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Biomedical subjects

R B Deber

Publications and source records attributed to R B Deber.

At least 37 records · Page 2Linked to original sources
PubMed1991

Health care in Canada: current trends and issues.

Canada's universal health care system is perceived as threatened by rising costs, an aging population, and technological growth. This popular and successful program has largely kept costs under control while maintaining quality and ensuring equity. However, its success demonstrates the limits of medical care; remaining health problems are less amenable to improvement by merely improving access to traditional services. A widening view of health implies a larger health role in other policy arenas, and a larger group of legitimate participants; coordinating an evolving and expanding system becomes increasingly difficult. Policy options include some combination of laissez faire, business as usual, managed care, manpower regulation, and system change. Change implies controversy and conflict. Hard decisions are clearly ahead.

Canada↗
PubMed1990

Variations in breast cancer treatment decisions and their impact in mounting trials.

Clinical trials are often hindered by insufficient participation. Difficulties may arise if a clinician is generally reluctant to enroll patients in clinical trials, if the clinician is unwilling to enroll a patient in a particular trial, or if the patient refuses to participate. In our three-stage survey of clinicians treating breast cancer, we found that a favorable orientation to trials in principle can be attenuated when clinicians do not like the treatment regimens in a particular trial. We also found a lack of consensus as to appropriate treatment for breast cancer coupled with a high confidence by individual clinicians in their own treatment decisions (a phenomenon we term "micro-certainty/macro-uncertainty"). Accordingly, in the most controversial situations, it may be hardest to mount trials. Trial design is also complicated by the variation among clinicians in the importance they assign to various patient characteristics in making their treatment decisions. This variation can lead to difficulties in establishing patient subgroups that will be accepted by the clinical community. The trial designer will need to be alert to these considerations; efforts to build consensus on which data are necessary and which therapies are acceptable should improve the design and application of clinical trials.

Attitude of Health Personnel↗
PubMed1989

Nonionic contrast media: economic analysis and health policy development.

The replacement of old radiologic contrast media with supposedly safer but more expensive media has created a dilemma for radiologists and hospital administrators. To quantitate the nature of this trade-off we performed a cost-utility analysis using optimistic assumptions that favoured the new media. A complete conversion to the new media would result in an incremental cost of at least $65,000 to gain 1 quality-adjusted life-year (QALY). For a selective strategy in which only high-risk patients would receive the new media the cost would be about $23,000 per QALY gained. However, the incremental cost for low-risk patients is over $220,000 per QALY gained. Conversion to the new contrast media, although not necessarily the most efficient use of scarce resources, has already occurred in Ontario, primarily because of press publicity, pressure from insurers and a political unwillingness of policymakers to decide the fate of identifiable victims. We found that funding of a new intervention associated with a high cost-utility ratio rather than interventions with lower ratios might save some identifiable victims at the expense of a larger number of unidentifiable ones.

Adult↗
PubMed1989

Economic evaluations in the Canadian Mental Health System. I: Theory behind economic evaluation.

Economic evaluation is becoming an increasingly important part of the evaluation of health and mental health services. Current models for conducting economic evaluation, including cost-effectiveness analysis, cost-benefit analysis, and cost-utility analysis, have great potential for improving the quality of decision-making and for making mental health programs more effective and efficient. This paper presents the basic economic theory underlying the various forms of economic evaluation and provides general guidelines for developing and conducting an economic analysis of a health program.

Canada↗
PubMed1989

Economic evaluations in the Canadian Mental Health System. II: From theory to practice in mental health care.

This paper follows from a previous paper which described the basic approaches to economic evaluation of health programs. The discussion in this paper builds and discusses the theoretical and practical concerns felt by practitioners and analysts about economic evaluations in mental health care. Two examples of economic evaluations that compare the costs of hospital care and community-based care are presented to illustrate some of the limitations of economic evaluation. Discussion also focuses on the difficulties involved in developing and conducting economic analyses in the mental health field, as well as problems faced in trying to generalize from one study setting to others.

Canada↗
PubMed1988

Technology acquisition in Canada. Control in a regulated market.

The authors provide a detailed overview of how the national and provincial health systems of Canada exercise control over the diffusion of medical technology. In particular, they examine the diffusion of CT scanning and the adoption of non-ionic radio contrast media. While the nature of the parliamentary system theoretically allows the government, especially the executive, to exert more control over its policy agenda than in the United States, the authors believe that effective control is hampered by a lack of political will and insufficient "teeth" in the Ministry of Health's mandate and policy. The authors also conclude that the manipulation of reimbursement systems to encourage or discourage the diffusion of various medical technologies is not always effective, and that political clout often triumphs over rational decision making.

Canada↗
PubMed1987

Corporatization and deprivatization of health services in Canada.

Canada's system of health services has been shaped by the forces and values in the Canadian political, cultural, social, and economic environment; these forces continue to place constraints on future changes. We distinguish between "corporatization" and "privatization", and the implications of each for improved efficiency of the system. Although the organization of health services is, in certain provinces, undergoing significant structural changes, there is evidence that rather than privatizing, the system may actually be continuing to experience what we have termed deprivatization, as the scope of government involvement expands to include a more comprehensive definition of health care. Trends in Canada differ considerably from those in the United States; universal health insurance has curbed the ability and desire of institutions to exclude members of some socioeconomic groups from receiving care. U.S.-based models, if applied to Canada, could lead to both higher costs and lower quality of care. Considerable efficiencies can be realized within Canada's current system.

Canada↗
PubMed1987

Who still prefers aggressive surgery for breast cancer? Implications for the clinical applications of clinical trials.

Conservative breast surgery and modified radical mastectomy may, according to recent reports, yield equivalent survival. Analysis of a 1985 Canada-wide study (N = 228) compared surgeons and oncologists still recommending modified radical mastectomy (30%) with those recommending less aggressive surgery (69%) for a hypothetical stage I patient. The groups did not differ significantly in most physician characteristics, estimated survival and cure probabilities, importance of most treatment goals, uncertainty about treatment choice, or most attitudinal responses. Although equally involved with and cognizant of the value of clinical trials, the modified radical group expressed more skepticism about the ability of trial results to be transferred to practice and to take sufficient account of patient uniqueness, indicating greater focus on variation than mean results. Trial results might be more readily adopted if they are reported in accessible data-bases, incorporating patient characteristics potentially relevant to treatment choice. This would allow clinicians to individualize treatment by analyzing patient subsets of their own choosing.

Attitude of Health Personnel↗
PubMed1986

Amino acid composition of the membrane and aqueous domains of integral membrane proteins.

To identify residues which might impart transport capability to the intramembranous regions of transport proteins, we surveyed available data for the 9991 amino acids contained in the aqueous and intramembranous regions of 24 integral membrane proteins: 10 transport (T) proteins and 14 nontransport (NT) proteins. Statistical comparison of percentage occurrence of each amino acid within T and NT samples provided a measure of "typical" composition of T and NT membrane-spanning regions, and showed that the residues partition into membrane and aqueous domains largely in accord with expectation from hydropathy indices. Comparison of aqueous and membrane domain composition between protein categories revealed a statistically similar distribution of residues in aqueous domains, but significant differences in membrane domains: seven residues (Asn, Asp, Gln, Glu, Phe, Pro, Tyr) were preferred in membrane regions of T proteins, and one (Val) was selectively excluded. Chemical and structural considerations suggested that three of these residues--Asn, Tyr, and Pro--are the most likely functional participants in transport processes.

Amino Acid Sequence↗
PubMed1986

Contraception with the cervical cap: effectiveness, safety, continuity of use, and user satisfaction.

With the growing interest in barrier contraceptive methods, the cervical cap has come back into use in North America. We examined the cap's effectiveness, safety, continuity of use, and user satisfaction among 617 women who were fitted at a family planning clinic in Toronto, Canada, between May 1981 and November 1983. Follow-up information was available for 516 of these women. Using a life table analysis with Bayesian adjustment, the probability of becoming pregnant after 12 months of use was 0.166 with a standard error of 0.022. There is evidence that after 1 year of use the caps deteriorate and that this deterioration may increase the risk of pregnancy. Many of the women in this study were very satisfied with the cervical cap; however, such problems as dislodgement, discomfort to user and partner, difficulty with insertion and removal, and unpleasant odour affected acceptability and continuity of use. It is likely that these problems could be alleviated by improving the quality of or changing the materials, modifying the design to improve the fit, and providing a greater range of sizes.

Adolescent↗
PubMed1986

The multidisciplinary renal team: who makes the decisions?

Members of renal unit teams across Canada and in Michigan were asked to describe the involvement of various occupational groups and of patients in the treatment decision-making process in their actual unit and in an ideal unit. All occupational groups shared a belief in a relatively egalitarian team, in which the nephrologists would have primary responsibility for decision-making and the other groups would be highly involved. Nephrologists perceived reality as largely in accord with this ideology, indicating little difference between their authority in actuality and in an ideal unit, and perceiving other team members as having greater responsibility for decision-making than those groups perceived themselves as having. Ambiguity existed as to the appropriate level of decision-making involvement for the semiprofessional roles, and a substantial minority of nonphysician respondents saw staff nurses in particular (as well as patients) as having too little involvement. The findings suggest that as a technology becomes routinized, the multidisciplinary team approach may become less realistic. The resulting dissonance between ideology and reality may lead to job stress and adverse effects on job functioning.

Attitude of Health Personnel↗
PubMed1985

The impact of selected patient characteristics on practitioners' treatment recommendations for end-stage renal disease.

Medical decision making under uncertainty was tested using an empirical study of practitioner judgments concerning the preferred treatment(s) for end-stage renal disease (ESRD) patients. Patient-specific factors were varied systematically in written case vignettes, which were mailed to physician and nonphysician practitioners who treated ESRD patients in Canada and Michigan. Respondents were asked to indicate for each vignette: a preferred treatment and all other acceptable treatments. Overall patterns of choice were analyzed; the clear preferences shown for certain treatment modalities (e.g., for continuous ambulatory peritoneal dialysis over home hemodialysis) have planning implications. The apparent receptivity to new ESRD treatments may affect the success of government policies aimed at encouraging greater use of home hemodialysis. The impact of each patient-specific variable on treatment choice was also examined. Factors such as the patient's age proved to be major determinants both of the preferred treatment modalities and of the number of alternatives considered acceptable. The research method allowed areas of medical consensus to be distinguished from those 'grey areas' in which patient characteristics alone could not explain treatment selection. The resulting 'controversy' cases are being used as the dependent variables in further studies.

Adult↗