Browsing by Author "Spackman, Eldon"

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    A Systematic Review and Theoretical Economic Analysis of the Impacts of Providing Material Benefits to Improve Food Access in People with Diabetes
    (2023-07-21) Steer, Kieran James Daniel; Spackman, Eldon; Olstad, Dana Lee; Beall, Reed Francis; Campbell, David John Thomas
    Background: Providing material benefits to increase access to healthy food (e.g., food coupons/vouchers, free food, or financial subsidies/incentives) for people with diabetes may be an effective healthcare intervention to improve food insecurity, dietary patterns, clinical parameters, and ultimately health outcomes. There are several studies that have investigated the impact of providing material benefits to improve food access among people with diabetes. There is also interest in Alberta, Canada in potentially implementing a healthy food prescription incentive for people with type 2 diabetes mellitus (T2DM) and food insecurity, which is being investigated in the “Food Rx” trial (NCT04725630). However, there has not been a systematic review or cost-effectiveness analysis on the impacts of providing material benefits to improve food access among people with diabetes. Thesis studies: a systematic review on the impacts of providing material benefits to improve food access on food insecurity, dietary patterns, and clinical parameters in people with diabetes; and a theoretical economic analysis to determine the minimum A1C improvement required for the Food Rx intervention to be cost-effective from the third-party healthcare payer perspective. Results: The systematic review showed that providing material benefits to improve food access for people with diabetes may improve household food insecurity, fruit and vegetable intake, and overall diet quality but is less likely to change clinical parameters and whole grain intake. The evidence from randomized controlled trials was limited to only six studies at high risk of bias, most commonly due to unblinded subjective outcomes measurement and high participant attrition. The economic threshold analysis showed that providing a healthy food prescription incentive to people with T2DM and food insecurity was unlikely to be cost-effective at $50,000/QALY, when projecting health outcomes from improvements in A1C and diabetes-related clinical parameters. Conclusion: The evidence of clinical effectiveness from providing material benefits to improve food access among people with T2DM is highly uncertain, and a healthy food prescription incentive for people with T2DM and food insecurity in Alberta has a low likelihood of cost-effectiveness, when measuring outcomes from improvements in diabetes-related clinical parameters
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    Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis
    (2018-07-13) Iragorri, Nicolas; Spackman, Eldon
    Abstract Background Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools. Objective This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them. Methods A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized. Results Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early. Conclusions To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.
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    Cost-effectiveness of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: An Economic Evaluation
    (2017) Zhang, Ziyu; Clement, Fiona; McBrien, Kerry; Spackman, Eldon
    Familial hypercholesterolemia is an autosomal inherited genetic disorder characterized by high levels of low-density lipoprotein cholesterol circulating in the bloodstream. If left untreated, this condition can substantially increase cardiovascular risk, lead to the rapid development of premature coronary artery disease, or cause sudden cardiac death. Despite the high risks associated with familial hypercholesterolemia, a considerable number of these individuals are unable to achieve adequate reductions in low-density lipoprotein cholesterol levels with conventional lipid lowering therapy. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are emerging pharmacological treatments for managing patients with these conditions. Therefore, the goal of this thesis is to assess the cost-effectiveness of PCSK9 inhibitors for the treatment of elevated low-density lipoprotein cholesterol in individuals with familial hypercholesterolemia.
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    Enhancing the Reproducibility of Health Technology Assessments
    (2021-12) Wagner, Daniel; Spackman, Eldon; Hazlewood, Glen; Beall, Reed; Bojke, Laura
    Health systems around the world depend on Health Technology Assessment (HTA) programs to provide policy guidance on many factors, including value-for-money. To ensure decisions are made with current information, methods of evidence synthesis and economic evaluation are used to inform a continuous process of evidence gathering and decision making. While computers are used in almost every part of this process, the act of updating an existing HTA often involves a duplication of the original effort. The experience of other scientific fields suggests this is attributable to a lack of reproducibility. This refers to the ability to obtain consistent computational results, using the same set of files and processes. The objective of this thesis was to explore how an emphasis on reproducibility can support the effective development and maintenance of HTAs. Satisfaction of this objective required the identification and implementation of computing strategies to enhance the reproducibility of HTAs. A literature review was used to identify techniques for reproducibility which had proven successful in other fields. The identified strategies encouraged the creation of an accurate and complete record of the research process in human and machine-readable formats. These findings were subsequently applied to a case study which redeveloped an existing appraisal of biologic treatment for psoriatic arthritis. The first part of the case study summarized the development and execution of an automated workflow. The second part explored how the computing strategies affected the programming of the economic model. Outcomes from the case study included improved quality control, more efficient updating, and the elimination of barriers to the characterization of uncertainty. With enough investment, enhancing the reproducibility of HTAs will enable improved transparency, better decision making, and ultimately population health gains.
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    The Impact of Geographic Deprivation Levels on Acute Ischemic Stroke Care in Alberta
    (2022-06) Eagles, Matthew; Spackman, Eldon; Beall, Reed; Wong, John; Hill, Michael
    Introduction: Acute ischemic stroke is a neurological emergency that is associated with significant morbidity and mortality. Treatments for this condition aim to reperfuse the ischemic brain and are time sensitive in nature. To optimize patient outcome, strokes need to be recognized quickly, triaged appropriately, and started down the optimal treatment pathway. Unfortunately, previous works have suggested that there are inequalities in the provision of stroke care and outcomes based on patient socioeconomic status (SES). The objective of this thesis was to assess for disparities in the management and outcomes of patients who suffer ischemic stroke in Alberta, Canada based on a measure of neighbourhood SES. Methods: We performed three retrospective cohort studies using population level data from the Quality Improvement in Clinical Research Database. All patients were treated with IV Alteplase between January 1, 2017, and December 31, 2019. The outcomes of interest were treatment with endovascular thrombectomy (EVT), patient outcome (home-time), and treatment acuity (emergency room triage scores and stroke to needle time). Our independent variable of interest was an individual’s neighbourhood deprivation, as calculated by the Pampalon Index. We used regression modeling to assess for relationships between our outcomes and independent variable of interest. Results: Overall deprivation was significantly associated with the odds of being treated with EVT, yet this difference was no longer statistically significant after controlling for the distance an individual lives from the nearest comprehensive stroke centre. There was no significant association between deprivation level and home-time or stroke to needle time; however, being from the most deprived areas of Alberta was significantly associated with less acute emergency room triage scores being assigned. Conclusions: We identified potential areas of disparity in the treatment of acute ischemic stroke based on a measure of neighbourhood SES. However, these gaps did not lead to significantly worse patient outcomes in this study cohort. Future works should attempt to replicate these findings while including patients who were not treated with Alteplase.
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    Improving care for residents in long term care facilities experiencing an acute change in health status
    (2020-11-25) Munene, Abraham; Lang, Eddy; Ewa, Vivian; Hair, Heather; Cummings, Greta; McLane, Patrick; Spackman, Eldon; Faris, Peter; Zuzic, Nancy; Quail, Patrick B; George, Marian; Heinemeyer, Anne; Grigat, Daniel; McMillen, Mark; Reid, Shawna; Holroyd-Leduc, Jayna
    Abstract Background Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community. Methods/design We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care. Discussion This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.
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    On the Optimization of Clostridioides difficile Diagnostics Through RT-PCR Cycle Threshold Defined Zones of Disease Probability
    (2022-02-02) Doolan, Cody Patrick; Pillai, Dylan; Beck, Paul; Spackman, Eldon
    Clostridioides difficile is an opportunistic pathogen with a large burden of disease and no gold standard test. Quantitative polymerase chain reaction (qPCR) offers excellent sensitivity but overcalls clinical C. difficile infections (CDI) due to the prevalence of colonization. The hypothesis of this thesis is that the CDI qPCR results can be titrated to determine clinical CDI more accurately and aid in predicting disease severity. A cross-sectional study was conducted on suspected CDI patients evaluating if qPCR cycle threshold (Ct) can be correlated to probability of CDI. Latent class analysis (LCA) was employed with observed variables including four commercial qPCR tests, toxin detection by enzyme immunoassay, toxigenic culture, fecal calprotectin, and clinical diagnosis. Three defined zones as a function of qPCR cycle threshold (Ct) were identified: CDI likely (>90% probability), CDI equivocal (<90% and >10%), CDI unlikely (<10%). A model comprising toxigenic culture, clinical diagnosis, and toxin EIA demonstrated the best fitness. The following Ct cut-offs for 4 commercial test platforms delineated CDI probability zones: GeneXpert®: 24.00, 33.61; Simplexa®: 28.97, 36.85; Elite MGB®: 30.18, 37.43; and BD Max™: 27.60, 34.26. A prospective cohort study was conducted to investigate if these zones can be further correlated to indicators of severe CDI. Primary diagnosis, demographic data and indicators of disease severity were captured: white blood cell, creatinine, albumin, C-reactive protein, and hospital length of stay. A sub analysis was conducted evaluating a subset of the patient population attempting to isolate patients whose clinical variables were most influenced by CDI. No significant correlations were found between the clinical variables investigated and Ct values or Ct zones. This work establishes a method of using deployed diagnostics to allow clinicians to reduce overdiagnosis of CDI. Decreasing false positives could have broad impacts, increase targeted treatments, and decrease antibiotics. The average cost attributed to CDI for one patient is estimated at $11,917. LCA models predict that qPCR confirmation overdiagnoses patients in Calgary by at least 20.9%. If CDI confirmation were reduced by 20.9% this could equate to massive savings; Foothills Medical Center alone could save over $929,000 annually with no additional investment in laboratory infrastructure.
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    Palliative care in the home: a scoping review of study quality, primary outcomes, and thematic component analysis
    (2018-03-07) Hofmeister, Mark; Memedovich, Ally; Dowsett, Laura E; Sevick, Laura; McCarron, Tamara; Spackman, Eldon; Stafinski, Tania; Menon, Devidas; Noseworthy, Tom; Clement, Fiona
    Abstract Background The aim of palliative care is to improve the quality of life of patients and families through the prevention and relief of suffering. Frequently, patients may choose to receive palliative care in the home. The objective of this paper is to summarize the quality and primary outcomes measured within the palliative care in the home literature. This will synthesize the current state of the literature and inform future work. Methods A scoping review was completed using PRISMA guidelines. PubMed, Embase, CINAHL, Web of Science, Cochrane Library, EconLit, PsycINFO, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database were searched from inception to August 2016. Inclusion criteria included: 1) care was provided in the “home of the patient” as defined by the study, 2) outcomes were reported, and 3) reported original data. Thematic component analysis was completed to categorize interventions. Results Fifty-three studies formed the final data set. The literature varied extensively. Five themes were identified: accessibility of healthcare, caregiver support, individualized patient centered care, multidisciplinary care provision, and quality improvement. Primary outcomes were resource use, symptom burden, quality of life, satisfaction, caregiver distress, place of death, cost analysis, or described experiences. The majority of studies were of moderate or unclear quality. Conclusions There is robust literature of varying quality, assessing different components of palliative care in the home interventions, and measuring different outcomes. To be meaningful to patients, these interventions need to be consistently evaluated with outcomes that matter to patients. Future research could focus on reaching a consensus for outcomes to evaluate palliative care in the home interventions.
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    Psoriatic Arthritis Screening: A Systematic Review, Meta-Analysis, and Economic Evaluation
    (2018-09-13) Iragorri Amaya, Nicolas; Spackman, Eldon; Manns, Braden; Hazlewood, Glen S.
    Psoriatic arthritis (PsA) is an autoimmune disease that affects the skin and the musculoskeletal system. It causes joint damage and psoriasis of the skin. Untreated disease is usually related to a delayed diagnosis and has been associated with physical disability and high treatment costs later on. Although expensive biologic therapy has proven to slow disease progression and improve health outcomes, rheumatologists have suggested initiating treatment with less expensive Disease Modifying Anti-Rheumatic Drugs (DMARDs). Identifying early PsA is expected to improve health outcomes through early treatment with DMARDs. It is also expected to reduce the proportion of severe disease and biologic treatment. Given that the prevalence of PsA among psoriasis patients is relatively high, dermatologists are well-positioned to screen for arthritis symptoms with already validated self-administered screening questionnaires for patients with psoriasis. The goal of this thesis is to systematically review the characteristics and accuracy estimates of the validated PsA screening tools (chapter 2). It also seeks to evaluate the cost-effectiveness of implementing a PsA screening program in Canada relative to the current practice where psoriasis patients are not systematically screened (chapter 3). The National Institute of Health Research is currently developing a randomized controlled trial for PsA screening in the United Kingdom that will inform the cost-effectiveness model presented in this thesis.
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