Economic appraisal of laser applications in health care. Report of a project

This article reports on the results of a project evaluating effectiveness and cost-effectiveness of laser applications in health care. The literature was collected, emphasizing well-designed clinical trials and cost-effectiveness analyses. Few randomized clinical trials (RCTs) have been done outside the specialty of ophthalmology. Even fewer cost-effectiveness studies have been done, despite the frequent claims of cost-effectiveness in the medical literature. Review papers were commissioned, and a group of laser experts, economists, and policy-analysts met for 2 days to discuss the policy implications of lasers. The main conclusion from the conference is that inappropriate and unskilled use of lasers is presently the greatest problem with their application in health care.     

Diffusion of minimally invasive therapy in The Netherlands

In the context of the European project, the diffusion of 10 selected cases of minimally invasive therapy (MIT) in the Dutch health care system was documented and analyzed. In each case the diffusion pattern resulting from the balance of stimulating and impeding factors is described, and summarized in a matrix framework. Budgetary pressures, lack of evidence on effectiveness and physician conservatism are the most important factors impeding diffusion of MIT. Patient demand, media reporting and presence of medical innovators are important diffusion-stimulating factors. Finally, a judgment is made on the policy implications of these findings, based on a comparison of the extent and speed of the diffusion of each case, the quality of evidence on effectiveness and cost-effectiveness and, in a few cases, existing policies. In most cases, more active policy making, either stimulating or otherwise guiding diffusion, would be desirable.     

Evaluation of argon laser treatment of diabetic retinopathy and its diffusion in The Netherlands

Argon laser treatment of diabetic retinopathy (DR) is the best evaluated case in the field of minimally invasive therapy. A well-organized randomized controlled trial was followed by formal cost-analyses and cost-effectiveness analyses. Laser treatment of DR proved to be cost-effective in a situation where there was no satisfactory treatment previously. Subsequently, screening strategies for retinopathy were developed. Systematic screening for DR in diabetic populations would be cost-saving from a societal perspective. The availability of effective and cost-effective therapy and cost-saving screening strategies for DR warrants active policy making to stimulate the implementation of strategies to control retinopathy in diabetic populations. Such strategies would ideally include both guided diffusion of argon lasers and the organization of screening programs. Data from the Netherlands are used to illustrate the diffusion of argon lasers in health care. After a slow start, argon lasers have diffused widely in the Dutch health care system. This development is complemented by recommendations for screening of the European diabetic population, which were issued in 1991. More active cooperation of all parties involved would benefit in preventing blindness from DR.     

13C NMR isotopomer analysis reveals a connection between pyruvate cycling and glucose-stimulated insulin secretion (GSIS)

Cellular metabolism of glucose is required for stimulation of insulin secretion from pancreatic beta cells, but the precise metabolic coupling factors involved in this process are not known. In an effort to better understand mechanisms of fuel-mediated insulin secretion, we have adapted 13C NMR and isotopomer methods to measure influx of metabolic fuels into the tricarboxylic acid (TCA) cycle in insulinoma cells. Mitochondrial metabolism of [U-13C3]pyruvate, derived from [U-13C6]glucose, was compared in four clonal rat insulinoma cell 1-derived cell lines with varying degrees of glucose responsiveness. A 13C isotopomer analysis of glutamate isolated from these cells showed that the fraction of acetyl-CoA derived from [U-13C6]glucose was the same in all four cell lines (44 +/- 5%, 70 +/- 3%, and 84 +/- 4% with 3, 6, or 12 mM glucose, respectively). The 13C NMR spectra also demonstrated the existence of two compartmental pools of pyruvate, one that exchanges with TCA cycle intermediates and a second pool derived from [U-13C6]glucose that feeds acetyl-CoA into the TCA cycle. The 13C NMR spectra were consistent with a metabolic model where the two pyruvate pools do not randomly mix. Flux between the mitochondrial intermediates and the first pool of pyruvate (pyruvate cycling) varied in proportion to glucose responsiveness in the four cell lines. Furthermore, stimulation of pyruvate cycling with dimethylmalate or its inhibition with phenylacetic acid led to proportional changes in insulin secretion. These findings indicate that exchange of pyruvate with TCA cycle intermediates, rather than oxidation of pyruvate via acetyl-CoA, correlates with glucose-stimulated insulin secretion.     

Glutamate dehydrogenase, insulin secretion, and type 2 diabetes: a new means to protect the pancreatic β-cell?

In this issue of Journal of Endocrinology, Dr Han and colleagues report a protective effect of the glutamate dehydrogenase activator 2-aminobicyclo-(2,2,1)-heptane-2-carboxylic acid (BCH) under diabetes-like conditions that impair β-cell function in both a pancreatic β-cell line and db/db mice. Based on these observations, the authors suggest that BCH could serve as a novel treatment modality in type 2 diabetes. The present commentary discusses the importance of the findings. Some additional questions are raised, which may be addressed in future investigations, as there is some concern regarding the BCH treatment of β-cell failure.     

Inhibition of lipase activity and lipolysis in rat islets reduces insulin secretion

Lipids may serve as coupling factors in K(ATP)-independent glucose sensing in beta-cells. We have previously demonstrated that beta-cells harbor lipase activities, one of which is the hormone-sensitive lipase. Whether beta-cell lipases are critical for glucose-stimulated insulin secretion (GSIS) by providing lipid-derived signals from endogenous lipids is unknown. Therefore, using a lipase inhibitor (orlistat), we examined whether lipase inhibition reduces insulin secretion. Islet lipolysis stimulated by glucose and diglyceride lipase activity was abolished by orlistat. Incubation of rat islets with orlistat dose dependently inhibited GSIS; this inhibition was reversed by 1 mmol/l palmitate, suggesting that orlistat acts via impaired formation of an acylglyceride-derived coupling signal. Orlistat inhibited the potentiating effect of forskolin on GSIS, an effect proposed to be due to activation of a lipase. In perifused islets, orlistat attenuated mainly the second phase of insulin secretion. Because the rise in islet ATP/ADP levels in response to glucose and oxidation of the sugar were unaffected by orlistat whereas the second phase of insulin secretion was reduced, it seems likely that a lipid coupling factor involved in K(ATP)-independent glucose sensing has been perturbed. Thus, beta-cell lipase activity is involved in GSIS, emphasizing the important role of beta-cell lipid metabolism for insulin secretion.     

Population-based study of place of death of patients with cancer: implications for GPs

BACKGROUND: A majority of patients with cancer who are seriously ill have a preference of dying at home. However, only a minority of patients actually die at home in most Western countries.AIM: To explore factors associated with place of death in an unselected population of patients with cancer. DESIGN OF STUDY: Case-control study. SETTING: County of Funen, Denmark. METHOD: Register linkage from six Danish healthcare registers. RESULTS: The GP's home visit during the last 3 months before death was inversely associated with dying in hospital (adjusted odds ratio [OR] = 0.08, 95% confidence interval [CI] = 0.06 to 0.12) and so were community nurses visiting the home (OR = 0.36, 95% CI = 0.26 to 0.48). Furthermore, being married (OR = 0.68, 95% CI = 0.56 to 0.85), and age at death of 40-65 years (OR = 0.70, 95% CI = 0.56 to 0.90) seemed to have an effect. Hospital death was associated with survival time of less than 1 month (OR = 2.27, 95% CI = 1.69 to 3.13). Type of cancer, sex, or residence (urban versus rural) were not associated with a hospital death in this multivariate analysis. CONCLUSIONS: Dying at home was, to a higher extent, associated with GP visit and, to a lesser extent, community nurse visit than with clinical and sociodemographic characteristics of patients with cancer. In our view, these findings indicate the importance of the GP in particular. To increase the opportunity to die at home, more research is needed on the role of the GP and the interface between GPs and other providers of health care at home for patients who are terminally ill with cancer.     

Kosteneffizienzvergleich von Physiotherapie, manueller Therapie und hausärztlicher Therapie in der Behandlung von Nackenschmerzen

Objective

To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neckpain.

Design

Economic evaluation alongside a randomized controlled trial.

Setting

Primary care.

Participants

A total of183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilization), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counseling, education, and drugs).

Main outcome measures

Clinical outcomes were perceived: recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques.

Results

The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow-up at 52 weeks. The total costs of manual therapy (447 EUR) were around one third of the costs of physiotherapy (1297 EUR) and general practitioner care (1379 EUR). These differences were significant: p<0.01 for manual therapy vs. physiotherapy and manual therapy vs. general practitioner care, and p=0.55 for general practitioner care vs. physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care.

Conclusions

Manual therapy (spinal mobilization) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.