stroke units versus general wards: costs comparison class 12: ana quintela, ana patrícia rosa,...
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Stroke Units versus General Wards: Costs
comparisonClass 12: Ana Quintela, Ana Patrícia Rosa, André Graça, Cristina Tavares, Inês Campos Costa, Isabel Junqueiro, João Gonçalves; João Rodrigues; José Fernandes, Liuba Germanova, Luís Mendonça, Nuno China, Rita Pereira
Teacher Luís Filipe Ribeiro de Azevedo
1. Summary of project’s theme
1.1. Cardiovascular Accident (CVA), Stroke Units and General Wards
1.2. Research question and aims
2. What we’ve already done
2.1. Primary research
2.2. Screening Phase
2.2.1. Inclusion and exclusion criteria
2.2.2 Articles Selected
2.2.3 Statistic Results
2.3. Inclusion Phase
2.3.1 Articles Selected
2.3.2. Statistic Results
3. What we’ll do
3.1. Data extraction and Outcome variables
3.2. Quality assessment
3.2.1. Checklist for quality assessment of randomized clinical
trials
3.2.2. Health economics checklist
3.3. Data synthesizing
3.4. Discussion
4. Expected results
5. References
1. Summary of project’s theme
• Stroke units and general wards
• Cost/effectiveness relation
So…
• Collect and select information
• Organize and relate it
• Conclusion
1.1. Cardiovascular Accident (CVA), Stroke Units and General Wards
Stroke Units:
• Health unit specifically designed for the treatment of acute stroke patients.
General Wards:
• General care unit.
• Follows the general treatment guidelines.
Cerebrovascular Accident (CVA):
• Occurs when blood flow suddenly stops and oxygen (O2) can’t reach that specific region.
• The lack of O2, due to a blockage or rupture of an artery in the brain, may damage or kill its cells.
1.2. Research question and aims
Amongst a population that suffered CVAs, what shall be their best option considering the cost/effectiveness of the
treatment: stroke-units or general wards?
Aims:
• Understand what’s the most effective treatment for the patient’s well-being.
• Analyze the best financial option for the institution.
2. What we’ve already done 2.1. Primary research
Query:
• (stroke OR "cerebrovascular accident") AND (cost OR costs) AND
(unit OR units)
Databases:
• PubMed through MEDLINE
• Cochrane through EBSCO
2. What we’ve already done 2.1. Primary research
456 articles found 456 articles found (434 PUBMED & 72 EBSCO)(434 PUBMED & 72 EBSCO)
2.2. Screening Phase1,11
The reliability of the process is determined by using specific methods (Kappa Statistic).
The final number of articles is ready for a second screen.
Two reviewers
Screen titles and abstracts
Apply inclusion/exclusion criteria
Selection of articles for second stage
Meet to discuss disagreements
Third reviewer
2.2.1. Inclusion and exclusion criteria
Inclusion Criteria
Randomized clinical trials that:
• Present over 18 years old participants
• Compare stroke units/general wards
including costs analysis
• Discriminate different types of costs
Exclusion Criteria
• Absence of comparison between stroke
units and general wards
• Absence of costs descrimination
• Clinical Trials not randomized
2.2.2. Articles Selected
61 articles included61 articles included
2.2.3. Statistic Results
2.2.3. Statistic Results
2.2.3. Statistic Results
2.2.3. Statistic Results
2.3. Inclusion Phase1,11
Get full articles.
Two reviewers
Read whole texts and select proper ones
Meet to discuss disagreements
Third reviewer
The reliability of the process is determined by using specific methods (Kappa Statistic).
Keep a log of excluded studies with the appropriate exclusion reasons.
2.3.1. Articles Selected
61 article, 31 processed61 article, 31 processed
2.3.2. Statistic Results
2.3.2. Statistic Results
3. What we’ll do3.1. Data extraction1,11 and Outcome
variables
ID number
Study characteristics Effect measures
InterventionControl Group
Local (intervention)
Dates (beginning/
end)
Sample
Mortality rate
Morbidity rate
Global costsSex
(participants)Age
(participants)Size
Extraction of data.
Quality assessment of included studies.
Outcome variables
Mortality rate + morbidity rate + global costs
Extract information according to inclusion and quality criteria
3.2. Quality assessment3.2.1.
Checklist for quality assessment of randomized clinical trials10
Methods
Participants
Interventions
Objectives
Outcomes
Sample size
RandomizationSequence generation
Allocation concealment Implementation
Blinding
Stathistical Methods
Checklist for quality assessment of randomized clinical trialsResults
Participant flow
Recruitment
Baseline Data
Numbers Analyzed
Outcomes and Estimation
Adverse Events
3.2. Quality assessment3.2.1.
Health economics checklist12
Study design
• The economic importance of the research question is stated.
• The viewpoint(s) of the analysis are clearly stated and justified.
• The rationale for choosing the alternative programmes or interventions compared is stated.
• The form of economic evaluation used is stated.
• The choice of the economic evaluation is justified in relation to the questions addressed.
3.2. Quality assessment3.2.2.
• The source(s) of effectiveness estimates used are stated;
• The primary outcome measure(s) for the economic evaluation are clearly stated;
• Costs are classified (direct or indirect);
• Unit costs are stated (diagnosis, treatment, short and long term costs associated with health states);
• Methods to value health states and other benefits are stated;
• Details of the subjects from whom valuations were obtained are given;
• Quantities of resources are reported separately from their unit costs;
• Methods for the estimation of quantities and unit costs are described
• Currency and price data are recorded;
• Details of any model used are given;
• The choice of model used and the key parameters on which it is based are justified;
Health economics checklistData collection
3.2. Quality assessment3.2.2.
Health economics checklistAnalysis and interpretation of results
• Time horizon of costs and benefits is state;
• Details of statistical tests and confidence intervals are given for stochastic data;
• Relevant alternatives are compared;
• Incremental analysis is reported;
• Major outcomes are presented in a disaggregated as well as aggregated; form;
• The answer to the study question is given;
• Conclusions follow from the data reported.
3.2. Quality assessment3.2.2.
3. What we’ll do3.3. Data synthesizing
Gather and analyze data:
• SPSS – enter data into database manager software to study
characteristics and tabulate them.
• Create forest plots of effect measures.
• Check heterogeneity explore it with statistical methods:
graphic methods and subgroup analysis.
• Funnel plots – possibility of publication bias.
3. What we’ll do3.4. Discussion
Interpret and discuss results implication in concrete
situations, possible research limitations
Final Report
4. Expected results
Information allowing to compare stroke-units and general
wards in the context of their cost/effectiveness relation.
Stroke Units: less morbidity but more expensive.
No significant diferences concerning mortality.
5. References
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by-step guide. The national medical journal of India Vol. 17, No 2, 2004.
2. Justo LP, Soares BGO, Cali HM. Revisão sistemática, metanálise e medicina baseada em evidências: considerações conceituais. J Bras Psiquiatr 54(3):
242-247, 2005.
3. Langhorne P, Dey P, Woodman P, Kalra L, Wood-Dauphinee S, Patel N, Hamrin E. Is stroke unit care portable? A systematic review of the clinical trials.
Age and Ageing 2005; 34: 324–330
4. Indredavik B, Bakke F, Slørdahl AS, Rokseth R, Håheim LL. Treatment in a Combined Acute and Rehabilitation Stroke Unit : Which Aspects Are Most
Important? Stroke 1999;30;917-923
5. Harold PA, Adams JR RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ.
Guidelines for the Early Management of Patients With Ischemic Stroke: A Scientific Statement From the Stroke Council of the American Stroke
Association. Stroke 2003;34;1056-1083.
6. Balas EA, Kretschemer RAC, Gnann W, West DA, Boren SA, Centor RM, Gupta M, West TD, Soderstrom NS. Interpreting Cost Analysis of Clinical
Interventions. JAMA Vol. 279, No 1, January 7, 1998.
7. Barber JA, Thompson SG. Analysis and interpretation of cost cost data in randomized controlled trials: review of published studies. BMJ Vol. 317,
October 31, 1998.
8. Walker D. Cost and effectiveness guidelines: which ones to use? Health policy and planning; 16(1): 113-121.
9. Claesson L, Gosman-Hedström G, Johannesson M, Fagerberg B, Blomstrand C. Resource Utilization and Costs of Stroke Unit Care Integrated in a Care
Continuum: A 1-Year Controlled, Prospective, Randomized Study in Elderly Patients: The Goterborg 70+ Stroke Study. Stroke 2000;31;2569-2577
10. Douglas G. Altman, Kenneth F. Schulz, David Moher, Matthias Egger, Frank Davidoff, Diana Elbourne, Peter C. Gøtzsche, Thomas Lang for the CONSORT
group. The Revised CONSORT statement for Reported Randomized Trials: Explanation and Elaboration.
11. Khalid S Khan, Jennie Popay, Jos Kleijen. Development of a review protocol.
12. Website from BMJ: http://resources.bmj.com/bmj/authors/checklists-forms/health-economics
Thank you for the attention.