Ontario health technology assessment series
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Ont Health Technol Assess Ser · Jan 2012
ReviewTranscatheter aortic valve implantation (TAVI) for treatment of aortic valve stenosis: an evidence-based Analysis (part B).
Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement (sAVR) for patients at high risk for surgery. ⋯ TAVI improves survival in patients who cannot undergo surgery. For those who are candidates for surgery, TAVI has a mortality rate similar to sAVR, but it is associated with significant adverse effects. TAVI may be cost-effective for patients who cannot undergo surgery, but is not cost-effective for patients who can.
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Ont Health Technol Assess Ser · Jan 2012
Epilepsy care in ontario: an economic analysis of increasing access to epilepsy surgery.
In August 2011 a proposed epilepsy care model was presented to the Ontario Health Technology Advisory Committee (OHTAC) by an Expert Panel on a Provincial Strategy for Epilepsy Care in Ontario. The Expert Panel recommended leveraging existing infrastructure in the province to provide enhanced capacity for epilepsy care. The point of entry for epilepsy care and the diagnostic evaluation for surgery candidacy and the epilepsy surgery would occur at regional and district epilepsy centres in London, Hamilton, Toronto, and Ottawa and at new centres recommended for northern and eastern Ontario. This economic analysis report was requested by OHTAC to provide information about the estimated budgetary impact on the Ontario health care system of increasing access to epilepsy surgery and to examine the cost-effectiveness of epilepsy surgery in both children and adults. ⋯ Epilepsy surgery for medically intractable epilepsy in suitable candidates has consistently been found to provide favourable clinical outcomes and has been demonstrated to be cost-effective in both adult and child patient populations. The first step to increasing access to epilepsy surgery is to provide access to evidence-based care for all patients with epilepsy, both adults and children, through the provision of resources to expand EMU bed capacity and associated clinical personnel across the province of Ontario.
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Ont Health Technol Assess Ser · Jan 2011
Constraint-induced movement therapy for rehabilitation of arm dysfunction after stroke in adults: an evidence-based analysis.
The purpose of this evidence-based analysis is to determine the effectiveness and cost of CIMT for persons with arm dysfunction after a stroke. ⋯ Stroke Impact Scale (SIS) SUMMARY OF FINDINGS: A significant difference was found in our primary outcome of arm motor function measured with the Action Research Arm Test in favour of CIMT compared with usual care delivered with the same intensity and duration. Significant differences were also found in three of the five secondary outcome measures including Arm Motor Impairment and Perceived Motor Function Amount of Use and Quality of Use. There was a nonsignificant effect found with the FIM score and the quality of life Stroke Impact Scale outcome measure. The nonsignificant effect found with the scale score and the quality of life score may be a factor of a nonresponsive outcome measure (FIM scale) and/or a type II statistical error from an inadequate sample size. The quality of evidence was moderate for arm motor function and low for all other outcome measures except quality of life, which was very low. Table 1:Summary of Results(*)OutcomeOutcome MeasureNumber of Studies (n)Mean Difference in Change scores CIMT vs. Usual Care [95% C.I.]ResultsGRADE Quality of EvidenceArm motor functionAction Research Arm Test4(43)13.6[8.7, 18.6]SignificantModerateArm motor impairmentFugl-Meyer Motor Assessment8(169)6.5[2.3, 10.7]SignificantLowActivities of daily livingFunctional Independence Measure4(128)3.6[-0.22, 7.4]NonsignificantLowSelf-reported amount of arm usePerceived Arm Motor Function (Amount of Use) Scale8(241)1.1[0.60, 1.7]SignificantLowSelf-reported quality of arm usePerceived Arm Motor Function (Quality of Use) Scale8(241)0.97[0.7, 1.3]SignificantLowQuality of lifeStroke Impact Scale2(66)3.9[-5.6, 13.5]NonsignificantVery Low*CI, Confidence Intervals; n, Sample Size.
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Ont Health Technol Assess Ser · Jan 2011
Collagen cross-linking using riboflavin and ultraviolet-a for corneal thinning disorders: an evidence-based analysis.
The main objectives for this evidence-based analysis were to determine the safety and effectiveness of photochemical corneal collagen cross-linking with riboflavin (vitamin B(2)) and ultraviolet-A radiation, referred to as CXL, for the management of corneal thinning disease conditions. The comparative safety and effectiveness of corneal cross-linking with other minimally invasive treatments such as intrastromal corneal rings was also reviewed. The Medical Advisory Secretariat (MAS) evidence-based analysis was performed to support public financing decisions. SUBJECT OF THE EVIDENCE-BASED ANALYSIS: The primary treatment objective for corneal cross-linking is to increase the strength of the corneal stroma, thereby stabilizing the underlying disease process. At the present time, it is the only procedure that treats the underlying disease condition. The proposed advantages for corneal cross-linking are that the procedure is minimally invasive, safe and effective, and it can potentially delay or defer the need for a corneal transplant. In addition, corneal cross-linking does not adversely affect subsequent surgical approaches, if they are necessary, or interfere with corneal transplants. The evidence for these claims for corneal cross-linking in the management of corneal thinning disorders such as keratoconus will be the focus of this review. The specific research questions for the evidence review were as follows: TECHNICAL: How technically demanding is corneal cross-linking and what are the operative risks? ⋯ A literature search was conducted on photochemical corneal collagen cross-linking with riboflavin (vitamin B(2)) and ultraviolet-A for the management of corneal thinning disorders using a search strategy with appropriate keywords and subject headings for CXL for literature published up until April 17, 2011. The literature search for this Health Technology Assessment (HTA) review was performed using the Cochrane Library, the Emergency Care Research Institute (ECRI) and the Centre for Reviews and Dissemination. The websites of several other health technology agencies were also reviewed, including the Canadian Agency for Drugs and Technologies in Health (CADTH) and the United Kingdom's National Institute for Clinical Excellence (NICE). The databases searched included OVID MEDLINE, MEDLINE IN-Process and other Non-Indexed Citations such as EMBASE. As the evidence review included an intervention for a rare condition, case series and case reports, particularly for complications and adverse events, were reviewed. A total of 316 citations were identified and all abstracts were reviewed by a single reviewer for eligibility. For those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. (ABSTRACT TRUNCATED)
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Ont Health Technol Assess Ser · Jan 2011
Endovascular radiofrequency ablation for varicose veins: an evidence-based analysis.
The objective of the MAS evidence review was to conduct a systematic review of the available evidence on the safety, effectiveness, durability and cost-effectiveness of endovascular radiofrequency ablation (RFA) for the treatment of primary symptomatic varicose veins. ⋯ THE MAS EVIDENCE SEARCH ON THE SAFETY AND EFFECTIVENESS OF ENDOVASCULAR RFA ABLATION OF VV IDENTIFIED THE FOLLOWING EVIDENCE: three HTAs, nine systematic reviews, eight randomized controlled trials (five comparing RFA to surgery and three comparing RFA to ELT), five controlled clinical trials and fourteen cohort case series (four were multicenter registry studies). The majority (12⁄14) of the cohort studies (3,664) evaluating RFA for VV involved treatment with first generation RFA catheters and the great saphenous vein (GSV) was the target vessel in all studies. Major adverse events were uncommonly reported and the overall pooled major adverse event rate extracted from the cohort studies was 2.9% (105⁄3,664). Imaging defined treatment effectiveness of vein closure rates were variable ranging from 68% to 96% at post-operative follow-up. Vein ablation rate at 6-month follow-up was reported in four studies with rates close to 90%. Only one study reported vein closure rates at 2 years but only for a minority of the eligible cases. The two studies reporting on RFA ablation with the more efficient second generation catheters involved better follow-up and reported higher ablation rates close to 100% at 6-month follow-up with no major adverse events. A large prospective registry trial that recruited over 1,000 patients at thirty-four largely European centers reported on treatment success in six overlapping reports on selected patient subgroups at various follow-up points up to 5 year. However, the follow-up for eligible recruited patients at all time points was low resulting in inadequate estimates of longer term treatment efficacy. The overall level of evidence of randomized trials comparing RFA with surgical ligation and vein stripping (n = 5) was graded as low to moderate. In all trials RFA ablation was performed with first generation catheters in the setting of the operating theatre under general anaesthesia, usually without tumescent anaesthesia. Procedure times were significantly longer after RFA than surgery. Recovery after treatment was significantly quicker after RFA both with return to usual activity and return to work with on average a one week less of work loss. Major adverse events occurring after surgery were higher [(1.8% (n=4) vs. 0.4% (n = 1) than after RFA but not significantly. Treatment effectiveness measured by imaging defined vein absence or vein closure was comparable in the two treatment groups. Significant improvements in vein symptoms and quality of life over baseline were reported for both treatment groups. (ABSTRACT TRUNCATED)