A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in the hospital setting

Background & aims: There is limited information about the economic impact of nutritional support despite its known clinical benefits. This systematic review examined the cost and cost effectiveness of using standard (non-disease specific) oral nutritional supplements (ONS) administered in the hospital setting only. Methods: A systematic literature search of multiple databases, data synthesis and analysis were undertaken according to recommended procedures. Results: Nine publications comprising four full text papers, two abstracts and three reports, one of which contained 11 cost analyses of controlled cohort studies, were identified. Most of these were based on retrospective analyses of randomised controlled trials designed to assess clinically relevant outcomes. The sample sizes of patients with surgical, orthopaedic and medical problems and combinations of these varied from 40 to 1.16 million. Of 14 cost analyses comparing ONS with no ONS (or routine care), 12 favoured the ONS group, and among those with quantitative data (12 studies) the mean cost saving was 12.2%. In a meta-analysis of five abdominal surgical studies in the UK, the mean net cost saving was $746 per patient (se$338; P = 0.027). Cost savings were typically associated with significantly improved outcomes, demonstrated through the following meta-analyses: reduced mortality (Risk ratio 0.650, P < 0.05; N = 5 studies), reduced complications (by 35% of the total; P < 0.001, N = 7 studies) and reduced length of hospital stay (by ~2 days, P < 0.05; N = 5 surgical studies) corresponding to ~13.0% reduction in hospital stay. Two studies also found ONS to be cost effective, one by avoiding development of pressure ulcers and releasing hospital beds, and the other by gaining quality adjusted life years. Conclusion: This review suggests that standard ONS in the hospital setting produce a cost saving and are cost effective. The evidence base could be further strengthened by prospective studies in which the primary outcome measures are economic

A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in community and care home settings

Background & aims: Despite the clinical benefits of using standard (non-disease specific) oral nutritional supplements (ONS) in the community and care homes, there is uncertainty about their economic consequences. Methods: A systematic review was undertaken according to recommended procedures to assess whether ONS can produce cost savings and cost-effective outcomes. Results: 19 publications with and without a hospital component were identified: 9 full text papers, 9 abstracts, and 1 report with retrospective analyses of 6 randomised controlled trials. From these publications a total of 31 cost and 4 cost-effectiveness analyses were identified. Most were retrospective analyses based on clinical data from randomised controlled trials (RCTs). In 9 studies/economic models involving ONS use for 0.05; 5 studies). In RCTs, ONS accounted for less than 5% of the total costs and the investment in the community produced a cost saving in hospital. Meta-analysis indicated that ONS reduced hospitalisation significantly (16.5%; P < 0.001; 9 comparisons) and mortality non-significantly (Relative risk 0.86 (95% CI, 0.61, 1.22); 8 comparisons). Many clinically relevant outcomes favouring ONS were reported: improved quality of life, reduced infections, reduced minor post-operative complications, reduced falls, and functional limitations. Of the cost-effectiveness analyses involving quality adjusted life years or functional limitations, most favoured the ONS group. The care home studies (4 cost analyses; 2 cost-effectiveness analyses) had differing aims, designs and conclusions. Conclusions: Overall, the reviewed studies, mostly based on retrospective cost analyses, indicate that ONS use in the community produce an overall cost advantage or near neutral balance, often in association with clinically relevant outcomes, suggesting cost effectiveness. There is a need for prospective studies designed to examine primary economic outcomes

Public health training in Europe. Development of European masters degrees in public health.

BACKGROUND: Changing political and economic relations in Europe mean that there are new challenges for public health and public health training. There have been several attempts to develop training at the master's level in public health which is focused on meeting the new needs. These have failed due to being too inflexible to allow participation by schools of public health. METHODS: A project funded by the European Union involving public health trainers has developed a new approach which allows participating schools to retain their national differences and work within local rules and traditions, but which aims to introduce the European dimension into public health training. This paper reports the conclusions of this project. CONCLUSIONS: A network of schools wishing to develop European Master's degrees is being established and other schools offering good quality programmes will be able to join

An assessment of thinking skills instruction in Massachusetts schools.

This research study assessed a sample of school districts in Massachusetts who have curricula which encompasses a thinking skills approach to instruction. An exhaustive review of literature clearly points to agreement among researchers and educators that this method of delivering instruction produces a literate and independent population. It is also an effective method for dealing with an ever increasing pool of information, and rapidly changing world events that cause textbooks to be outdated before they are even printed. By means of a survey questionnaire and an observation instrument designed for on-site visits the quantity and quality of available programs in Massachusetts schools was evaluated. Also of interest was the method used to implement such programs; that is, were they infused into course content material or was the program separate and distinct from the already established curriculum. Given the extensive number of commercially prepared programs now available that are designed to teach thinking skills, the research depicted the number of school officials who are using the prepared programs versus those who have opted to design their own program. The most recognizable and accepted thinking behaviors were charted in the form of a frequency distribution and polygons so that appropriate skills could be replicated in school systems contemplating the implementation of a thinking skills curriculum. The study examined, therefore, the number of school districts who teach thinking skills, how they are taught, and which behaviors displayed by both teachers and students are common to this type of instruction

Interplay between shear loading and structural aging in a physical gel

We show that the aging of the mechanical relaxation of a gelatin gel exhibits the same scaling phenomenology as polymer and colloidal glasses. Besides, gelatin is known to exhibit logarithmic structural aging (stiffening). We find that stress accelerates this process. However, this effect is definitely irreducible to a mere age shift with respect to natural aging. We suggest that it is interpretable in terms of elastically-aided elementary (coil$\to$helix) local events whose dynamics gradually slows down as aging increases geometric frustration

Squashing Models for Optical Measurements in Quantum Communication

Measurements with photodetectors necessarily need to be described in the infinite dimensional Fock space of one or several modes. For some measurements a model has been postulated which describes the full mode measurement as a composition of a mapping (squashing) of the signal into a small dimensional Hilbert space followed by a specified target measurement. We present a formalism to investigate whether a given measurement pair of mode and target measurements can be connected by a squashing model. We show that the measurements used in the BB84 protocol do allow a squashing description, although the six-state protocol does not. As a result, security proofs for the BB84 protocol can be based on the assumption that the eavesdropper forwards at most one photon, while the same does not hold for the six-state protocol.Comment: 4 pages, 2 figures. Fixed a typographical error. Replaced the six-state protocol counter-example. Conclusions of the paper are unchange

Effects of curvature on hydrothermal waves instability of radial thermocapillary flows

URL: http://www-spht.cea.fr/articles/s01/006 Effets de courbure sur l'instabilité en ondes hydrothermales d'un écoulement thermocapillaire radialInternational audienceThe stability of a thermocapillary flow in an extended cylindrical geometry is analysed. This flow occurs in a thin liquid layer with a disk shape when a radial temperature gradient is applied along the horizontal free surface. Besides the aspect ratio, a second parameter related to the local curvature is introduced to describe completely the geometrical effects. We recover classical hydrothermal waves as predicted by Smith and Davis [1] but the properties of these waves are shown to evolve with the curvature parameter, thus leading to a non uniform pattern over the cell. Moreover, it is shown that the problem is not invariant with respect to the exchange of the hot and cold sides.Nous étudions la stabilité linéaire d'un écoulement thermocapillaire en géométrie cylindrique étendue. Un tel écoulement est produit dans un disque de fluide dont la surface libre horizontale est soumise à un gradient de température purement radial. Outre le rapport d'aspect, un second paramètre lié à la courbure locale est introduit pour caractériser la géométrie du problème. L'instabilité en ondes hydrothermales prédite par [1] est retrouvée mais les propriétés des ondes sont altérées par la courbure locale ce qui explique l'existence de structures non uniformes. La dissymétrie du problème vis-à-vis d'une inversion du gradient de température est aussi mise en évidence

Activated sampling in complex materials at finite temperature: the properly-obeying-probability activation-relaxation technique

While the dynamics of many complex systems is dominated by activated events, there are very few simulation methods that take advantage of this fact. Most of these procedures are restricted to relatively simple systems or, as with the activation-relaxation technique (ART), sample the conformation space efficiently at the cost of a correct thermodynamical description. We present here an extension of ART, the properly-obeying-probability ART (POP-ART), that obeys detailed balance and samples correctly the thermodynamic ensemble. Testing POP-ART on two model systems, a vacancy and an interstitial in crystalline silicon, we show that this method recovers the proper thermodynamical weights associated with the various accessible states and is significantly faster than MD in the diffusion of a vacancy below 700 K.Comment: 10 pages, 3 figure

A systematic review of the role of bisphosphonates in metastatic disease

Objectives: To identify evidence for the role of bisphosphonates in malignancy for the treatment of hypercalcaemia, prevention of skeletal morbidity and use in the adjuvant setting. To perform an economic review of current literature and model the cost effectiveness of bisphosphonates in the treatment of hypercalcaemia and prevention of skeletal morbidity Data sources: Electronic databases (1966-June 2001). Cochrane register. Pharmaceutical companies. Experts in the field. Handsearching of abstracts and leading oncology journals (1999-2001). Review methods: Two independent reviewers assessed studies for inclusion, according to predetermined criteria, and extracted relevant data. Overall event rates were pooled in a meta-analysis, odds ratios ( OR) were given with 95% confidence intervals (CI). Where data could not be combined, studies were reported individually and proportions compared using chi- squared analysis. Cost and cost-effectiveness were assessed by a decision analytic model comparing different bisphosphonate regimens for the treatment of hypercalcaemia; Markov models were employed to evaluate the use of bisphosphonates to prevent skeletal-related events (SRE) in patients with breast cancer and multiple myeloma. Results: For acute hypercalcaemia of malignancy, bisphosphonates normalised serum calcium in >70% of patients within 2-6 days. Pamidronate was more effective than control, etidronate, mithramycin and low-dose clodronate, but equal to high dose clodronate, in achieving normocalcaemia. Pamidronate prolongs ( doubles) the median time to relapse compared with clodronate or etidronate. For prevention of skeletal morbidity, bisphosphonates compared with placebo, significantly reduced the OR for fractures (OR [95% CI], vertebral, 0.69 [0.57-0.84], non-vertebral, 0.65 [0.54-0.79], combined, 0.65 [0.55-0.78]) radiotherapy 0.67 [0.57-0.79] and hypercalcaemia 0.54 [0.36-0.81] but not orthopaedic surgery 0.70 [0.46-1.05] or spinal cord compression 0.71 [0.47-1.08]. However, reduction in orthopaedic surgery was significant in studies that lasted over a year 0.59 [0.39-0.88]. Bisphosphonates significantly increased the time to first SRE but did not affect survival. Subanalyses were performed for disease groups, drugs and route of administration. Most evidence supports the use of intravenous aminobisphosphonates. For adjuvant use of bisphosphonates, Clodronate, given to patients with primary operable breast cancer and no metastatic disease, significantly reduced the number of patients developing bone metastases. This benefit was not maintained once regular administration had been discontinued. Two trials reported significant survival advantages in the treated groups. Bisphosphonates reduce the number of bone metastases in patients with both early and advanced breast cancer. Bisphosphonates are well tolerated with a low incidence of side-effects. Economic modelling showed that for acute hypercalcaemia, drugs with the longest cumulative duration of normocalcaemia were most cost-effective. Zoledronate 4 mg was the most costly, but most cost-effective treatment. For skeletal morbidity, Markov models estimated that the overall cost of bisphosphonate therapy to prevent an SRE was pound250 and pound1500 per event for patients with breast cancer and multiple myeloma, respectively. Bisphosphonate treatment is sometimes cost-saving in breast cancer patients where fractures are prevented. Conclusions: High dose aminobisphosphonates are most effective for the treatment of acute hypercalcaemia and delay time to relapse. Bisphosphonates significantly reduce SREs and delay the time to first SRE in patients with bony metastatic disease but do not affect survival. Benefit is demonstrated after administration for at least 6-12 months. The greatest body of evidence supports the use of intravenous aminobisphosphonates. Further evidence is required to support use in the adjuvant setting