4 research outputs found
L’intérêt général dans l’Union européenne : du fédéralisme doctrinal aux biens publics européens ?
Quelles sont les pratiques censées servir l'intérêt général européen ? Éloi Laurent, chercheur à l’OFCE, montre d’abord qu’il n'est pas facile de savoir exactement quelle institution communautaire incarne l'intérêt général – même si cette tâche revient principalement à la Commission européenne. Une fois cette recherche faite, on s'aperçoit que la notion d'intérêt général se réduit de fait essentiellement au champ économique. Hélas même dans le secteur des services économiques d’intérêt général, l'Union reste incapable d’offrir aux citoyens de véritables services publics. Le problème tient au fait que l’Union ne semble pas savoir où aller, puisqu'elle ne définit même pas les biens publics qu'elle doit produire, ne se pose jamais la question des fins mais simplement celle des moyens
Postoperativ smärtlindring - till vilket pris? : En hälsoekonomisk modellanalys av två smärtlindringsmetoder
Utgångspunkten för denna rapport var en kvalitetskontroll av rutiner för postoperativ smärtlindring vid Anestesikliniken på US i Linköping under 1997-1999. Vid denna kontroll upptäckte vi en del svagheter i rutiner, bl.a. att epiduralsmärtlindring avslutades tidigare än avsetts i högre frekvens än väntat. Under denna period registrerades en mängd uppgifter om aktuell behandling och olika utfall i en databas. Resultatet pekade på att den mest använda metoden i praktiken var förenad med extrainsatser som bidrog till högre kostnader. Denna kunskap ledde fram till en vidare frågeställning än vad som traditionellt diskuterats i dessa sammanhang nämligen hur de aktuella metoderna förhåller sig till varandra när även kostnader för behandlingen tas i beaktande. Det första steget att besvara denna fråga var ett projektarbete i kursen om Klinisk Utvärderingsvetenskap (KLUV) som anordnades av Linköpings universitet med stöd av Forskningsrådet i Sydvästra Sjukvårdsregionen. Studien har sedan vidareutvecklats och färdigställts vid CMT med ekonomiskt stöd från Landstinget i Östergötland. Syftet med rapporten är att belysa hur två metoder för postoperativ smärtlindring (epiduralbedövning och intravenös opioidbehandling med patientkontrollerad pump) fungerar i vardagssjukvård med hänsyn tagen till både kostnader och effekten på smärta. Frågan om vilken metod som är den bättre av dessa har diskuterats under senaste decenniet. Epiduralbedövning tycks ge bättre smärtlindring, men det är oklart vilket mervärde som den skillnaden i smärtintensitet ger oavsett om den mäts som patientupplevd, medicinsk eller samhällelig nytta. Frågan om vilken behandlingsform som är mest kostnadseffektiv är intressant eftersom den här typen av smärtlindring är vanlig och berör ett stort antal patienter i sjukvården. Vår förhoppning är att vi med hjälp av denna hälsoekonomiska modellanalys av beslutsproblemet kan bidra till ett bättre beslutsunderlag men också väcka ett intresse för att göra hälsoekonomiska utvärderingar av smärtlindringsmetoder vilket hittills varit relativt ovanligt. Studien har genomförts i samarbete mellan CMT och AnOp Centrum vid US i Linköping. Flera personer har bidragit till denna rapport och vi vill tacka Mona Lindblad och Lilian Adamsson som var ansvariga för databasen under åren 1997-1999. Vi vill vidare tacka Martin Henriksson vid CMT för värdefulla synpunkter.The common method for postoperative pain control after major abdominal surgery in routine care is epidural analgesia (EDA) using a combination of local anaesthetics with opiate and patient-controlled intravenous analgesia using opiate (PCIA). It is a matter of dispute which method is better and should be favoured in different clinical situations. The superior analgesic effect of epidural analgesia reported in clinical trials has been difficult to transform into clinical practice. In a large number of patients the epidural analgesia is discontinued earlier than planned because of technical difficulties. The influence of better analgesic effect on outcome in terms of mortality and morbidity has also been an issue of controversy. There are no clear recommendations which treatment should be selected in specific situations. According to the guidelines of the Swedish Society of Anaesthesiology both EDA and PCIA can be chosen in several situations. Apart from efficacy and effectiveness a policy decision should also consider cost-effectiveness. Since economic analyses on postoperative pain treatment are rare an analysis of costs and consequences of planned and discontinued treatment is of interest when comparing these two strategies. The aim of this report is to estimate cost-effectiveness of treatment with EDA and PCIA under clinical circumstances by a decision analytic model using a clinical database as datasource. Using a decision-tree, treatment with EDA was compared with PCIA (morphine) by describing the possible clinical pathways for the successful and early-terminated treatments. The length of treatment was 3 days. A database on 644 patients collected for the purpose of quality control during 1997-99 was the main data source. By using the model costs and effects were established. The effects were expressed as number of pain-free days and the costs in Swedish krona (SEK). Number of pain-free days at rest (pain intensity<30 using visual analogue scale 1-100 mm) was the primary measure of effect. The cost- effectiveness, the average cost for reaching a particular outcome with a given treatment, is expressed as cost-effectiveness ratio (CER). When decision has to be taken to replace a treatment with a more expensive and more effective treatment, an estimate of the additional resources that have to be used to obtain the additional benefit is needed. That is the incremental cost-effectiveness ratio (ICER). The result of the main analysis is that the cost for each pain-free day is 6.489 SEK for treatment with EDA and 2.602 SEK for PCIA. The incremental cost- effectiveness ratio is 50.215 SEK. This is the additional cost for each of additional pain-free day in a situation when treatment strategy from PCIA is converted to EDA. The sensitivity analysis of our result shows that the result of the cost analysis is robust. However changes in assumptions of effect size have substantial impact on the result*. * See an English version of the report. Bartha E, Carlsson P, Kalman S. Evaluation of costs and effects of epidural analgesia and patient-controlled intravenous analgesia after major abdominal surgery. Br J Anaesth. 2005 Oct 28; [Epub ahead of print
Difficulties in Controlling Mobilization Pain Using a Standardized Patient-Controlled Analgesia Protocol in Burns
The aim of this study was to evaluate pain relief for patients with burns during rest and mobilization with morphine according to a standard protocol for patient-controlled analgesia (PCA). Eighteen patients with a mean (SD) burned TBSA% of 26 (20) were studied for 10 days. Using a numeric rating scale (NRS, 0 = no pain and 10 = unbearable pain), patients were asked to estimate their acceptable and worst experienced pain by specifying a number on a scale and at what point they would like additional analgesics. Patients were allowed free access to morphine with a PCA pump device. Bolus doses were set according to age, (100 - age)/24 = bolus dose (mg), and 6 minutes lockout time. Degrees of pain, morphine requirements, doses delivered and demanded, oral intake of food, and antiemetics given were used as endpoints. Acceptable pain (mean [SD]) was estimated to be 3.8 (1.3) on the NRS, and additional treatment was considered necessary at scores of 4.3 (1.6) or more. NRS at rest was 2.7 (2.2) and during mobilization 4.7 (2.6). Required mean morphine per day was 81 (15) mg, and the number of doses requested increased during the first 6 days after the burn. The authors found no correlation between dose of morphine required and any other variables. Background pain can be controlled adequately with a standard PCA protocol. During mobilization, the pain experienced was too intense, despite having the already high doses of morphine increased. The present protocol must be refined further to provide analgesia adequate to cover mobilization as well.Original Publication: Andreas Nilsson, Sigga Kalman, Anders Arvidsson and Folke Sjöberg, Difficulties in Controlling Mobilization Pain Using a Standardized Patient-Controlled Analgesia Protocol in Burns, 2011, JOURNAL OF BURN CARE and RESEARCH, (32), 1, 166-171. http://dx.doi.org/10.1097/BCR.0b013e31820334e5 Copyright: Lippincott Williams & Wilkins http://www.lww.com