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PubMed2006

Prioritising for fertility treatments--the effect of excluding women with a high body mass index.

The effect of clinical priority access criteria for access to infertility treatment was examined for women outside the body mass index (BMI) range of 18-32 kg/m2. Treatments and outcomes were analysed from 1280 cases referred from 1998 to May 2005. Sixteen percent of women had a BMI of >32 kg/m2. Overall, 38% of these women had a birth from conceiving a treatment-related pregnancy or spontaneous pregnancy, compared with 52% of women with BMI < 32 kg/m2. Weight loss allowed women in the BMI group >32<35 kg/m2 to access treatment, but women in higher BMI groups were less successful.

Adult↗
PubMed1993

Prioritising health services in an era of limits: the Oregon experience.

How do we decide who should receive the benefits that medical science has to offer? One approach to this decision process, that used by the state of Oregon, is described: who and what are covered, and how health care is financed and delivered, are considered. Oregon's priorities were set on the basis of broad consensus. The objective of health care reform, it was agreed, is to improve, maintain, or restore health--not universal coverage, access to health care, or cost containment. A Health Services Commission was created to consider clinical effectiveness and, through public involvement, to attempt to integrate social values into the priority list. Oregon's legislature can use the list to develop an overall health policy which recognises that health can be maintained only if investments in several related areas are balanced.

Attitude to Health↗
PubMed2025

Should neighbours of tuberculosis (TB) cases be prioritised for active case finding in high TB-burden settings? A prospective molecular epidemiological study.

INTRODUCTION: In high tuberculosis (TB)-burden countries, considerable transmission of Mycobacterium tuberculosis (M. tb) likely occurs outside of households. We aimed to estimate the TB prevalence and incidence in households and neighbourhoods around known TB cases and to understand transmission patterns. METHODS: Household and neighbourhood contacts of pulmonary TB index cases from contiguous areas in Bandung, Indonesia, were screened and followed up for 12 months. Sputum samples underwent smear microscopy, M. tb culture, Xpert MTB/RIF, DNA isolation and whole-genome sequencing (WGS). Pairwise single-nucleotide polymorphism (SNP) distance &#x2264;12 defined transmission for pairs with known epidemiological links, or SNP&#x2264;3 for pairs without epidemiological link. An SNP=12 cut-off was used to characterise transmission clusters. RESULTS: From 213 index cases, 514 household and 4141 neighbourhood contacts underwent TB screening: 19 household (3.70%, 95%&#x2009;CI 2.24 to 5.71) and 45 neighbourhood (1.09%, 95%&#x2009;CI 0.79 to 1.45) contacts were identified with TB, of whom 18 (3.50%, 95%&#x2009;CI 2.20 to 5.48) and 38 (0.92%, 95%&#x2009;CI 0.65 to 1.13) respectively, were bacteriologically confirmed. During follow-up, 11 household and 13 neighbourhood contacts were identified with TB (incidence per 100&#x2009;000 person-years: 2286 (95% CI 1286 to 4148) and 350 (95% CI 190 to 563)), of whom 6 and 8, respectively, were bacteriologically confirmed (incidence per 100&#x2009;000 person-years: 1247 (95% CI 560 to 2776) and 201 (95% CI 101 to 402)). A total of 223 patient M. tb isolates underwent WGS. Of 15 intra-household pairs, 8 (53.3%) were transmission pairs. Of 24 neighbour to index case pairs, 1 (4.2%) was a transmission pair. 11 of 19 transmission pairs shared no epidemiological link. We identified 25 M. tb genetic clusters from 205 mono-TB isolates overall. CONCLUSION: Neighbours have lower prevalence and incidence of TB than household contacts, but twice as many cases. Very few received M. tb from their index case, suggesting uncontrolled community-wide transmission. Whole population active case finding may be necessary in high TB-burden settings.

Humans↗
PubMed1996

Prioritising elective care: a cost utility analysis of orthopaedics in the north west of England.

STUDY OBJECTIVE: To produce a priority list for purchasers to use when purchasing elective care in the speciality of orthopaedics so that efficiency in health care purchasing (that is, maximising the benefit per unit of resource available for the resident population) can be achieved. DESIGN: The study used cost utility analysis in the elective speciality of orthopaedics. The diagnostic groups in the study were chosen on the basis of those conditions that constituted the greatest proportion of the orthopaedic waiting list, and consequently the greatest proportion of activity within the speciality. Costs were derived by two methods: the extra contractual referral tariff (ECR) and individual patient based costings. Outcome was assessed before surgery and again approximately six months afterwards. The outcome of the procedures was derived in two ways: Rosser and EuroQol indices. SETTING: The study took place at Wrightington hospital, a specialist orthopaedic hospital in north west England. PATIENTS: Prospective assessments were obtained from 99 patients for nine orthopaedics procedures. All the patients were individually interviewed on each occasion. Rosser and EuroQol assessments were completed for each patient by the patient and the patient's consultant before and after surgery. MAIN RESULTS: Priority lists presenting cost utility rankings for each of the procedures were derived from the patients' and consultants' assessments. CONCLUSIONS: It is feasible to generate priority lists in a systematic way. Purchasers may then use the results from these priority lists to help them maximise the benefits per unit of resource for their resident population.

Cost-Benefit Analysis↗
PubMed2002

Renal transplantation of highly sensitised patients via prioritised renal allocation programs. Shorter waiting time and above-average graft survival.

BACKGROUND: Highly sensitised renal transplant candidates (HSP) have a reduced chance of receiving a transplant. In Eurotransplant (ET), two special allocation programs have been made available for such patients: the Highly Immunised Tray (HIT) program and the Acceptable Mismatch program (AM), albeit with different inclusion and exclusion criteria (HIT, current PRA% >or=85%; AM, current and/or historical PRA% >or=85%). When a suitable kidney is available for a patient, included in these special programs, the kidney is mandatory offered. In contrast, in the point score system of the standard ET kidney allocation procedure (ETKAS), HSP (PRA >or=85%) only get a marginal bonus according to their current sensitisation. It was tested whether the allocation priority of the two special allocation programs is justified from the perspective of transplant outcome. METHODS: The post- transplant outcomes of recent consecutive cohorts of AM, HIT and HSP-ETKAS transplants were compared. The end points were initial graft function, rejection episodes during the first three months post-transplant, and 1-year kidney graft outcome. RESULTS: Between January 1, 1997 and June 30, 1998, 101 HSP received a kidney-only transplant: 29 via AM, 39 via HIT and 33 via ETKAS. HLA-A,B,DR matching was more favourable in the AM and HIT allocation groups and their waiting times till transplantation were much shorter than those of the HSP-ETKAS allocation group. The incidence of initial graft non-function was similar among the three HSP allocation groups, averaging 50%. Recovery of the initial non-function was more likely for AM and HIT transplants. No difference was present with regard to the percentage of patients who experienced at least one rejection episode during the first three months post-transplant, averaging 43%. However, the AM group had less severe and/or less recurrent rejection episodes. The 1-year kidney graft survival, censored for death with functional graft, was 96% for AM, 82% for HIT and 75% for HSP-ETKAS transplants (p = 0.04). CONCLUSIONS: The two special allocation programs for HSP do yield adequate results and offer a shorter waiting time, compared to the standard kidney allocation procedure. The AM approach might be preferred because of the smoother post-transplant management and the better graft survival, keeping the HIT approach as a back up. Since the allocation priority is justified in view of efficiency, the renal transplant community should support the incorporation of a special allocation program for HSP in their respective organ exchange program.

Graft Rejection↗
PubMed2006

Prioritising between direct observation of therapy and case-finding interventions for tuberculosis: use of population impact measures.

BACKGROUND: Population impact measures (PIMs) have been developed as tools to help policy-makers with locally relevant decisions over health risks and benefits. This involves estimating and prioritizing potential benefits of interventions in specific populations. Using tuberculosis (TB) in India as an example, we examined the population impact of two interventions: direct observation of therapy and increasing case-finding. METHODS: PIMs were calculated using published literature and national data for India, and applied to a notional population of 100,000 people. Data included the incidence or prevalence of smear-positive TB and the relative risk reduction from increasing case finding and the use of direct observation of therapy (applied to the baseline risks over the next year), and the incremental proportion of the population eligible for the proposed interventions. RESULTS: In a population of 100,000 people in India, the directly observed component of the Directly Observed Treatment, Short-course (DOTS) programme may prevent 0.188 deaths from TB in the next year compared with 1.79 deaths by increasing TB case finding. The costs of direct observation are (in international dollars) 5960 I dollars and of case finding are 4839 I dollars or 31702 I dollars and 2703 I dollars per life saved respectively. CONCLUSION: Increasing case-finding for TB will save nearly 10 times more lives than will the use of the directly observed component of DOTS in India, at a smaller cost per life saved. The demonstration of the population impact, using simple and explicit numbers, may be of value to policy-makers as they prioritize interventions for their populations.

Cost-Benefit Analysis↗