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Health Technology Assessment... 2003To evaluate the effectiveness and cost-effectiveness of tension-free vaginal tape (TVT) in comparison with the standard surgical interventions currently used. (Comparative Study)
Comparative Study Review
OBJECTIVES
To evaluate the effectiveness and cost-effectiveness of tension-free vaginal tape (TVT) in comparison with the standard surgical interventions currently used.
DATA SOURCES
Literature searches were carried out on electronic databases and websites for data covering the period 1966--2002. Other sources included references lists of relevant articles; selected experts in the field; abstracts of a limited number of conference proceedings titles; and the Internet.
REVIEW METHODS
A systematic review of studies including comparisons of TVT with any of the comparators was conducted. Alternative treatments considered were abdominal retropubic colposuspension (including both open and laparoscopic colposuspension), traditional suburethral sling procedures and injectable agents (periurethral bulking agents). The identified studies were critically appraised and their results summarised. A Markov model comparing TVT with the comparators was developed using the results of the review of effectiveness and data on resource use and costs from previously conducted studies. The Markov model was used to estimate costs and quality-adjusted life-years for up to 10 years following surgery and it incorporated a probabilistic analysis and also sensitivity analysis around key assumptions of the model.
RESULTS
Based on limited data from direct comparisons with TVT and from systematic reviews, laparoscopic colposuspension and traditional slings have broadly similar cure rates to TVT and open colposuspension, whereas injectable agents appear to have lower cure rates. TVT is less invasive than colposuspension and traditional sling procedures, and is also usually performed under regional or local anaesthesia. The principal operative complication is bladder perforation. There are currently no randomised controlled trial (RCT) data beyond 2 years post-surgery, and long-term effects are therefore currently not known reliably. TVT was more likely to be considered cost-effective compared with the other surgical procedures. Increasing the absolute probability of cure following TVT reduced the likelihood that TVT would be considered cost-effective.
CONCLUSIONS
The long-term performance of TVT in terms of both continence and unanticipated adverse effects is not known reliably at the moment. Despite relatively few robust comparative data, it appears that in the short to medium term TVT's effectiveness approaches that of alternative procedures currently available, and is of lower cost. As TVT is a less invasive procedure, it is possible that some women who would currently be managed non-surgically will be considered eligible for TVT. Increased adoption of TVT will require additional surgeons proficient in the technique. It is likely that some of the higher rates of complications, e.g. bladder perforation, reported for TVT are associated with a 'learning curve'. Appropriate training will therefore be needed for surgeons new to the operation, in respect of both the technical aspects of the procedure and the choice of women suitable for the operation. Further research suggestions include unbiased assessments of longer term performance from follow-up of controlled trials or population-based registries; more data from methodologically sound RCTs using standard outcome measures; a surveillance system to detect longer term complications, if any, associated with the use of tape; and rigorous evaluation before extending the use of TVT to women who are currently managed non-surgically.
Topics: Colposcopy; Cost-Benefit Analysis; Female; Humans; Prostheses and Implants; Quality-Adjusted Life Years; Technology Assessment, Biomedical; Treatment Outcome; Urethra; Urinary Incontinence, Stress; Urologic Surgical Procedures; Vagina
PubMed: 13678548
DOI: 10.3310/hta7210 -
BMC Geriatrics Feb 2018Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and... (Review)
Review
BACKGROUND
Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and can best be implemented in such settings. We aimed to develop a theory that outlines the hypothetical causal pathway of ACP in nursing homes, i.e. what changes are expected, by means of which processes and under what circumstances.
METHODS
The Theory of Change approach is a participatory method of programme design and evaluation whose underlying intention is to improve understanding of how and why a programme works. It results in a Theory of Change map that visually represents how, why and under what circumstances ACP is expected to work in nursing home settings in Belgium. Using this approach, we integrated the results of two workshops with stakeholders (n = 27) with the results of a contextual analysis and a systematic literature review.
RESULTS
We identified two long-term outcomes that ACP can achieve: to improve the correspondence between residents’ wishes and the care/treatment they receive and to make sure residents and their family feel involved in planning their future care and are confident their care will be according to their wishes. Besides willingness on the part of nursing home management to implement ACP and act accordingly, other necessary preconditions are identified and put in chronological order. These preconditions serve as precursors to, or requirements for, accomplishing successful ACP. Nine original key intervention components with specific rationales are identified at several levels (resident/family, staff or nursing home) to target the preconditions: selection of a trainer, ensuring engagement by management, training ACP reference persons, in-service education for healthcare staff, information for staff, general practitioners, residents and their family, ACP conversations and documentation, regular reflection sessions, multidisciplinary meetings, and formal monitoring.
ONCLUSIONS
The Theory of Change map presented here illustrates a theory of how ACP is expected to work in order to achieve its desired long-term outcomes while highlighting organisational factors that potentially facilitate the implementation and sustainability of ACP. We provide the first comprehensive rationale of how ACP is expected to work in nursing homes, something that has been called for repeatedly.
Topics: Advance Care Planning; Aged; Belgium; Communication; Documentation; Humans; Nursing Homes; Physicians; Professional-Family Relations; Program Evaluation
PubMed: 29444645
DOI: 10.1186/s12877-018-0723-5 -
Frontiers in Psychiatry 2024Midwives may be key stakeholders to improve perinatal mental healthcare (PMHC). Three systematic reviews considered midwives' educational needs in perinatal mental... (Review)
Review
BACKGROUND
Midwives may be key stakeholders to improve perinatal mental healthcare (PMHC). Three systematic reviews considered midwives' educational needs in perinatal mental health (PMH) or related interventions with a focus on depression or anxiety. This systematic review aims to review: 1) midwives' educational/training needs in PMH; 2) the training programs in PMH and their effectiveness in improving PMHC.
METHODS
We searched six electronic databases using a search strategy designed by a biomedical information specialist. Inclusion criteria were: (1) focus on midwives; (2) reporting on training needs in PMH, perinatal mental health problems or related conditions or training programs; (3) using quantitative, qualitative or mixed-methods design. We used the Mixed Methods Appraisal Tool for study quality.
RESULTS
Of 4969 articles screened, 66 papers met eligibility criteria (47 on knowledge, skills or attitudes and 19 on training programs). Study quality was low to moderate in most studies. We found that midwives' understanding of their role in PMHC (e.g. finding meaning in opening discussions about PMH; perception that screening, referral and support is part of their routine clinical duties) is determinant. Training programs had positive effects on proximal outcomes (e.g. knowledge) and contrasted effects on distal outcomes (e.g. number of referrals).
CONCLUSIONS
This review generated novel insights to inform initial and continuous education curriculums on PMH (e.g. focus on midwives' understanding on their role in PMHC or content on person-centered care).
REGISTRATION DETAILS
The protocol is registered on PROSPERO (CRD42021285926).
PubMed: 38711873
DOI: 10.3389/fpsyt.2024.1345738 -
Medicine Apr 2021A recent trend in the field of primary knee osteoarthritis suggests that elastic tape (e.g., K-tape) relieves pressure on the joint by increasing tension on fascia....
BACKGROUND
A recent trend in the field of primary knee osteoarthritis suggests that elastic tape (e.g., K-tape) relieves pressure on the joint by increasing tension on fascia. Elastic tape (ET) is expected to decrease pain and help patients to recover faster.
OBJECTIVE
This systematic review aims to analyze the efficacy of this method on pain in patients with knee osteoarthritis by using The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score.
DATA SOURCES
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard for reporting systematic reviews of qualitative and quantitative evidence, we used 3 electronic databases, PubMed, Cochrane, and EBSCO, and grey literature was included.
STUDY ELIGIBILITY CRITERIA
Articles were screened for duplicates, screened for inclusion and exclusion criteria, and critically appraised.
PARTICIPANTS AND INTERVENTION
People older than 45 years old with primary osteoarthritis (OA) and application of ET.
STUDY APPRAISAL AND SYNTHESIS METHODS
2005 Oxford standard.
RESULTS
Amongst all the papers found, 6 Randomized Control Trials (RCT) for a total of 392 participants met the criteria and were included in our review. Three papers out of the 6 RCT had low risks of bias. When the ET was compared to sham taping, the results show no to moderate decreases of WOMAC scores in patients with primary knee osteoarthritis.
LIMITATIONS
We focused on a single index test (WOMAC) and could not perform meta-analyses.
CONCLUSION AND IMPLICATIONS OF KEY FINDINGS
Although ET does not provide strong adverse outcomes, our data do not support the use of ET as a treatment alone because of too slight reductions of the WOMAC score for reaching clinical efficiency. Thus, our systematic review shows no strong evidence regarding the use of elastic taping for pain improvement in patients with primary knee osteoarthritis.
Topics: Arthralgia; Compression Bandages; Humans; Osteoarthritis, Knee; Pain Management; Pain Measurement; Treatment Outcome
PubMed: 33787644
DOI: 10.1097/MD.0000000000025382 -
Health Technology Assessment... Mar 2019Urinary incontinence in women is a distressing condition that restricts quality of life and results in a large economic burden to both the NHS and women themselves.
BACKGROUND
Urinary incontinence in women is a distressing condition that restricts quality of life and results in a large economic burden to both the NHS and women themselves.
OBJECTIVE
To evaluate the clinical effectiveness, safety and cost-effectiveness of surgical treatment for stress urinary incontinence (SUI) in women and explore women's preferences.
DESIGN
An evidence synthesis, a discrete choice experiment (DCE) and an economic decision model, with a value-of-information (VOI) analysis. Nine surgical interventions were compared. Previous Cochrane reviews for each were identified and updated to include additional studies. Systematic review methods were applied. The outcomes of interest were 'cure' and 'improvement'. Both a pairwise and a network meta-analysis (NMA) were conducted for all available surgical comparisons. A DCE was undertaken to assess the preferences of women for treatment outcomes. An economic model assessed the cost-effectiveness of alternative surgeries and a VOI analysis was undertaken.
RESULTS
Data from 175 studies were included in the effectiveness review. The majority of included studies were rated as being at high or unclear risk of bias across all risk-of-bias domains. The NMA, which included 120 studies that reported data on 'cure' or 'improvement', showed that retropubic mid-urethral sling (MUS), transobturator MUS, traditional sling and open colposuspension were more effective than other surgical procedures for both primary outcomes. The results for other interventions were variable. In general, rate of tape and mesh exposure was higher after transobturator MUS than after retropubic MUS or single-incision sling, whereas the rate of tape or mesh erosion/extrusion was similar between transobturator MUS and retropubic MUS. The results of the DCE, in which 789 women completed an anonymous online questionnaire, indicate that women tend to prefer surgical treatments associated with no pain or mild chronic pain and shorter length of hospital stay as well as those treatments that have a smaller risk for urinary symptoms to reoccur after surgery. The cost-effectiveness results suggest that, over a lifetime, retropubic MUS is, on average, the least costly and most effective surgery. However, the high level of uncertainty makes robust estimates difficult to ascertain. The VOI analysis highlighted that further research around the incidence rates of complications would be of most value.
LIMITATIONS
Overall, the quality of the clinical evidence was low, with limited data available for the assessment of complications. Furthermore, there is a lack of robust evidence and significant uncertainty around some parameters in the economic modelling.
CONCLUSIONS
To our knowledge, this is the most comprehensive assessment of published evidence for the treatment of SUI. There is some evidence that retropubic MUS, transobturator MUS and traditional sling are effective in the short to medium term and that retropubic MUS is cost-effective in the medium to long term. The VOI analysis highlights the value of further research to reduce the uncertainty around the incidence rates of complications. There is a need to obtain robust clinical data in future work, particularly around long-term complication rates.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42016049339.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Cost-Benefit Analysis; Female; Humans; Models, Economic; Network Meta-Analysis; Suburethral Slings; Technology Assessment, Biomedical; Treatment Outcome; Urinary Incontinence, Stress; Urologic Surgical Procedures
PubMed: 30929658
DOI: 10.3310/hta23140 -
Systematic Reviews Jun 2021Current clinical guidelines recommend conservative management including non-pharmacologic therapy prior to considering surgery for knee OA. There is a paucity of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Current clinical guidelines recommend conservative management including non-pharmacologic therapy prior to considering surgery for knee OA. There is a paucity of clinical trials investigating the use of biomechanical device therapies on those with patellofemoral joint osteoarthritis (PFJOA). The aim was to systematically review the effectiveness of biomechanical devices (bracing, taping, and footwear) in the management of symptomatic PFJOA.
METHOD
The Cochrane, PEDro, MEDLINE, CINAHL, AMED and EMBASE electronic databases were search from inception to October 31, 2020. Included studies were randomised controlled or clinical trials studying any form of biomechanical device therapy in the management of PFJOA in the English language. Studies included in the search were quality-appraised using the PEDro scoring system.
RESULT
Eleven studies were identified which included assessment of either patellar taping, or foot orthotics, knee bracing or combined physiotherapy treatments. Trial quality ranged from 'poor' through 'fair' to 'good'. For patellar bracing, pooled analysis of two good quality randomised controlled trials showed no overall significant improvement on a visual analogue scale (VAS) (random effects (RE) standardised mean difference (SMD) = -0.42 (95%CI -1.12 to +0.29). Pooled data from the same two studies showed a non-significant improvement in favour of bracing assessed by the KOOS/WOMAC (RE SMD = -0.18 (95%CI -0.66 to +0.31). Two studies of 'fair' and 'good' quality applying patellar tape showed a significant reduction in pain immediately after application and after 4 days. A randomised trial of a foot orthotic showed a non-significant improvement in pain after 6 weeks with a between groups adjusted mean difference for maximum VAS of 21.9 mm (95% CI - 2.1 to 46.0) and 8.1 (95% CI- 6.9 to 23.1) for KOOS pain. A multimodal physiotherapy intervention (which included taping in two studies) showed a pooled significant improvement in VAS (SMD = -0.4; (95% CI -0.71 to -0.09) at 3 months compared to controls.
CONCLUSION
There is some good quality evidence that a combined physiotherapy approach significantly reduces short-term pain in those with PFJOA. Long-term effects of all interventions are still unknown, which indicates the need for further research to determine the longer term impact of all biomechanical devices on outcomes in symptomatic PFJOA.
Topics: Humans; Knee Joint; Osteoarthritis, Knee; Pain; Pain Measurement; Patellofemoral Joint
PubMed: 34108025
DOI: 10.1186/s13643-021-01708-3