| Objective:Stroke is the second leading cause of death and disability in the world,and the severity and location of the stroke and the duration of the stroke,can have a significant impact on whether or not a patient has difficulty swallowing,and the degree to which they have difficulty swallowing,and studies show that about half of stroke survivors have difficulty swallowing.The swallowing disorder after stroke treatment with rehabilitation treatment is given priority to,more and more evidence that acupuncture can promote the function recovery of patients with swallowing disorder swallowing after stroke.However,the current clinical evidence fails to fully reflect the value of acupuncture and moxibustion in the treatment of the disease,and no research has provided a basis for the government's medical and health decision-making from the perspective of health economics and the whole society.This study started with acupuncture and rehabilitation therapy for swallowing disorders after stroke.Acupuncture and rehabilitation therapy will be analyzed from existing guidelines,RCT and other literatures,comprehensive evaluation of existing clinical evidence using multiple methods,and will conduct real-world research,to evaluate the contents of health economics and clinical effect of acupuncture and moxibustion rehabilitation therapy in treating swallowing disorder after stroke.Methods:1.The key words of the search strategy are 'stroke' AND 'guidelines'OR 'recommendations' OR 'consensus' OR 'health policy',etc.I will search the guidelines in seven databases of MEDLINE,EMBASE,PubMed,CINAHL,China National Knowledge Infrastructure(CNKI),Wanfang and VIP,And I will conduct additional retrieval,such as The EQUATOR website,Google academic,Medlive,GIN,The National Institute for Health and Care Excellence(NICE),The Agency for Healthcare Research and Quality(AHRQ)and The Scottish Intercollegiate Guidelines Network(SIGN),etc.,and carry out manual retrieval at the same time.Criteria for inclusion and exclusion set by the study were used to screen eligible guidelines,and reasons and quantities were recorded in a standardized format.This study was a retrospective review of the 2014-2019 stroke guidelines using the RIGHT checklist and AGREE II statement.In addition,the treatment of swallowing disorders after stroke mentioned in the guidelines will be extracted,and the recommended situation of acupuncture treatment of swallowing disorders after stroke in the guidelines will be understood.This study was conducted in accordance with the guidelines of the systematic review and meta-analysis(PRISMA)preferred reporting project.This study will extract the following information from the guidelines:the title of the guideline,the country or region in which the guideline was developed,the year of publication,the source of publication,the organization of the guideline' s development,the author,the target population,the fund,the focus of the guideline,and whether it has been updated.According to the RIGHT statement,Other information related to the format of the guidelines,includes:basic information,background,evidence,recommendations,reviews and quality assurance,funding and conflict of interest statements and management,and other information,including recommendations for further study of the guidelines and deficiencies in the guidelines.Assess the quality of the reports included in the guidelines based on the percentage of fully reported items.Other information related to the guideline methodology includes six areas,including scope and purpose,participants,rigor,clarity,application,and independence,according to the AGREE II statement.This study was evaluated by three researchers,and the evaluation results will show a score of 1-7,with 1 as the lowest quality and 7 as the highest quality.Scores for each area will be displayed.In the study of the guidelines,the most important content is to summarize the recommendations mentioned in the different guidelines for the treatment of swallowing disorders after stroke,and analyze the reasons for the limited application of acupuncture therapy.2.The network meta-analysis on the effectiveness of acupuncture and rehabilitation therapy for dysphagia after stroke was performed by computer retrieval,including Chinese and English databases including CNKI,wanfang,VIP,OVID,PubMed,Cochrane Library and Web of Science.The retrieval time was from the establishment of the database to November 2019.The search terms were "dysphagia after stroke"["dysphagia after stroke "OR" post-stroke dysphagia"]AND "clinical observation"["randomized "OR" clinical trial"].In order to eliminate the bias of retrieval,the author carried out manual retrieval at the same time to ensure that enough literatures conforming to the standard were included.Eligible RCTS were screened according to the inclusion and exclusion criteria set by the study,and the reasons and quantities were recorded according to the standard format.In this part of the study,clinical efficiency was taken as the main outcome indicator,the evaluation was based on the self-established efficacy evaluation criteria of each experiment,the results were presented by the ratio of the number of clinically effective patients to the total number of patients after treatment.Two researchers(Yu Zhang,Zhijie Wang)independently screened the literature and extracted the general information of the included literature.And then we'll summarize the discussion,if we need to discuss when we disagree,if no agreement can be reached,a third party(Liming Lu)is required to advise and determine the outcome.General data include:first author,year of literature publication,intervention measures,sample size,patient age,treatment cycle,etc.Using R language and GeMTC 0.14.3 software package to analyze data,the effective rates are all counting data,so the ratio(OR)analysis is adopted.The consistency model was used to represent the effect size with a 95%confidence interval(95%CI).Using Stata14.0 software package to draw network diagram.3.Applying the real world research methods,the efficacy and health economics of acupuncture combined rehabilitation group and rehabilitation group were compared,and to provide the basis for the government' s medical and health decisions.The cases of patients with post-stroke swallowing disorders who were admitted to Sun Yat-sen Memorial Hospital of Sun Yat-sen University,Anhui Acupuncture Hospital and the first Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine were investigated on January 1,2018 and September 30,2019.The included patients were divided into acupuncture combined rehabilitation group(exposure group)and rehabilitation group(non-exposure group)according to the different means of intervention.Baseline data of patients,namely demographic characteristics,were collected,and major efficacy indicators were recorded:evaluation of swallowing VFSS(video fluoroscopic swallowing study,kubota drinking water test and the secondary outcome indicators Modified Barthel Index,the observation points are when the patient begins to be hospitalized and when he leaves the hospital.The economics of health records direct medical costs and direct non-medical costs,Direct medical costs include the total cost of hospitalization,out-of-pocket expenses,and the total cost of swallowing rehabilitation interventions,Direct non-medical costs include escort costs,food costs,transportation costs and missed work costs.The method of propensity match score was used for matching analysis.And the cost-effectiveness ratio was calculated.Results:1.Through systematic search of professional databases and authoritative national guide websites,a total of 2,172 guidelines were retrieved,and after extensive examination and careful reading,44 were included in the final study.Eighteen of the guides came from China,13 from the United States and 13 from other parts of the world.The researchers used RIGHT checklist to assess the quality of the inclusion guidelines report and to summarize the quality assessment of all reports included in the inclusion guidelines.We evaluated each item strictly according to the criteria and gave a percentage calculation of the full reported items.The highest score for report quality was 94.3 percent and the lowest was 17.1 percent.Only 21 of the guidelines had a percentage of fully reported items greater than or equal to 60%.Description into 44 guide report quality good and bad are intermingled.In the methodological evaluation using AGREE II tool,the included guidelines scored poorly in terms of participants,rigor,applicability,and independence.Overall RIGHT and AGREE II scores were higher than 0.75 for the three scorers using spearman correlation,indicating strong internal evaluation consistency,which can be considered as high reliability and reliable results.There are only 10 guidelines for the treatment,diagnosis or management of post-stroke swallowing disorders,only three guidelines which come from China refer to acupuncture,and two of which refer only to acupuncture with a low level of evidence.Only one acupuncture treatment guideline,recommend acupuncture as A level of evidence.2.A network meta-analysis of the effectiveness of acupuncture and rehabilitation therapy in the treatment of post-stroke dysphagia was finally included in 27 eligible literatures,with a total of 2339 patients.12 of the interventions were routine acupuncture combined with s swallowing training,2 were electroacupuncture combined with swallowing training,1 was wrist and ankle acupuncture combined with routine acupuncture and swallowing training,4 were routine acupuncture combined with electrical stimulation,5 were routine acupuncture combined with electrical stimulation and swallowing training,1 was acupuncture combined with moxibustion and electrical stimulation and swallowing training,1 was acupoint injection combined with electrical stimulation,and 1 was fire acupuncture therapy.After the network meta-analysis,the possible ranking results of different treatment schemes were obtained as follows:C:wrist and ankle acupuncture combined with routine acupuncture and swallowing training>F:acupuncture combined with moxibustion and electrical stimulation and swallowing training>G:acupoint injection combined with electrical stimulation>D:routine acupuncture combined with electrical stimulation>B:electroacupuncture combined with swallowing training>E:acupuncture combined with electrical stimulation and swallowing training>A:routine acupuncture combined with swallowing training>H:fire acupuncture,I:swallowing training,J:electrical stimulation,and K:electrical stimulation combined with swallowing training,there was no statistically significant difference in the efficacy of the three therapies.3.A total of 248 cases were obtained in three hospitals,including 151 cases in Anhui Acupuncture Hospital,43 cases in the first Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine,and 54 cases in Sun Yat-sen Memorial Hospital of Sun Yat-sen University.Before the propensity match score,167 patients in the acupuncture and rehabilitation group were treated,and the kubota drinking water test rating of 163 patients downgraded to 1-2,with an effective rate of 97.6%.In the rehabilitation group,39 of the 44 patients had their kubota drinking water test rating downgraded to grade 1-2,with an effective rate of 88.6%.There were statistically significant differences in MBI scores between the two groups before and after treatment,with scores rising.In terms of health economics,there was no difference between the two groups in lost wages,the total hospitalization expenses,out-of-pocket expenses,total swallowing rehabilitation intervention expenses,accompanying expenses,food expenses and transportation expenses were all statistically significant,and the acupuncture combined with rehabilitation group was superior to the rehabilitation group.After the propensity match score was matched,42 patients in each group were matched.After treating 42 patients in the acupuncture combined with rehabilitation group,the kubota drinking water test rating of 42 patients downgraded to 1-2,with an effective rate of 100%.In the rehabilitation group,30 of the 36 patients had their kubota drinking water test rating downgraded to grade 1-2,with an effective rate of 83.3%.In terms of the evaluation of health economics,the total hospital expenses,out-of-pocket expenses,total swallowing rehabilitation intervention expenses,accompanying expenses and transportation expenses were all statistically significant,except for the absence of difference between the two groups in lost wages and food expenses.The acupuncture combined with rehabilitation group was superior to the rehabilitation group.In the calculation of cost-effectiveness ratio,it was found that the CER of the acupuncture combined with rehabilitation group before matching was 20433.9,which was less than 63437.5 of the rehabilitation group.After matching,the CER of the acupuncture combined with rehabilitation group was 20985.03,which was still lower than the 60931.1 of the rehabilitation group.Conclusion:1.This study evaluated the methodological and reporting quality of stroke guidelines published in recent years at home and abroad through AGREE ? and RIGHT tool.Clinical practice guidelines for discovering stroke cover many countries and territories.However,based on each item,the quality of reporting and methodological quality of the guidelines is assessed,the results showed inadequate reporting quality and methodological quality,and all included guidelines were recommended as"modified for use" recommendations.Based on the recommendations summarized in the 44 included guidelines for the diagnosis,screening,management,and treatment of swallowing disorders after stroke,only three national guidelines mention acupuncture as a treatment for swallowing disorders after stroke,two of the guidelines refer only to acupuncture,with a low level of evidence.The other is acupuncture therapy guidelines,which recommend acupuncture as grade A.2.According to the results of the network meta-analysis in this study,acupuncture combined with other rehabilitation therapies can benefit patients with dysphagia after stroke.Acupuncture,in combination with other therapies,is effective in treating post-stroke swallowing disorders,but definitive conclusions depend on higher-quality clinical studies in the future3.In the clinical efficacy and health economics evaluation of acupuncture combined with rehabilitation for post-stroke dysphagia,the study found that there were some differences in the research results before and after the propensity score matching.The matched patients were more comparable and the results were more reliable.Before and after the matching,the results showed that acupuncture combined with rehabilitation therapy was effective in treating dysphagia after stroke,and the direct medical cost and direct non-medical cost were lower than the rehabilitation group.The cost-effectiveness ratio of acupuncture rehabilitation was much lower than that of the rehabilitation group. |
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