Browsing by Author "Sivapragasam, Nirmali"

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    ItemOpen Access
    Cost-Effectiveness of Drug-Coated Balloon Angioplasty Versus Conventional Balloon Angioplasty for Treating Below-the-Knee Arteries in Chronic Limb-Threatening Ischemia: The SINGA-PACLI Trial.
    (Cardiovascular and interventional radiology, 2022-03-02) Sivapragasam, Nirmali; Matchar, David B; Zhuang, Kun Da; Patel, Ankur; Pua, Uei; Win, Hlaing Hlaing; Chandramohan, Sivanathan; Venkatanarasimha, Nanda; Chua, Jasmine ME; Tan, Glenn Wei Leong; Irani, Farah G; Leong, Sum; Tay, Kiang Hiong; Chong, Tze Tec; Tan, Bien Soo

    Purpose

    Drug-coated balloon angioplasty (DCBA) has been studied as a potentially superior option compared to conventional percutaneous transluminal angioplasty (PTA) in treating below-the-knee (BTK) arteries in chronic limb-threatening ischemia (CLTI). The aim of this study is to examine the cost-effectiveness of DCBA versus PTA in BTK arteries based on a randomized controlled trial.

    Material and methods

    A prospective economic study was embedded in a randomized controlled trial of 138 patients with CLTI. Resource use and health outcomes were assessed at baseline, and at 3, 6 and 12 months post-intervention. Costs were calculated from a societal perspective and health outcomes measured using quality-adjusted life years with probabilistic sensitivity analysis performed to account for subject heterogeneity.

    Results

    Compared with participants randomized to receive PTA, participants randomized to DCBA gained an average baseline-adjusted quality-adjusted life years (QALYs) of .012 while average total costs were USD$1854 higher; this translates to an incremental cost-effectiveness ratio (ICER) of US$154,500 additional cost per QALY gained. However, the estimate of ICER had substantial variance with only 48% of bootstrap ICERs meeting a benchmark threshold of US$57,705 (the average gross domestic product (GDP) per capita of Singapore).

    Conclusion

    The use of DCBA in BTK arteries in CLTI patients was not cost-effective compared with PTA.

    Level of evidence

    2, Randomized trial.
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    ItemOpen Access
    Developing a toolkit for implementing evidence-based guidelines to manage hypertension and diabetes in Cambodia: a descriptive case study.
    (Health research policy and systems, 2022-11) Sivapragasam, Nirmali; Matchar, David B; Chhoun, Pheak; Kol, Hero; Loun, Chhun; Islam, Amina Mahmood; Ansah, John; Yi, Siyan
    In Cambodia, economic development accompanied by health reforms has led to a rapidly ageing population and an increasing incidence and prevalence of noncommunicable diseases. National strategic plans recognize primary care health centres as the focal points of care for treating and managing chronic conditions, particularly hypertension and type 2 diabetes. However, health centres have limited experience in providing such services. This case study describes the process of developing a toolkit to facilitate the use of evidence-based guidelines to manage hypertension and type 2 diabetes at the health-centre level. We developed and revised a preliminary toolkit based on the feedback received from key stakeholders. We gathered feedback through an iterative process of group and one-to-one consultations with representatives of the Ministry of Health, provincial health department, health centres and nongovernmental organizations between April 2019 and March 2021. A toolkit was developed and organized according to the core tasks required to treat and manage hypertension and type 2 diabetes patients. The main tools included patient identification and treatment cards, risk screening forms, a treatment flowchart, referral forms, and patient education material on risk factors and lifestyle recommendations on diet, exercise, and smoking cessation. The toolkit supplements existing guidelines by incorporating context-specific features, including drug availability and the types of medication and dosage guidelines recommended by the Ministry of Health. Referral forms can be extended to incorporate engagement with community health workers and patient education material adapted to the local context. All tools were translated into Khmer and can be modified as needed based on available resources and arrangements with other institutions. Our study demonstrates how a toolkit can be developed through iterative engagement with relevant stakeholders individually and in groups to support the implementation of evidence-based guidelines. Such toolkits can help strengthen the function and capacity of the primary care system to provide care for noncommunicable diseases, serving as the first step towards developing a more comprehensive and sustainable health system in the context of population ageing and caring for patients with chronic diseases.
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    Sequential Multiple Assignment Randomized Trial (SMART) to identify optimal sequences of telemedicine interventions for improving initiation of insulin therapy: A simulation study.
    (BMC medical research methodology, 2021-09-30) Yan, Xiaoxi; Matchar, David B; Sivapragasam, Nirmali; Ansah, John P; Goel, Aastha; Chakraborty, Bibhas

    Background

    To examine the value of a Sequential Multiple Assignment Randomized Trial (SMART) design compared to a conventional randomized control trial (RCT) for telemedicine strategies to support titration of insulin therapy for Type 2 Diabetes Mellitus (T2DM) patients new to insulin.

    Methods

    Microsimulation models were created in R using a synthetic sample based on primary data from 63 subjects enrolled in a pilot study of a smartphone application (App), Diabetes Pal compared to a nurse-based telemedicine strategy (Nurse). For comparability, the SMART and an RCT design were constructed to allow comparison of four (embedded) adaptive interventions (AIs).

    Results

    In the base case scenario, the SMART has similar overall mean expected HbA1c and cost per subject compared with RCT, for sample size of n = 100 over 10,000 simulations. SMART has lower (better) standard deviations of the mean expected HbA1c per AI, and higher efficiency of choosing the correct AI across various sample sizes. The differences between SMART and RCT become apparent as sample size decreases. For both trial designs, the threshold value at which a subject was deemed to have been responsive at an intermediate point in the trial had an optimal choice (i.e., the sensitivity curve had a U-shape). SMART design dominates the RCT, in the overall mean HbA1c (lower value) when the threshold value is close to optimal.

    Conclusions

    SMART is suited to evaluating the efficacy of different sequences of treatment options, in addition to the advantage of providing information on optimal treatment sequences.