Discounting of Life-Saving and Other Nonmonetary Effects

Cost-effectiveness analysts generally assume that preferences over time are such that streams of monetary and nonmonetary program effects can be reduced to one discounted sum of monetary costs and another of effects. It is known that if the nonmonetary effects can be cashed out in a way that does not vary with time, then the rates of discount for monetary and nonmonetary effects have to be equal. This paper presents a more compelling argument for the equality of those rates when hard to monetize benefits such as life-saving are involved. It shows that if the ability to produce the nonmonetary effect does not diminish too quickly over time, failure to discount benefits implies that programs are always improved by delay. In general, discounting benefits and costs at different rates can lead to peculiar results.cost-effectiveness analysis, philosophy of modeling

A Conceptual Framework for Evaluating Outpatient Electronic Prescribing Systems Based on Their Functional Capabilities

Objective: Electronic prescribing (e-prescribing) may substantially improve health care quality and efficiency, but the available systems are complex and their heterogeneity makes comparing and evaluating them a challenge. The authors aimed to develop a conceptual framework for anticipating the effects of alternative designs for outpatient e-prescribing systems. Design: Based on a literature review and on telephone interviews with e-prescribing vendors, the authors identified distinct e-prescribing functional capabilities and developed a conceptual framework for evaluating e-prescribing systems' potential effects based on their capabilities. Analyses of two commercial e-prescribing systems are presented as examples of applying the conceptual framework. Measurements: Major e-prescribing functional capabilities identified and the availability of evidence to support their specific effects. Results: The proposed framework for evaluating e-prescribing systems is organized using a process model of medication management. Fourteen e-prescribing functional capabilities are identified within the model. Evidence is identified to support eight specific effects for six of the functional capabilities. The evidence also shows that a functional capability with generally positive effects can be implemented in a way that creates unintended hazards. Applying the framework involves identifying an e-prescribing system's functional capabilities within the process model and then assessing the effects that could be expected from each capability in the proposed clinical environment. Conclusion: The proposed conceptual framework supports the integration of available evidence in considering the full range of effects from e-prescribing design alternatives. More research is needed into the effects of specific e-prescribing functional alternatives. Until more is known, e-prescribing initiatives should include provisions to monitor for unintended hazards

Do patient consent procedures affect participation rates in health services research?

BackgroundFew studies have examined the effects of Institutional Review Board (IRB) requirements to contact potential research participants.ObjectiveTo examine the association between requirements to contact potential research subjects and participation rates in a multisite health services research study. RESEARCH DESIGN, SUBJECTS: Prospective observational study of survey participation by 2673 individuals with diabetes and 1974 individuals with congestive heart failure treated at 15 clinical sites in the United States that had implemented a quality improvement intervention.Main outcome measuresTelephone survey response rates.ResultsOf 15 IRBs, seven required sites to obtain authorization from participants to release contact information to the study team. Five required oral and two required written advance permission. The response rate was 58% (913/1571) at sites where no advance permission was required, 39% (989/2530) from sites that required oral advance permission and 27% (145/546, P <0.001) at sites requiring written advance permission. Although 85% of eligible participants contacted directly by the study team consented to complete the survey, only 43% of individuals at sites requiring written advance permission allowed the release of contact information to the study team.ConclusionsMany potential participants did not grant advance permission to be contacted by the study team. Requiring advance permission reduced participation rates, especially at sites requiring written authorization

Do patient consent procedures affect participation rates in health services research?

BackgroundFew studies have examined the effects of Institutional Review Board (IRB) requirements to contact potential research participants.ObjectiveTo examine the association between requirements to contact potential research subjects and participation rates in a multisite health services research study. RESEARCH DESIGN, SUBJECTS: Prospective observational study of survey participation by 2673 individuals with diabetes and 1974 individuals with congestive heart failure treated at 15 clinical sites in the United States that had implemented a quality improvement intervention.Main outcome measuresTelephone survey response rates.ResultsOf 15 IRBs, seven required sites to obtain authorization from participants to release contact information to the study team. Five required oral and two required written advance permission. The response rate was 58% (913/1571) at sites where no advance permission was required, 39% (989/2530) from sites that required oral advance permission and 27% (145/546, P <0.001) at sites requiring written advance permission. Although 85% of eligible participants contacted directly by the study team consented to complete the survey, only 43% of individuals at sites requiring written advance permission allowed the release of contact information to the study team.ConclusionsMany potential participants did not grant advance permission to be contacted by the study team. Requiring advance permission reduced participation rates, especially at sites requiring written authorization

Quality collaboratives: lessons from research.

Quality improvement collaboratives are increasingly being used in many countries to achieve rapid improvements in health care. However, there is little independent evidence that they are more cost effective than other methods, and little knowledge about how they could be made more effective. A number of systematic evaluations are being performed by researchers in North America, the UK, and Sweden. This paper presents the shared ideas from two meetings of these researchers. The evidence to date is that some collaboratives have stimulated improvements in patient care and organisational performance, but there are significant differences between collaboratives and teams. The researchers agreed on the possible reasons why some were less successful than others, and identified 10 challenges which organisers and teams need to address to achieve improvement. In the absence of more conclusive evidence, these guidelines are likely to be useful for collaborative organisers, teams and their managers and may also contribute to further research into collaboratives and the spread of innovations in health care