Biomedical subjects
J Gladman
Publications and source records attributed to J Gladman.
Direct magnetic resonance imaging of carotid artery thrombus in acute stroke.
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Cost-effectiveness analysis of antiplatelet therapy in the prevention of recurrent stroke in the UK. Aspirin, dipyridamole and aspirin-dipyridamole.
OBJECTIVES: To evaluate the cost effectiveness from a UK health and social services perspective of antiplatelet therapies tested in the Second European Stroke Prevention Study (ESPS-2) in preventing recurrent stroke. To demonstrate the value of modelling studies in this area. DESIGN AND SETTING: A decision-analytic model was developed to evaluate health outcomes and associated costs. Sources of data for efficacy, adverse events, background event risks, disability and mortality were ESPS-2, the Oxfordshire Community Stroke Project and UK national statistics. Published national unit costs were applied to clinician panel estimates of resource use for acute stroke, rehabilitation and long term care. Outcome measures were strokes or disabled life-years averted, and disability-free, stroke-free or quality-adjusted life-years gained. PATIENTS AND INTERVENTIONS: 30-day survivors of ischaemic stroke treated with low dose aspirin, modified-release dipyridamole; the coformulation of low dose aspirin plus modified-release dipyridamole, or no antiplatelet therapy. MAIN OUTCOME MEASURES AND RESULTS: The model predicted that over 5 years the coformulation prevented 29 more strokes than aspirin alone per 1000 patients, at an additional cost of 1900 Pounds per stroke averted (1996 values). Over 5 years, each antiplatelet therapy was cost saving compared with no therapy. Results were sensitive to the cost of acute care, the cost of long term care of disabled stroke survivors, the effectiveness of therapy and the background risk of recurrent stroke. In sensitivity analyses, the cost effectiveness did not exceed 7000 Pounds per stroke averted or 11,000 Pounds per quality-adjusted life-year (QALY) gained, except when varying the effectiveness parameter. CONCLUSIONS: Application of a decision-analytic model to the results of ESPS-2 indicated that first-line therapy with the coformulation of modified-release dipyridamole and low dose aspirin to patients with a previous ischaemic stroke is likely to generate significant health benefits at modest extra costs to health and social services. The extra costs of treatment are balanced by the savings in future costs of acute care and long term care of the disabled. Future economic evaluations in this area should pay particular attention to the cost perspective, the duration of analysis, the selection of trials from which effectiveness data are derived, and the impact of the pooling of outcome events with potentially different economic consequences.
Specialist rehabilitation after stroke.
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Hospital- and home-based rehabilitation after discharge from hospital for stroke patients: analysis of two trials.
We examined the methodology and results of two previously published randomized controlled trials of home- and hospital-based rehabilitation for stroke patients after discharge from hospital in Bradford and Nottingham, in view of apparently discrepant findings in the two trials. In an analysis of the combined findings of both studies, there was little difference in terms of efficacy between home- and hospital-based care, but a small advantage in favour of home therapy was found in reducing disability between hospital discharge and 6 months. Contrary to an earlier report, we did not find a differential effect of treatment between those who were and those who were not frail. We conclude that home therapy is the method of stroke after-care of choice in urban settings in the UK, although this conclusion may not apply in other health-care settings and further studies are required.
Cost comparison of domiciliary and hospital-based stroke rehabilitation. DOMINO Study Group.
The DOMINO study (DOMiciliary rehabilitation In NOttingham) was a randomized controlled trial comparing domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital, stratified according to the ward at hospital discharge. The outcomes of these patients have been reported previously. In this paper, we present estimates of health service costs of care. No difference in outcome had been found between the overall services, but we have found the hospital-based costs to be 27% cheaper. However, different cost-effectiveness patterns are observable when the strata are analysed. Patients from geriatric wards had been shown to be 2.4 times less likely to die or become institutionalized by 6 months if allocated to a day hospital service, although the cost of this service was 25% more than that of the domiciliary service. Patients from the Stroke Unit who had received domiciliary rehabilitation had been shown to have greater household and leisure abilities at 6 months than those treated in outpatient departments, but the domiciliary service was found to cost 2.6 times more. Patients from general medical wards had similar outcomes whether treated at home or in outpatient departments, but the cost of the latter service was 56% of the former. Some patients may be best cared for in day hospitals and others may do better if treated at home, but for these groups the clinical advantages are achieved at an expense greater than that incurred by the alternative services. Other patients may do as well if treated in outpatient departments as at home, but the former approach is cheaper. A range of services is required for stroke patients leaving hospital.
A hospital study of community acquired pneumonia in the elderly.
Studies on community acquired pneumonia in the United States in patients over the age of 65 years have shown that Gram negative bacilli account for an appreciable proportion of cases, in addition to usual pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. There have been no reports of community acquired pneumonia in the elderly in the United Kingdom. We undertook such a study to determine the clinical features, aetiology, and outcome. Seventy three patients (38 men) with ages ranging from 65 to 97 (median 79) years were studied prospectively. Pneumonia was defined as an acute lower respiratory tract infection with new, previously unrecorded shadowing on a chest radiograph. Patients with severe chronic illness in whom pneumonia was an expected terminal event were excluded. Nearly all the patients (96%) had respiratory symptoms or signs but many had features that might obscure the true diagnosis of pneumonia. Over half the patients had non-respiratory symptoms and over a third had no systemic signs of infection. A pathogen was identified in 43% of patients, most commonly Streptococcus pneumoniae, Haemophilus influenzae and influenza B virus. Gram negative bacilli were not seen. The mortality rate was high (33%). Early deaths were due to infection whereas later deaths were associated with other factors, such as stroke (two patients) and pulmonary embolism (two patients). Prognostic indicators for mortality were apyrexia, systolic hypotension, increasing hypoxaemia, and new urinary incontinence. As the range of pathogens causing pneumonia was the same in the elderly in this study as in other age groups it is suggested that initial antibiotic treatment for patients in this age group should always cover S pneumoniae and H influenzae.
A survey of survivors of acute stroke discharged from hospital to private nursing homes in Nottingham.
Increasing numbers of disabled elderly stroke survivors are being discharged from hospital to Private Nursing Homes. However, there is little data available on which specific guidelines for the care of stroke patients in these homes can be based. A survey was undertaken therefore, to review patients on their discharge from hospital to Private Nursing Homes, and to assess the severity of their disability and handicap before and after entering the home. Nearly all patients were severely disabled on discharge from hospital, and the Barthel Activities of Daily Living scores of the survivors showed no significant change after four months. High levels of emotional distress and loneliness were identified by the Nottingham Health Profile, with little change after four months of nursing home care. The National Health Service has a continuing responsibility for the welfare of such vulnerable elderly people. The findings of this survey indicate that the emphasis of their care should be on the management of severe physical disability, exploitation of opportunities for further rehabilitation, alleviation of emotional distress and loneliness and, where appropriate, the provision of humane terminal care.