ABSTRACT
BACKGROUND: Alternatives to allogeneic blood transfusion exist and are being used to varying extents in Australian hospitals. Evidence on effectiveness and cost-effectiveness is generally inconclusive and provides a suboptimal basis for policy development. AIM: To describe the influences on uptake of transfusion technologies as perceived by national and institutional stakeholders. METHODS: Qualitative interview study. Interview transcripts were coded and analysed independently by at least two researchers. Participants had opportunity to comment on their transcript and the manuscript. RESULTS: A total of 71 interviews were conducted with representatives of the media, specialist medical societies, consumer special interest groups, the Australian Red Cross Blood Service (ARCBS), government, private health insurers, technology manufacturers, prominent clinicians in the area and a sample of clinicians drawn from hospitals with variable use of blood-saving technologies. Technical advances and acceptance of lower transfusion triggers were identified as the main influences on the decrease in use of allogeneic blood transfusion in the past decade. Participants indicated that patients were most aware and supportive of autologous predonation. Participants noted that 'enthusiasts' were involved in educating about the need for alternatives, negotiating resourcing and maintaining the use of a technology. Funding mechanisms were seen as main barriers to use of alternatives. A discrepancy was noted in the rigour of evaluation and regulation of pharmaceuticals and devices/procedures. CONCLUSIONS: Uptake of blood transfusion technologies by institutions was dependent mostly on funding arrangements and the presence of an 'enthusiast'. Critical review of the evidence for effectiveness or cost-effectiveness of these technologies was rarely mentioned. Opportunities exist for evidence-based medicine principles to play a greater role in policy decisions in this area.
Subject(s)
Blood Donors , Blood Transfusion/methods , Medical Laboratory Science/methods , Perioperative Care/methods , Humans , Interviews as TopicABSTRACT
OBJECTIVE: To assess the effectiveness, safety and cost implications of leflunomide treatment for rheumatoid arthritis. DESIGN: Systematic review. SETTING: Four trials retrieved from Medline, Embase, the Cochrane Library, Econlit, HMIC (Dhdata), HMIC (Helmis), HMIC (King's Fund Database) and Best Evidence3. MAIN OUTCOME MEASURES: Efficacy measures (including tender joint counts, swollen joint counts, assessment of functioning, Health Assessment Questionnaire, Modified Health Assessment Questionnaire, pain (visual analogue scale), Erythrocyte Sedimentation Rate, C-reactive Protein), radiological progression and treatment adverse events. RESULTS: Leflunomide therapy was demonstrated to be significantly superior to placebo in relation to the efficacy outcome measures and it slowed the radiological progression of patients' disease in three studies. Treatment success and duration of sustained response were also significantly superior than on placebo, as were quality of life measures. Leflunomide treatment was comparable to sulphasalazine and methotrexate with respect to efficacy, radiological progression and quality of life measures. The most common adverse effects leading to withdrawal from leflunomide treatment were gastrointestinal symptoms (diarrhoea and nausea), allergic reactions (rash and pruritus), alopecia, dyspepsia, hypertension and elevated transaminase levels. Weight loss and dizziness have also been reported for leflunomide therapy. Leflunomide is more expensive than most DMARDs, costing about pound400 a year more than sulphasalazine. CONCLUSION: Despite the small number of published articles relating to leflunomide treatment, the evidence suggests that leflunomide is similar in efficacy to both sulphasalazine and methotrexate, although with a differential pattern of side-effects. There is a need for further research to assess the long-term outcomes of leflunomide treatment.
