260 research outputs found
Interpersonal comparison of welfare in Harsanyiâs veil-of-ignorance model
Selon le voile dâignorance proposĂ© par John Harsanyi (1953, 1955), lâobservateur rationnel derriĂšre le voile dâignorance cherche Ă maximiser la somme des utilitĂ©s individuelles. Cependant, le modĂšle dâHarsanyi est fondĂ© sur une hypothĂšse erronĂ©e que la fonction dâutilitĂ© Ă la von Neumann-Morgenstern de lâobservateur permet la comparaison interpersonnelle de bien-ĂȘtre. Ce papier suggĂšre une modification du modĂšle dâHarsanyi qui permet la comparaison interpersonnelle de bien-ĂȘtre, en utilisant les annĂ©es de vie en parfaite utilitĂ© ou les annĂ©es de vie heureuse comme mesure du bien-ĂȘtre
Pharmaceutical expenditure and gross domestic product: Evidence of simultaneous effects using a two-step instrumental variables strategy
This paper estimates the income elasticity of government pharmaceutical spending
and assesses the simultaneous effect of such spending on gross domestic product
(GDP). Using a panel dataset for 136 countries from 1995 to 2006, we employ a
two-step instrumental variable procedure where we first estimate the effect of
GDP on public pharmaceutical expenditure using tourist receipts as an Instrument for GDP.
In the secondstep,we construct an adjusted pharmaceutical expenditure
series where the response of public pharmaceutical expenditure to GDP is
partialled out and use this endogeneity adjusted series as an instrument for pharmaceutical
expenditure. Our estimations show that GDP has a strong positive
impact on pharmaceutical spending with elasticity in excess of unity in countries
with low spending on pharmaceuticals and countries with large economic freedom.
In the second step, we find that when the quantitatively large reverse effect
of GDP is accounted for, public pharmaceutical spending has a negative effect
on GDP per capita particularly in countries with limited economic freedom
Hitzschlag mit Alpha-Koma: Ein Fallbericht
Zusammenfassung: Wir berichten ĂŒber einen 41-jĂ€hrigen komatösen Patienten, der einen schwer verlaufenden Hitzschlag mit einer Körperkerntemperatur von 41,5°C erlitt. Der klinische Verlauf wurde kompliziert durch eine akute systemische inflammatorische Reaktion und Multiorganversagen. Das EEG zeigte ein prognostisch ungĂŒnstiges Alpha-Koma ohne ReaktivitĂ€t auf externe Stimuli. Der Patient erlangte das Bewusstsein wieder und wurde nach 16Tagen aus der intensivmedizinischen Behandlung entlassen. Im weiteren Verlauf entwickelte sich eine zerebrale Toxoplasmose, die mit einer Kombinationstherapie aus Sulfadiazin und Pyrimethamin behandelt wurde. Nach 65Tagen erfolgte eine Verlegung in eine Neurorehabilitationsklinik mit einem moderaten neurologischen Defizi
Binge Drinking: A Confused Concept and its Contemporary History
Binge drinking is a matter of current social, political and media concern. It has a long-term, but also a recent, history. This paper discusses the contemporary history of the concept of binge drinking. In recent years there have been significant changes in how binge drinking is defined and conceptualised. Going on a âbingeâ used to mean an extended period (days) of heavy drinking, while now it generally refers to a single drinking session leading to intoxication. We argue that the definitional change is related to the shifts in the focus of alcohol policy and alcohol science, in particular in the last two decades, and also in the role of the dominant interest groups. The paper is a case study in the relationship between science and policy. We explore key themes, raise questions and point to a possible agenda for future research
Future costs in cost-effectiveness analysis: an empirical assessment
To assess the usage of cost-utility analysis (CUA) in oral health interventions and to evaluate the methods used and the reporting quality of CUA in publications on oral health interventions
Cost and feasibility: an exploratory case study comparing use of a literature review method with questionnaires, interviews and focus groups to identify barriers for a behaviour-change intervention
Background: It is often recommended that behaviour-change interventions be tailored to barriers. There is a scarcity of research into the best method of barrier identification, although combining methods has been suggested to be beneficial. This paper compares the feasibility and costs of three different methods of barrier identification used in three implementation projects conducted in primary care. Methods: Underpinned by a theory-base, project one used a questionnaire and interviews; project two used a single focus group and questionnaire, and project three used a literature review of published barriers. The feasibility of each project, as experienced by the research team, and labour costs are summarised. Results: The literature review of published barriers was the least costly and most feasible method, being quick to conduct and avoiding the challenges of recruitment experienced when using interviews or a questionnaire. The feasibility of using questionnaires was further reduced by the time taken develop the instruments. Conducting a single focus group was also found to be a more feasible method, taking less time than interviews to collect and analyse the barriers. Conclusions: Considering the ease of recruitment, time required and cost of the different methods to collect barriers is crucial at the start of implementation studies. The literature review method is the least costly and most feasible method. Use of a single focus group was found to be more feasible than conducting individual interviews or administering a questionnaire, with less recruitment challenges experienced, and quicker data collection. Future research would benefit from comparing the robustness of the methods in terms of the comprehensiveness of barriers identified
Patient Outcomes with Teaching Versus Nonteaching Healthcare: A Systematic Review
BACKGROUND: Extensive debate exists in the healthcare community over whether outcomes of medical care at teaching hospitals and other healthcare units are better or worse than those at the respective nonteaching ones. Thus, our goal was to systematically evaluate the evidence pertaining to this question. METHODS AND FINDINGS: We reviewed all studies that compared teaching versus nonteaching healthcare structures for mortality or any other patient outcome, regardless of health condition. Studies were retrieved from PubMed, contact with experts, and literature cross-referencing. Data were extracted on setting, patients, data sources, author affiliations, definition of compared groups, types of diagnoses considered, adjusting covariates, and estimates of effect for mortality and for each other outcome. Overall, 132 eligible studies were identified, including 93 on mortality and 61 on other eligible outcomes (22 addressed both). Synthesis of the available adjusted estimates on mortality yielded a summary relative risk of 0.96 (95% confidence interval [CI], 0.93â1.00) for teaching versus nonteaching healthcare structures and 1.04 (95% CI, 0.99â1.10) for minor teaching versus nonteaching ones. There was considerable heterogeneity between studies (I(2) = 72% for the main analysis). Results were similar in studies using clinical and those using administrative databases. No differences were seen in the 14 studies fully adjusting for volume/experience, severity, and comorbidity (relative risk 1.01). Smaller studies did not differ in their results from larger studies. Differences were seen for some diagnoses (e.g., significantly better survival for breast cancer and cerebrovascular accidents in teaching hospitals and significantly better survival from cholecystectomy in nonteaching hospitals), but these were small in magnitude. Other outcomes were diverse, but typically teaching healthcare structures did not do better than nonteaching ones. CONCLUSIONS: The available data are limited by their nonrandomized design, but overall they do not suggest that a healthcare facility's teaching status on its own markedly improves or worsens patient outcomes. Differences for specific diseases cannot be excluded, but are likely to be small
Impact of population ageing on the cost of hospitalisations for cardiovascular disease: a population-based data linkage study
Background: Cardiovascular disease (CVD) is the most costly disease in Australia. Measuring the impact of ageing on its costs is needed for planning future healthcare budget. The aim of this study was to measure the impact of changes in population age structure in Western Australia (WA) on the costs of hospitalisation for CVD. Methods: All hospitalisation records for CVD occurring in WA in 1993/94 and 2003/04 inclusive were extracted from the WA Hospital Morbidity Data System (HMDS) via the WA Data Linkage System. Inflation adjusted hospitalisation costs using 2012 as the base year was assigned to all episodes of care using Australian Refined Diagnosis Related Group (AR-DRG) costing information. The component decomposition method was used to measure the contribution of ageing and other factors to the increase of hospitalisation costs for CVD. Results: Between 1993/94 and 2003/04, population ageing contributed 23% and 30% respectively of the increase in CVD hospitalisation costs for men and women. The impact of ageing on hospitalisation costs was far greater for chronic conditions than acute coronary syndrome (ACS) and stroke. Conclusions: Given the impact of ageing on hospitalisation costs, and the disparity between chronic and acute conditions, disease-specific factors should be considered in planning for future healthcare expenditure
Implantable cardioverter defibrillators for the treatment of arrhythmias and cardiac resynchronisation therapy for the treatment of heart failure: systematic review and economic evaluation
Background
This assessment updates and expands on two previous technology assessments that evaluated implantable cardioverter defibrillators (ICDs) for arrhythmias and cardiac resynchronisation therapy (CRT) for heart failure (HF).
Objectives
To assess the clinical effectiveness and cost-effectiveness of ICDs in addition to optimal pharmacological therapy (OPT) for people at increased risk of sudden cardiac death (SCD) as a result of ventricular arrhythmias despite receiving OPT; to assess CRT with or without a defibrillator (CRT-D or CRT-P) in addition to OPT for people with HF as a result of left ventricular systolic dysfunction (LVSD) and cardiac dyssynchrony despite receiving OPT; and to assess CRT-D in addition to OPT for people with both conditions.
Data sources
Electronic resources including MEDLINE, EMBASE and The Cochrane Library were searched from inception to November 2012. Additional studies were sought from reference lists, clinical experts and manufacturersâ submissions to the National Institute for Health and Care Excellence.
Review methods
Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment were undertaken by one reviewer and checked by a second. Data were synthesised through narrative review and meta-analyses. For the three populations above, randomised controlled trials (RCTs) comparing (1) ICD with standard therapy, (2) CRT-P or CRT-D with each other or with OPT and (3) CRT-D with OPT, CRT-P or ICD were eligible. Outcomes included mortality, adverse events and quality of life. A previously developed Markov model was adapted to estimate the cost-effectiveness of OPT, ICDs, CRT-P and CRT-D in the three populations by simulating disease progression calculated at 4-weekly cycles over a lifetime horizon.
Results
A total of 4556 references were identified, of which 26 RCTs were included in the review: 13 compared ICD with medical therapy, four compared CRT-P/CRT-D with OPT and nine compared CRT-D with ICD. ICDs reduced all-cause mortality in people at increased risk of SCD, defined in trials as those with previous ventricular arrhythmias/cardiac arrest, myocardial infarction (MI) >â3 weeks previously, non-ischaemic cardiomyopathy (depending on data included) or ischaemic/non-ischaemic HF and left ventricular ejection fraction â€â35%. There was no benefit in people scheduled for coronary artery bypass graft. A reduction in SCD but not all-cause mortality was found in people with recent MI. Incremental cost-effectiveness ratios (ICERs) ranged from ÂŁ14,231 per quality-adjusted life-year (QALY) to ÂŁ29,756 per QALY for the scenarios modelled. CRT-P and CRT-D reduced mortality and HF hospitalisations, and improved other outcomes, in people with HF as a result of LVSD and cardiac dyssynchrony when compared with OPT. The rate of SCD was lower with CRT-D than with CRT-P but other outcomes were similar. CRT-P and CRT-D compared with OPT produced ICERs of ÂŁ27,584 per QALY and ÂŁ27,899 per QALY respectively. The ICER for CRT-D compared with CRT-P was ÂŁ28,420 per QALY. In people with both conditions, CRT-D reduced the risk of all-cause mortality and HF hospitalisation, and improved other outcomes, compared with ICDs. Complications were more common with CRT-D. Initial management with OPT alone was most cost-effective (ICER ÂŁ2824 per QALY compared with ICD) when health-related quality of life was kept constant over time. Costs and QALYs for CRT-D and CRT-P were similar. The ICER for CRT-D compared with ICD was ÂŁ27,195 per QALY and that for CRT-D compared with OPT was ÂŁ35,193 per QALY.
Limitations
Limitations of the model include the structural assumptions made about disease progression and treatment provision, the extrapolation of trial survival estimates over time and the assumptions made around parameter values when evidence was not available for specific patient groups.
Conclusions
In people at risk of SCD as a result of ventricular arrhythmias and in those with HF as a result of LVSD and cardiac dyssynchrony, the interventions modelled produced ICERs of <âÂŁ30,000 per QALY gained. In people with both conditions, the ICER for CRT-D compared with ICD, but not CRT-D compared with OPT, was <âÂŁ30,000 per QALY, and the costs and QALYs for CRT-D and CRT-P were similar. A RCT comparing CRT-D and CRT-P in people with HF as a result of LVSD and cardiac dyssynchrony is required, for both those with and those without an ICD indication. A RCT is also needed into the benefits of ICD in non-ischaemic cardiomyopathy in the absence of dyssynchrony.
Study registration
This study is registered as PROSPERO number CRD42012002062.
Funding
The National Institute for Health Research Health Technology Assessment programme
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