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Industry's perception of presenting pharmacoeconomic models to managed care organizations.

BACKGROUND: Previous research has shown that pharmacoeconomic (PE) data are considered important but may not be optimally utilized by decision makers. No research has compared the effectiveness of different types of PE models. OBJECTIVES: The purpose of this study was to examine the perceived value and understanding of PE models among decision makers in managed care organizations. The perspective of this study was from research scientists working in the pharmaceutical industry who present PE models to managed care clients. The study objectives were to (1) examine what types of models are best received by decision makers, (2) investigate the barriers to using PE models, and (3) recommend methods for improving PE models. METHODS: A telephone survey of 39 items was conducted with 20 PE research scientists from various U.S. pharmaceutical and biotechnology companies. Topics addressed included factors contributing to how well PE models are received, barriers to using PE models, and recommendations for improving PE models. RESULTS: Models have an impact on health policy decision making. Nineteen of 20 respondents had at least one experience where a PE model played a role in optimizing the formulary positioning of a product. No single model format (e.g., decision analytic tools, spreadsheet analyses, Markov models, multivariate regression models) was regarded as the most effective model type. Although 7 of 20 respondents said simple spreadsheet models were most effective, well-designed, scientifically sound regression models were also reported to be very effective. CONCLUSIONS: The respondents commonly used models to share PE information, which was said to play a role in making health policy decisions by decision makers in managed care. There was no consensus regarding the type of model that was most effective. Study participants indicated that a variety of model designs are effective, ranging from simple spreadsheet models to multivariate regression models. Recommendations for improving PE models include (1) producing scientifically sound models, (2) customizing models where possible, (3) making models transparent, (4) making models user friendly, and (5) involving a nonbiased third party for model development.

Decision Making↗

Staphylococcus aureus endocarditis in Danish intravenous drug users: high proportion of left-sided endocarditis.

In a retrospective study covering the years 1982-1989 episodes of Staphylococcus aureus endocarditis in 51 intravenous drug users were studied. Tricuspid involvement dominated (34/51), but the frequency of left-sided involvement (33.3%) was greater than in earlier reports. Involvement of both sides of the heart was not detected, but 27.8% of the left-sided endocarditis cases had multiple pulmonary infiltrates, indicating that some of them might have had a concomitant right-sided endocarditis. The 2 groups were compared: patients with left-sided endocarditis were significantly older and with a longer time of intravenous drug use. The complication rate was the same (44.1%) as was the duration of antibiotic treatment (median 42 days). In total, five patients underwent surgery, two (5.8%) due to right-sided failure and three (29.4%) because of left-sided endocarditis. The mortality of tricuspid endocarditis was low (2.9%), whereas 5 patients (29.4%) with left-sided involvement died. The patients who died were significantly older and had a shorter duration of symptoms before hospitalization.

Adolescent↗

Client-centered approach to develop a seating clinic satisfaction questionnaire: a qualitative study.

OBJECTIVE: The purpose of this study was to develop a program evaluation tool through a client-centered approach. Client satisfaction questionnaires previously developed for service recipients of a pediatric seating clinic have reflected the professionals' views on what should be asked. METHOD: Seven parents and caregivers of recent service recipients of the seating clinic participated in tape-recorded semistructured interviews. They were asked their views on the seating clinic, how the service could be improved, and the quality of the seat received through the clinic. RESULTS: Data were coded into nine themes related to the process and the product. Using these themes and the vocabulary used by the participants, we developed a satisfaction questionnaire. The validity of the questionnaire was evaluated by requesting feedback on clarity, content, and design from all participants and from a panel of five health professionals. CONCLUSION: A client-centered approach can be used to develop a client satisfaction tool that reflects the needs of the users. Future work will involve testing the tool in the clinical setting.

Ambulatory Care↗

Disseminating quality care for upper gastrointestinal cancer.

This presentation discusses the problem involved in providing quality care for patients with Upper GI Cancer throughout a healthcare delivery system. It is argued that appropriate telecommunications technology exists for widespread dissemination of "best clinical practice", but that it cannot be used effectively at present because of some limiting factors. These include lack of precisely defined aims concerning use of technology, lack of interactive quality control, and insufficient involvement of end-users. Upper gastrointestinal cancer is selected as a model for discussion-since there is wide discrepancy between outcome of therapy in early and late cases, there is evidence that early diagnosis is possible-and there is substantial evidence that it does not take place widely in practice. Prospects for the future (with special reference to the 4th Framework) are discussed. It is argued that considerable opportunities exist. Future work should build on existing experience in informatics (eg. the "Telegastro" program) and in clinical practice (e.g. the Leeds "outreach" programmes) for (a) widespread dissemination of effective "best" clinical practice; and (b) continuing medical education.

Computer Communication Networks↗

Buying a healthcare information system.

Replacing an antiquated computer system with state of the art equipment and software is a lengthy, at times frustrating, and never an easy decision. At Wesley Woods Center on Aging, Atlanta, an integrated provider of healthcare for the elderly affiliated with Emory University, the process consumed more than two and a half years. This article takes the reader through the entire process, from the initial decision to replace an existing system, through the final purchase and installation. It looks candidly at the problems that were encountered, including turnover among key personnel, difficulties with involving all of the user groups, changes in the technology and coordination with the University. The lessons Wesley Woods learned in its experience can be of benefit to any healthcare facility contemplating an information system change.

Aged↗

Methadone treatment practices and outcome for opiate addicts treated in drug clinics and in general practice: results from the National Treatment Outcome Research Study.

BACKGROUND: General practitioners (GPs) are increasingly urged to become more involved in the care and treatment of drug misusers. Little information is available about the effectiveness of treatments delivered in primary health care or specialist settings. The impact of treatment setting is investigated as part of the National Treatment Outcome Research Study (NTORS). This is the largest study of treatment outcome for drug misusers ever conducted in the United Kingdom (UK). AIM: This paper presents six-month treatment outcomes for patients who received community-based methadone treatment in either a specialist drug clinic or a general practice setting. METHOD: A prospective, multisite follow-up study of treatment outcome was conducted with 452 opiate addicts who had been given methadone treatment in primary health care and specialist clinic settings. Outcome data are presented for substance use behaviours, health, and crime. RESULTS: Improvements at follow-up were found among both the GP and the clinic-treated groups in drug-related problems, health, and social functioning. Problems at intake were broadly comparable among the clinic-based and the GP patients. Similar levels and types of improvement were found for both groups at six-month follow-up. CONCLUSIONS: Results demonstrate the feasibility of treating opiate addicts using methadone in primary health care settings, and show that treatment outcomes for such patients can be as satisfactory as for patients in specialist drug clinics. The GPs in our study are unrepresentative in their willingness to be actively involved with problem drug users; moreover, several services treated relatively large numbers of drug users. Issues surrounding the growth of 'GP specialists' are discussed.

Adolescent↗

[Strategic problems in counteracting the spread of HIV infection in the Altai Territory].

The Altai Territory belongs at present to regions with the insignificant level of the spread of HIV infection. By December 1, 1999, the Altai Territory had 31 registered cases of HIV infection, which constituted 1.33 per 10,000 of the population (the corresponding figure for the whole of Russia being 14.92). But the situation with HIV/AIDS showed the general tendency to the development of the epidemic of HIV infection due to steady growth and the wide involvement of injecting drug users in the epidemic process. Before 1999 all cases of HIV infection registered in the Altai Territory were imported. Out of 31 HIV infected persons detected in the territory, 18 were injecting drug users. In 1999 local foci of HIV infection were formed among drug users in two big cities of the Altai Territory, which was indicative of the gradual transition of HIV infection from the phase of the registration of individual cases to the phase of the formation of local foci among some groups of the population.

Adolescent↗

[The French and English health systems: compared evolution after the mid-1990s].

In the recent past, the British and French health care systems have both undergone significant reforms, enveloped in a state of Urgency, resulting primarily in France from the increasing rate of growth in health expenditure and in England from malfunctioning procedures such as waiting lists. After describing current features of the National Health Service (NHS), this study extracts and considers the points of convergence and divergence in the respective policies of the two countries: similarities in the choice of priorities, decentralisation of decision-making, negotiation between actors at the local level, development of the quality concept, and the differences in formulating objectives and involving the system's users. The considerations provided here should allow for a better understanding of the developments of these respective health policies and their future evolution.

Delivery of Health Care↗

Evaluating the computer as a data camera in family planning research.

"This chapter explores both the potential and limitations of the micro-computer as a research tool for unobtrusive data collection in the area of population and family planning.... To provide concrete examples of the computer's potential usefulness as well as its limitations, two research projects undertaken [in the United States] by the author and colleagues will be discussed.... Each program offers different applications of how the computer can be used to: (1) evaluate programs; (2) collect descriptive data about users' values, decisions, and previous behaviors regarding sexual issues, and (3) develop and test cognitive and behavior models. Each application also offers examples of the limitations of the computer in terms of external validity issues (i.e., how representative are samples of persons who use the computer voluntarily), the need to check the validity of responses typed by computer users, and ethical issues involved in using the computer to collect data."

Americas↗

Equivalence of items on the mini-mental state.

Procedural variations affecting the reliability of the Mini-Mental State (MMS) were investigated in three studies using three different populations. Consistent results were obtained from studies of neurologically normal, at-risk, and impaired individuals which show that the test item involving serial subtractions is significantly more difficult than the alternative item involving backward spelling. MMS users are cautioned against assuming the comparability of scores across individuals, and should specify which attention and concentration task they employ in their evaluations.

Journal Article↗

Citizen Health System: telehealth homecare.

The Citizen Health System (CHS) is a European Commission (CEC) funded project in the field of IST for Health. Its main goal is to develop a generic contact center which in its pilot stage can be used in the monitoring, treatment, and management of chronically ill patients at home in Greece, Spain, and Germany. Such contact centers, using any type of communication technology, and providing timely and preventive prompting to the patients, are envisaged in the future to evolve into well-being contact centers providing services to all citizens. In this paper, we present the structure of such a generic contact center and in particular the telecommunication infrastructure, the communication protocols and procedures, and finally the educational modules that are integrated into this contact center. We present the procedures followed for two target groups of patients, namely diabetic patients, and congestive heart failure patients, in which two randomized controlled clinical trials are under way. We present examples of the communication means between the contact center medical personnel and these patients, and elaborate on the educational, user, and telecommunication issues involved.

Chronic Disease↗

Effects of wheelchair posture on patient safety.

Wheelchairs originally were designed to transport people from one place to another quickly and easily. They have evolved to rank among the most important therapeutic devices used in rehabilitation. Currently, an estimated 2.2 million people who use wheelchairs generally are living longer and moving about more. However, the increased use of wheelchairs has been accompanied by many types of adverse events and repetitive stress injuries. Wheelchair prescription, posture, training, and maintenance are critical components of safety in this population, and may be enhanced through increased awareness and education. Since nurses and nursing staff are most often involved directly with wheelchair users (particularly in long-term-care settings), providing specialized programs for adaptive wheelchair fitting allows for a proactive approach to seating problems.

Aged↗

[Effect of administration of hormonal contraceptives on prognostic factors in breast cancer].

Up to now, there are only a few and different results from investigations concerning a possible influence of oral contraceptive use on the prognosis of breast cancer. In this study, data from 195 patients with breast cancer showed no significant differences of histologic types, grading and extent or axillary node involvement between oral contraceptive users and nonusers. The frequency of local recurrencies and metastases as well as the disease-free interval and the short-time survival showed also no significant differences. There was a slight but not significant trend in increasing undifferentiated carcinomas after use of oral contraceptives, but the survival rate of these patients was not different from that of non-users.

Berlin↗

Glide psychophysics and related Mpeak and Speak speech performance.

Speech test results have indicated that improvements in speech comprehension can be achieved by means of coding strategies with high pulse rates. A possible effect of using high rates to encode speech information is that temporal information such as formant transitions could be better represented in the resulting electrode activity. A psychophysical study involving 4 cochlear implant users was carried out to observe the effect of various carrier pulse rates on the absolute identification of stimuli with a transient electrode trajectory. Also, the duration of the trajectory was varied. The results from this study indicated, first, that the trajectory identification became progressively more difficult as the duration of the trajectory was shortened. The identification score generally deteriorated much faster at a lower rate (100 pulses per second [pps]) than at higher rates (300 and 500 pps) with decreasing transient duration. The higher two pulse rates, 300 pps and 500 pps, yielded results similar to one another for longer (500 and 300 milliseconds) transient durations, but the identification of shorter (100 and 50 milliseconds) transient durations was better at 500 pps than at 300 pps. The implication is that higher carrier pulse rates are likely to be able to transmit short transient information better than lower ones. A comparison with speech test results using the Speak (spectral peak) speech-coding strategy shows that the place of articulation feature is significantly improved when compared to the slower-rate Mpeak (Multipeak) pitch-synchronous strategy.

Auditory Perception↗

Current developments in departmental PACS for ultrasound.

1. INTRODUCTION TO DEPARTMENTAL PACS. Full or partial Departmental PACS is generally taken to mean an image management system focused on serving the needs of a specific modality or modality application. It will provide a modality specific means of image acquisition, specialized redisplay of images, distribution, and local long term storage of images. A Departmental PACS can be considered in isolation or as a component in a distributed Radiology PACS which consists of one or more departmental work groups on a back bone, potentially with shared resources. 2. DEPARTMENTAL PACS Issues Implementation of a Departmental PACS requires an in-depth knowledge of departmental clinical practice and work flow in all affected areas in the department, including patient intake, image collection, data routing, retrieval of previous image data, reporting, and long term data management and storage. Optimization of modality specific image display systems requires significant involvement from representative physician users. System architectures and user interfaces must be flexible enough to support the span of variation in clinical practice encountered in the site. A departmental PACS should offer a variety of "open" communications interfaces, both local and wide area, recognizing that outreach efforts are often driven by specific imaging departments. Interfaces to other departmental PAC systems and other information systems must be considered in order to facilitate institutions developing "Best of Breed" PACS systems. As hospitals move toward the integrated electronic medical record, means need to exist for a client process launched from a physician desktop to acquire images and/or reports from a departmental system. At minimum, HIS/RIS interfaces need to be considered to minimize re-keying of data and reduce data entry errors. 3. DESIGN OBJECTIVES FOR ALI ULTRAPACS. The key objectives were to design a product which could function either as a free standing PACS or as a departmental subnet on a larger PACS backbone, one which could function in a local or mixed local and wide area environment and one which could provide a cost effective implementation based on currently available technologies. 4. IMPLEMENTATION STRATEGIES. In order to attain the product design objectives, ALI made the following critical implementation decisions: 1) to build the UltraPACS application as a suite of separable UNIX processes based on a message passing client server model; 2) to host the application and operating system on a Digital Equipment Corporation PC using an Intel microprocessor because of the competition and broad variety of suppliers in the PC arena; and 3) to use NEXTSTEP as the UNIX variant of choice because of NEXTSTEPUs strong object orientation, superb development tools, and the excellent integration between the Graphical User Interface level and the underlying operating system layers. 5. CONCLUSION. ALI is convinced that a departmental approach to PACS offers significant advantages over monolithic PACS in several key areas including: optimization for modality specific clinical practice and workflow, cost effectiveness, the potential for an institution to implement PACS in a stepwise fashion, starting with the department with the potential for the greatest savings, and the capability for an institution to build a "best of breed" solution for large scale PACS.

Radiology Department, Hospital↗

Quitting marijuana.

Marijuana quitters, continuing users and never-users were compared. Never-users are found to be more conservative, traditional, and strongly identified with their parental role models. Continuing users are more unconventional, involved in risk-taking behavior, and lacking a stable identity. Quitters are intermediate in cultural attitudes and stance. They have the highest rate of determined ego identify, but have more often reported problems with intimacy and have more often sought help for emotional problems. Three types of quitters are identified: the experimenter whose use was a social accident, the ex-rebel who used marijuana during the post adolescent stage of psychosocial moratorium, and the emotionally fragile individual for whom marijuana was psychologically threatening.

Cannabis↗

Advancing AIDSVAX to phase 3. Safety, immunogenicity, and plans for phase 3.

AIDSVAX (VaxGen, Inc., South San Francisco, CA), a possible vaccine to protect against human immunodeficiency virus type 1 (HIV-1) infection, is being tested for efficacy in phase 3 studies. It has been tested for potential efficacy in chimpanzees, and tested for safety and immunogenicity in human clinical studies. Four candidate vaccines, each with a different envelope protein antigen or combination of antigens, have been produced in alum formulations. In both design and clinical testing, AIDSVAX has an excellent safety profile. Because these highly purified proteins were prepared using recombinant DNA technology, there is no possibility of these vaccines causing HIV infection. Having been administered to over 1200 people, the only side effects attributable to AIDSVAX have been local pain and inflammation at the injection site. After immunization, essentially all recipients developed a robust antibody response, including binding and neutralizing antibodies. The neutralizing antibodies peaked after a 12-month boost. Excellent memory is induced. Two phase 3 trials of two bivalent formulations will evaluate their efficacy. One trial will use a bivalent subtype B formulation. This trial in North America will involve 5000 men who have sex with men and heterosexual women at high risk. The other study will use a bivalent subtype B/subtype E formulation. This trial in Thailand and will involve 2500 intravenous drug users. Both studies will be randomized, double-blinded and placebo controlled. The volunteers will be followed for 3 years. The end points of the studies are infection, as defined by seroconversion to standard diagnostic tests, and viral load, as defined by commercial polymerase chain reaction (PCR) tests.

AIDS Vaccines↗

Predicting seat belt use in fatal motor vehicle crashes from observation surveys of belt use.

There is a large difference between the rates of observed seat belt use by the general public and belt use by motor vehicle occupants who are fatally injured in crashes. Seat belt use rates of fatally injured occupants, as reported in the Fatality Analysis Reporting System (FARS), are much lower than the use rates found in observation surveys conducted by the states. A series of mathematical models describing the empirical relationship between FARS and observed rates were explored. The initial model was a 'straw man' and used two simplifying assumptions: (a) belt users and nonusers are equally likely to be involved in 'potentially fatal collisions', and (b) belts are 45% effective in preventing deaths. The model was examined by comparing each state's FARS use rate with the predicted rate. The model did not fit the state data points even when possible biases in the data were controlled. We next examined the assumptions in the model. Changing the seat belt effectiveness parameter provided a reasonable fit, but required an assumption that seat belts are 67% effective in preventing fatalities. The inclusion of a risk coefficient for non-belted occupants also provided a reasonable fit between the model and data. A variable risk model produced the best fit with the data. The major finding was that a model consistent with the data can be obtained by incorporating the assumption that nonusers of seat belts have a higher risk of involvement in potentially fatal collisions than do seat belt users. It was concluded that unbelted occupants are over-represented in fatal collisions for two reasons: (a) because of a greater chance of involvement in potentially fatal collisions in the first place, and (b) because they are not afforded the protection of seat belts when a collision does occur.

Accidents, Traffic↗