Nutritional Strategies in the Management of Alzheimer Disease: Systematic Review With Network Meta-Analysis

Background

Alzheimer disease (AD) is the major cause of dependency and disability in the elderly. Numerous studies have sought to achieve its prevention and/or management examining a role for modifiable risk factors, such as nutrition. This work aims to investigate the effects of food and/or nutrients in the management of AD at different stages.

Measurement Properties of the EQ VAS Around the Globe: A Systematic Review and Meta-Regression Analysis

ObjectivesThis study aimed to synthesize and evaluate published evidence on the measurement properties of the EQ VAS, a component of all EQ-5D questionnaires.MethodsThis systematic review followed the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines. Five electronic databases were searched for EQ-5D-3L and EQ-5D-5L validation articles published from January 1, 2009, to November 5, 2019. Evidence for construct validity, test–retest reliability, and responsiveness was extracted from individual studies before being aggregated for evaluation of the populations represented by the studied samples. Multivariable logistic meta-regression was conducted to explore the effects of potential covariates on construct validity.ResultsA total of 50 articles containing 488 studies, using samples drawn from 12 different populations, were identified. Generally, the quality of evidence was high for construct validity studies (n = 397) but only moderate for both test–retest reliability studies (n = 21) and responsiveness studies (n = 70). “Sufficient” construct validity of EQ VAS was found in 8 of 12 populations, “sufficient” test–retest reliability was found in 3 of 11 populations, and “sufficient” responsiveness was found in 5 of 12 populations. Meta-regression analyses suggested that construct validity studies from the Asian-Pacific region were more likely to show a negative rating compared with studies from Europe and North America.ConclusionThe EQ VAS exhibits “sufficient” construct validity, “inconsistent” test–retest reliability, and “inconsistent” responsiveness across a broad range of populations. Additional studies are needed to explore the suboptimal validity of the EQ VAS in the Asian-Pacific region, whereas more high-quality validation studies are needed to assess its reliability and responsiveness.     

Health Utility Values Associated with Surgical Site Infection: A Systematic Review

BackgroundSurgical site infection (SSI) is a costly postoperative complication whose impact on patients' health-related quality of life is highly uncertain and has not been summarized to date.ObjectiveThe objective was to summarize the evidence base on SSI health utility values reported in patient-level studies and decision models.MethodsA systematic review of SSI utility values reported in patient-level and decision modeling studies was carried out. Studies in which utility values for SSI were either invoked (e.g., model-based economic evaluations) or elicited (e.g., valuation exercises), or at least one non–preference-based instrument was administered to patients with SSI after open surgery were included. Mapping algorithms were used, where appropriate, to calculate utilities from primary data. Results were summarized narratively, and the quality of the utility values used in the included modeling studies was assessed.ResultsOf 6552 records identified in the database search, 28 studies were included in the review: 19 model-based economic evaluations and 9 patient-level studies. SSI utility decrements ranged from 0.04 to 0.48, of which 19 ranged from 0.1 to 0.3. SSI utility decrements could be calculated for three patient-level studies, and their values ranged from 0.05 (7 days postoperatively) to 0.124 (1 year postoperatively). In most modeling studies, SSI utilities were informed by authors’ assumptions or by secondary sources.ConclusionsSSI may substantially affect patients’ health utility and needs to be considered when modeling decision problems in surgery. The evidence base for SSI utilities is of questionable quality and skewed toward orthopedic surgery. Further research must concentrate on producing reliable estimates for patients without orthopedic problems.     

A Comparison of Physician and Patient Time Trade-Offs for Postoperative Hip Outcomes

Objective:  To elicit infected hip arthroplasty preferences from outpatients and surgeons using time trade-off method based on a paper-based survey.
Methods:  Outpatients were included if they were 20 to 80 years of age, did not have a history of hip pain or surgery, and did not have a diagnosis of dementia. Orthopedic surgeons were high-volume joint replacement specialists or who performed ≥50 joint replacements per year. Preference measures were elicited using trade-offs between impaired health versus full health with shortened life, and between two temporary health states.
Results:  Patient preference scores were in some cases higher than surgeon preference scores. The difference was most pronounced for the health state constant severe pain . Outpatients revealed much higher preferences for staying in short-term major medical complication as compared with surgeons.
Conclusions:  Preference measures derived in this study can be used in decision-making for complications related to hip surgeries.     

Acceptability and Validity of the EQ-5D in Patients Living With Dementia

ObjectivesTo assess the acceptability and validity of the 3 levels of the EQ-5D (EQ-5D-3L) compared with the Quality of Life in Alzheimer’s Diseases (QoL-AD) in patients living with dementia.MethodsThe analysis was based on 560 dyads of persons with dementia and their caregivers of the multicenter observational study of dementia care networks in Germany (DemNet-D). Health-related quality of life was assessed by face-to-face interviews using the EQ-5D-3L (self-rating) and the QoL-AD (self- and proxy-rating). The number of missing values, the score ranges (observed vs possible range) and the floor and ceiling effects were used to assess the acceptability. We used one-way analyses of variance and multivariate linear regression models to evaluate the discriminative ability. The convergent validity was assessed using Spearman's correlation coefficient (r_s) and multivariate regression models.ResultsThe EQ-5D index had a higher response rate (89% vs 84%) and a comparable floor (>1%) but a higher ceiling effect (18% vs >1%) compared with the QoL-AD. Both measures can significantly differentiate between different stages of general health, instrumental activities of daily living, and depression. The EQ-5D index and the visual analog scale self-rating scores strongly correlated with the QoL-AD self-rating (r_s = 0.644 and 0.553, respectively) but not with the proxy-rating score (r_s = 0.314 and r_s = 0.170, respectively), which was confirmed by multivariate regression analyses.ConclusionThe results satisfy acceptability, discriminative ability, and convergent validity for moderately cognitively and functionally impaired patients living with dementia. The EQ-5D-3L performed comparably with the QoL-AD, and could, therefore, be used in economic evaluations in dementia. The differences between self- and proxy-ratings should be evaluated and considered in the interpretation of health-related quality of life scores.     

Effectiveness of Mealtime Interventions on Behavior Symptoms of People With Dementia Living in Care Homes: A Systematic Review

ObjectiveElderly residents with dementia commonly exhibit increased agitation at mealtimes. This interferes with eating and can be distressing for both the individual and fellow residents. This review examines the effectiveness of mealtime interventions aimed at improving behavioral symptoms in elderly people living with dementia in residential care.DesignSystematic review.Data sourcesMedline, PsycINFO, Embase, HMIC, AMED (OvidSP); CDSR, CENTRAL, DARE (Cochrane Library, Wiley); CINAHL (EBSCOhost); British Nursing Index (NHS Evidence); ASSIA (ProQuest); Social Science Citation Index (Web of Knowledge); EThOS (British Library); Social Care Online and OpenGrey from inception to November 2012. Forward and backward citation chases, hand searches of other review articles identified in the search, and key journals.Types of studyAll comparative studies were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Data were not suitable for meta-analysis so narrative synthesis was carried out.ResultsA total of 6118 articles were identified in the original search. Eleven articles were finally included. Mealtime interventions were categorized into 4 types: music, changes to food service, dining environment alteration, and group conversation. Study quality was poor, making it difficult to reach firm conclusions. Although all studies showed a trend in favor of the intervention, only 6 reported a statistically significant improvement in behavioral symptoms. Four studies suggest cumulative or lingering effects of music on agitated and aggressive behaviors.ConclusionThere is some evidence to suggest that mealtime interventions improve behavioral symptoms in elderly people with dementia living in residential care, although weak study designs limit the generalizability of the findings. Well designed, controlled trials are needed to further understand the utility of mealtime interventions in this setting.     

Dementia,Nutrition, and Self-Feeding: A Systematic Review of the Literature

SUMMARY

The outcomes of feeding training are typically evaluated in terms of feeding skills and swallowing abilities rather than the ultimate goal of feeding, namely, adequate nutritional status. To increase occupational therapy practitioners' awareness of nutritional status as an outcome of feeding training, a systematic review of the research literature was conducted to examine the relationship between nutritional status and self-feeding skills in people with dementia. Studies were evaluated by the strength of their evidence and analyzed to determine the relationships among dementia, nutritional status, and the ability to feed one's self. Results revealed that although nutritional status in people with dementia is variable, there is a tendency for lower body weight, lower measures of body composition, and lower body mass indexes in persons with dementia compared to those with no cognitive impairment. Individuals who feed themselves tend to weigh more compared to those who need assistance for feeding. There is also evidence to support that as feeding status improves or declines, body weight similarly increases or decreases.     

Interventions to Reduce Inappropriate Prescribing of Antipsychotic Medications in People With Dementia Resident in Care Homes: A Systematic Review

Background

Antipsychotic medications are commonly used to manage the behavioral and psychological symptoms of dementia. Several large studies have demonstrated an association between treatment with antipsychotics and increased morbidity and mortality in people with dementia.

Aims

To assess the effectiveness of interventions used to reduce inappropriate prescribing of antipsychotics to the elderly with dementia in residential care.

Method

Systematic searches were conducted in 12 electronic databases. Reference lists of all included studies and forward citation searching using Web of Science were also conducted. All quantitative studies with a comparative research design and studies in which recognized methods of qualitative data collection were used were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by 1 reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary.

Results

Twenty-two quantitative studies (reported in 23 articles) were included evaluating the effectiveness of educational programs (n = 11), in-reach services (n = 2), medication review (n = 4), and multicomponent interventions (n = 5). No qualitative studies meeting our inclusion criteria were identified. Eleven studies were randomized or controlled in design; the remainder were uncontrolled before and after studies. Beneficial effects were seen in 9 of the 11 studies with the most robust study design with reductions in antipsychotic prescribing levels of between 12% and 20%. Little empirical information was provided on the sustainability of interventions.

Conclusion

Interventions to reduce inappropriate prescribing of antipsychotic medications to people with dementia resident in care homes may be effective in the short term, but longer more robust studies are needed. For prescribing levels to be reduced in the long term, the culture and nature of care settings and the availability and feasibility of nondrug alternatives needs to be addressed.     

Cost-Effectiveness of COVID-19 Policy Measures: A Systematic Review

ObjectivesThe COVID-19 pandemic has had a major impact on our society, with drastic policy restrictions being implemented to contain the spread of the severe acute respiratory syndrome coronavirus 2. This study aimed to provide an overview of the available evidence on the cost-effectiveness of various coronavirus disease 2019 policy measures.MethodsA systematic literature search was conducted in PubMed, Embase, and Web of Science. Health economic evaluations considering both costs and outcomes were included. Their quality was comprehensively assessed using the Consensus Health Economic Criteria checklist. Next, the quality of the epidemiological models was evaluated.ResultsA total of 3688 articles were identified (March 2021), of which 23 were included. The studies were heterogeneous with regard to methodological quality, contextual factors, strategies’ content, adopted perspective, applied models, and outcomes used. Overall, testing/screening, social distancing, personal protective equipment, quarantine/isolation, and hygienic measures were found to be cost-effective. Furthermore, the most optimal choice and combination of strategies depended on the reproduction number and context. With a rising reproduction number, extending the testing strategy and early implementation of combined multiple restriction measures are most efficient.ConclusionsThe quality assessment highlighted numerous flaws and limitations in the study approaches; hence, their results should be interpreted with caution because the specific context (country, target group, etc) is a key driver for cost-effectiveness. Finally, including a societal perspective in future evaluations is key because this pandemic has an indirect impact on the onset and treatment of other conditions and on our global economy.     

Comparative Effectiveness of 3 Settings of Cognitive Stimulation Therapy on Cognition and Quality of Life for People With Dementia: A Systematic Review and Network Meta-analysis

ObjectiveTo compare and rank the effectiveness of group cognitive stimulation therapy (group CST), maintenance cognitive stimulation therapy (MCST), and individual cognitive stimulation therapy (iCST) on cognition and quality of life (QoL) in people with dementia.DesignSystematic review and network meta-analysis (NMA).Setting and ParticipantsAll published randomized controlled trials (RCTs) that compared the differences among 3 different settings of CST or a control group in treating people with dementia.MethodsRelevant electronic databases, including PubMed, Embase, Cochrane Library for clinical trials, Web of Science, CINAHL, PsycINFO, Chinese National Knowledge Infrastructure (CNKI), and Wanfang Data were systematically searched from inception to March 2021. RCTs that compared the differences among 3 different settings of CST or a control group in treating people with dementia were included. Then, a pairwise and network meta-analysis was conducted to evaluate the relative effects and rank probability of different CST settings. PRISMA guidelines were used for abstracting data, and the Cochrane Risk of Bias tool was used to assess data quality.ResultsIn total, 17 studies were included, which enrolled 1680 participants. Compared with the control group, MSCT [standardized mean difference (SMD) = 1.39, 95% CI 0.86, 1.91; low-quality evidence] and group CST (SMD 0.62, 95% CI 0.39, 0.84; very low-quality evidence) could significantly improve cognitive function. MCST (SMD 1.00, 95% CI 0.16, 1.85; low-quality evidence) and group CST (SMD 0.53, 95% CI 0.13, 0.92; low-quality evidence) demonstrated a statistically significant effect in improving the QoL, whereas iCST was not significantly inferior to the control condition. None of the treatments were significantly different from each other with respect to acceptability.Conclusions and ImplicationsFor people with dementia, group CST and MCST seems to promote more consistent benefits in terms of cognition and QoL than the iCST, and MCST was likely to be the most effective CST setting. Further RCTs with respect to the MCST and iCST efficacy are needed.     

Economic Evaluation of Systemic Treatments for Advanced Melanoma: A Systematic Review

BackgroundMany high cost treatments for advanced melanoma have become available in recent years. National health technology assessment agencies have raised concerns regarding uncertainty in their clinical and cost-effectiveness.ObjectiveThe aim of this systematic review is to identify economic evaluations of treatments for advanced melanoma and review model assumptions, outcomes, and quality as preparation for a health technology assessment.MethodsA search of Embase, MEDLINE, EconLit, and the Cochrane Database was conducted. Only studies using decision-analytic models were included. Two authors independently completed full-text review and data extraction.ResultsFifteen studies were identified. There were major differences in the structural assumptions underpinning the models. There was general agreement in study conclusions, although the predicted costs and quality-adjusted life years for each treatment varied. BRAF monotherapy (vemurafenib, dabrafenib) or BRAF/MEK combination therapy (BRAF monotherapy with cobimetinib or trametinib) has not been shown to be cost-effective in any jurisdiction. PD-1 inhibitors (pembrolizumab, nivolumab) are consistently found to be cost-effective compared with ipilimumab, although their cost-effectiveness compared with chemotherapy is not established. Combination therapy with nivolumab and ipilimumab is unlikely to be cost-effective in any setting. One study including all agents found that none of the new treatments were cost-effective relative to chemotherapy. Publication of the study in a health economics journal is associated with better reporting of and higher-quality assessment than those published in clinical journals.ConclusionDespite differences in model structures and assumptions, the conclusions of most included studies were consistent. Health technology assessment has a key role in maximizing value from high-cost innovative treatments. Consideration should be given to divestment from BRAF/MEK inhibitors and ipilimumab in favor of reimbursement of PD-1 inhibitors.     

A Systematic Review of the Techniques Used to Value Temporary Health States

Background

A broad literature on health state utility values exists, but compared with chronic health states (HSs), issues surrounding the valuation of temporary health states (THSs) have been poorly explored.

Effectiveness of Workplace-Based Diet and Lifestyle Interventions on Risk Factors in Workers with Metabolic Syndrome: A Systematic Review,Meta-Analysis and Meta-Regression

Workplace health interventions are essential to improve the health and well-being of workers and promote healthy lifestyle behaviours. We carried out a systematic review, meta-analysis and meta-regression of articles measuring the association between workplace dietary interventions and MetS risk. We recovered potentially eligible studies by searching MEDLINE, the Cochrane Library, Embase, Scopus and Web of Science, using the terms “Metabolic syndrome” and “Occupational Health”. A total of 311 references were retrieved and 13 documents were selected after applying the inclusion and exclusion criteria. Dietary interventions were grouped into six main types: basic education/counselling; specific diet/changes in diet and food intake; behavioural change/coaching; physical exercise; stress management; and internet/social networks. Most programmes included several components. The interventions considered together are beneficial, but the clinical results reflect only a minimal impact on MetS risk. According to the metaregression, the interventions with the greatest impact were those that used coaching techniques and those that promoted physical activity, leading to increased HDL (effect size = 1.58, sig = 0.043; and 2.02, 0.015, respectively) and decreased BMI (effect size = −0.79, sig = −0.009; and −0.77, 0.034, respectively). In contrast, interventions offering information on healthy habits and lifestyle had the contrary effect, leading to increased BMI (effect size = 0.78, sig = 0.006), systolic blood pressure (effect size = 4.85, sig = 0.038) and diastolic blood pressure (effect size = 3.34, sig = 0.001). It is necessary to improve the efficiency of dietary interventions aimed at lowering MetS risk in workers.     

Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality

BackgroundEconomic evaluations provide a unique opportunity to identify the optimal strategies for the diagnosis and management of traumatic brain injury (TBI), for which uncertainty is common and the economic burden is substantial.ObjectiveThe objective of this study was to systematically review and examine the quality of contemporary economic evaluations in the diagnosis and management of TBI.MethodsTwo reviewers independently searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, Health Technology Assessment Database, EconLit, and the Tufts CEA Registry for comparative economic evaluations published from 2000 onward (last updated on August 30, 2013). Data on methods, results, and quality were abstracted in duplicate. The results were summarized quantitatively and qualitatively.ResultsOf 3539 citations, 24 economic evaluations met our inclusion criteria. Nine were cost-utility, five were cost-effectiveness, three were cost-minimization, and seven were cost-consequences analyses. Only six studies were of high quality. Current evidence from high-quality studies suggests the economic attractiveness of the following strategies: a low medical threshold for computed tomography (CT) scanning of asymptomatic infants with possible inflicted TBI, selective CT scanning of adults with mild TBI as per the Canadian CT Head Rule, management of severe TBI according to the Brain Trauma Foundation guidelines, management of TBI in dedicated neurocritical care units, and early transfer of patients with TBI with nonsurgical lesions to neuroscience centers.ConclusionsThreshold-guided CT scanning, adherence to Brain Trauma Foundation guidelines, and care for patients with TBI, including those with nonsurgical lesions, in specialized settings appear to be economically attractive strategies.     

Health State Utility Values for Type 2 Diabetes and Related Complications in East and Southeast Asia: A Systematic Review and Meta-Analysis

ObjectivesEast and Southeast Asia has the greatest burden of diabetes in the world. We sought to derive a reference set of utility values for type 2 diabetes without complication and disutility (utility decrement) values for important diabetes-related complications to better inform economic evaluation.MethodsA systematic review to identify utility values for diabetes and related complications reported in East and Southeast Asia. We searched MEDLINE (OVID) from inception to May 26, 2020 for utility values elicited using direct and indirect methods. Identified studies were assessed for quality based on the National Institute of Health and Care Excellence guidelines. Utility and disutility estimates were pooled by meta-analyses with subgroup analyses to evaluate differences by nationality and valuation instrument. (PROSPERO: CRD42020191075).ResultsWe identified 17 studies for the systematic review from a total of 13 035 studies in the initial search, of which 13 studies met the quality criteria for inclusion in the meta-analyses. The pooled utility value for diabetes without complication was 0.88 (95% CI 0.83-0.93), with the pooled utility decrement for associated complications ranged from 0.00 (for excess BMI) to 0.18 (for amputation). The utility values were consistently more conservative than previous estimates derived in Western populations. Utility decrements were comparable for SF-6D and EQ-5D valuation instruments and for Chinese and other Asian groups.ConclusionsA reference set of pooled disutility and utility values for type 2 diabetes and its complications in East and Southeast Asian populations yielded more conservative estimates than Western populations.     

Barriers to Implementation of Case Management for Patients With Dementia: A Systematic Mixed Studies Review

PURPOSE

Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation.

METHODS

We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers.

CONCLUSIONS

Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.