Double jeopardy and the use of QALYs in health care allocation.

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it.     

慢性危重症的特点及预测因素研究进展

随着现代循证医学的开展及医疗水平的提高,部分重症患者经治疗渡过了最初的急性疾病期存活下来,但仍存在持续的器官衰竭,需要长期依赖重症监护和脏器支持。这些患者经历持续的器官功能损害,甚至长期处于持续炎症、免疫抑制和分解代谢综合征状态,即进展到慢性危重症。慢性危重症容易出现身体、心理和认知相关的功能障碍,具有高死亡率和高致残率,这些患者的健康并没有得到保护,而是通过技术延长生存时间。往往存在住院时间较长、承受永久性残疾和严重的痛苦、生活质量降低,影响到患者整个家庭。目前慢性危重症的定义尚未统一,但标准都是以一定时间的住院时长加上严重的器官功能损害为基础。多国的流行病学调查均显示慢性危重症发病率逐年增加,且随着人口老龄化,已成为一个日益严重的全球性问题。目前开展了许多研究,在持续炎症、免疫抑制和分解代谢基础上探讨慢性危重症的发病机制及危险因素,预测慢性危重症的发展,以减轻慢性危重症对患者及家庭的影响。现将慢性危重症定义、流行病学、发病机制及预测因素的研究进展进行综述,以便临床医师更好地认识及预防慢性危重症,为慢性危重症的诊治提供参考,丰富慢性危重症患者的诊疗策略以进一步提高慢性危重症患者的生存质量。      

Brain abscess caused by Streptococcus pneumoniae with acute onset and rapid progressive symptoms

Although the decline of the morbidity and mortality in recent years, brain abscess is still an important problem in neurocritical care medicine and remains a serious illness that can result in severe disability or even death, especially if misdiagnosed or managed improperly. We report a very rare case of a patient who developed a bacterial brain abscess in the posterior fossa with an atypical rapid progression of neurological symptoms. Furthermore, MRI demonstrated additional brain stem and left hemispheric lesions. Early onset broad antibiotic therapy, corticosteroid application and extensive intermediate care management was leading to a complete regression of the initially dramatic symptoms.     

The management of bipolar disorder in general practice

General practitioners have a key role in managing patients with bipolar disorder, a condition which affects at least one in 200 Australians each year and is the sixth leading cause of disability in the population. Although diagnosis and treatment of the illness is complex, effective treatment can lead to good outcomes for many patients. GPs can contribute significantly to early recognition of bipolar disorder, avoiding the long delays in accurate diagnosis that have been reported. As in other complex recurrent or persistent illnesses, GPs are well placed to coordinate multidisciplinary "shared care" with specialists and other health care professionals. GPs also provide continuing general medical care for patients with bipolar disorder, and are in a unique position to understand patients' life circumstances and to monitor their progress over time. The last decade has seen many advances in medication for bipolar disorder, including the introduction of new therapies and the refinement of treatment protocols using older medications. There has also been increasing recognition of the contribution of psychological therapies to symptom relief, relapse prevention, optimal function, and quality of life.     

军队休养员心理健康状况与休养需求调查分析

目的调查了解休养员的需求及心理健康状况。方法采用休养需求调查表和症状自评量表（Symptom Checklist 90,SCL-90）进行问卷调查。结果军队休养员躯体化、强迫症状、抑郁、恐怖因子均分明显高于全国常模（P〈0.01）;军队休养员躯体化、抑郁、因子均分明显高于地方组（P〈0.01）;女性休养员在躯体化、强迫、抑郁、焦虑、恐怖因子均分明显高于男性（P〈0.01）;人际关系敏感、抑郁、焦虑、敌对因子分与休养预期符合程度成负相关（P〈0.05）;人际关系敏感、敌对因子分与休养满意程度成负相关（P〈0.05）。结论休养员心理健康状况需要引起关注,可以通过营造良好休养环境,增强保健知识教育,丰富休养生活安排等,以满足不同休养需要,提升休养效果,促进身心健康。     

Depressive disorders in old age

People are living longer life since with the improvement in health and medical services provided. Developing countries are not lagging behind the developed world as far as the life expectancy is concerned. The principal mental disorders of elderly people are mood disorders and dementia. In older people living in a community the rates of depressive disorders are likely to be the same as for all age groups of the general population, yet its prevalence in old age institution is high. Aetiology of depression in old age is caused by a variety of conditions namely genetic factors, physiological changes in all the systems, disability, loss of resources, some medical illness, etc. Clinical features include depressed mood most of the day, significant weight loss, persistent sleeplessness, fatigue, feelings of worthlessness, recurrent thoughts of death and suicidal attempt, etc. Tricyclic antidepressants are effective in elderly depressives. Selective serotonin re-uptake inhibitors are well tolerated by elderly patients and are effective too. Electroconvulsive therapy is an alternative treatment of acute depression. Psychotherapy is often helpful and long-term care should be planned for to reduce disability.     

Persistent Pain and Well-being: A World Health Organization Study in Primary Care

Context.— There is little information on the extent of persistent pain across cultures. Even though pain is a common reason for seeking health care, information on the frequency and impacts of persistent pain among primary care patients is inadequate. Objective.— To assess the prevalence and impact of persistent pain among primary care patients. Design and Setting.— Survey data were collected from representative samples of primary care patients as part of the World Health Organization Collaborative Study of Psychological Problems in General Health Care, conducted in 15 centers in Asia, Africa, Europe, and the Americas. Participants.— Consecutive primary care attendees between the age of majority (typically 18 years) and 65 years were screened (n=25916) and stratified random samples interviewed (n=5438). Main Outcome Measures.— Persistent pain, defined as pain present most of the time for a period of 6 months or more during the prior year, and psychological illness were assessed by the Composite International Diagnostic Interview. Disability was assessed by the Groningen Social Disability Schedule and by activity-limitation days in the prior month. Results.— Across all 15 centers, 22% of primary care patients reported persistent pain, but there was wide variation in prevalence rates across centers (range, 5.5%-33.0%). Relative to patients without persistent pain, pain sufferers were more likely to have an anxiety or depressive disorder (adjusted odds ratio [OR], 4.14; 95% confidence interval [CI], 3.52-4.86), to experience significant activity limitations (adjusted OR, 1.63; 95% CI, 1.41-1.89), and to have unfavorable health perceptions (adjusted OR, 1.26; 95% CI, 1.07-1.49). The relationship between psychological disorder and persistent pain was observed in every center, while the relationship between disability and persistent pain was inconsistent across centers. Conclusions.— Persistent pain was a commonly reported health problem among primary care patients and was consistently associated with psychological illness across centers. Large variation in frequency and the inconsistent relationship between persistent pain and disability across centers suggests caution in drawing conclusions about the role of culture in shaping responses to persistent pain when comparisons are based on patient samples drawn from a limited number of health care settings in each culture.      

Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure"

In older patients, acute medical illness that requires hospitalization is a sentinel event that often precipitates disability. This results in the subsequent inability to live independently and complete basic activities of daily living (ADLs). This hospitalization-associated disability occurs in approximately one-third of patients older than 70 years of age and may be triggered even when the illness that necessitated the hospitalization is successfully treated. In this article, we describe risk factors and risk stratification tools that identify older adults at highest risk of hospitalization-associated disability. We describe hospital processes that may promote hospitalization-associated disability and models of care that have been developed to prevent it. Since recognition of functional status problems is an essential prerequisite to preventing and managing disability, we also describe a pragmatic approach toward functional status assessment in the hospital focused on evaluation of ADLs, mobility, and cognition. Based on studies of acute geriatric units, we describe interventions hospitals and clinicians can consider to prevent hospitalization-associated disability in patients. Finally, we describe approaches clinicians can implement to improve the quality of life of older adults who develop hospitalization-associated disability and that of their caregivers.     

护理关怀在ICU患者家属关爱中的应用价值

目的 探讨护理关怀在ICU患者家属关爱中的应用效果.方法 选取100例ICU患者家属为研究对象,随机分为观察组和对照组,对照组仅对患者进行常规护理,观察组在对照组的基础上对家属实施护理关怀,比较两组的护理效果.结果 观察组在躯体化、抑郁、焦虑、人际关系敏感、精神病性评分等方面均显著低于对照组（P＜0.05）.观察组护理后的家庭负担评分显著低于对照组,社会支持总分显著高于对照组（均P＜0.05）.结论 护理关怀照顾到了ICU患者家属的身心需要,可有效缓解家属的不良情绪和行为,提高心理健康水平.     

Foregone health care among adolescents

CONTEXT: No annual national population estimates exist of the numbers of adolescents who think they need but do not receive health care or their risk of health problems. OBJECTIVE: To describe the proportion of adolescents who report foregone health care each year and the influence of sociodemographic factors, insurance status, past health care, and health risks/behaviors on foregone care. DESIGN: Cross-sectional analyses of data from wave 1 of the National Longitudinal Study of Adolescent Health, conducted during 1995. SETTING: In-home interviews conducted throughout the United States. PARTICIPANTS: Of 27000 adolescents in grades 7 through 12 who were invited to participate, 20746 (76.8%) completed the in-home interview. MAIN OUTCOME MEASURE: Reported foregone health care in the preceding year by individual and family characteristics, insurance status, past health care, health/behavior risk factors, and symptoms. RESULTS: On average, 2268 (18.7%) of 12 079 adolescents reported foregone health care within the past year. Factors associated with decreased risk of foregone care included continuous private or public insurance (adjusted relative risk [95% confidence interval], 0.64 [0.50-0.82] to 0.82 [0.70-0.96]), and having a physical examination within the past year (0.87 [0.78-0.97] for male and 0.79 [0.70-0.88] for female adolescents). Factors associated with increased risk of foregone care included older age (1.12 [1.06-1.15] for male), minority race/ethnicity (1.25 [1.06-1.46] to 1.50 [1.30-1.73]), single-parent home (1.31 [1.18-1.46] for female), and disability (2.03 [1.61-2.52] for male and 1.66 [1.20-2.10] for female). Adolescents participating in the following behaviors were more likely to report foregone care than those who did not: daily cigarette use (26.0% vs 16.8%; 1.34 [1.16-1.55]), frequent alcohol use (30.3% vs 18.1%; 1.34 [1.11-1.62] for male), and sexual intercourse (25.1% vs 15.1%; 1.23 [1.09-1.39] for male and 1.39 [1.23-1.56] for female). From 32.4% to 38.2% of adolescents with symptoms suggesting health problems reported foregone care (1.61 [1.13-2.26] to 2.03 [1.81-2.28]). CONCLUSIONS: Our study suggests that adolescents who forego care are at increased risk of physical and mental health problems. Efforts to improve adolescent health through health care should address factors influencing foregone care.     

The need for a holistic approach to patient care

A review of the literature shows that psychological disorders frequently complicate physical illness. Similarly, biological factors have been shown to be important in psychiatric patients. The social environment of patients similarly contributes to their susceptibility to physical and mental disorders. The need to encourage a biopsychosocial model of health care is emphasized. It is suggested that there is an urgent need to evolve better collaboration between psychiatric and non-psychiatric physicians in clinical services, research and training at the primary, secondary and tertiary levels of health care.     

"Compensation neurosis". An invalid diagnosis

The concept of "compensation neurosis"--sometimes denoted by one of its numerous synonyms--has been invoked for many years in discussing the emotional sequelae of accidental injury when litigants present with symptoms and disability that are disproportionate to the original injury or to any demonstrable continuing physical abnormality. Although such "diagnoses" carry with them certain assumptions about the aetiology and the prognosis of the patient's symptoms, the clinical validity of these terms has not come under scrutiny in the literature dealing with issues of diagnosis and classification. An examination of "compensation neurosis" as an illness entity, using standard criteria of diagnostic validity, does not support the view that such a distinct disease exists. It is concluded that the possibility of financial gain after a compensable injury should be regarded as one of several potential secondary gains from an hysterical conversion reaction, and that multiple factors need to be considered in the medical assessment and treatment of litigants who complain of continuing symptoms after recovery from physical injury.     

关注老年心血管疾病患者的心理健康

心血管疾病是老年人常见病,是影响老年人心理健康的主要因素。而心理问题诱发或加重躯体疾病,并影响治疗效果,心理健康与治疗躯体疾病同等重要,临床医务人员不仅要重视药物等临床治疗,还要对患者的心理状况采用个体化心理干预,提高心理健康水平,减轻或消除患者的病理心理状态,以及由此引起的各种躯体症状,从而达到治疗目的;还可提早康复,预防复发,以减少医药费用。     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient's acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

社区精神分裂症病人康复治疗研究

目的探讨社区精神分裂症病人康复治疗的方法。方法对本地区66例患者为研究对象,实施积极的社区康复方法。结果精神残疾严重程度有随治疗持续状况的好转而减轻的趋势。患者的服药落实率和病情显好率明显上升。结论社区康复治疗有利于帮助精神病患者达到心理和社会康复,而且对控制症状也有独到的优点。     

杰氏棒杆菌致导尿管相关尿路感染一例报道并文献复习

导尿管相关尿路感染是医院感染的常见类型,尤其是长期置管和免疫力低下的患者。主要特点为尿量增多、尿管内可见持续血尿并有絮状沉渣,伴有或不伴有全身感染症状。本文分析1例留置导尿管引起逆行性感染患者的临床症状、病原学检测、治疗措施,并进行相关文献复习。     

Does capitation affect the health of the chronically mentally ill? Results from a randomized trial.

OBJECTIVE--To determine the effect on health outcomes of enrollment of chronically mentally ill Medicaid recipients in prepaid plans vs traditional fee-for-service Medicaid. DESIGN--A randomized controlled trial. Clients who were randomly assigned to prepaid care were then permitted to choose among four capitated health plans. Clients returned to fee-for-service care at the end of the demonstration. SETTING--The Medicaid Demonstration Project in Hennepin County, Minnesota, the urban center of which is Minneapolis. PATIENTS--Seven hundred thirty-nine Medicaid clients who were classified as having chronic mental illness on the basis of Medicaid claims. Clients were interviewed at baseline (time 1) and at two follow-up points. Data were available for 96% of participants at the end of the intervention (time 2). Average duration of follow-up was 11 months. A subset of 370 clients with schizophrenia was followed up 11 months after the return of the prepaid group to fee-for-service care (time 3). MAIN OUTCOME MEASURES--General health status, physical functioning, social functioning, and psychiatric symptoms, assessed using the Schedule of Affective Disorders and Schizophrenia-Change version, the Global Assessment Scale, and indicators of community function. RESULTS--No significant differences between prepaid and fee-for-service groups in general health or psychiatric symptoms from baseline to time 2. After regression adjustment, 12% fewer clients in the prepaid group reported being victimized (P less than .01). At the end of time 3, the regression-adjusted Global Assessment Scale scores had worsened by 7.6 points more in the prepaid group in comparison with the fee-for-service group (P less than .02). CONCLUSION--There was no consistent evidence of harmful effects of enrolling chronically mentally ill Medicaid clients in prepaid care, at least in the short run. The generalizability of these findings may be limited to plans that control utilization by methods similar to those used in this study setting. Longer-term outcome studies should be undertaken to clarify the strength of the findings.     

Perspectives on care at the close of life. Serving patients who may die soon and their families: the role of hospice and other services

The case story of a 47-year-old man with advanced rectal carcinoma illustrates the professional services and care system strategies available to help clinicians serve patients coming to the end of life. For this patient, who understands his prognosis, primary care physician services include (1) prevention and relief of symptoms, (2) assessment of each treatment before and during implementation, (3) ensuring that the patient designates a surrogate decision-maker and makes advance plans, and (4) preparation of patient and family for the time near death. Good care may entail enduring unavoidably difficult times with patients and their families. Enrollment in a hospice program requires that decision-makers confront the prognosis and their uncertainties about it, consider the desirability of other services, recognize variations among available hospice programs, address financial issues, and weigh the distress of patients and loved ones at being labeled as "dying." Hospice provides competent, continuous, and reasonably comprehensive care, but it has some constraints. Function and symptoms for those living with serious chronic illness at the end of life generally follow 1 of 3 trajectories: (a) a short period of obvious decline at the end, which is typical of cancer; (b) long-term disability, with periodic exacerbations, and unpredictable timing of death, which characterizes dying with chronic organ system failures; or (c) self-care deficits and a slowly dwindling course to death, which usually results from frailty or dementia. Effective and reliable care for persons coming to the end of life will require changes in the organization and financing of care to match these trajectories, as well as compassionate and skillful clinicians.     

全科医生-心理治疗师联合团队模式探讨：以躯体不适为主诉的心理障碍案例报道

以躯体不适为主诉的心理障碍患者常就诊于综合医院消化、妇科、神经内科等非精神心理专科，正确识别率低，以致病情延误，医疗负担加重。本文报道了１例以头晕、胸闷、气短为主诉的心理障碍患者全科医生与心理治疗师共同照顾过程，探讨了全科医生-心理治疗师联合团队模式在照顾以躯体不适为主诉的心理障碍患者上的优势：尽早正确识别、提高心理治疗实际利用率、更好协助促进干预效果。该模式是综合医院心理卫生服务模式的一次创新探索，为日后构建切实可行的综合医院新型心理卫生服务模式提供启发与思路。