What do Australian patients with inflammatory arthritis value in treatment? A discrete choice experiment

Clinical Rheumatology - The purpose of this study was to develop an understanding of treatment preferences in patients with inflammatory arthritis (IA) [rheumatoid arthritis (RA), ankylosing...     

Using Population Reach as a Proxy Metric for Intervention Impact to Prioritize Selection of Obesity Prevention Strategies in Los Angeles County, 2010–2012

Recent federal initiatives have used estimates of population reach as a proxy metric for intervention impact, in part to inform resource allocation and programmatic decisions about competing priorities in the community. However, in spite of its utility, population reach as a singular metric of intervention impact may be insufficient for guiding multifaceted program decisions. A more comprehensive, validated approach to measure or forecast dose may complement reach estimates to inform decision makers about optimal ways to use limited resources.Although federal initiatives in obesity prevention have typically recommended the use of evidence-based community strategies,1 less is known about the level of impact that these strategies can contribute to improving health in the real world. The absence of this type of practice-based information often poses significant challenges to funding agencies and program planners that are tasked with prioritizing and selecting intervention strategies for a city or community. Given that this information is not readily available or regularly reported, recent federal initiatives have begun to request data on intervention impact, using estimates of population reach as a proxy metric for predicting the extent of intervention effectiveness. The Centers for Disease Control and Prevention, for example, recently provided guidance on how to measure and report reach for a range of obesity prevention interventions focused on improving systems and environments in cities and communities across the United States.2 They broadly defined “reach” as the number of unique individuals affected by a program initiative and further refined this concept to include direct reach as the number of unique individuals exposed to the intervention in some way and indirect reach as the number of unique individuals indirectly exposed to the intervention in some way but who are not residents of a targeted community (e.g., visitors).2 To provide more specificity, other agencies and organizations (e.g., the Center for Community Health and Evaluation) have sought to account for the effects of community health interventions by incorporating intervention dose as an additional parameter for consideration in their priority-setting process and program planning.3 In this context, “dose” has been defined as the product of reach (percentage of people exposed to an intervention) and strength (the degree to which people reached by the intervention changed their health behaviors).3 Although dose is a more robust measure of intervention impact, reach is generally easier to estimate and use, given the time constraints and limited availability of relevant data sources to local leaders who must make daily decisions about policy development, program implementation, and operations. It is important to note, however, that the Centers for Disease Control and Prevention and the Center for Community Health and Evaluation differ in their definitions of “reach.” Although the former’s definition distinguishes between direct and indirect number of unique individuals, the latter’s does not, making comparisons of this metric across studies, interventions, places, settings, and times difficult to achieve.Although the aforementioned metrics (reach and dose) can provide meaningful data to inform health and public health decisions,4,5 few strategic planning efforts have incorporated their use in the prioritization process.6 In this article, we describe the effort of the Los Angeles County Department of Public Health (DPH) to systematically incorporate population reach as a proxy metric of intervention impact, using it to guide prioritization of system and environmental change strategies for community implementation (when appropriate). The motivation for writing this article is to inform the efforts of other agencies similarly tasked with addressing the obesity epidemic in their communities but often constrained by limited resources and several competing priorities in their jurisdictions.     

The cost-effectiveness of deep brain stimulation in combination with best medical therapy, versus best medical therapy alone, in advanced Parkinson’s disease

Parkinson’s disease (PD) is a complex progressive movement disorder leading to motor and non-motor symptoms that become increasingly debilitating as the disease advances, considerably reducing quality of life. Advanced treatment options include deep brain stimulation (DBS). While clinical effectiveness of DBS has been demonstrated in a number of randomised controlled trials (RCT), evidence on cost-effectiveness is limited. The cost-effectiveness of DBS combined with BMT, versus BMT alone, was evaluated from a UK payer perspective. Individual patient-level data on the effect of DBS on PD symptom progression from a large 6-month RCT were used to develop a Markov model representing clinical progression and capture treatment effect and costs. A 5-year time horizon was used, and an incremental cost-effectiveness ratio (ICER) was calculated in terms of cost per quality-adjusted life-years (QALY) and uncertainty assessed in deterministic sensitivity analyses. Total discounted costs in the DBS and BMT groups over 5 years were £68,970 and £48,243, respectively, with QALYs of 2.21 and 1.21, giving an incremental cost-effectiveness ratio of £20,678 per QALY gained. Utility weights in each health state and costs of on-going medication appear to be the key drivers of uncertainty in the model. The results suggest that DBS is a cost-effective intervention in patients with advanced PD who are eligible for surgery, providing good value for money to health care payers.     

A Collective Review on Mesh-Based Repair of Umbilical and Epigastric Hernias

In accordance with the tension-free principles for other hernias, umbilical and epigastric hernia repair should probably be mesh-based. The number of randomized studies is increasing, most of them showing significantly less recurrences with the use of a mesh. Different devices are available and are applicable by several approaches. The objective of this review was to evaluate recent literature for the different types of mesh for umbilical and epigastric hernia repair and recurrences after mesh repair. A multi-database search was conducted to reveal relevant studies since 2001 reporting mesh-based repair of primary umbilical/epigastric hernia and their outcomes in adult patients. A total of 20 studies were included, 15 of them solely involved umbilical hernias, whereas the remaining studies included epigastric hernias as well. A median of 124 patients (range, 17–384) was investigated per study. Three quarters of the included studies had a follow-up of at least 2 years. Six studies described the results of laparoscopic approach, of which one reported a recurrence rate of 2.7 %; in the remaining studies, no recurrences occurred. Two comparative studies reported a lower incidence of complications and postoperative pain after laparoscopic repair compared to open repair. Seventeen studies reported results of open techniques, of which seven studies showed no recurrence. Other studies reported recurrence rates up to 3.1 %. A wide range of complication rates were reported (0–33 %). This collective review showed acceptable recurrence rates for mesh-based umbilical and epigastric hernia repair. A wide range of devices was investigated. A tendency toward more complications after laparoscopic repair was found compared to open repair.