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OBJECTIVE: High voltage devices (implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy defibrillators referred to jointly as ICDs) reduce rates of sudden cardiac death in patients with cardiovascular disease. However, shocks from ICDs may be associated with healthcare resource use (HCRU) and costs. The aim of this study was to estimate the costs associated with both appropriate and inappropriate shocks from ICDs.
METHODS: Patients with appropriate and inappropriate shocks from ICDs were identified via CareLink data from Liverpool Heart and Chest Hospital between March 2017 and March 2019. The devices were SmartShock activated, with anti-tachycardia pacing. Costs were estimated according to the dominant episode of healthcare, from an NHS payer perspective.
RESULTS: There were 2445 patients on the CareLink system with ICDs. Over the two-year period, HCRU data from 143 shock episodes among 112 patients were reported. The total cost for all shocks was £ 252,552 with mean costs of £ 1608 and £ 2795 for appropriate and inappropriate shocks respectively. There was substantial variation in HCRU between shock episodes.
CONCLUSION: While there was a low rate of inappropriate shocks from ICDs, there were still substantial HCRU and costs incurred. In this study, the specific HCRU was not costed independently, meaning the costs reported are likely to be a conservative estimate. Whilst every attempt to reduce shocks should be made, appropriate shocks cannot be avoided. Strategies to reduce the incidence of inappropriate and unnecessary shocks should be implemented to reduce overall health care costs associated with ICDs.
BACKGROUND:Antimicrobial resistance (AMR) is a global public health threat. The wider implications of AMR, such as the impact of antibiotic resistance (ABR) on surgical procedures, are yet to be quantified. The objective of this study was to produce a conceptual modeling framework to provide a basis for estimating the current and potential future consequences of ABR for surgical procedures in England.
DESIGN: A framework was developed using literature-based evidence and structured expert elicitation. This was applied to populations undergoing emergency repair of the neck of the femur and elective colorectal resection surgery.
RESULTS: The framework captures the implications of increasing ABR by allowing for higher rates of surgical site infection (SSI) as the effectiveness of antibiotic prophylaxis wanes and worsened outcomes following SSIs to reflect reduced antibiotic treatment effectiveness. The expert elicitation highlights the uncertainty in quantifying the impact of ABR, reflected in the results. A hypothetical SSI rate increase of 14% in a person undergoing emergency repair of the femur could increase costs by 39% (-2% to 108% credible interval [CI]) and decrease quality-adjusted life-years by 11% (0.4% to 62% CI) over 15 y.
CONCLUSIONS: The modeling framework is a starting point for addressing the implication of ABR on the outcomes and costs of surgeries. Due to clinical uncertainty highlighted in the expert elicitation process, the numerical outputs of the case studies should not be focused on but rather the framework itself, illustration of the evidence gaps, the benefit of expert elicitation in quantifying parameters with limited data, and the potential magnitude of the impact of ABR on surgical procedures.
IMPLICATIONS: The framework can be used to support research surrounding the health and cost burden of ABR in England.
OBJECTIVES: To identify which international health technology assessment (HTA) agencies are undertaking evaluations of medical tests, summarize commonalities and differences in methodological approach, and highlight examples of good practice.
METHODS: A methodological review incorporating: systematic identification of HTA guidance documents mentioning evaluation of tests; identification of key contributing organizations and abstraction of approaches to all essential HTA steps; summary of similarities and differences between organizations; and identification of important emergent themes which define the current state of the art and frontiers where further development is needed.
RESULTS: Seven key organizations were identified from 216 screened. The main themes were: elucidation of claims of test benefits; attitude to direct and indirect evidence of clinical effectiveness (including evidence linkage); searching; quality assessment; and health economic evaluation. With the exception of dealing with test accuracy data, approaches were largely based on general approaches to HTA with few test-specific modifications. Elucidation of test claims and attitude to direct and indirect evidence are where we identified the biggest dissimilarities in approach.
CONCLUSIONS: There is consensus on some aspects of HTA of tests, such as dealing with test accuracy, and examples of good practice which HTA organizations new to test evaluation can emulate. The focus on test accuracy contrasts with universal acknowledgment that it is not a sufficient evidence base for test evaluation. There are frontiers where methodological development is urgently required, notably integrating direct and indirect evidence and standardizing approaches to evidence linkage.
A systematic review was undertaken to identify randomized controlled trials (RCTs) comparing the efficacy and safety of lurasidone, brexpiprazole and cariprazine (selected because of a shared safety profile) with each other or placebo in adult patients with schizophrenia. Key outcomes included: Positive and Negative Syndrome Scales (PANSS), Clinical Global Impression-Severity (CGI-S) scores and cardiovascular and metabolic parameters. A feasibility assessment evaluated the trials' suitability for inclusion in a Bayesian network meta-analysis (NMA). Random effects models were used. In total, 1138 records were identified and 19 RCTs contributed to the NMA. Lurasidone doses of 160 mg performed best in terms of change in PANSS and CGI-S scores at 6 weeks, with stronger evidence when compared with brexpiprazole than cariprazine. The safety outcomes were variable; for all treatments, the 95% credible intervals usually contained 'no difference'. Active treatments were associated with lower odds of discontinuation due to any cause, and higher odds of experiencing any adverse event. Lurasidone was comparable to brexpiprazole and cariprazine for efficacy and safety outcomes assessed at 6 weeks, with the 160 mg dose being superior for the change in PANSS and CGI-S outcomes. The lurasidone results were relatively consistent across doses compared with brexpiprazole and cariprazine.
OBJECTIVE: To estimate the cost-effectiveness of single-use hydrophilic-coated intermittent catheters (HCICs) versus single-use uncoated intermittent catheters (UICs) for urinary catheterization.
METHODS: The evaluation took a UK national health service (NHS) perspective. The population of interest were people using intermittent catheters, with either a spinal cord injury or multiple sclerosis. A Markov model was developed that estimated costs and clinical evidence over the lifetime of a hypothetical cohort and applied health-related quality-of-life estimates. Model inputs were sourced from published evidence, including a network meta-analysis to inform the treatment effect (reduction in catheter-associated urinary tract infections [CAUTIs]), and were supported by expert opinion. The model outputs included per-patient lifetime costs, quality-adjusted life years (QALYs), and the incremental cost effectiveness ratio (ICER). Event counts were also produced.
RESULTS: Using HCICs instead of UICs could prevent seven CAUTI events per patient over a lifetime horizon (1.8 requiring secondary care). Overall, lifetime use of HCICs is £3,183 more expensive than use of UICs per patient. However, for these additional costs, 0.55 QALYs are gained. The ICER is £5,755 per additional QALY gained. Key drivers of the model results were identified and subject to sensitivity analyses. The results were found to be robust to parameter uncertainty.
CONCLUSION: HCICs are likely to be a cost-effective alternative to UICs, a result driven by substantial reductions in the number of CAUTIs. Their adoption across clinical practice could avoid a substantial number of infections, freeing up resources in the NHS and reducing antibiotic use in urinary catheter users.
BACKGROUND: The Systematic Review (SR) Toolbox was developed in 2014 to collate tools that can be used to support the systematic review process. Since its inception, the breadth of evidence synthesis methodologies has expanded greatly. This work describes the process of updating the SR Toolbox in 2022 to reflect these changes in evidence synthesis methodology. We also briefly analysed included tools and guidance to identify any potential gaps in what is currently available to researchers.
METHODS: We manually extracted all guidance and software tools contained within the SR Toolbox in February 2022. A single reviewer, with a second checking a proportion, extracted and analysed information from records contained within the SR Toolbox using Microsoft Excel. Using this spreadsheet and Microsoft Access, the SR Toolbox was updated to reflect expansion of evidence synthesis methodologies and brief analysis conducted.
RESULTS: The updated version of the SR Toolbox was launched on 13 May 2022, with 235 software tools and 112 guidance documents included. Regarding review families, most software tools (N = 223) and guidance documents (N = 78) were applicable to systematic reviews. However, there were fewer tools and guidance documents applicable to reviews of reviews (N = 66 and N = 22, respectively), while qualitative reviews were less served by guidance documents (N = 19). In terms of review production stages, most guidance documents surrounded quality assessment (N = 70), while software tools related to searching and synthesis (N = 84 and N = 82, respectively). There appears to be a paucity of tools and guidance relating to stakeholder engagement (N = 2 and N = 3, respectively).
CONCLUSIONS: The SR Toolbox provides a platform for those undertaking evidence syntheses to locate guidance and software tools to support different aspects of the review process across multiple review types. However, this work has also identified potential gaps in guidance and software that could inform future research.
BACKGROUD AND AIMS: Patients on acute adult and older adult inpatient mental health wards are at an increased risk of accidental injuries and deliberate harm to self and others. A vision-based patient monitoring and management (VBPMM) system was designed by Oxehealth Limited to support ward staff to provide better and more efficient care and to reduce incidents. The VBPMM system uses an infrared-sensitive camera, installed in a patient's room, that works with cleared medical device software to deliver contact-free vital sign and activity insights to clinical teams. Data from two studies undertaken at an English National Health Service (NHS) mental health trust were used to inform an early economic assessment of VBPMM implementation into acute adult and older adult mental health wards.
METHODS: A cost calculator was used to compare the introduction of the VBPMM system as an adjunct to standard care versus standard care alone. Observational data were collected at two English NHS mental health trusts. Both compared data pre- and post-VBPMM implementation using a 12-month baseline period. The model estimated cost per occupied bed day, cost per patient, annual cost per average-sized ward, and total cost to NHS mental health trusts across England. Costs were modeled from an NHS perspective over a 12-month time horizon. Scenario analysis was conducted to test the uncertainty of results using statistical significance of key inputs.
RESULTS AND CONCLUSIONS: This early analysis indicated that the VBPMM system is likely to be cost saving within both settings examined, with an estimated cost saving of £272 per acute adult mental health patient and £4,591 per older adult mental health patient. This translates to £22.3 and £63.3 million, respectively, across NHS mental health trusts in England every year. VBPMM, therefore, has the potential to augment standard care, leading to positive clinical outcomes and monetary savings.
