Health technology assessment : HTA
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Health Technol Assess · Mar 2004
Review Comparative StudyThe use of modelling to evaluate new drugs for patients with a chronic condition: the case of antibodies against tumour necrosis factor in rheumatoid arthritis.
To address the structural issues relating to mortality and quality of life (QoL) effects and to identify data on the general pattern of QoL of rheumatoid arthritis (RA) patients through a restructured and enhanced version of the Birmingham Preliminary Model (BPM). ⋯ The main achievement of this work was to bring about a more realistic modelling of real-life clinical pathways and events, as it has developed from the BPM to the BRAM. This has been brought about by overcoming structural and data limitations. In addition, the modelling approach reflected in the BRAM is applicable to other chronic conditions, especially those where a sequential approach to therapeutic options exists. The model has been successfully restructured so that different sequences of treatment can readily be considered, including the sequence that best represents current clinical practice in the UK. In addition, the flexibility inherent in using a modelling approach to consider these health policy questions has been demonstrated. One of the key uncertainties that can now be explored concerns the impact of new drugs on disease progression. Current evidence on this is weak, but should new agents demonstrate such a benefit then the BRAM may be a suitable vehicle through which to investigate the costs and full effects. Inevitably, there remain problems and limitations with the BRAM, but these are almost entirely data limitations. As data on these issues become available the BRAM provides a convenient tool through which reanalysis might be undertaken.
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Health Technol Assess · Feb 2004
Review Randomized Controlled Trial Comparative Study Clinical TrialPsychological treatment for insomnia in the regulation of long-term hypnotic drug use.
To evaluate the clinical and cost impact of providing, in routine general practice settings, a cognitive-behaviour therapy (CBT) package for insomnia to long-term hypnotic drug users with chronic sleep difficulties; and to identify factors associated with variations in clinical outcomes. ⋯ In routine general practice settings, psychological treatment for insomnia can improve sleep quality, reduce hypnotic drug use, and improve health-related quality of life at a favourable cost among long-term hypnotic users with chronic sleep difficulties. These positive outcomes appear robust over time, persisting for at least 1 year among the more treatment-adherent patients. While these benefits may be reduced among those patients presenting with higher levels of psychological distress, the present study clearly indicates that older age per se presents no barrier to successful treatment outcomes. Further research should assess the long-term clinical and cost-effectiveness of psychological treatments for insomnia among non-hypnotic-using patients, and establish the minimum psychological treatment input required.
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Health Technol Assess · Feb 2004
ReviewSystematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care.
To ascertain the value of a range of methods - including clinical features, resting and exercise electrocardiography, and rapid access chest pain clinics (RACPCs) - used in the diagnosis and early management of acute coronary syndrome (ACS), suspected acute myocardial infarction (MI), and exertional angina. ⋯ Where an ACS is suspected, emergency referral is justified. ECG interpretation in acute chest pain can be highly specific for diagnosing MI. Point of care testing with troponins is cost-effective in the triaging of patients with suspected ACS. Resting ECG and exercise ECG are of only limited value in the diagnosis of CHD. The potential advantages of RACPCs are lost if there are long waiting times for further investigation. Recommendations for further research include the following: determining the most appropriate model of care to ensure accurate triaging of patients with suspected ACS; establishing the cost-effectiveness of pre-hospital thrombolysis in rural areas; determining the relative cost-effectiveness of rapid access chest pain clinics compared with other innovative models of care; investigating how rapid access chest pain clinics should be managed; and establishing the long-term outcome of patients discharged from RACPCs.
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Health Technol Assess · Feb 2004
ReviewEffectiveness and efficiency of guideline dissemination and implementation strategies.
To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. ⋯ There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.
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Health Technol Assess · Feb 2004
Review Comparative StudySystematic review of the clinical effectiveness and cost-effectiveness of capecitabine (Xeloda) for locally advanced and/or metastatic breast cancer.
To examine the clinical effectiveness and cost-effectiveness of oral capecitabine for locally advanced and metastatic breast cancer in relation to its licensed indications. ⋯ No conclusions could be drawn regarding the therapeutic benefit of capecitabine monotherapy; RCTs are required. Capecitabine appeared cost-effective compared with vinorelbine, but serious doubts remain; the poor quality of the trials may invalidate this conclusion. Based on limited evidence, combination therapy was more effective than single-agent docetaxel and likely to be cost-effective, but was associated with higher incidences of hand-foot syndrome, nausea, diarrhoea and stomatitis.