Local Clinical Experts Research Articles

The budget impact of procalcitonin-guided antibiotic stewardship compared to standard of care for patients with suspected sepsis admitted to the intensive care unit in Belgium.

In Belgium, antibiotic resistance leads to approximately 530 deaths with a €24 million financial burden annually. This study estimated the impact of procalcitonin-guided antibiotic stewardship programs to reduce antibiotic consumption versus standard of care in patients with suspected sepsis. A decision analytic tree modelled health and budget outcomes of procalcitonin-guided antibiotic stewardship programs for patients admitted to the intensive care unit (ICU). A literature search, a survey with local clinical experts, and national database searches were conducted to obtain model input parameters. The main outcomes were total budget impact per patient, reduction in number of antibiotic resistance cases, and cost per antibiotic day avoided. To evaluate the impact of parameter uncertainty on the source data, a deterministic sensitivity analysis was performed. A scenario analysis was conducted to investigate budget impact when including parameters for reduction in length of ICU stay and mechanical ventilation duration, in addition to base-case parameters. Based on model predictions, procalcitonin-guided antibiotic stewardship programs could reduce the number of antibiotic days by 66,868, resulting in €1.98 million savings towards antibiotic treatment in current clinical practice. Antibiotic resistance cases could decrease by 7.7% (6.1% vs 9.2%) in the procalcitonin-guided setting compared with standard of care. The base-case budget impact suggests an investment of €1.90 per patient. The sensitivity analysis showed uncertainty, as the main drivers can alter potential cost savings. The scenario analysis indicated a saving of €1,405 per patient, with a reduction of 1.5 days in the ICU (14.8 days vs 12.8 days), and a reduction of 22.7% (18.1-27.2%) in mechanical ventilation duration. The associated sensitivity analysis was shown to be robust in all parameters. Procalcitonin-guided antibiotic stewardship programs are associated with clinical benefits that positively influence antimicrobial resistance in Belgium. A small investment per patient to implement procalcitonin testing may lead to considerable cost savings.

POSC111 Cost-Minimization Analysis of Bovine and Porcine Bioprosthetic Aortic Valves for the Treatment of Severe Aortic Stenosis in Colombia

Surgical Aortic Valve Replacement (SAVR) is the recommended treatment for severe aortic stenosis according to current guidelines in Latin America. The most commonly bioprosthetic valves used today are from porcine or bovine tissue. Regarding the valve selection rational , previous studies have reported superior hemodynamic performance using bovine compared with porcine valves and long-term outcomes have been recently reported. Additionally, considering the current restricted budget scenario, a rational resource utilization is vital. Therefore, the aim of this study was to conduct a long-term costs study of both bovine and porcine valves in Colombia from a public payers perspective. A cost-minimization analysis was carried out based in a Markov model with annual cycle length to estimate costs associated to each alternative over a 15-year time horizon. The model and the transition probabilities were based in the long-term clinical results previously reported in a previous study and were validated with local clinical experts. Considered costs included the initial procedure, the valves, standard monitoring, and reoperation. A 3.5% annual discount rate was considered according to local guidelines. All costs were estimated using the Social Security (Instituto del Seguro Social) Rates Manual and are presented in 2021 COP. Bovine valves presented a cost difference of -$1,149,865 COP versus porcine valves over the 15-year time horizon, which makes them a cost-saving alternative. Bovine valves were associated to $32,031,426 COP whereas porcine valves to $33,181,291 and the main cost driver between both alternatives was the reoperation rate. Savings associated to bovine valves were presented after the 10th year. From a public healthcare payer perspective, using bovine valves in SAVR patients could represent savings after the 10th year for the Colombian healthcare system. Considering the inevitable epidemiological transition, a rational use of resources is relevant, today more than ever.

STOPDVTs: Development and testing of a clinical assessment tool to guide nursing assessment of postoperative patients for Deep Vein Thrombosis.

To develop and test a clinical tool to guide nurses' assessment of postoperative patients for Deep Vein Thrombosis. Preventing venous thromboembolism in hospitalised patients is an international patient safety priority. Despite high-level evidence for optimal venous thromboembolism prophylaxis, implementation is inconsistent and the incidence of Deep Vein Thrombosis remains high. A two-stage sequential multi-method design was used. In stage 1, the STOPDVTs tool was developed using a review of the literature and focus groups with local clinical experts. Stage 2 involved pilot testing the tool with 38 surgical nurses who conducted repeated assessments on a prospective sample of 50 postoperative orthopaedic patients. Stage 1: The focus group members who were members of the nursing leadership team agreed on eight local and systemic signs and symptoms that should be included in a nursing patient assessment tool for early Deep Vein Thrombosis. Local symptoms were pain in the limbs, calf swelling and tightness, changes in the affected limb's skin temperature. Systemic signs included in the tool were as follows: increased shortness of breath, increased respiratory and heart rates, and decreased oxygen saturation. Stage 2: The STOPDVTs tool had acceptable face and content validity, the agreement between the expert nurse and surgical nurses on assessments of individual signs and symptoms varied between 44%-94%. Surgical nurses were less likely than the expert nurse to identify signs indicative of Deep Vein Thrombosis. Despite finding the STOPDVTs clinical assessment tool was a useful guide for nursing assessment, surgical nurses often underestimated the potential importance of clinical signs. The findings reveal a gap in nursing knowledge and skill in assessing for Deep Vein Thrombosis in postoperative orthopaedic patients. This study identified a possible risk to patient safety related to under-recognition of the signs and symptoms of possible Deep Vein Thrombosis (DVT) in postoperative orthopaedic patients. The findings demonstrate the feasibility of developing and implementing a protocol for consistent screening by nurses for possible DVT in the postoperative period.

Cost-effectiveness analysis of universal screening for thyroid disease in pregnant women in Spain

Objective To assess the cost-effectiveness of universal screening for thyroid disease in pregnant women in Spain as compared to high risk screening and no screening. Methodology A decision-analytic model comparing the incremental cost per quality-adjusted life year (QALY) of universal screening versus high risk screening and versus no screening. was used for the pregnancy and postpartum period. Probabilities from randomized controlled trials were considered for adverse obstetrical outcomes. A Markov model was used to assess the lifetime period after the first postpartum year and account for development of overt hypothyroidism. The main assumptions in the model and use of resources were assessed by local clinical experts. The analysis considered direct healthcare costs only. Results Universal screening gained .011 QALYs over high risk screening and .014 QALYS over no screening. Total direct costs per patient were €5,786 for universal screening, €5,791 for high risk screening, and €5,781 for no screening. Universal screening was dominant compared to risk-based screening and a very cost-effective alternative as compared to no screening. Use of universal screening instead of high risk screening would result in €2,653,854 annual savings for the Spanish National Health System. Conclusions Universal screening for thyroid disease in pregnant women in the first trimester is dominant in Spain as compared to risk-based screening, and is cost-effective as compared to no screening (incremental cost-effectiveness ratio of €374 per QALY). Moreover, it allows diagnosing and treating cases of clinical and subclinical hypothyroidism that may not be detected when only high-risk women are screened.

Análisis coste-efectividad del cribado universal de la enfermedad tiroidea en mujeres embarazadas en España

ObjectiveTo assess the cost-effectiveness of universal screening for thyroid disease in pregnant women in Spain as compared to high risk screening and no screening. MethodologyA decision-analytic model comparing the incremental cost per quality-adjusted life year (QALY) of universal screening versus high risk screening and versus no screening. was used for the pregnancy and postpartum period. Probabilities from randomized controlled trials were considered for adverse obstetrical outcomes. A Markov model was used to assess the lifetime period after the first postpartum year and account for development of overt hypothyroidism. The main assumptions in the model and use of resources were assessed by local clinical experts. The analysis considered direct healthcare costs only. ResultsUniversal screening gained .011 QALYs over high risk screening and .014 QALYS over no screening. Total direct costs per patient were €5,786 for universal screening, €5,791 for high risk screening, and €5,781 for no screening. Universal screening was dominant compared to risk-based screening and a very cost-effective alternative as compared to no screening. Use of universal screening instead of high risk screening would result in €2,653,854 annual savings for the Spanish National Health System. ConclusionsUniversal screening for thyroid disease in pregnant women in the first trimester is dominant in Spain as compared to risk-based screening, and is cost-effective as compared to no screening (incremental cost-effectiveness ratio of €374 per QALY). Moreover, it allows diagnosing and treating cases of clinical and subclinical hypothyroidism that may not be detected when only high-risk women are screened.

Cost-per-responder analysis comparing romiplostim to rituximab in the treatment of adult primary immune thrombocytopenia in Spain

Background and objectiveRomiplostim, a thrombopoietin-receptor agonist, is approved for second-line use in idiopathic thrombocytopenic purpura (ITP) patients where surgery is contraindicated. Anti-CD20 rituximab, an immunosuppressant, is currently used off-label. This analysis compared the cost per responder for romiplostim versus rituximab in Spain. Materials and methodA decision analytic model was constructed to estimate the 6-month cost per responding patient (achieving a platelet count ≥50×109/L) according to the most robust published data. A systematic literature review was performed to extract response rates from phase 3 randomised controlled trials. Romiplostim patients received weekly injections; rituximab patients received 4 weekly intravenous infusions. Medical resource costs were obtained from Spanish reimbursement lists. Treatment non-responders incurred bleeding-related event (BRE) management costs as reported in clinical trials. Medical resource utilisation and clinical practice were based on Spanish treatment guidelines and validated by local clinical experts. ResultsThe literature review identified phase 3 romiplostim trials with a response rate of 83%. Due to a lack of phase 3 controlled rituximab trials, a systematic review of studies was selected as the best source, reporting a response rate of 62.5%. The mean cost per patient for romiplostim was €16,289 and €13,459 for rituximab. Rituximab resulted in a 10% higher cost per responder (€21,535 versus €19,625 for romiplostim). Romiplostim use reduced drug administration, intravenous immunoglobulin, and bleeding-related costs compared to rituximab. ConclusionsDue to its high level of efficacy leading to lower BRE costs, romiplostim represents an efficient use of resources for adult ITP patients in the Spanish Healthcare System.

The development and implementation of a newborn medicine program in a resource-limited setting.

The reduction in global neonatal mortality rates remains a challenge. Internationally recognized protocols for hospital care of sick and small newborns are limited, although this specialized area lends itself to standardization. An interdisciplinary team including international and local clinical experts worked with the Rwandan Ministry of Health and Rwandan professional associations to develop and implement a neonatal care program in a rural Rwandan district hospital that was ultimately accepted as the national standard for newborn medicine. Successful features and challenges are discussed. It is realistic to develop, implement and disseminate neonatal protocols for sick newborns.

Coste por paciente con respuesta a romiplostim y rituximab en el tratamiento de la trombocitopenia inmune primaria en España

Background and objectiveRomiplostim, a thrombopoietin-receptor agonist, is approved for second-line use in idiopathic thrombocytopenic purpura (ITP) patients where surgery is contraindicated. Anti-CD20 rituximab, an immunosuppressant, is currently used off-label. This analysis compared the cost per responder for romiplostim versus rituximab in Spain. Materials and methodA decision analytic model was constructed to estimate the 6-month cost per responding patient (achieving a platelet count≥50×109/l) according to the most robust published data. A systematic literature review was performed to extract response rates from phase 3 randomized controlled trials. Romiplostim patients received weekly injections; rituximab patients received 4 weekly intravenous infusions. Medical resource costs were obtained from Spanish reimbursement lists. Treatment non-responders incurred bleeding-related event (BRE) management costs as reported in clinical trials. Medical resource utilization and clinical practice were based on Spanish treatment guidelines and validated by local clinical experts. ResultsThe literature review identified phase 3 romiplostim trials with a response rate of 83%. Due to a lack of phase 3 controlled rituximab trials, a systematic review of studies was selected as the best source, reporting a response rate of 62.5%. The mean cost per patient for romiplostim was €16,289 and €13,459 for rituximab. Rituximab resulted in a 10% higher cost per responder (€21,535 versus €19,625 for romiplostim). Romiplostim use reduced drug administration, intravenous immunoglobulin, and bleeding-related costs compared to rituximab. ConclusionsDue to its high level of efficacy leading to lower BRE costs, romiplostim represents an efficient use of resources for adult ITP patients in the Spanish Healthcare System.

Point/Counterpoint. Future radiotherapy practice will be based on evidence from retrospective interrogation of linked clinical data sources rather than prospective randomized controlled clinical trials.

Andre L. A. J. Dekker, Sarah L. Gulliford, Martin A. Ebert, and Colin G. Orton Citation: Medical Physics 41, 030601 (2014); doi: 10.1118/1.4832139 View online: http://dx.doi.org/10.1118/1.4832139 View Table of Contents: http://scitation.aip.org/content/aapm/journal/medphys/41/3?ver=pdfcov Published by the American Association of Physicists in Medicine Articles you may be interested in Response to “Comment on ‘Future radiotherapy practice will be based on evidence from retrospectiveinterrogation of linked clinical data sources rather than prospective randomized controlled clinical trials’” [Med.Phys.41(3), 030601 (3pp.) (2014)] Med. Phys. 41, 057103 (2014); 10.1118/1.4871786 Response to “Comment on ‘Future radiotherapy practice will be based on evidence from retrospectiveinterrogation of linked clinical data sources rather than prospective randomized controlled clinical trials’” [Med.Phys.41(3) 030601 (3pp.) (2014)] Med. Phys. 41, 057102 (2014); 10.1118/1.4871785 Comment on “Future radiotherapy practice will be based on evidence from retrospective interrogation of linkedclinical data sources rather than prospective randomized controlled clinical trials” [Med. Phys.41(3) 030601 (3pp.)(2014)] Med. Phys. 41, 057101 (2014); 10.1118/1.4871784 PET-based GTV definition is the future of radiotherapy treatment planning Med. Phys. 39, 5791 (2012); 10.1118/1.3694666 Determination of prospective displacement-based gate threshold for respiratory-gated radiation delivery fromretrospective phase-based gate threshold selected at 4D CT simulation Med. Phys. 34, 4247 (2007); 10.1118/1.2794169

Atrial septal defects - clinical manifestations, echo assessment, and intervention.

Atrial septal defect (ASD) is a common congenital abnormality that occurs in the form of ostium secundum, ostium primum, sinus venosus, and rarely, coronary sinus defects. Pathophysiologic consequences of ASDs typically begin in adulthood, and include arrhythmia, paradoxical embolism, cerebral abscess, pulmonary hypertension, and right ventricular failure. Two-dimensional (2D) transthoracic echocardiography with Doppler is a central aspect of the evaluation. This noninvasive imaging modality often establishes the diagnosis and provides critical information guiding intervention. A comprehensive echocardiogram includes evaluation of anatomical ASD characteristics, flow direction, associated abnormalities (eg, anomalous pulmonary veins), right ventricular anatomy and function, pulmonary pressures, and the pulmonary/systemic flow ratio. The primary indication for ASD closure is right heart volume overload, whether symptoms are present or not. ASD closure may also be reasonable in other contexts, such as paradoxical embolism. ASD type and local clinical expertise guide choice of a percutaneous versus surgical approach to ASD closure.

P308 Data Driven Best Practice In General Practice Prescribing

BackgroundA national quality improvement programme to understand how medicines are used was launched in 2011. The programme collects clinical data from general practice electronic health records to identify prescribing/management gaps.ContextThe...

The cost-effectiveness of paliperidone extended release in Spain

Background:Paliperidone Extended Release OROS (ER) is a new atypical antipsychotic for the treatment of schizophrenia. The objective is, based on a previously published model, to analyze the clinical and economic effects of Paliperidone ER in a Spanish setting compared to olanzapine oral and aripiprazole.Methods:An existing discrete event simulation model was adapted to reflect the treatment of schizophrenia in Spain in terms of costs, resource use, and treatment patterns. Inputs for the model were derived from clinical trial data, literature research, database analysis and interviews with local clinical experts. The time horizon is 5 years and Spanish discount rate was applied. Outputs include direct medical costs and Quality Adjusted Life-Years (QALYs). Extensive sensitivity analyses were carried out to assess the robustness of the results, using ordinary least squares analysis and cost-effectiveness scatter plots.Results:The results show that the mean incremental QALYs (95% CI) compared to olanzpine is 0.033 [−0.143, 0.304] and compared to aripiprazole 0.029 [−0.107, 0.300]. The corresponding mean incremental costs and corresponding confidence intervals are −€1425 [−€10,247, €3084] and −€759 [−€10,479, €3404], respectively. The probability that paliperidone ER is cost-saving and health gaining compared to olanzapine and aripiprazole is 76% and 72%, respectively. Paliperidone ER was estimated to have 80% and 81% probability of being cost-effective compared to olanzapine at a willingness to pay of €20,000 and €30,000 and 73% and 74% compared to aripiprazole, respectively.Limitations:Some of the modeled inter-relationships had to be based on expert opinion due to a lack of information. Also, foreign sources for the disutility of adverse events had been used due to a lack of Spanish data. Prolactin-related side-effects, indirect costs, and potential compliance advantages of paliperidone ER were not considered. It is unlikely that these limitations affected the conclusions.Conclusion:Based on differences in drug acquisition costs, side-effects, and risk of relapse, the model predicts that, in the Spanish healthcare setting, paliperidone ER dominates oral olanzapine and aripiprazole, with a probability of 76% and 72%, respectively.

1374P - Advancing Clinical Oncology Practice in Developing Countries: Integrating Research Informatics for Continuous Process Improvement

ABSTRACT In developing countries, Clinical Research is considered a luxurious interest with lower priority.Ongoing studies show considerable gap in responses between developed countries where most research is conducted and developing countries where most of needy population is located. We demonstrate a case where practice was improved in a multi-disciplinary cancer center through setting the institution vision and objectives to be patient centered, research focused and outcome oriented. Since the development of the Protocol Monitoring unit and the Research Department, a monitoring process has been established which identified violations and deviations from the developed clinical protocols with a continuous feedback to the attending treatment and research teams i.e treating each treatment regimen as a research protocol. This process proved effective and necessitated developing tools for providing more comprehensive treatment roadmaps and tracking patients' treatment milestones. Another advantage of applying the system is the improvement of medical team conduct knowing that their performance is being reviewed in what's known as Hawthorne Effect. With the establishment of first research informatics unit in the region Monitoring process became live web-based activity where performance and survival can be monitored instantaneously. The customized treatment protocols were developed through identifying key evidence-based practices, integrating it with research questions and local clinical expertise. Cooperation with international centers like St. Jude Children's Research hospital and Dana Farber Cancer Institute as well as Children's Hospital-Boston has supported our transition into an international center through benchmarking and training. Conclusion Within five years we've developed a model example for developing countries to improve clinical practice through integrating research methods and informatics. Dealing with all treatment regimens as research protocol with the integration of audit and feedback approach in the treatment process definitely improves treatment outcome most specifically at poorly established settings. Disclosure All authors have declared no conflicts of interest.

PMH33 The Cost-Effectiveness of Paliperidone ER in Spain

Paliperidone ER Extended Release OROS (ER) is a relatively new atypical antipsychotic for the treatment of schizophrenia. The objective is, based on a previously published model, to analyze the clinical and economic effects of Paliperidone ER in Spain compared to olanzapine oral and aripiprazole. An existing discrete event simulation model was adapted to reflect the treatment of schizophrenia in Spain in terms of costs, resource use and treatment patterns. Inputs for the model were derived from clinical trial data, literature search, database analysis, and interviews with local clinical experts. The time horizon is five years and Spanish discount rates were applied. Outputs included direct medical costs and Quality Adjusted Life-Years (QALYs). Sensitivity analyses were conducted to assess the uncertainty surrounding incremental outcomes and to identify model drivers, by performing probabilistic sensitivity analysis (PSA) and ordinary least squares analysis (OLSA). The mean (95% CI) incremental QALYs compared to olanzapine is 0.033 [-0.14, 0.30] and compared to aripiprazole 0.029 [-0.11,0.30]. The corresponding mean incremental costs (95% CI) are -€ 1,425 [-€ 10,247, €3,084] and -€ 759 [-€ 10,479, € 3,404] respectively. Based on the PSA, the probability that paliperidone ER is cost-saving and improves QALYs compared to olanzapine and aripiprazole is 76% and 72% respectively. Paliperidone ER was estimated to have 80% and 81% probability of being cost effective compared to olanzapine at a willingness to pay of €20,000 and €30,000 and 73% and 74% compared to aripiprazole respectively. OLSA identified drug acquisition costs, side effects and risk of relapse to be major model drivers. Based on differences in drug acquisition costs, side effects and risk of relapse, the model predicts that in Spain paliperidone ER provides QALY gains and cost savings compared with oral olanzapine and aripiprazole with a probability of 76% and 72% respectively.

Lexically suggest, logically define: Quality assurance of the use of qualifiers and expected results of post-coordination in SNOMED CT

A study of the use of common qualifiers in SNOMED CT definitions and the resulting classification was undertaken using combined lexical and semantic techniques. The accuracy of SNOMED authors in formulating definitions for pre-coordinated concepts was taken as a proxy for the expected accuracy of users formulating post-coordinated expressions. The study focused on “acute” and “chronic” as used within a module based on the UMLS CORE Problem List and using the pattern of SNOMED CT’s definition Acute disease and Chronic disease. Scripts were used to identify potential candidate concepts whose names suggested that they should be classified as acute or chronic findings. The potential candidates were filtered by local clinical experts to eliminate spurious lexical matches. Scripts were then use to determine which of the filtered candidates were not classified under acute or chronic findings as expected. The results were that 28% and 20% of candidate chronic and acute concepts, respectively, were not so classified. Of these candidate misclassifications, the large majority occurred because “acute” and “chronic” are sometimes specified by qualifiers for clinical course and sometimes for morphology, a fact mentioned but not fully detailed in the User Guide distributed with the SNOMED releases. This heterogeneous representation reflects a potential conflict between common usage in patient care and SNOMED’s origins in pathology. Other incidental findings included questions about the qualifier hierarchies themselves and issues with the underlying model for anatomy. The effort required for the study was kept modest by using module extraction and scripts, showing that such quality assurance of SNOMED is practical. The results of a preliminary study using proxy measures must be taken with caution. However, the high rate of misclassification indicates that, until the specifications for qualifiers are better documented and/or brought more in line with common clinical usage, anyone attempting to use post-coordination in SNOMED CT must be aware that there are significant pitfalls.

From PALSA PLUS to PALM PLUS: adapting and developing a South African guideline and training intervention to better integrate HIV/AIDS care with primary care in rural health centers in Malawi

BackgroundOnly about one-third of eligible HIV/AIDS patients receive anti-retroviral treatment (ART). Decentralizing treatment is crucial to wider and more equitable access, but key obstacles are a shortage of trained healthcare workers (HCW) and challenges integrating HIV/AIDS care with other primary care. This report describes the development of a guideline and training program (PALM PLUS) designed to integrate HIV/AIDS care with other primary care in Malawi. PALM PLUS was adapted from PALSA PLUS, developed in South Africa, and targets middle-cadre HCWs (clinical officers, nurses, and medical assistants). We adapted it to align with Malawi's national treatment protocols, more varied healthcare workforce, and weaker health system infrastructure.Methods/DesignThe international research team included the developers of the PALSA PLUS program, key Malawi-based team members and personnel from national and district level Ministry of Health (MoH), professional associations, and an international non-governmental organization. The PALSA PLUS guideline was extensively revised based on Malawi national disease-specific guidelines. Advice and input was sought from local clinical experts, including middle-cadre personnel, as well as Malawi MoH personnel and representatives of Malawian professional associations.ResultsAn integrated guideline adapted to Malawian protocols for adults with respiratory conditions, HIV/AIDS, tuberculosis, and other primary care conditions was developed. The training program was adapted to Malawi's health system and district-level supervision structure. PALM PLUS is currently being piloted in a cluster-randomized trial in health centers in Malawi (ISRCTN47805230).DiscussionThe PALM PLUS guideline and training intervention targets primary care middle-cadre HCWs with the objective of improving HCW satisfaction and retention, and the quality of patient care. Successful adaptations are feasible, even across health systems as different as those of South Africa and Malawi.

Current provision of rheumatology education for undergraduate nursing, occupational therapy and physiotherapy students in the UK

Rheumatological conditions are common and all health professionals (HPs) therefore need sufficient knowledge and skills to manage patients safely and effectively. The aim of this study was to examine current undergraduate education in rheumatology for HPs in the UK. A questionnaire was sent to curriculum organizers and clinical placement officers for all undergraduate courses in adult nursing, occupational therapy (OT) and physiotherapy (PT) in the UK to ascertain the nature and amount of rheumatology theory and clinical exposure provided. Of the 47 adult nursing, 26 OT and 30 PT undergraduate courses surveyed, 85-90% responded. Overall, rheumatology teaching is 5-10 h over 3 yr. Nursing students receive moderate/in-depth teaching on rheumatoid arthritis (RA) in only 52% of courses (OT 91%, PT 96%) and on osteoarthritis (OA) in 63% (OT 91%, PT 92%). Clinical experience of RA is probably/definitely available in only 56% of nursing courses (OT 72%, PT 88%), with similar results in OA. Overall, nursing students receive the least rheumatology exposure, particularly in psychosocial issues and symptom management, while PT students receive the most. OT students have limited opportunities for clinical exposure to psychosocial and joint protection issues. Use of local rheumatology clinical HP experts is variable (18-93%) and cross-disciplinary exposure is limited (0-36%). Many educators consider their rheumatology training to be insufficient (nursing 50%, PT 42%, OT 24%). Rheumatology training for undergraduate HPs is limited in key areas and often fails to take advantage of local clinical expertise, with nursing students particularly restricted. Clinical HP experts should consider novel methods of addressing these shortfalls within the limited curriculum time available.

Coronary artery stents in the treatment of ischaemic heart disease: a rapid and systematic review.

Coronary artery stents are prosthetic linings inserted into coronary arteries via a catheter to widen the artery and increase blood flow to ischaemic heart muscle. They are used in the treatment of ischaemic heart disease (IHD). IHD is a major cause of morbidity and mortality (123,000 deaths per annum) in the UK and a major cost to the NHS. Clinical effects of IHD include subacute manifestations (stable and unstable angina) and acute manifestations (particularly myocardial infarction [MI]). Treatment includes attention to risk factors, drug therapy, percutaneous invasive interventions (PCIs) (including percutaneous transluminal coronary angioplasty [PTCA] and stents) and coronary artery bypass graft surgery (CABG). In the last decade there has been a steady and significant increase in the rate of PCIs for IHD. In the UK, rates per million population increased from 174 in 1991 to 437 in 1998. Stents are now used in about 70% of PCIs. Data from the rest of Europe suggest there is potential for PCI and stent rates to increase considerably. In the UK there is evidence of under-provision and inequity of access to revascularisation procedures. The following questions were addressed. 1. What are the effects and effectiveness of elective stent insertion versus PTCA in subacute IHD, particularly stable angina and unstable angina? 2. What are the effects and effectiveness of elective stent insertion versus CABG in subacute IHD, particularly stable angina and unstable angina? 3. What are the effects and effectiveness of elective stent insertion versus PTCA in acute MI (AMI)? 4. What are best estimates of UK cost for elective stent insertion, PTCA and CABG in the circumstances of review questions 1 to 3? 5. What are best estimates of cost-effectiveness and cost-utility for elective stent insertion relative to PTCA or CABG in the circumstances of review questions 1 to 3? A systematic review addressing the objectives was undertaken. A search was made for RCTs comparing stents (inserted during a PTCA procedure) with PTCA alone or with CABG in any manifestation of IHD. The search strategy covered the period from 1990 to November 1999 and included searches of electronic databases (MEDLINE, EMBASE, BIDS ISI, The Cochrane Library), Internet sites, and hand-searches of cardiology conference abstracts and 1999 issues of cardiology journals. Lead researchers and local clinical experts were contacted. Manufacturers' submissions to the National Institute for Clinical Excellence were searched. The search strategy was expanded to look for relevant economic analyses and information to inform the economic model (including searching MEDLINE, the NHS Economic Evaluation Database and the Database of Abstracts of Reviews of Effectiveness). Searches focused on research that reported costs and quality of life data associated with IHD and interventional cardiology. For the review of clinical effectiveness, inclusion criteria were: (i) RCT design; (ii) study population comprising adults with IHD in native or graft vessels (including patients with subacute IHD or AMI); (iii) procedure involving elective insertion of coronary artery stents; (iv) elective PTCA (including PTCA with provisional stenting) or CABG as comparator; (v) outcomes defined as one or more of: combined event rate (or event-free survival), death, MI, angina, target vessel revascularisation, CABG, repeat PTCA, angiographic outcomes; (vi) trials that had closed and reported results for all or almost all recruited patients. For the economic evaluation, studies of adults with IHD were included if they were of the following types: studies reporting UK costs; comparative economic evaluation combining both costs and outcomes; economic evaluations reporting costs and outcomes separately for the years 1998 and 1999 (to ensure current practice was included).(ABSTRACT TRUNCATED)