ABSTRACT
OBJECTIVE: To evaluate clinical and cost effectiveness of implementing evidence-based guidelines for the prevention of stroke. DESIGN: Cluster-randomised trial SETTING: Three primary care organisations in the North of England covering a population of 400,000. PARTICIPANTS: Seventy six primary care teams in four clusters: North, South & West, City I and City II. INTERVENTION: Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack (TIA) were developed and implemented using a multifaceted approach including evidence-based recommendations, audit and feedback, interactive educational sessions, patient prompts and outreach visits. OUTCOMES: Identification and appropriate treatment of patients with atrial fibrillation or TIA, and cost effectiveness. RESULTS: Implementation led to 36% increase (95% CI 4% to 78%) in diagnosis of atrial fibrillation, and improved treatment of TIA (odds ratio of complying with guidelines 1.8; 95% CI 1.1 to 2.8). Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater (OR 1.46 95% CI 1.10 to 1.94) in the condition for which practices had received the implementation programme. The development and implementation of guidelines cost less than 1500 pounds per practice. The estimated costs per quality-adjusted life year gained by patients with atrial fibrillation or TIA were both less than 2000 pounds, very much less than the usual criterion for cost effectiveness. CONCLUSIONS: Implementation of evidence-based guidelines improved the quality of primary care for atrial fibrillation and TIA. The intervention was feasible and very cost effective. Key components of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication and use of established networks and opinion leaders.
Subject(s)
Guideline Adherence , Outcome Assessment, Health Care , Practice Guidelines as Topic , Primary Health Care/standards , Stroke/economics , Stroke/prevention & control , Atrial Fibrillation/diagnosis , Atrial Fibrillation/mortality , Atrial Fibrillation/therapy , Cluster Analysis , Confidence Intervals , Cost-Benefit Analysis , England , Evaluation Studies as Topic , Evidence-Based Medicine , Female , Guideline Adherence/economics , Humans , Ischemic Attack, Transient/diagnosis , Ischemic Attack, Transient/mortality , Ischemic Attack, Transient/therapy , Male , Outcome Assessment, Health Care/economics , Quality-Adjusted Life Years , Stroke/mortality , Survival AnalysisABSTRACT
OBJECTIVES: The aim of this study was to evaluate the cost-effectiveness of neonatal screening for phenylketonuria (PKU) and medium-chain acyl-coA dehydrogenase (MCAD) deficiency using tandem mass spectrometry (tandem MS). METHODS: A systematic review of clinical efficacy evidence and cost-effectiveness modeling of screening in newborn infants within a UK National Health Service perspective was performed. Marginal costs, life-years gained, and cost-effectiveness acceptability curves are presented. RESULTS: Substituting the use of tandem MS for existing technologies for the screening of PKU increases costs with no increase in health outcomes. However, the addition of screening for MCAD deficiency as part of a neonatal screening program for PKU using tandem MS, with an operational range of 50,000 to 60,000 specimens per system per year, would result in a mean incremental cost of -pound 17,298 (-pound 129,174, pound 66,434) for each cohort of 100,000 neonates screened. This cost saving is associated with a mean incremental gain of 57.3 (28.0, 91.4) life-years. CONCLUSIONS: Cost-effectiveness analysis using economic modeling indicates that substituting the use of tandem MS for existing technologies for the screening of PKU alone is not economically justified. However, the addition of screening for MCAD deficiency as part of a neonatal screening program for PKU using tandem MS would be economically attractive.
