Stroke Units versus General Wards: Costs comparison

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





2.3. 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



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


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.


• 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


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. 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

1. Pai M, McCulloch M, Gorman JD, Pai N, Enanoria W, Kennedy G, Tharyan P, Colford Jr JM. Systematic reviews and meta-analysis: An illustrated, step-

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.

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Stroke Units versus General Wards: Costs comparison