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PubMed2002

Unlocking the numerator-denominator bias. I: Adjustments ratios by ethnicity for 1991-94 mortality data. The New Zealand Census-Mortality Study.

AIM: To determine the extent of the under-reporting of Mäori and Pacific mortality among 0-74 year olds for the period 1991-94. METHODS: A subset (n=22,578) of highly probable linked 1991 census and 1991-94 mortality records were selected from the 31,635 census-mortality links in the New Zealand Census-Mortality Study. The numbers of decedents assigned as Mäori, Pacific, and non-Mäori non-Pacific were compared between mortality and census data. RESULTS: Compared to the death registration form, 29% more 0-74 year old decedents during 1991-94 had self-identified as sole-Mäori on the 1991 census (46% for prioritised-Mäori). This numerator-denominator bias was greater among the young and those living in central and southern New Zealand. Among 0-14, 15-24, 25-44, 45-64, and 65-74 year old decedents, respectively, 91%, 50%, 41%, 26% and 15% more decedents had self-identified as sole-Mäori on the 1991 census. For Northern, Midland, Central and Southern regional health authority areas, respectively, 14%, 17%, 81% and 102% more decedents had self-identified as sole-Mäori. Among Pacific decedents 68% more 0-74 year old decedents had self-identified as sole-Pacific on the 1991 census (78% for prioritised-Pacific group). This bias for Pacific decedents did not notably vary by age and region. CONCLUSIONS: This study confirms substantial underestimation of Mäori and Pacific mortality rates for the period 1991-94, even using the recommended sole-ethnic group denominator. The results from this study should be used to adjust ethnic-specific mortality rates for the early 1990s. Population-based funding formulas that included region-specific Mäori mortality rates would have particularly disadvantaged central and southern regions.

Adolescent↗

PubMed2004

Planning research in rural and remote areas.

INTRODUCTION: In order to set a regional research agenda, an interactive research workshop was planned by the joint University of Queensland and University of Southern Quennsland Centre for Rural and Remote Area Health (CRRAH), in which researchers and regional organisations would meet together to discuss and prioritise local research needs, then formulate constructive ideas and activities. METHODS: Selection of Participants: Organisations representing all key consumer, academic and health professionals within the Toowoomba, Queensland, Australia region were sent a letter inviting them to attend and to send at least one representative, resulting in a total of 75 workshop participants from 45 organisations representing 20 separate entities. The Design of the Workshop: The workshop was planned as an interactive research workshop, with a preliminary brainstorming to identify and prioritise topics, followed by facilitated small group discussions, and finally presentations to the reassembled total group. RESULTS: Forty three topics were put forward by participants during the plenary session, in which the following 12 major themes were evident: (1) health professional development and support; (2) mechanisms for identifying regional/local needs; (3) mental health; (4) health and interaction with the environment; (5) management of common conditions of which little is known; (6) post acute/aged care; (7) evidence based practice; (8) health workforce including volunteers; (9) indigenous health; (10) access to health service delivery; (11) economic impact of new programs; and (12) outcomes impact of research partnerships. Five subject areas from four of these themes were chosen for further small group discussion. A summary of the views, ideas and conclusions of each group, which were presented to a plenary session of reassembled participants over a 10-15 minute period by each group facilitators, are discussed below. Following each presentation, a 5-10 minute question session was provided after each topic. CONCLUSION: A workshop, enabling rural and remote organisations and regional researchers to meet and identify local research needs attracted strong local support. Although the final benefits of the workshop remain to be determined, a number of new collaborative research avenues are now being actively explored within the region, by a number of the participants.

Journal Article↗

PubMed2006

Communication on end-of-life decisions with patients wishing to die at home: the making of a guideline for GPs in Flanders, Belgium.

BACKGROUND: Communication with patients on end-of-life decisions is a delicate topic for which there is little guidance. AIM: To describe the development of a guideline for GPs on end-of-life communication with patients who wish to die at home, in a context where patient autonomy and euthanasia are legally regulated. DESIGN OF STUDY: A three-phase process (generation, elaboration and validation). In the generation phase, literature findings were structured and then prioritised in a focus group with GPs of a palliative care consultation network. In the elaboration phase, qualitative data on patients' and caregivers' perspectives were gathered through a focus group with next-of-kin, in-depth interviews with terminal patients, and four quality circle sessions with representatives of all constituencies. In the validation phase, the acceptability of the draft guideline was reviewed in bipolar focus groups (GPs-nurses and GPs-specialists). Finally, comments were solicited from experts by mail. SETTING: Primary home care in Belgium. SUBJECTS: Participants in this study were terminal patients (n = 17), next-of-kin of terminal patients (n = 17), GPs (n = 25), specialists (n = 3), nurses (n = 8), other caregivers (n = 2) and experts (n = 41). RESULTS: Caregivers and patients expressed a need for a comprehensive guideline on communication in end-of-life decisions. Four major communication themes were prioritised: truth telling; exploration of the patient's wishes regarding the end of life; dealing with disproportionate interventions; and dealing with requests for euthanasia in the terminal phase of life. Additional themes required special attention in the guideline: continuity of care by the GP; communication on foregoing food and fluid; and technical aspects of euthanasia. CONCLUSION: It was feasible to develop a guideline by combining the three cornerstones of evidence-based medicine: literature search, patient values and professional experience.

Advance Directives↗

PubMed2006

Coronary artery bypass graft surgery in New Zealand's Auckland region: a comparison between the clinical priority assessment criteria score and the actual clinical priority assigned.

AIMS: To describe the cohort of patients waiting for Coronary Artery Bypass Graft (CABG) surgery in the Auckland region; compare the Clinical Priority Assessment Criteria (CPAC) score with the actual priority assigned; and to assess the impact of a patient's demographic characteristics on the CPAC score and the assigned priority. METHODS: An electronic register was developed to capture all patients who had a CPAC form completed for isolated CABG surgery during the period June 2002 to September 2004 in the Auckland region. CPAC scores and clinical priority assigned were collected from the CABG booking form. Demographic characteristics came from the booking form (age, gender) or linkage via the National Health Index (NHI) number (ethnicity, deprivation score). RESULTS: The cohort displayed severe coronary artery disease and symptoms: 70% had class 3 or class 4 angina; 89% had their ability to work, live independently, or care for dependents threatened; 65% had three-vessel coronary disease; and 26% had left-main coronary disease. The CPAC score correlated only modestly with the actual clinical priority assigned, with an extremely wide range of scores for any given clinical priority. The mean CPAC score varied by the age of the patient, level of deprivation, and ethnicity--with higher mean scores among male patients who were Maori, Pacific, or more socioeconomically deprived. Clinical priority varied less by demographic characteristics than did the CPAC score, except more women than men were assigned the 'emergency' category. Despite higher CPAC scores for Maori and Pacific men, these did not translate to greater urgency in clinical priority. CONCLUSIONS: The CPAC scoring system is used to limit access onto the CABG surgery waiting list in Auckland, but is not used to prioritise patients as to the urgency of surgery once on the list. The challenge is to determine why clinicians do not consider that the CPAC score is adequate to prioritise the urgency of surgery and to build in a process whereby any such score can be continuously evaluated and improved. We have demonstrated that the establishment of an electronic register of such patients can provide timely analysis of patterns of practice and could be used on a national scale to improve future CPAC scoring systems.

Activities of Daily Living↗

PubMed1991

Towards better discharge summaries: brevity and structure.

In an investigation of the communication between Hospital and General Practitioners, 99 General Practitioners were asked by means of a postal questionnaire to state the relative importance they attached to the issues of speed of delivery, format, author, and the content of the discharge summaries. The issue of speed of delivery proved to be a central and recurrent theme in the replies received, with a clear demand for increased speed and efficiency in Hospital-General Practitioner communication. In addition, an overwhelming support was revealed for summaries in the form of short prioritised problem lists, as opposed to longer conventional prose accounts. This response proved to be independent of the style of summary being received by the General Practitioners in the study. With a clear need nationally to improve communication with General Practitioners, consideration should be given to adopting prioritised problem lists as a means of upgrading the quality of data sent to General Practitioners.

Communication↗

PubMed1997

[Analysis of prescriptions in primary care: evaluation of a system of indicators].

OBJECTIVE: To evaluate a system of qualitative indicators which serve as a tool for prioritising the level of intervention in Base Health Districts (BHDs). DESIGN: Retrospective, descriptive study. SETTING: Primary Care. MEASUREMENTS AND MAIN RESULTS: Medical prescription dispensed by the doctors from 36 BHDs in the Costa de Ponent (Barcelona) region in 1995 were analysed, with different qualitative indicators used. Three stages of indicators were established. 25% of the BHDs had a %PIV < 75%; 25% of them over 80%; and the rest between 75 and 80%. CONCLUSIONS: The three stages of indicators described contribute different and complementary information to the qualitative prioritising of pharmaceutical prescription. Absence of correlation between the third-stage indicators suggests the importance of choosing them according to the desired pharmacological group and in line with a pre-established criterion for selecting medicines.

Drug Prescriptions↗

PubMed1998

[No "unnecessary" care when measured by American standards. The Oregon list tested at a department of otorhinolaryngology in Halmstad].

It is often asserted in the health care debate that stricter priority setting would be one way of solving some of the economic problems. However, comparison of the workload at a Swedish ENT department with the Oregon list, one of the strictest prioritisation instruments yet devised, suggests that this is not the case. After adaptation of the Oregon list to the norms of Swedish practice (e.g., current policy regarding tonsillectomy, as elicited from Scandinavian studies), very little of the remaining workload would not be approved according to the Oregon list. Thus the scope for economy would appear to derive from professional skill in the internal planning of diagnostic investigation and treatment, rather than from the application of prioritisation systems devised by others.

Decision Making↗

PubMedDate not supplied

An exercise on the feasibility of carrying out secondary economic analyses.

Purchasers of health services need up to date information on cost-effectiveness of interventions to help in prioritising spending. But economists have not yet developed a formal methodology for reviewing and summing up evidence from individual economic evaluations which may have been conducted at different times and in different places, or indeed for assessing whether such systematic reviews are possible in this context. This paper discusses the problems of reviewing available economic information, using a body of literature on the economics of influenza vaccination to illustrate some relevant issues. First, the paper examines alternative methods for adjusting prices to take into account differences in currency and time periods: Retail Price Indices are compared with health specific inflation indices, and exchange rates are compared with Purchasing Power Parity (PPP) data. For the studies reviewed, the choice of conversion method made little practical difference. Secondly, the paper explores the possibility of summarising the results of a review in terms of quantities of resources used, rather than prices. This method is constrained by the available data, but could be more generally useful as it allows direct comparison of underlying technologies, and calculation of costs by attaching local unit costs to the resources associated with an intervention. These two exercises highlight many of the problems that arise in generalising from economic studies. Both methods need to be developed further if they are to be useful to decision makers.

Cost-Benefit Analysis↗

PubMed1998

Discounting life-years: whither time preference?

If elicited time preferences are to be incorporated into economic evaluations, not only social but also individual preferences may be included. The view of this paper is that social intertemporal preferences should govern social intertemporal choices when prioritising between the saving of lives now or in the future. However, the present value of an individual's stream of future health benefits is a matter of private consumption and hence either individual time preferences or social interpersonal preferences could be applied when evaluating the value of extended life or improved quality of life. This paper shows that it is possible to incorporate both types of time preferences in an economic evaluation; using the individual time preference or the social interpersonal preference when discounting the remaining life expectancy and the social intertemporal time preference for discounting the health benefits from the time of the risk reduction to present time. Such a scenario could solve potential problems such as double discounting of QALYs, the paradox of intertemporal equity versus interpersonal equity, as well as include elements of quantity, risk and uncertainty which are otherwise ignored in evaluations of life-saving therapies.

Attitude to Health↗

PubMedDate not supplied

Immunisation strategies for viral diseases in developing countries.

In just under a quarter of a century, the Expanded Programme on Immunisation has been associated with an increase in infant immunisation coverage from around 5% to 80%, and the prevention of at least 3 million deaths annually, at very low cost. The global target of poliomyelitis eradication by the year 2000 appears feasible. Measles is the next likely target for eradication via immunisation, through 'catch-up', 'keep up' and 'follow-up' strategies which have proven highly effective in the Americas. Yet much needs to be done in order to extend readily achievable immunisation benefits equitably to all the world's people and to realise the potential of existing and soon to be available vaccines for disease control and eradication, as experience with yellow fever and hepatitis B vaccines demonstrates. Unsafe injection practices are widespread, have received inadequate attention, and cause a substantial global burden of blood-borne infections. The risk of increasing global inequity in immunisation highlights the centrality of resource allocation priorities in determining the extent to which the benefits of immunisation will be realised, particularly for new vaccines which are significantly more costly than established EPI vaccines. WHO/UNICEF strategies to target more effectively immunisation support to the neediest countries, to prioritise new vaccines, and to target carefully vaccine procurement and encourage sharply tiered vaccine pricing support both equity and sustainability. However, increasing the resources available to immunisation is vital and requires powerful advocacy on public health, moral, cost-effectiveness and legal grounds. More appropriate resource allocation priorities could readily provide the means necessary to address both technical and operational immunisation challenges.

Child↗

PubMed2004

Direct analysis of the genes encoding G proteins G alpha T2, G alpha o, G alpha Z in ADHD.

We have followed up the extensive replicated evidence that the dopamine DRD4 receptor is involved in the aetiology of ADHD by undertaking direct analysis of genes encoding other proteins in this effector system. We prioritised the genes encoding G protein alpha subunits G alpha(T2), G alpha(o), G alpha(Z) as these have been shown to transduce the effects of ligand binding at DRD4. We screened the exons of all three genes for sequence variation in 28 unrelated subjects with ADHD and identified 13 novel polymorphisms. All were tested for possible association with ADHD using a combination of pooled and individual genotyping. The results of our study do not suggest that polymorphisms in these genes contribute to susceptibility to ADHD.

Adolescent↗

PubMed2006

Comparative analysis of the surface interaction properties of the binding sites of CDK2, CDK4, and ERK2.

Recently developed hydrogen-bonding and hydrophobic analysis algorithms were used to investigate the interaction properties of the ATP binding sites of CDK2, CDK4, and ERK2. We were able to prioritise those hydrogen-bonding groups that are observed to bind the native ATP ligand, as well as to identify other important groups found to bind inhibitors of these enzymes. However, as the hydrogen-bonding groups in the ATP binding sites of these enzymes are fairly well-conserved, we have confirmed that inhibitor selectivity may be predominantly due to differences in either the hydrophobic or steric properties of their binding sites. In particular, the hydrophobic properties of regions outside the specificity surface were observed to provide a rationale for the differences in specificity between various inhibitors to these enzymes. Our method was thus able to identify variations in hydrophobicity. The greater hydrophobicity of certain regions of CDK4 over analogous regions in CDK2 was detectable; likewise, it was possible to distinguish variations in hydrophobicity for regions of CDK2 against those in ERK2, despite the fact that these regions are largely composed of similar residue types.

Adenosine Triphosphate↗

PubMedDate not supplied

Considerations on blood glucose management in Type 2 diabetes mellitus.

In recent years the benefits of more intensive management in preventing or delaying the development and progression of diabetic complications have been well documented. What is not as well documented is how to motivate the person with diabetes to manage the condition, how to set, assess and quantify glucose goals, and the glucose variables that should be routinely measured. This review discusses the importance of setting targets and communicating them in a way that the patient understands. When aiming for a glycaemia target, balance is required (1) between achieving reduction of complications and causing an increased degree of hypoglycaemia, and (2) between what is achievable and what degree of benefit is gained. Target values given in guidelines should be adapted by the clinician to take into account the patient's susceptibility to hypoglycaemia, stage and type of complications, age and life expectancy, co-morbidity, social environment, understanding of the steps required and level of commitment to the treatment. Several suggestions are given regarding possible improvements and amendments to existing guidelines for diabetes management in treating to glucose goal. For example, attention should be drawn to the need to individualize goals and to consider education, long-term support, patient needs and treatment outcome when formulating diabetes management plans. The relative properties of the different glucose variables-fasting plasma glucose (FPG), postprandial plasma glucose (PPG), glycated haemoglobin A(1c) (HbA(1c)), and glycated protein-in terms of their convenience of measurement, usefulness and relevance to the physician and patient are also evaluated. When prioritising the variables to be measured it is suggested that where feasible, HbA(1c) should be the standard measurement by which to gauge risk and treatment efficacy. Serial measurements should be made and, where possible, the use of blood glucose meters encouraged, in order to obtain a blood glucose profile for the patient.

Biomarkers↗

PubMedDate not supplied

Painful diabetic neuropathy--providing the best patient service.

Painful diabetic neuropathy is just one of a myriad of secondary conditions that may result from poor glycaemic control. Educating the patient to suspect diabetic complications, understanding why they may occur, what their progression is likely to be and what measures can be taken to avoid them can significantly improve outcomes. Education within the diabetes management framework needs to be consistent, prioritised, tailored to the needs of each patient and ongoing in order to be maximally effective, with tight glycaemic control playing the anchoring central role. The specialist diabetes nurse is in the ideal situation to coordinate this education and to ensure that the patient with diabetes receives the care and support needed to take dual responsibility for their condition.

Blood Glucose↗

PubMed2003

The needs of older people with mental health problems according to the user, the carer, and the staff.

BACKGROUND: Individual assessment of needs has been recognised as the most appropriate way to allocate health and social care resources. These assessments, however, are often made by the staff or by a carer who acts as an advocate for the user themselves. Little is known about how these proxy measures compare to how individual patients perceive their own needs. AIM: The aim of this study was to measure and compare ratings of need for older people with mental health problems by the older person themselves, their carer, and an appropriate staff member. METHOD: One-hundred and one older people were identified from various mental health services and 87 users, 57 carers, and 95 staff were interviewed using the Camberwell Assessment of Need for the Elderly (CANE) to identify met and unmet needs. RESULTS: Users identified significantly fewer of their needs (5.5) than either staff (8.1) or carers (8.3) did, but this difference was accounted for by people with dementia reporting less needs. Users identified fewer psychological or social needs (e.g. daytime activities, company, or carer distress) than staff or carers did. The average Kappa indicating level of agreement between staff and user was 0.52, between user and carer was 0.53, and between carer and user was 0.58. This showed only a fair level of reliability between different ratings of need. CONCLUSIONS: User perspectives should be given a high priority when assessing individual needs. Fears that assessment of need would be unduly time-consuming or would simply reflect individual demands should be allayed. A user-based assessment will assist healthcare providers to prioritise needs according to what the user themselves consider to be most important, beneficial, and acceptable to them. Reliance solely on assessment by staff or carers may not lead to the most equitable or appropriate use of services.

Aged↗

PubMed2005

The Irish health system: developments in strategy, structure, funding and delivery since 1980.

As the Irish health system embarks upon its first major structural reorganisation in over 30 years, developments within this system over the past two decades are assessed. Real cuts in health expenditure achieved in the 1980s contrast sharply with the unprecedented increase in resources devoted to the health system in the 1990s. While successive statements of health strategy have prioritised the objectives of equity, efficiency and quality of care, questions arise regarding the return achieved with the increased investment. With higher levels of economic growth, more people have been buying private health insurance such that almost half the population are now privately insured. At the same time, the numbers with eligibility for health services without charge have decreased while those from lower socio-economic groups continue to have higher levels of utilisation. Equity issues arise, however, with regard to access to public hospitals as the rate of growth in admissions for private patients outstrips that for public patients. The establishment of a National Treatment Purchase Fund to purchase treatment in private facilities for public patients on waiting lists raises efficiency and equity questions as the treatment of private patients in public hospitals is heavily subsidised while the State pays full cost for the treatment of public patients in private facilities.

Financial Management↗

PubMed2006

Non-linearity in the cost-effectiveness frontier.

Conventional cost-effectiveness decision rules rely on the assumptions that all health care programmes are divisible and exhibit constant returns to scale for a homogeneous population; hence, the path between adjacent programmes on a cost-effectiveness frontier must be linear. In this paper we build a framework to analyse non-linear 'expansion' paths. We model the impact of two key sources of non-linearity: economies of scale or scope in the production of health care; and prioritisation of patients who are most likely to benefit from more expensive and more effective treatments. We conclude that the expansion path might be linear, convex or concave, depending on the situation. The path might also exhibit vertical discontinuity due to fixed costs or horizontal discontinuity due to indivisibility. The efficiency of resource allocation might be improved by empirical estimation of expansion paths. We discuss the advantages and disadvantages of this approach compared with a standard stratified analysis.

Cost-Benefit Analysis↗

PubMed1993

QALY league tables: handle with care.

This paper examines some of the difficulties in using QALY league tables in priority setting. Such tables sometimes are seen as being 'the' way to prioritise in health care and in particular, at present, with respect to priority setting among purchasers in the UK NHS. However the paper highlights the fact that the base on which such tables is built is small--relatively few studies in the English language using CUA have been conducted anywhere. Further, four issues which require handling with care are set out: (i) the relevant measure of cost in QALY league tables has to be restricted to health service resource use; (ii) the relevant measure of benefit in QALY league tables is clearly restricted to QALYs, thereby the utility of health gains and indeed the maximisation of the utility of health gains; (iii) in incorporating the results of CUA studies into QALY league tables there is a need for greater clarification on what the margin constitutes; and (iv) those who might use CUA results in QALY league tables need to ascertain whether the original context of the study will allow the results to be transferred to the local context of the decision maker. The paper suggests that there is a need to be quite clear what goal QALY league tables serve. The authors argue that the only legitimate (and clearly important) goal of QALY league tables is the maximization of the utility of health gains within a health service budget.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-Benefit Analysis↗