Usual Care In Terms Research Articles

Effectiveness of shared medical appointments delivered in primary care for improving health outcomes in patients with long-term conditions: a systematic review of randomised controlled trials

ObjectivesTo examine the effectiveness of shared medical appointments (SMAs) compared with one-to-one appointments in primary care for improving health outcomes and reducing demand on healthcare services by people with one...

Effectiveness of a coordinated ambulatory care program for patients with mental disorders or multiple sclerosis: results of a prospective non-randomized controlled trial in South Germany.

The Psychiatry, Neurology, Psychosomatics and Psychotherapy (PNP) program of the German statutory health insurance AOK BW promotes coordinated and evidence-based specialist care with the aim of providing individualized, guideline-based outpatient care, strengthening the collaboration between health care providers, as well as reducing care costs. The purpose of this study was to evaluate its effectiveness regarding patient-reported outcomes compared to the less specialized general practitioner program (GP) and usual care (UC). AOK insured patients, who were on sick leave due to a mental disorder (affective disorder, anxiety disorder, adjustment disorder, somatoform disorder, alcohol abuse disorder, schizophrenia) or multiple sclerosis were included in the prospective non-randomized controlled study. All patients either participated in the PNP program (intervention group, IG-PNP), the general practitioner program (control group, CG-GP) or usual care (control group, CG-UC). Entropy balancing was used to adjust for baseline imbalance between groups. Primary outcome was health-related quality of life, assessed by the Short-form health survey (SF-36) 12 months after diagnosis. Secondary outcomes included symptom severity, functional health, and treatment satisfaction. Of the 14,483 insured patients who were contacted, 1,104 patients participated at baseline and 725 at follow-up. The adjusted mean differences of SF-36 sum score did not significantly differ between groups: -1.89 (95%-CI = -4.60; 0.81, p = 0.170) between IG-PNP and CG-GP, and -1.42 (95%-CI = -4.05; 1.22, p = 0.293) between PNP and CG-UC. The adjusted mean differences of secondary outcomes did not differ between groups, except for a slightly higher increase of functional health in CG-UC. We found no evidence that the PNP program is superior to the GP program or to usual care in terms of patient-reported outcomes or treatment satisfaction. The results are limited by the low response rate. Accordingly, future studies should strive for more representative samples. To improve the program, an integration of further collaborative care elements and guideline recommendations might be useful. DRKS (German Clinical Trials Register https://drks.de/search/en); identifier (DRKS00013114).

Effects of a multilevel intervention of resistance training with or without beta-hydroxy-beta-methylbutyrate in medical ICU patients during entire hospitalisation: a four-arm multicentre randomised controlled trial

BackgroundIntensive care unit-acquired weakness (ICU-AW) is a prevalent and severe issue among ICU patients. Resistance training and beta-hydroxy-beta-methylbutyrate (HMB) intervention have demonstrated the potential to enhance muscle function in patients with sarcopenia and in older adults. The purpose of this study was to determine whether resistance training and/or HMB administration would improve physical function, muscle strength, and quality of life in medical ICU patients.MethodsIn this multicentre, four-arm, single-blind randomised control trial, a total of 112 adult patients with internal medical diagnoses admitted to the ICU were enrolled. These participants were then randomly assigned to one of four treatment groups: the resistance training group received protocol-based multilevel resistance exercise, the HMB group received 3 g/day of HMBCa, combination group and control groups received standard care, from the ICU to the general ward until discharge. The primary outcomes assessed at discharge included six-minute walking distance (6MWD) and short physical performance battery (SPPB). Secondary outcomes measured included muscle mass, MRC score, grip strength, and health reports quality of life at different time points. Data analysis was performed using a generalised linear mixed model, adhering to the principles of intention-to-treat analysis.ResultsResistance training and combination treatment groups exhibited significant increases in SPPB scores (3.848 and 2.832 points, respectively) compared to the control group and substantial improvements in 6WMD (99.768 and 88.577 m, respectively) (all with P < 0.01). However, no significant changes were observed in the HMB group. Muscle strength, as indicated by MRC and grip strength tests conducted at both ICU and hospital discharge, showed statistically significant improvements in the resistance training and combination groups (P < 0.05). Nevertheless, no significant differences were found between the treatment groups and usual care in terms of 60-day mortality, prevalence of ICU-AW, muscle mass, quality of life, or other functional aspects.ConclusionsResistance training with or without beta-hydroxy-beta-methylbutyrate during the entire hospitalisation intervention improves physical function and muscle strength in medical ICU patients, but muscle mass, quality of life, and 60-day mortality were unaffected.Trial registrationChiCTR2200057685 was registered on March 15th, 2022.

Towards the standardization of physical activity programs for severe mental ill health: A survey of current practice across 54 mental health trusts in England

AimsWhile physical activity (PA) is recommended in the treatment of severe mental illness (SMI), there are no standardized processes for implementing PA in mental healthcare, and the extent to which PA programs have been implemented is unknown. Therefore, we sought to describe usual care in terms of the provision of PA in the National Health Service (NHS) mental health trusts in England for people with SMI. MethodsWe invited all NHS Mental Health Trusts across England to participate in a bespoke survey. ResultsFifty-two mental health trusts (96.2%) responded, of which 47 (87%) offered some form of physical activity provision. The provision across these 47 trusts comprised 93 different types of PA programs. The programs that were identified showed vast differences in the types of physical activity offered, the settings in which they were provided, and the providers. ConclusionsAlthough existing mental healthcare services are demonstrating good practice in some areas, the findings of this survey underline the pressing need for more standardization of PA programs that are delivered to people with SMI, better allocation of resources, staff training, improved monitoring of the delivery of these programs, and better PA support for patients as they transition to community care.

Short-term effects of a digital patient journey solution on patient-reported outcomes and health care utilization in arthroplasty: a pragmatic randomized controlled trial

Mobile health solutions for patient support have been proposed as promising and safe alternatives to usual care in adults undergoing primary total hip and knee arthroplasty. Studies of such applications, however, have produced conflicting results and only moderate- to low-quality evidence. This study aims to evaluate the short-term effects of a digital patient journey solution on patient-reported outcomes and health care utilization in patients undergoing total hip and knee arthroplasty using a pragmatic randomized controlled trial design. Randomly allocated patients in the control arm (n = 35, 64 ± 9 years) received usual care, while patients in the intervention arm (n = 34, 62 ± 11 years) received the digital patient journey solution in addition to usual care. The primary outcome was health-related quality of life as measured by the EuroQol EQ-5D-5L scale. Secondary outcomes included functional recovery, pain, self-efficacy, patient experience, adherence to fast-track protocol, and health care utilization. Participants were followed from a preoperative surgical visit until a postoperative follow-up visit at 6–12 weeks. The health-related quality of life, functional recovery, pain, patient experience, adherence to the fast-track protocol, and health care utilization did not differ between the arms. During the study, however, the self-efficacy to use digital health services (p=0.027) increased in the intervention arm. The use of the digital patient journey solution was not superior to usual care in terms of patient-reported outcomes and health care utilization. However, the solution improved the self-efficacy of patients to use digital health services, which may lead to greater demand for similar digital offerings as patient become more familiar with mobile health solutions.

Remote care through telehealth for people with inflammatory bowel disease.

Remote care through telehealth for people with inflammatory bowel disease.

The potential of mobile health applications to improve couples' fertility: a systematic review and meta-analysis of randomized controlled trials

The purpose of this systematic review was to examine the safety and effectiveness of mobile health applications in couples with infertility. Nineteen databases were searched from their inception to August 2022. Only randomized controlled trials (RCTs) in which mobile health was used as an intervention in infertile couples were included. A quantitative analysis of RCTs was employed using RevMan software. Study selection, data extraction and validation were performed by two independent reviewers according to the guidelines. The Cochrane criteria for risk-of-bias were used to evaluate the methodological quality of the trials. Eight RCTs met the inclusion criteria. Among the eight RCTs, two RCTs were from the Netherlands and the remaining six RCTs were from China. Meta-analysis showed that mobile health interventions in infertile couples in China were found to be superior to usual care in terms of clinical pregnancy rate (p = 0.001), psychological status (SAS (Self-Rating Anxiety Scale): p &lt; 0.001; SDS (Self-Rating Depression Scale) p &lt; 0.001;), infertility knowledge levels (p &lt; 0.001), quality of life (p &lt; 0.001), and serum levels of 5-hydroxytryptamine (p &lt; 0.001). The effects on intervention groups using mobile health interventions in the Netherlands were not superior to the control groups that used usual care in terms of improving dietary factors (p &gt; 0.05). In general, the positive effect of mobile health on improving clinical pregnancy rate, psychological status, infertility knowledge levels, quality of life and satisfaction with information was better than that of usual care. Mobile health interventions could be a viable supplement to the usual care for infertile couples. However, more high-quality RCTs need to be included in the future to provide additional evidence of the positive effects of mobile health in infertile couples.

Safety and efficacy of a cardiovascular polypill in people at high and very high risk without a previous cardiovascular event: the international VULCANO randomised clinical trial

BackgroundCardiovascular (CV) polypills are a useful baseline treatment to prevent CV diseases by combining different drug classes in a single pill to simultaneously target more than one risk factor. The aim of the present trial was to determine whether the treatment with the CNIC-polypill was at least non-inferior to usual care in terms of low-density lipoprotein cholesterol (LDL-c) and systolic BP (SBP) values in subjects at high or very high risk without a previous CV event.MethodsThe VULCANO was an international, multicentre open-label trial involving 492 participants recruited from hospital clinics or primary care centres. Patients were randomised to the CNIC-polypill -containing aspirin, atorvastatin, and ramipril- or usual care. The primary outcome was the comparison of the mean change in LDL-c and SBP values after 16 weeks of treatment between treatment groups.ResultsThe upper confidence limit of the mean change in LDL-c between treatments was below the prespecified margin (10 mg/dL) and above zero, and non-inferiority and superiority of the CNIC-polypill (p = 0.0001) was reached. There were no significant differences in SBP between groups. However, the upper confidence limit crossed the prespecified non-inferiority margin of 3 mm Hg. Significant differences favoured the CNIC-polypill in reducing total cholesterol (p = 0.0004) and non-high-density lipoprotein cholesterol levels (p = 0.0017). There were no reports of major bleeding episodes. The frequency of non-serious gastrointestinal disorders was more frequent in the CNIC-polypill arm.ConclusionThe switch from conventional treatment to the CNIC-polypill approach was safe and appears a reasonable strategy to control risk factors and prevent CVD.Trial registration This trial was registered in the EU Clinical Trials Register (EudraCT) the 20th February 2017 (register number 2016-004015-13; https://www.clinicaltrialsregister.eu/ctr-search/search?query=2016-004015-13).

Economic Evaluations of Mindfulness-Based Interventions: a Systematic Review.

ObjectivesThis study includes a systematic review of cost-effectiveness analyses (CEAs) and cost–benefit analyses (CBAs) of mindfulness-based interventions (MBIs).MethodsA literature search was conducted using PubMed, Web of Science, JSTOR, and CINAHL for studies published between January 1985 and September 2021, including an original cost-related evaluation of an MBI. A qualitative assessment of bias was performed using the Drummond checklist.ResultsTwenty-eight mindfulness-based intervention studies (18 CEAs and 10 CBAs) were included in this review. Mindfulness-based stress reduction (MBSR) was less costly and more effective when compared with the usual care of cognitive behavioral therapy among patients with chronic lower back pain, fibromyalgia, and breast cancer. MBSR among patients with various physical/mental conditions was associated with reductions in healthcare costs. Mindfulness-based cognitive therapy (MBCT) was also less costly and more effective than the comparison group among patients with depression, medically unexplained symptoms, and multiple sclerosis. MBCT’s cost-effectiveness advantage was also identified among breast cancer patients with persistent pain, non-depressed adults with a history of major depressive disorder episodes, adults diagnosed with ADHD, and all cancer patients. From a societal perspective, the cost-saving property of mindfulness training was evident when used as the treatment of aggressive behaviors among persons with intellectual/developmental disabilities in mental health facilities.ConclusionsBased on this review, more standardized MBI protocols such as MBSR and MBCT compare favorably with usual care in terms of health outcomes and cost-effectiveness. Other MBIs may result in cost savings from both healthcare and societal perspectives among high-risk patient populations.

Telemedicine home CPAP titration and follow-up in the COVID-19 scenario.

IntroductionContinuous positive airway pressure (CPAP) titration was dramatically affected by the coronavirus disease 2019 (COVID-19) pandemic due to increased biological risk. This study aimed to compare successful CPAP adaptation and compliance with home telemedicine CPAP titration with the usual method based on face-to-face visits.MethodologyA prospective cohort using telemedicine home CPAP titration and follow-up during the COVID-19 pandemic (TC) was compared with a retrospective cohort receiving face-to-face pre-pandemic home titration (RC). The TC included a subgroup with a smartphone application (TC-APP). Successful CPAP adaptation and compliance at 1 month of follow-up were the main endpoints, while patient satisfaction and costs were secondary endpoints.Results210 consecutive patients were evaluated (80 RC and 130 TC). 36 patients were in the TC-APP subgroup. CPAP titration was successful in 90% in RC versus 95% in TC and 100% in TC-APP. No compliance differences between groups were found at 1 month (4.79 h·night−1 RC, 4.33 h·night−1 TC and 4.59 h·night−1 TC-APP). Mean±sd patient satisfaction out of 10 was 7.69±2.05 in RC versus 9.02±0.64 in TC (p<0.001). 64% of the TC-APP subgroup reported that their telemedicine strategy influenced an increase in CPAP use (p=0.011). CPAP adaptation with follow-up had an estimated direct staff cost per patient of EUR 19.61±8.61 in TC with no smartphone application used versus EUR 23.79±9.94 in TC-APP (p=0.048).ConclusionsTelemedicine in CPAP titration and early follow-up is equivalent to the usual care in terms of successful adaptation and compliance, while achieving greater patient satisfaction.

General practitioner-centred paediatric primary care reduces risk of hospitalisation for mental disorders in children and adolescents with ADHD: findings from a retrospective cohort study

Background General practitioners (GPs) play an essential role in the sustainable management of attention-deficit/hyperactivity disorder (ADHD). To our knowledge, the healthcare programme described here is the first integrated care programme for paediatric ambulatory care embedded in GP-centred-healthcare in Germany. Objectives To compare the health-service-utilisation of patients with ADHD enrolled in a GP-centred-paediatric-primary-care-programme with usual care in terms of disease-related hospitalisation, pharmacotherapy and psychotherapy. Methods In 2018, we conducted a retrospective cohort study of 3- to 18-year-old patients with ADHD in Baden-Wuerttemberg, southern Germany. The intervention group (IG) comprised patients enrolled in a GP-centred-paediatric-primary-healthcare-programme and consulted a participating GP for ADHD at least once. GP-centred-paediatric-primary-care provides high continuity of care, facilitated access to specialist care, extended routine examinations and enhanced transition to adult healthcare. Patients in the control group (CG) received usual care, meaning they consulted a non-participating GP for ADHD at least once. Main outcomes were disease-related hospitalisation, pharmacotherapy and psychotherapy. Multivariable logistic regression was performed to compare groups. Results A total of 2317 patients were included in IG and 4177 patients in CG. Mean age was 8.9 ± 4.4. The risk of mental-disorder-related hospitalisations was lower in IG than CG (odds ratio (OR): 0.666, 95% confidence interval (CI): 0.509–0.871). The prescription rate for stimulants was lower in IG (OR: 0.817; 95% CI: 0.732–0.912). There was no statistically significant difference in the participation rate of patients in cognitive behavioural therapy between groups (OR: 0.752; 95% CI: 0.523–1.080). Conclusion Children and adolescents with ADHD enrolled in GP-centred-paediatric-primary-care are at lower risk of mental-disorder-related hospitalisation and less likely to receive stimulants.

Identifying the Conditions for Cost-Effective Minimally Invasive Neurosurgery in Spontaneous Supratentorial Intracerebral Hemorrhage

BackgroundIn patients with spontaneous supratentorial intracerebral hemorrhage (ICH), open craniotomy has failed to improve a functional outcome. Innovative minimally invasive neurosurgery (MIS) may improve a health outcome and reduce healthcare costs.AimsBefore starting phase-III trials, we aim to assess conditions that need to be met to reach the potential cost-effectiveness of MIS compared to usual care in patients with spontaneous supratentorial ICH.MethodsWe used a state-transition model to determine at what effectiveness and cost MIS would become cost-effective compared to usual care in terms of quality-adjusted life-years (QALYs) and direct healthcare costs. Threshold and two-way sensitivity analyses were used to determine the minimal effectiveness and maximal costs of MIS, and the most cost-effective strategy for each combination of cost and effectiveness. Scenario and probabilistic sensitivity analyses addressed model uncertainty.ResultsGiven €10,000 of surgical costs, MIS would become cost-effective when at least 0.7–1.3% of patients improve to a modified Rankin Scale (mRS) score of 0–3 compared to usual care. When 11% of patients improve to mRS 0–3, surgical costs may be up to €83,301–€164,382, depending on the population studied. The cost-effectiveness of MIS was mainly determined by its effectiveness. In lower mRS states, MIS needs to be more effective to be cost-effective compared to higher mRS states.ConclusionMIS has the potential to be cost-effective in patients with spontaneous supratentorial ICH, even with relatively low effectiveness. These results support phase-III trials to investigate the effectiveness of MIS.

Self-management interventions for people with chronic obstructive pulmonary disease.

Self-management interventions for people with chronic obstructive pulmonary disease.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review.

Chuna Manual Therapy vs Usual Care for Patients With Nonspecific Chronic Neck Pain

The incidence rate of neck pain is increasing worldwide, and the disease is associated with a high social burden. Manual therapy has been widely applied in the treatment of neck pain, but a high-quality, pragmatic randomized clinical trial for this treatment has not been conducted to date. This study aimed to compare the effectiveness of Chuna manual therapy with that of usual care for patients with chronic neck pain. A multicenter, assessor-blinded, pragmatic, randomized clinical trial was conducted between October 18, 2017, and June 28, 2019. This intention-to-treat analysis included 108 patients with chronic neck pain persisting for at least 3 months; patients were recruited from 5 hospitals in Korea. Ten sessions (2 sessions per week for 5 weeks) of Chuna manual therapy or usual care (electrotherapy and oral medication) were conducted. The main outcome was the difference in visual analog scale (VAS) score for chronic neck pain between baseline and 5 weeks after randomization. This randomized clinical trial recruited 108 patients (mean [SD] age, 38.4 [9.3] years; 73 women [67.6%]). Fifty-four patients were allocated to the Chuna therapy group, and 54 received usual care. At 5 weeks after randomization, manual therapy showed statistically superior results compared with usual care in terms of pain (difference in chronic neck pain VAS, 16.8 mm; 95% CI, 10.1-23.5 mm), function (difference in Neck Disability Index, 8.6%; 95% CI, 4.2%-13.1%), and quality of life (difference in the European Quality of Life-5 Dimension 5 Levels (EQ-5D-5L) scores, -0.07 points; 95% CI, -0.11 to -0.02 points). Regarding the 1-year cumulative values measured using area under the curve analyses, superior outcomes were attained in the manual therapy group in terms of the numerical rating scale for chronic neck pain (1.3 points; 95% CI, 0.5-2.0 points), Neck Disability Index (6.7%; 95% CI, 2.5%-10.9%), Neck Pain Questionnaire (7.4%; 95% CI, 2.3%-12.6%), and EQ-5D-5L scores (-0.03 points; -0.07 to 0.00 points). In this randomized clinical trial, for patients with chronic neck pain, Chuna manual therapy was more effective than usual care in terms of pain and functional recovery at 5 weeks and 1 year after randomization. These results support the need to consider recommending manual therapies as primary care treatments for chronic neck pain. ClinicalTrials.gov identifier: NCT03294785.

An aetiology-based subanalysis of the Telerehabilitation in Heart Failure Patients (TELEREH-HF) trial.

AimsThe aim of our study was to analyse the benefits of a 9 week hybrid comprehensive telerehabilitation (HCTR) programme in heart failure (HF) patients according to aetiology, as a subanalysis of the Telerehabilitation in Heart Failure Patients (TELEREH‐HF) trial.Methods and resultsOverall, 555 (65.3%) patients with ischaemic (IS) and 295 (34.7%) patients with non‐ischaemic (NIS) HF aetiology were randomized. There were no differences between the effect of HCTR and usual care (UC) on the primary outcome of number of days alive and out of the hospital in 26 months from the time of randomization in either aetiology (Wilcoxon–Mann–Whitney test), and no heterogeneity of effect between the aetiologies was noted (van Elteren test, P = 0.746). In Cox proportional hazards regression analysis, treatment was not independently associated with the secondary outcomes. For all‐cause mortality, the adjusted hazard ratio for HCTR vs. UC was 0.90 (95% confidence interval, 0.54–1.51) in IS and 1.42 (95% confidence interval, 0.69–2.94) in NIS (P interaction = 0.316). Differences between HCTR and UC in terms of change in the 6 min walk test distance and cardiopulmonary exercise test time after 9 weeks reached statistical significance in the IS arm (P = 0.015 and P < 0.001, respectively), but not in the NIS arm; however, tests of heterogeneity indicated no statistically significant differences.ConclusionsThe trial showed no difference between HCTR and UC in the primary outcome of percentage of days alive and out of the hospital for either IS or NIS aetiology. Moreover, the magnitude of changes in the clinical and functional statuses of the HF patients did not differ by aetiology. HCTR might have had beneficial effects on the 6 min walk test distance and cardiopulmonary exercise test time after 9 weeks in the IS patients; however, the effect was not statistically significantly different from that observed in the NIS patients.

Blood pressure telemonitoring and remote counseling in uncontrolled hypertension

Predictive modeling of long-term clinical and social outcomes and the cost-effectiveness analysis of blood pressure (BP) telemonitoring and remote counseling (BPTM) in patients with HTN. A Markov cohort-based (1000 patients in each study arm) model was developed and adopted a 10-year time horizon with 12-month time cycles. Cost and outcome data collected from the three-month study of 240 patients (160 in BPTM group and 80 controls, 48 y.o.). All patients started at a non-complicated HTN well state with a certain possibility of disease progression in a number of health states over a discrete time period. BPTM was compared with usual care in terms of 10-year healthcare costs, quality adjusted life years (QALY) using a Ministry of Health of Russian Federation perspective. In the long-term run when compared with usual care BPTM was more effective in terms mortality (67 versus 91 patients lost and 9.6 versus 9.71 life years gained) and costs (cost of illness 102 508 000 RUR versus 145 237 700 RUR). Taking quality of life measures into account, the effect of BPTM was also more pronounced (8.31 versus 7.82 QALYs gained). The resultant incremental cost-utility ratio for BPTM was 275 178.98 RUR/1 QALY gained/1 patient (134 837.70 RUR/0.49 QALY/1 patient). According to the results of predictive modeling, implementation of BPTM into clinical practice is likely lead to reduced cardiovascular morbidity and mortality in a cost-effective way.

Depression treatment in Germany \u2013 using claims data to compare a collaborative mental health care program to the general practitioner program and usual care in terms of guideline adherence and need-oriented access to psychotherapy

BackgroundSocieties strive for fast-delivered, evidence-based and need-oriented depression treatment within budget constraints. To explore potential improvements, selective contracts can be implemented. Here, we evaluate if the German collaborative psychiatry-neurology-psychotherapy contract (PNP), which extends the gatekeeping-based general practitioner (GP) program, improved guideline adherence or need-oriented and timely access to psychotherapy compared to usual care (UC).MethodsWe conducted a retrospective observational cohort study based on health insurance claims data. After we identified patients with depression who were on sick leave due to a mental disorder in 2015, we applied entropy balancing to adjust for selection effects and employed chi-squared tests to compare guideline adherence of the received treatment between PNP, the GP program and UC. Subsequently, we applied an extended cox regression to assess need-orientation by comparing the relationship between accumulated sick leave days and waiting times for psychotherapy across health plans.ResultsN = 23,245 patients were included. Regarding guideline adherence, we found no significant differences for most severity subgroups; except that patients with a first moderate depressive episode received antidepressants or psychotherapy more often in UC. Regarding need-orientation, we observed that the effect of each additional month of sick leave on the likelihood of starting psychotherapy was increased by 6% in PNP compared to UC.Irrespective of the health plan, we found that within the first 12 months only between 24.3 and 39.7% (depending on depression severity) received at least 10 psychotherapy sessions or adequate pharmacotherapy.ConclusionsThe PNP contract strengthens the relationship between sick leave days and the delay until the beginning of psychotherapy, which suggests improvements in terms of need-oriented access to care. However, we found no indication for increased guideline adherence and – independent of the health plan – a gap in sufficient utilization of adequate treatment options.

Rapid Access Arrhythmia Clinics (RAACs) Versus Usual Care: Improving Efficiency and Safety of Arrhythmia Management

Rapid access cardiology services have been proposed for assessment of acute cardiac conditions via an outpatient model-of-care that potentially could reduce hospitalisations. We describe a new Rapid Access Arrhythmia Clinic (RAAC) and compare major safety endpoints to usual care. We matched 312 adult patients with suspected arrhythmia in RAAC to historical age and sex-matched controls discharged from hospital within Western Sydney Local Health District with suspected arrhythmia. The primary endpoint was a composite of time to first unplanned cardiovascular hospitalisation or cardiac death over 12 months. The average age of RAAC patients was 52.2±18.8 years and 51.6±18.8 years for controls, and 48.4% were female in both groups. Mean time from referral to first attended RAAC appointment was 10.5 days. Most were referred from emergency (177, 56.7%) and cardiologists at time of discharge (65, 20.8%). The most common reason for referral was palpitations (180, 57.7%). In total, 155 (49.7%) had a documented arrhythmia, with the most common being atrial fibrillation/flutter (88, 28.2%). The primary endpoint occurred in 35 (11.2%) patients in the RAAC pathway (97.1[95% CI 70-131.3] per 1,000 person-years), compared to 72 (23.1%) patients for usual care controls (229.5[95% CI 180.2-288.1] per 1,000 person-years). Using a propensity score analysis, RAAC pathway significantly reduced the primary endpoint by 59% compared to usual care (HR 0.41, 95% CI 0.27-0.62; p<0.001). RAACs for the early investigation and management of suspected arrhythmia is superior to usual care in terms of reduction in unplanned cardiovascular hospitalisation and death.

Economic rationale on the use of m-Health in uncontrolled hypertensive outpatients: from three months and beyond

Abstract Background/Introduction Current scientific data show that blood pressure (BP) telemonitoring with/without additional counseling is rather effective in hypertension (HTN) management. However, cost-effectiveness and long-term social sequelae are lacking. This is because of diverse technologies and economic climate which make results highly heterogeneous across countries. Purpose To construct predictive model of long-term outcomes and to conduct the cost-effectiveness analysis of BP telemonitoring and remote counseling (BPTM) using m-Health in Russian population of outpatients with HTN. Methods Total of 240 patients were randomized (2:1) to either BPTM (n=160, mean age 47 y.o.) and to usual care (UC, n=80, mean age 49 y.o.) with baseline, three-month follow-up clinic visits combined with ambulatory BP measurement (ABPM). BPTM consisted of m-Health tool for patients, desktop module for clinicians. It enables BP data transfer and analysis, secure web chatting to support and counsel. Main outcomes were change in office, ambulatory systolic (S) BP and rate of BP control. A Markov cohort-based (1000 patients per study arm) model was developed and adopted a 10-year time horizon with 12-month time cycles. All patients started at a non-complicated HTN “well” state with a certain possibility of disease progression in a number of health states over a discrete time period. BPTM was compared with usual care in terms of 10-year healthcare costs, quality adjusted life years (QALY) using a Ministry of Health of Russian Federation perspective. Incremental cost-effectiveness ratio (ICER), incremental cost-utility ratio (ICUR) represented economic analysis. Results BPTM was associated with steeper decrease in office, ambulatory SBP (−16,8 mm Hg and −8,9 mm Hg, respectively; p&amp;lt;0,05) with the same treatment intensity (2,4 drugs per patient). There were 102 (64%) and 11 (14%) patients with fully controlled HTN in BPTM and UC groups, respectively (OR 11,03 95% CI [5,4–22,5]). An ICER of BPTM resulted in additional 11,1 EUR/1 mm Hg/year. It is expected that BPTM will be at least 76% cost-effective as per relevant Russian willingness-to-pay threshold. In a modelled 10-year period BPTM was life-saving (9,71 vs 9,6 life years gained) and cheap (cost of illness 1,5 mln vs 2,1 mln EUR). BPTM was also more valuable (8,31 versus 7,82 QALYs gained) so the ICUR was 3601,47 EUR/QALY gained. Cost-effectiveness was further confirmed by one-way deterministic sensitivity analysis. Conclusion BPTM seems to be clinically and economically effective when implemented into clinical practice. It provides greater BP reduction, improves BP control short-term. In a long-term it is likely to reduce cardiovascular morbidity and mortality in a cost-effective way. Larger randomized studies are needed to confirm these pilot results. Cost-effectiveness acceptability curve Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The Russian Scientific Foundation