Population growth, epidemiological and demographic transition, and a shortage of healthcare workers are affecting health care systems in Australia, Canada, the United Kingdom (UK), and the United States (US). Community paramedicine (CP) programs provide a bridge between primary care and emergency care to address the needs of patients with low acuity but lack of access to primary care. However, how to capture the key characteristics of these programs and present them in a meaningful way is still a challenge. The objective of this presentation is to identify and describe the characteristics of currently existing CP programs in the four countries to inform policy-making on CP program development in Alberta.

Information was obtained from systematic reviews, health technology assessments, general reviews, and government documents identified through a comprehensive literature search. The characteristics of the CP programs are described using a framework originally developed in Australia with three categories: (i) the primary health care model, (ii) the health integration model (in Australia, called the substitution model), and (iii) the community coordination model.

In general, Australia emphasizes rural/remote paramedics, whereas Canada, the UK, and the US implement expanded paramedic practice within different environments including rural, remote, regional, and metropolitan settings. Extended care provider programs have been intensively investigated and widely implemented in the UK. While the identified CP programs vary in terms of program components, designation of providers, skill mix, target population, and funding model, the majority of these CP programs fall under the primary health care category of the Australian framework.

Transitioning from hospital-based to community-based health care requires careful consideration of all key factors that could contribute to future program success. Delineating key components of CP programs using the Australian framework will help Alberta decision-makers design, develop, and implement appropriate CP programs that adequately address local needs.

Health state utilities measured by the generic multi-attribute utility instruments (MAUIs) differ. Empirical evidence suggests that some MAUIs are more sensitive than others in reflecting the quality of life (QoL) of patients in particular disease areas. Additionally, in order to estimate utilities based on cancer-specific health-related quality of life instruments (CSQoLs), a number of mapping functions have emerged. Although it is common practice to apply a CSQoL instead of a MAUI in clinical trials, CSQoL cannot be used to estimate utility values for economic evaluations. Mappings based on MAUIs that are not sensitive to changes in cancer patients’ QoL may result in misleading approximations of utilities that could affect allocation of resources. The study objective is to explore the validity and sensitivity of the major MAUIs to variation in the QoL measured by cancer-specific instruments. We aimed to investigate (i) the sensitivity of the general MAUIs scores to changes in the CSQoL, and (ii) whether particular dimensions of the general instrument are more sensitive.

A two stage systematic literature review is conducted. First, an update of the review done by McTaggart-Cowan et al. (2013) on the mapping methods used to determine utilities from cancer-specific instrument. Second, an analysis of studies that measure the relationship between CSQoLs and general MAUIs.

The literature suggests that differences exist between MAUIs in their capacity to capture the QoL dimensions of the CSQoLs. Additionally, the main challenge to build an appropriate mapping function for deriving utilities values from CSQoL is the definition of an appropriate methodology that (i) responds to the distribution of the selected sample and (ii) can successfully be validated in additional samples.

In the context of health technology assessment and cost effectiveness analysis, it is crucial to carefully select and report the CSQoL and MAUI involved in the estimation of the additional benefits. Policy makers need to be awarded of the sensitivity of the instruments to changes in QoL in relation to the CSQoL dimensions QoL.

Systematic reviews (SRs) are the most valid and reliable scientific evidence to evaluate the effectiveness of healthcare interventions. However, substantial resources and months are required to conduct such a review. Most hospital-based health technology assessment (HB-HTA) units don't have the time and the academic team to produce SRs. Rapid evidence assessment (REA) may represent, in this local context, an interesting avenue. The aim was to evaluate characteristics of REA and their impacts on healthcare decision making.

A SR was performed in several databases and grey literature to search data on REA including Mini-HTA and rapid reviews methodologies through March 2017. Data selection, extraction and quality assessment were performed by two independent researchers. Outcomes were about REA's methodology including question, search strategy, inclusion criteria, study selection, data extraction, quality assessment, critical appraisal and impacts on decision making.

Twelve publications on REA have been included. More similarities were found in the methodology between rapid review and SR than with Mini-HTA. Shortcuts in performing rapid reviews included evaluation scope, number of databases, gray literature websites, studies design mainly SR, reviewers number, critical appraisal and production time (3 to 6 months). Study selection and data extraction by two independent reviewers in rapid reviews were seen in thirty-four percent to thirty-eight percent and ten percent to twenty-two percent, respectively. Furthermore, assessment quality was optional. Although it is performed within a short timeframe (2 months), methodology to conduct Mini-HTA is not well defined in the literature. The scope is mainly to support decision making in the introduction of new medical devices. Impacts of REA on local health decision making process are not well documented.

Methodology to conduct REA is quite diverse. According to the data available, rapid review is a more robust methodology for HB-HTA producers than Mini-HTA. Although impacts were not well reported, rapid reviews could be more useful to support health decision making in local context.

Deprescribing – a process for reducing or stopping drugs when the balance of benefits and harms may no longer be in a person's interests – is a key aspect of managing multimorbidity and polypharmcacy in older people. Several deprescribing interventions have been developed (e.g. in Australia and Canada), although significant challenges for successful implementation remain. Through key stakeholder consultation in the care home setting in South West England, we take the initial steps to develop a context-informed deprescribing approach. Engaging stakeholders from the outset gains insight into acceptability, feasibility, and relevance of deprescribing interventions developed elsewhere informing co-production of an effective, implementable approach.

Consultation workshops were held with two groups of stakeholders: (i) care home residents and their families; (ii) care home staff and health care professionals (general practitioners, medical specialists, pharmacists, nurses, allied health professionals). Focus groups were held with each group separately to understand perspectives on: deprescribing in general; contextual considerations; and, perspectives on deprescribing interventions developed in other countries. A combined focus group then considered components of a deprescribing intervention for care homes. Qualitative data were audio recorded, transcribed, and thematically coded.

Participants described the nature of local relationships, dynamics, structures, and resources, as important considerations in the development of a deprescribing approach in care homes. Perspectives and concerns around deprescribing among the stakeholder groups varied, although the importance of eliciting local stakeholder feedback in the early stages of developing a deprescribing intervention was a common thread.

Early engagement and co-production are crucial in developing an approach to deprescribing in care homes. The combination of stakeholder involvement and qualitative research is important for developing an effective, contextually relevant intervention as the balance between interests can be incorporated into the approach. Leveraging the experience in other countries is a novel and valuable step.

Procurement is one tool for the public sector to acquire need-based, innovative and effective solutions. To succeed in purchasing services that succeed in improving patients’ outcomes and optimize cost of care, the process must be accompanied with tools for early decisional support. Documenting the effects of healthcare innovation is therefore fundamental when dealing with prioritizing adequate technology. The aim of the present study was to review the literature to identify early assessment methodology applicable to innovative procurement processes.

A scoping review was performed in January and February 2017 with the objective of selecting literature reporting on early assessment of health innovation. Methods for early assessment of health innovation were identified with the aim of investigating whether the methods change depending on where in the innovation process (development, introduction, and early diffusion) they are applied, and if the literature pointed to dominant methods. Next, critical elements of the innovative procurement process were identified, and methods relevant to the need-based phase of procurement were assessed.

In total 1064 articles met the search strategy. Based on predefined inclusion and exclusion criteria, thirty-nine articles were included in the study. When viewed in the light of innovative procurement, stakeholder insight was an important source of data in early assessment of potential benefits of health innovation. Such data can be applied in scenario analyses to provide necessary outcome overviews and to direct and accelerate the procurement process. Further, various simulation and analysis methods may be used in new ways to increase the impact of the scarce availability of data in early innovation phase.

The present review identified tools for early decisional support that address risks and step-wise healthcare management support. Information based on the present review will also be addressed in Panel 26 “Accelerating Value Based Health Care with Innovative Procurement and Early Decisional Support”

Horizon scanning (HS) is an important tool for guiding health policy formulation and the decision-making process in Brazil. In 2016, the Ministry of Health started to draft Brazilian clinical practice guidelines for transthyretin familial amyloid polyneuropathy (TTR-FAP), which is a rare disease caused by a mutation of the transthyretin gene. An initial HS report was conducted that provided information about new and emerging technologies for TTR-FAP. The HS identified five drugs that were based on two mechanisms of action: transthyretin stabilization (diflunisal, tafamidis, and tolcapone) and gene silencing (ALN-TTR02 and ISIS-TTR-Rx). At that time in Brazil there were no drugs registered for the treatment of TTR-FAP. However, a few months later tafamidis was licensed in Brazil. In early 2017 the manufacturer submitted an application to the National Committee for Health Technology Incorporation (CONITEC), with the aim of incorporating tafamidis into the Brazilian health system. As a result the HS report was updated to support the assessment by CONITEC. This study aims to show how HS is being used to support CONITEC in this issue.

As per the EuroScan toolkit, we performed a reassessment of the technologies included in the initial HS report. We searched clinical trial registers, the websites of pharmaceutical companies, conference proceedings, scientific journals, HS databases, and regulatory websites for further information. The data were synthesized and a reformulated landscape of the technological environment for TTR-FAP therapy was presented to the CONITEC Plenary.

The main difference between the initial and final HS output was that tafamidis was approved for use in Brazil, making it the only registered drug for TTR-FAP. Another difference was related to the start of a new clinical trial with diflunisal for TTR-FAP, indicating that this drug could be a potential competitor for tafamidis. It was also possible to add published positive results from a clinical trial with ISIS-TTR-Rx, which were unavailable when the first report was written. Beyond that, it appears that there are two promising gene silencers on the horizon that could represent potential competitors for tafamidis.

The analysis of tafamidis for incorporation into the Brazilian health system is ongoing, but HS was able to deliver strategic information that could affect the final recommendation of CONITEC.

Stakeholders from the innovation field in Québec (Canada) have collectively stressed the need to formalize the process for evaluating innovative technologies in the province. In the context of innovation, and more so for non-pharmaceutical technologies where the pace of development is rapid and the lifecycle short, evidence supporting the added value can be limited and uncertainties are common. Therefore, pragmatic approaches are needed to guide recommendations and to assure that the process is rigorous, transparent and fair.

Inspired by international experiences, the Institut national d'excellence en santé et services sociaux (INESSS) has developed a novel framework, where four types of recommendations are possible (introduction, refusal, limited or conditional introduction). The starting point is an evaluation of the technology's added value, for the patient, the population and the healthcare system, and the identification of uncertainties. The value of addressing uncertainty with further research is assessed, based on the value-of-information theory, and the distinct characteristics of medical devices are taken into account (e.g. learning curve effect, irrecoverable costs and incremental innovation). Those elements interact to support the formulation of recommendations by INESSS’ advisory committee.

The development of the framework was an iterative process supported by the use of the preliminary framework for the assessment of several innovative technologies. Challenges with its use were identified, and led to methodological and operational improvements. So far, the experience with the framework is positive and stakeholders confirm its relevance to support fair and reasonable recommendations for innovations.

In the rapidly changing landscape of innovation, HTA has to adapt to the challenges of assessing technologies in a context of promise and uncertainties. The framework developed by INESSS is a tool for supporting timely and fair value-based decision-making, which will benefit the healthcare system, and the patients and population it serves.

Speech recognition is increasingly used in medical reporting. The aim of this article is to identify in the literature the advantages and weaknesses of this technology, as well as barriers and facilitators to its implementation.

A systematic review of systematic reviews has been conducted in PubMed, Scopus, Cochrane Library and Center for Reviews and Dissemination up to August 2017. The grey literature has also been consulted. The quality of systematic reviews has been assessed with the AMSTAR checklist. Inclusion criteria were to use speech recognition for medical reporting (front or back-end). A Survey has also been conducted in Quebec, Canada, to identify the dissemination of this technology in this province, as well as the factors of success or failure in its implementation.

Five systematic reviews were identified. These reviews indicated a high level of heterogeneity across studies. The quality of the studies reported was generally poor. Speech recognition is not as accurate as human transcription but can dramatically reduce the turnaround times for reporting. In front-end use, medical doctors need to spend more time for dictation and correction than with human transcription. With speech recognition, major errors can be up to three times more frequent. In back-end use, a potential increase in the productivity of transcriptionist is noted.

Speech recognition offers some advantages for medical reporting, the main one being a reduction in turnaround times. However, these advantages are challenged by an increased burden for medical doctor and risks of additional errors in medical reports. It is also hard to identify for which medical specialties and which clinical activities the use of speech recognition will be the most beneficial.

Impacted third molars (I3Ms) are blocked from fully erupting; many I3Ms are asymptomatic, however there could be pain and pathological changes. Historically, I3Ms were removed prophylactically. Current options in the United Kingdom include either retention with standard care (watchful waiting), or removal due to pathological changes. We conducted a systematic review of the prophylactic removal of asymptomatic impacted mandibular third molars (IM3Ms) compared with standard care.

We searched five electronic databases from 1999 onwards. Inclusion criteria: randomized and non-randomized trials, observational studies, and systematic reviews (SRs) comparing the prophylactic removal of IM3Ms with standard care or studies assessing the outcomes of either approach; outcomes included pathology associated with retention, postoperative complications, adverse effects of treatment and health-related quality of life. Two reviewers independently screened all titles and/or abstracts, applied inclusion criteria to potentially relevant publications, and quality assessed and data extracted the included studies. No meta-analysis or network meta-analyses were undertaken.

Following screening of 11,373 references, 13 studies (four cohort studies and nine SRs) were included. One cohort study investigated the prophylactic removal of asymptomatic IM3Ms in comparison with standard care and retention, two investigated the prophylactic removal of asymptomatic IM3Ms, and one studied the retention and standard care of asymptomatic IM3Ms. Two studies reporting surgical complications found no serious complications; however, one study reported intense pain and postoperative infection. Pathological changes due to retention of asymptomatic IM3Ms were reported by three studies. Nine SRs of the management of third molars were included in this review, however none focused solely on IM3Ms.

Consistent with previous systematic reviews, we found no RCT data to support or refute the prophylactic removal of asymptomatic IM3Ms, despite extensive searching of the literature. The review however did identify evidence from two longitudinal studies demonstrating the outcomes when asymptomatic IM3Ms are left in situ.

Healthcare advances in hemophilia have led to near-normal life expectancies in a disorder previously associated with early death. Unlike other disorders where the therapeutic goal is to restore deficiencies to normal levels, prophylaxis in hemophilia is used to achieve a plasma level of FVIII >1%, such that severe hemophilia may be reduced to a moderate/mild phenotype. With the development of new therapies, treatment goals are evolving from on-demand treatment or prevention of bleeds to one where the risk of bleeding is minimal/absent. To accelerate this development, a new treatment paradigm is needed, with consensus from key stakeholder communities, to facilitate a shared vision for the future of hemophilia healthcare.

A panel of hemophilia providers, patient advocates, and industry representatives convened to develop a new treatment model that establishes specific treatment milestones and target outcomes in a stepwise fashion, culminating in a progressive definition of cure.

To represent the collective experience of hemophilia for patients and treaters around the world, the following treatment milestones were defined based on optimized outcomes: (i) Sustain Life – prevention of premature death; (ii) Minimal Joint Impairment – improved quality of life; participation in activities of daily living; (iii) Freedom From Spontaneous Bleeds – ability to engage in low-risk activities; (iv) Attainment of ‘Normal’ Mobility – participation in work, career, and family life without restriction; (v) Able to Sustain Minor Trauma – more unrestricted lifestyle; (vi) Ability to Sustain Major Surgery or Trauma Without Additional Intervention – no dependency on specialized healthcare; (vii) Normal Hemostasis – optimal health and well-being; and (viii) Cure – health equity.

With milestones for disease management leading toward normalized hemostasis, this treatment model provides a vision to improve hemophilia care for all patients. And by providing achievable outcomes, the community—patients, treaters, and their industry partners—has a clear path to achieve that goal.

The fact that HTA is a value-laden process is recognized in the literature. This is one of the reasons for promoting a better integration of ethics in HTA processes. Although what is meant by value-judgment (VJ) and how it can be used in HTA is not clear for some authors; others have proposed the elicitation of implicit VJs, to make them more explicit, as one way for clarifying the role ethics may play in HTA. In order to clarify what a VJ is, a conceptual analysis is needed to distinguish it from a factual-judgment and see how they diverge on certain aspects and converge on others.

The distinction between VJs and factual-judgments was debated in the fifties. At the core of the philosophy of language was a distinction between factual-scientific assertions about facts, considered objective, and VJs on what is right/wrong-good/bad, considered subjective. In speech-act theory these distinctions were treated as two different operations: assertive and evaluative. A conceptual analysis of VJs, considering them as specific speech-acts, was used for clarifying/deciphering the role of VJs in HTA.

VJs are intrinsically embedded in decision-making since they are the reasons justifying decisions. This is why implicit VJs can be identified at every decision-step in the HTA process. Assessment is usually considered objective while appraisal seems subjective. Since VJs are entrenched in the decisions taken throughout the assessment process, the results are not completely objective. Ethical analysis also distinguishes two types of VJs, those based on normative criteria and those based on various degrees of value actualization. Furthermore, since evaluation requires criteria based on a rational process, VJs are not totally subjective.

Elicitation of VJs in HTA is one way of integrating ethics in HTA and offers decision-makers a more thorough picture of the ethical issues involved in their decision.

There is continuing controversy surrounding the funding of insulin glargine versus neutral protamine Hagedorn (NPH) insulin in Brazil, due to substantial differences in their prices, and recent meta-analyses of randomized controlled trials and independent observational studies that show no difference in effectiveness; however, sponsored observational studies show greater effectiveness of insulin glargine. Overall, the cost-effectiveness of insulin glargine in Brazil is controversial. In view of the continuing controversy, there is a need to address this using patient level data within the public health system in Brazil.

We conducted a retrospective historical cohort study of type 1diabetes patients receiving insulin glargine from January 2011 to January 2015, including patients in the public health system in Minas Gerais. Variables included (i) demographic variables, (ii) clinical variables e.g. time with a diagnosis of type 1 diabetes, (iii) treatment characteristics, and (iv) laboratory results of HbA1c. Individuals were compared with themselves in an analysis of HbA1c values before and after six months of using insulin glargine, with each patient acting as their own control.

Five hundred and eighty patients were included in the study. HbA1c varied from 8.80±1.98 percent in NPH insulin users to 8.54±1.88 percent after insulin glargine for six months, which is not clinically significant. The frequency of glycemic control varied from 22.6 percent with NPH insulin to 26.2 percent with insulin glargine. No statistically significant difference was observed between groups for all analyzed factors, including type and frequency of insulin use and carbohydrate counting.

There were limited differences between NPH insulins and insulin analogues in this real world study. As a result, the continued appreciable cost difference in between insulin glargine and NPH insulin in Brazil cannot be justified.

A gap exists between the evidence for reducing risk of knee osteoarthritis (KOA) progression and its application in patients’ daily lives. We aimed to bridge this gap by identifying patient and family physician (FP) self-management priorities to conceptualize and develop a mobile-health application (m-health app). Our co-design approach combined priorities and concerns solicited from patients and FPs with evidence on risk of progression to design and develop a KOA self-management tool.

Parallel qualitative research of patient and FP perspectives was conducted to inform the co-design process. Researchers from the Enhancing Alberta Primary Care Research Networks (EnACT) evaluated the mental models of FPs using cognitive task analysis through structured interviews with four FPs. Using grounded theory methods, patient researchers from the Patient and Community Engagement Research (PaCER) program interviewed five patients to explore their perspectives about needs and interactions within primary care. In three co-design sessions relevant stakeholders (four patients, five FPs, and thirteen researchers) participated to: (i) identify user needs with regard to KOA self-management; and (ii) conceptualize and determine design priorities and functionalities of an m-health app using a modified nominal group process.

Priority measures for symptoms, activities, and quality of life from the user perspective were determined in the first two sessions. The third co-design session with our industry partner resulted in finalization of priorities through interactive patient and FP feedback. The top three features were: (i) a symptoms graph and summary; (ii) information and strategies; and (iii) setting goals. These features were used to inform the development of a minimum viable product.

The novel use of co-design created directive dialog around the needs of patients, highlighting the contrasting views that exist between patients and FPs and emphasizing how exploring these differences might lead to strong design options for patient-oriented m-health apps. Characterizing these disjunctions has important implications for operationalizing patient-centered health care.

Chagas disease (ChD), also known as American trypanosomiasis, is a neglected tropical disease caused by the protozoan parasite Trypanosoma cruzi. About 6 to 7 million people worldwide are estimated to be infected, most in Latin America. Health-related quality of life (HRQoL) and utility measures are still poorly employed for assessment of ChD lifetime impairments. Brazilian HRQoL published data showed that the cardiac subgroup of patients have worse scores than other ChD chronic groups. For the time being, utility scores are not available yet for the ChD population. The present study aims to assess quality of life (QoL), as utility scores, of patients with chronic Chagas Disease.

This is a cross-sectional study. Data were collected from 183 outpatients with chronic ChD in a reference center in Brazil. Information pertaining to sociodemographics, clinical status, and quality of life were collected using self-administered questionnaires. Utilities were obtained by the European Quality of Life – 5 Dimensions (EQ-5D) questionnaire. Comparisons were made between clinical subtypes and population normative values. Continuous variables were compared using t-test or ANOVA, and categorical variables were compared using Chi-square test. Associations between QoL and patient characteristics stratified by demographics, clinical status were identified by linear regression models.

Most subjects were female (61 percent). The average age of men was 53.3 years and women 56.6. When analyzing the EQ-5D utility scores, it was observed that the results were lower for cardiac patients (0.610–95% CI 0.582–0.638) in comparison to indeterminate form patients (0.659–0.632–0.687). When comparing patients with the general population of the same age and sex, patients with ChD showed lower utility scores than normative values (0.624–95% CI 0.596–0.652).

Chronic ChD causes a negative impact on quality of life, physical functioning, as well as psychosocial function, with the impairment becoming worse in cardiac patients.

Metastatic breast cancer (MBC) is considered incurable. Trastuzumab (T), a monoclonal antibody that blocks HER-2 is used in combination with other chemotherapies or as monotherapy to treat various stages of breast cancer, including MBC. The aim of this study was to evaluate the safety of T as first line treatment or after progression in women with MBC.

We conducted a systematic review of randomized controlled trials. We searched the databases: MEDLINE (Pubmed), LILACS, Cochrane Library and EMBASE (accessed November 2016) and performed manual search. The methodological quality assessment was performed using the Cochrane Collaboration risk of bias tool. We adopted the random effects model for meta-analysis. The results were presented as relative risk (RR) with 95% confidence intervals.

The search retrieved 2,238 publications. After eligibility criteria assessment we included five studies on T in the first line treatment (T n = 493; no-T n = 492) and two studies on T after progression (T n = 226; no-T n = 226). In general, studies presented moderate quality. Five were funded by the pharmaceutical industry. Regarding first line treatment, the group of patients that used T had three times higher risk of developing cardiac adverse event compared to the group that did not use T (RR = 3.3; 95% CI: 1.52 − 7.29; I2 = 0%, p = 0.39). The continuity of T after progression revealed no difference between the groups regarding the risk of developing cardiac adverse event (RR = 5.31; 95% CI: 0.62 − 45.49; I2 = 0%, p = 0.62).

The evidence regarding the higher risk of cardiac adverse event with T as first line treatment for MBC is robust and this should be taken into account when balancing risks and benefits of treatment. The evidence for continuation of T after MCB progression is week and more studies are needed to confirm the findings.

Aiming for hepatitis C elimination by 2030, Taiwan has set up a mid-term goal of “over 50 percent of patients treated by 2025.” Among various aspects of evidence that are needed, the target number to be treated is difficult to estimate with certainty due to great geographical heterogeneity of hepatitis C prevalence, and the absence of a nation-wide large scale prevalence survey.

A broad estimate of the number of patients to be treated with high uncertainty was calculated, and reimbursement criteria were set for year 2017 given limited data and treatment budget. In the meanwhile, various sources and approaches to estimate the target number to be treated, and to identify the high prevalence areas, were collected and synthesized for future planning through a systematic review of published data and consulting experts for unpublished data. An expert panel was consulted for the level of confidence and completeness of the evidence. A plan for using real-world data to reduce the uncertainty after initial actions of national program was also in place.

Eight thousand patients who fulfilled the reimbursement criteria were treated in 2017 as planned. Strategic steps were identified based on the collected data, and the treatment target, namely 200,000 patients to be treated during 2018 to 2025, was then set for appropriate action plans. National registry infrastructure is planned for supporting future policy modification.

Hepatitis C elimination is an important public health task and it requires immediate actions. The expected expenses are high, yet the number of patients is difficult to estimate with precision. How to deal with this uncertainty (financially and in care program design) will be the most challenging part. An adaptive approach (“evidence”-”action”-”more evidence”-”modified action”) could be the pragmatic way to move forward without sacrificing the quality of decision-making.

Self-reported outcomes are considered to be useful to understand physical and mental conditions in daily life. Sleep quality is an important factor related to healthy lifestyle and work productivity, as well as to diseases. We examined the relationship of sleep condition with lifestyle and diseases based on self-reported sleep.

A Japanese employee-based health insurance claims database with annual medical check-up data was used. Individuals were questioned about sleep quality as: “Do you get enough rest by sleeping?” during the medical check-up. The prevalence of diseases and medical check-up data were compared between those who answered “Yes” or “No”.

Among 1,310,157 individuals who answered about sleep quality, 540,564 (41.3 percent) answered “No”. The female ratio was around 38 percent for both answers, and the average age was lower for those who answered “No” (45.3) than “Yes” (47.3). Matched individuals for same examination year, sex, and age were 536,218 in each group. Individuals diagnosed with sleep disorder were 8.7 percent of those who answered “No”, representing the highest relative risk (RR=1.64), followed by other anxiety disorders (RR = 1.47), and depressive episode (RR = 1.45), with statistical significance. Other diseases diagnosed in more than 200,000 patients, and which had significantly higher RRs in patients who answered “No”, included vasomotor and allergic rhinitis (RR = 1.09), disorders of refraction and accommodation (RR =1.02), acute upper respiratory infections (RR = 1.11), gastritis and duodenitis (RR = 1.17), and acute bronchitis (RR = 1.13). The RR of other diseases of the liver (RR = 1.13), diabetes (RR = 1.12), hypertension (RR = 1.08), and disorders of lipoprotein metabolism and other lipidaemias (RR = 1.06) were also significantly higher for those who answered “No”.

Sleep quality is suggested to be associated with various chronic diseases as well as mental disorders. Therefore, self-reported outcomes should be a useful tool to understand health-condition, prevent the onset and progression of diseases, and evaluate patient-centered care.

Patent foramen ovale (PFO) is an open hole between the right and left upper chambers of the heart. It may increase the risk of stroke, so closure of the hole is considered a secondary prevention in patients who have experienced cryptogenic stroke. Recent evidence has been published on the effectiveness of PFO closure, including a publicly funded prospective study on the effectiveness of PFO closure for preventing recurrent stroke or transient ischemic attack in selected Korean patients who have experienced cryptogenic stroke. The objective of this study was to examine the cost-effectiveness of PFO closure using this recent evidence.

Available clinical data from the aforementioned Korean prospective study and other recent multicenter trials funded by public bodies were used. The cost data were obtained from the current Korean National Health Insurance fee schedule. Utility data were extracted from local research on stroke patients. A cost-effectiveness analysis, based on a 20-year Markov model, was conducted using these data to compare PFO closure plus antiplatelet therapy with oral anticoagulants alone.

The initial analysis showed that PFO plus antiplatelet therapy costs KRW 7.13 million (USD 6,547) more than oral anticoagulants alone but has a higher utility of 1.3 quality-adjusted life-years (QALYs) per patient, which corresponds to an incremental cost-effectiveness ratio (ICER) of KRW 5.6 million (USD 5,142) per QALY. The implicit Korean ICER threshold is KRW 25 million (USD 22,955) for non-cancer drugs, so it seems that PFO plus antiplatelet therapy is cost effective in the Korean setting.

Since this study used some transition probabilities from foreign sources, the results may not be completely transferable to the Korean setting. However, this is the best available evidence so far in Korea for the economic evaluation of the PFO closure procedure. Therefore, use of PFO closure in carefully selected patients with a history of cryptogenic stroke may benefit the public payer in Korea.

Methods to assess evidence and to use that evidence to inform practices and policies are under developed in the area of social services. Although health professions have developed robust methods in recent decades to collect, analyze and synthesize scientific evidence and to inform clinical recommendations, the use of these methods often remains difficult in social services. A taskforce was implemented to address this and to propose a method that may be more appropriate for the social sciences.

The project was comprised of four steps: (i) performing a qualitative review of discussions between experts, (ii) designing a cognitive map of the data, (iii) conducting a systematic literature search, and (iv) comparing the data from the meetings with experts with the scientific literature. These steps were completed using the grounded theory approach. In order to test the method developed, focus groups were then conducted and four case studies were used to assess the evidence and provide recommendations for youths with mental health problems and for elderly care.

Although robust scientific data remain crucial when developing recommendations for practice, results showed that these data are incomplete if considered alone, and that contextual (circumstances in which the intervention is delivered) and experiential data (how the intervention is perceived by stakeholders) must also be taken into consideration. A method to triangulate these three types of data is proposed. Using this technique, the value of the data is established by means of various measurements that converge towards the same result or that provide a consistent overall picture or some important nuances that need to be considered, as illustrated by the four case studies.

The proposed method can be used to address the limitations that are inherent to the use of techniques and procedures drawn from the medical field when assessing evidence and developing recommendations for the social sciences. The case studies that the proposed method is not only a viable option to methods drawn from medicine, but also adds to the quality of the recommendations that are made and is more congruent with the epistemology of social sciences.

Malaria is a leading cause of mortality and morbidity in children under five in low and middle income countries (LMICs). Management of malaria in children under five years of age is challenging. One challenge faced by clinical practice in LMICs is lack of evidence to guide practice. This challenge is further compounded by different training backgrounds of team members. In the management of malaria in Cameroon, conflicts usually arise between clinicians, lab technicians and pharmacists resulting in over diagnosis and treatment of malaria. The patient's view is usually not considered. This leads to over diagnosis and over prescriptions for malaria in children under five years of age.

We used the Joanna Briggs Institute (JBI) approach of getting research into practice to organize stakeholder meetings, assess existing evidence in malaria care, develop evidence criteria for management based on levels of evidence, assess the gamut of care for malaria, provide feedback to clinicians and re-assess practice. We used the JBI practical application of clinical evidence system (PACES) and getting research into practice (GRiP) evidence implementation tools in the process to facilitate teamwork, collaboration on evidence and provide feedback.

A collaborative approach to assessments and feedback including all healthcare stakeholders significantly improved workplace culture of evidence-based care and staff-to-staff relationships as well as staff-to-patient relationships. Over a period of twelve months, we reported eighty-four percent fewer conflicts between staff and ninety-eight percent fewer conflicts between staff and patients. For malaria management, overall criteria showed a thirty-one percent improvement in compliance with best practice recommendations with evidence levels of Grade 1.

The project demonstrated that local leadership and evidence-based care can significantly improve practice in resource limited settings.