Stroke Units versus General Wards: Costs comparison

1. Stroke Units versus General Wards: Costs comparison Class 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

2. 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

3. 1. Summaryofproject’stheme • Stroke units and general wards • Cost/effectiveness relation • So… • Collect and select information • Organize and relate it • Conclusion

4. 1.1. Cardiovascular Accident (CVA), Stroke Units and General Wards • 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. • Stroke Units: • Health unit specifically designed for the treatment of acute stroke patients. • General Wards: • General care unit. • Follows the general treatment guidelines.

5. 1.2. Researchquestionandaims 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.

6. 2. Whatwe’vealreadydone 2.1. Primaryresearch • Query: • (stroke OR "cerebrovascular accident") AND (cost OR costs) AND (unit OR units) • Databases: • PubMed through MEDLINE • Cochrane through EBSCO

7. 2. Whatwe’vealreadydone 2.1. Primaryresearch 456 articles found (434 PUBMED & 72 EBSCO)

8. 2.2. Screening Phase1,11 Apply inclusion/exclusion criteria Two reviewers Screen titles and abstracts Selection of articles for second stage Meet to discuss disagreements Third reviewer The reliability of the process is determined by using specific methods (Kappa Statistic). The final number of articles is ready for a second screen.

9. 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

10. 2.2.2. Articles Selected 61 articles included

11. 2.2.3. Statistic Results

12. 2.2.3. Statistic Results

13. 2.2.3. Statistic Results

14. 2.2.3. Statistic Results

15. 2.3. Inclusion Phase1,11 Get full articles. Two reviewers Meet to discuss disagreements Read whole texts and select proper ones 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.

16. 2.3.1. Articles Selected 61 article, 31 processed

17. 2.3.2. Statistic Results

18. 2.3.2. Statistic Results

19. 3. What we’ll do 3.1. Data extraction1,11 and Outcome variables Extraction of data. Quality assessment of included studies. Outcome variables Mortality rate + morbidity rate + global costs Extract information according to inclusion and quality criteria

21. 3.2. Quality assessment 3.2.1. Checklist for quality assessment of randomized clinical trials10 Methods Participants Interventions Objectives Outcomes Sample size Randomization Sequence generation Allocation concealment Implementation Blinding Stathistical Methods

22. 3.2. Quality assessment 3.2.1. Checklist for quality assessment of randomized clinical trials Results Participant flow Recruitment Baseline Data Numbers Analyzed Outcomes and Estimation Adverse Events

23. 3.2. Quality assessment 3.2.2. 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 thequestions addressed.

24. 3.2. Quality assessment 3.2.2. Health economics checklist Data collection • 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;

25. 3.2. Quality assessment 3.2.2. Health economics checklist Analysis 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.

26. 3. Whatwe’ll do 3.3. 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.

27. 3. Whatwe’ll do 3.4. Discussion Interpret and discuss results  implication in concrete situations, possible research limitations Final Report

28. 4. Expectedresults 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.

29. 5. References • 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. • Justo LP, Soares BGO, Cali HM. Revisão sistemática, metanálise e medicina baseada em evidências: considerações conceituais. J Bras Psiquiatr 54(3): 242-247, 2005. • 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 • 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 • 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. • 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. • 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. • Walker D. Cost and effectiveness guidelines: which ones to use? Health policy and planning; 16(1): 113-121. • 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 • 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. • Khalid S Khan, Jennie Popay, Jos Kleijen. Development of a review protocol. • Website from BMJ: http://resources.bmj.com/bmj/authors/checklists-forms/health-economics

30. Thank you for the attention.