those with multimorbidity compared with those with respiratory disease alone. Multivariate analysis showed that increasing age and low socio-economic status were significantly associated with multimorbidity. Conclusion: The majority of patients with chronic respiratory disease have multimorbidity. Clinical guidelines based on single disease entities and outcomes are not as easy to implement and may not be as effective in this group. [ABSTRACT FROM AUTHOR]

Background:Rectal bleeding is a recognised early symptom of colorectal cancer. This study aimed to assess the diagnostic accuracy of symptoms, signs and diagnostic tests in patients with rectal bleeding in relation to risk of colorectal cancer in primary care.Methods:Diagnostic accuracy systematic review. Medline (1966 to May 2009), Embase (1988 to May 2009), British Nursing Index (1991 to May 2009) and PsychINFO (1970 to May 2009) were searched. We included cohort studies that assessed the diagnostic utility of rectal bleeding in combination with other symptoms, signs and diagnostic tests in primary care. An eight-point quality assessment tool was produced to assess the quality of included studies. Pooled positive likelihood ratios (PLRs), sensitivities and specificities were calculated.Results:Eight studies incorporating 2323 patients were included. Average weighted prior probability of colorectal cancer was 7.0% (range: 3.3–15.4%, median: 8.1%). Age 60 years (pooled PLR: 2.79, 95% confidence interval (CI) 2.00–3.90), weight loss (pooled PLR: 1.89, 95% CI: 1.03–3.07) and change in bowel habit (pooled PLR: 1.92, 95% CI: 0.54–3.57) raise the probability of colorectal cancer into the range of referral to secondary care but do not conclusively ‘rule in’ the diagnosis. Presence of severe anaemia has the highest diagnostic value (pooled PLR: 3.67, 95% CI: 1.30–10.35), specificity 0.95 (95% CI: 0.93–0.96), but still only generates a post-test probability of 21.6%.Conclusions:In patients with rectal bleeding who present to their general practitioner, additional ‘red flag’ symptoms have modest diagnostic value. These findings have implications in relation to recommendations contained in clinical practice guidelines. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) is a medication (Tenovofir disoproxil) taken to prevent human immunodeficiency virus (HIV) infection in individuals at high risk of contracting HIV. Outcomes were reported as incremental cost-effectiveness ratios (ICERs) using cost per quality-adjusted life years (QALYs) gained/saved, disability-adjusted life years and life years saved. The key drivers pertaining to cost-effectiveness were the lifetime cost of HIV and the efficacy and cost of PrEP medication. [Extracted from the article]

Objectives Heroin users are at high risk of premature mortality. Despite the evidence supporting methadone maintenance programmes (MMT), methadone itself has been associated with drug-related deaths. This study aims to determine whether people prescribed methadone have an elevated risk of overdose mortality during periods of treatment transition, particularly during treatment initiation. Method Retrospective cohort study of 3162 Scottish people prescribed and dispensed liquid methadone between January 1993 and February 2004. Observation time was defined as a period during methadone treatment or a period of maximum 6 months after leaving treatment. Individual observation time was censored after 6 months off-treatment. A person's observation time started again if they re-entered treatment after an off-treatment period. The main outcome measure was drug-related mortality by means of Cox-proportional hazards models during the 12 years of follow-up. Drug-related deaths occurring during treatment or within 3 days after last methadone prescription were considered as cases “on treatment”. Fatalities occurring 4 days or more after leaving treatment were considered to be drug-related deaths “off treatment”. Results Overall 130 people died, with 51 deaths identified as drug-related deaths (20 off treatment and 31 in treatment). Risk of drug-related mortality was higher during treatment than off treatment (adjusted hazard ratio 11.17, 95% CI 4.51 to 27.64). Inspection of timing of death showed that the risk of drug-related mortality was higher during the initial two weeks of treatment (adjusted hazard ratio 16.93, 95% CI 5.17 to 55.46) compared to the risk of mortality off treatment. Similarly, retention in treatment for more than 3 weeks was associated with increased mortality relative to being off treatment (adjusted hazard ratio 9.97, 95% CI 4.08 to 24.39). In relation to risk of mortality during treatment, being in treatment for 3–10 weeks (adjusted hazard ratio 0.36, 95% CI 0.15 to 0.85) or greater than 10 weeks (adjusted hazard ratio 0.13, 95% CI 0.04 to 0.39) was associated with a reduced risk of mortality compared to the initial two weeks on treatment. These effects were observed after adjusting for all or some of the following covariates; co-prescribing of benzodiazepines, psychiatric admission, number of methadone treatments, overuse of methadone and urine testing, where appropriate. Conclusion Excess mortality risk in the initial two weeks of methadone treatment indicates the need for more care in prescribing and monitoring of methadone when starting or restarting a patient on methadone maintenance therapy. [ABSTRACT FROM AUTHOR]

We performed a cost-effectiveness and budget impact analysis of a national programme of CRP POCT to improve antimicrobial stewardship for RTIs in primary care in Ireland. We performed a network meta-analysis to establish clinical effectiveness and developed a probabilistic decision tree to investigate cost-effectiveness and budget impact from the perspective of the healthcare system. [Extracted from the article]

The hepatitis C virus (HCV) is a blood-borne virus which may not become symptomatic until decades following exposure. Economic evaluations comparing birth cohort screening with no screening or risk-based screening, where patients were treated with DAAs, were eligible for inclusion. One study found that birth cohort screening dominated no screening. [Extracted from the article]

Previous systematic reviews have found a significant inverse relationship between procedural volumes and mortality for percutaneous coronary interventions (PCI). A systematic review was undertaken for the period 01/01/2008 to 28/05/2019 with four primary outcomes: the relationship between postoperative (inpatient/30-day) mortality and 1) total PCI (any indication) hospital volume; 2) total PCI operator volume; 3) primary PCI (emergent indications) hospital volume; 4) primary PCI operator volume. A volume-outcome relationship may still exist in favour of high-volume hospitals and operators, although this relationship appears to be attenuating with time and there is very low certainty of evidence. [Extracted from the article]