盐酸瑞芬太尼用于腹式子宫切除术后病人自控镇痛的研究

目的评价盐酸瑞芬太尼用于妇科病人术后自控镇痛(PCA)的效应和安全性。方法60例妇科开腹子宫切除病人,术后随机分为盐酸瑞芬太尼组(R组,n=30)和吗啡组(M组,n=30)接受PCA治疗。R组使用盐酸瑞芬太尼(20ug/次,1mg/24h),M组使用吗啡(1mg/次,30mg/24h)。结果盐酸瑞芬太尼与吗啡组24h总疼痛程度差值(SPID)分别为300(92)和213(87)(P<005)。R组恶心(2667%和3667%,P<005)及呕吐(1667%和2333%,P<005)等的发生率均低于M组。结论盐酸瑞芬太尼用于妇科手术后PCA的镇痛效应强于吗啡,副作用弱于吗啡。     

酒石酸布托啡诺应用于子宫切除术后静脉镇痛的临床效果观察

目的比较酒石酸布托啡诺与芬太尼用于子宫切除术后患者自控静脉镇痛（PCIA）的临床效果。方法选择60例择期行子宫切除术患者随机分为两组,临床观察组（酒石酸布托啡诺组30例）：酒石酸布托啡诺8嘴＋氟哌利多5mg＋0．9％生理盐水加至100ml;对照组（芬太尼组30例）：芬太尼1．0rag＋氟哌利多5mg＋0．9％生理盐水加至100ml,选择负荷剂量加维持剂量即微泵连续给药方式行静脉镇痛（持续注药速度为2．0ml／h,单次PCA剂量为1ml,锁定时间30min）。结果酒石酸布托啡诺组与芬太尼组相比,镇痛评分（VAS）、镇静评分、恶心呕吐、尿潴留发生均无显著差异性（P〉0．05）,两组患者均无呼吸抑制发生。结论酒石酸布托啡诺用于术后静脉镇痛,效果确切。不良反应少。     

An economic evaluation of the market for physicians' services: shortage versus surplus

The paper examines the existence of a shortage or surplus in the market for physicians' services over time. The assessment is carried out within a framework provided by economic theory, and three basic indicators are utilized: earnings, rates of return to education, and quantity of work. The third indicator is examined in various forms including vacancies, weeks of work, and hours of work. The outcomes of this assessment do not support the existence of a surplus of physicians; rather, they are consistent with a shortage which appears to be growing.     

An economic evaluation of occupational health

There is an increasing need to evaluate the costs and benefits of an occupational health service (OHS). However, measuring benefits from an OHS is inherently difficult. Instead, an economic model can be constructed to present the minimum threshold benefits required for OHSs to be cost-effective, given what is known about costs. This model assumes that the benefits of an OHS are to maximize health and morale of employees; maximize performance and increase productivity; minimize medico-legal costs; enhance workplace safety; and reduce sickness absence. A certain distribution across these benefits can be assumed for each OHS. The overall required value of all benefits brought about by use of an OHS is in the range 158-199 Pounds per year. The plausibility of results can be assessed using known data and judgement. Despite many uncertainties it is likely that the minimum benefit thresholds will be achieved overall.     

Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management

Clinicians have long been aware of the danger of overreliance on opioids to manage acute pain, such as the pain accompanying surgery. The risk of adverse drug events is higher with opioids than with any other common class of drugs. Overreliance on opioids increases length of stay and hospital costs, while decreasing patient satisfaction. Opioids can lead to problems that continue well after discharge, including chronic pain, abuse and addiction, and even death. Increasingly, prescribed opioids have proved to lead to heroin addiction. Studies show that the same professionals who prescribe, administer, and monitor opioids lack basic knowledge about their safe and effective use. The alternative to opioid monotherapy in controlling acute pain is multimodal analgesia, an approach that relies on a nonopioid foundation with addition of adjunctive opioids as needed. An increasing number of nonopioid analgesics have proved effective in this role, with fewer side effects and a higher degree of safety than opioids. Accordingly, multimodal analgesia is recommended as best practice by most recognized authorities. Increasingly, governmental authorities hold prescribing clinicians and institutions legally liable for the downstream negative effects of opioids, including abuse and addiction. Addressing this issue should be a top priority for hospital risk managers.     

An economic evaluation of universal pertussis vaccination in Italy.

An economic evaluation was performed of universal acellular pertussis vaccination in Italy, where until recently the overall coverage of pertussis vaccination was estimated at 50%. Over the last two years coverage seems to have increased rapidly. By means of a mathematical simulation model, the consequences of pertussis vaccination in terms of both health effects and economic costs were calculated for a single birth cohort followed for 6 years. Incremental analyses were performed for each additional 10% increase in coverage from 50-90%. The results indicate that a 50% coverage rate of pertussis vaccination in Italy was not optimal on the basis of cost-effectiveness and cost-benefit considerations. Additional increases in coverage were found to yield extra health gains at modest net costs or even potential net savings to the health care sector. For example, an increase in coverage to 90% would yield direct net savings of US$42 per extra vaccinee in comparison to a situation of 50% coverage. The total net savings for this strategy would be well over US$100 per additional vaccinee. In the sensitivity analysis, the positive relationship between incremental coverage and incremental efficiency remained unchanged.     

Quality of life associated with daily opioid therapy in a primary care chronic pain sample.

BACKGROUND: Daily opioid therapy is widely used in the treatment of chronic noncancer pain, yet there is limited empirical evidence on the relationship of opioid dosing and health-related quality of life (HRQoL) in primary care settings. METHODS: An analysis was conducted to assess the relationship of opioid dose to quality of life. The sample consisted of 801 chronic pain patients who were prescribed daily opioids and 93 nonopioid users recruited from the practices of 235 primary care physicians. Eight HRQoL domain scores were calculated and compared with US norms and across opioid use groups. A new modeling technique, propensity score matching analysis, was performed to adjust for potential confounding factors across 4 morphine-equivalent opioid dose groups (<20 mg, 20-40 mg, 41-105 mg, >105 mg). RESULTS: HRQoL scores were significantly lower in chronic noncancer pain patients relative to the US general population regardless of opioid use. In unadjusted comparisons, those using up to 20 mg/d of opioids had the highest HRQoL scores, whereas those using >105 mg/d had the lowest. After adjusting for potential confounders, those in the 20 mg to 40 mg/d dosing group had significantly better HRQoL scores than their nonopioid-treated or higher dosed counterparts. CONCLUSION: Use of low- to moderate-dose opioid therapy provides an improvement in HRQoL scores for chronic noncancer pain patients compared to no opioid therapy, while high-dose opioids have a smaller positive effect that is limited to mental health quality of life and patient satisfaction, and that may not justify treatment.     

Costs of opioid therapy for chronic nonmalignant pain in Germany: an economic model comparing transdermal fentanyl (Durogesic) with controlled-release morphine

The fentanyl transdermal therapeutic system ( fentanyl-TTS; Durogesic) has a distinct route of administration and safety profile compared with other opioids used in the treatment of moderate to severe pain. These aspects are likely to have an impact on patient acceptance and functioning as well as efficacy. We compared the cost-utility of fentanyl-TTS and controlled-release morphine (cr-morphine) in the treatment of moderate to severe nonmalignant pain in outpatients in Germany. A 1-year, three-phased decision-analytic model was constructed, incorporating estimates of a variety of aspects of pain control. Use of fentanyl-TTS was predicted to incur higher costs than cr-morphine over 1 year of treatment (DM 6950 vs. DM 6186, respectively) but was associated with a higher number of quality-adjusted life days (234 vs. 216, respectively), thus achieving an incremental cost-utility ratio of DM 15,960 per quality-adjusted life-year gained. The results of the decision-analytic model support the use of fentanyl-TTS as a favorable cost-effective option for the treatment of moderate to severe nonmalignant pain.     

An economic evaluation of health-promotive built environment changes

ObjectivesThis study aimed to help public investment decision makers see the greatest return on their built environment investments by developing an analysis framework for identifying the most promising improvement strategies and assessing the attainable return on investment.MethodsThe 2001 National Household Travel Survey sample (N = 4974) from Dane County, Wisconsin, was used to develop a Spatial Seemingly Unrelated Regression model of daily vehicle miles traveled and miles walked or biked. The empirical model was used to analyze the travel impacts of hypothetical built environment changes. These travel impacts were translated into health impacts and monetary values using cost-benefit analysis.ResultsTwo win-win built environment strategies were found: increased regional retail accessibility and increased prevalence of sidewalks. Based on the present analyses, an investment of $450 million to make sidewalks available to all Dane County residents was estimated to yield a cost-benefit ratio of 1.87 over a 10-year life cycle.ConclusionCertain built environment measures could be predicted to be effective strategies for exerting a positive influence on people’s travel behavior and the health of the community. Quantifiable public health benefits gained by better air quality and increased physical activity were shown to outweigh the cost of implementing the built environment measure of adding sidewalks to all roads.     

不同剂量舒芬太尼复合氟比洛芬酯在子宫切除术后患者自控静脉镇痛中的应用效果

目的探讨子宫切除术后患者自控静脉镇痛中不同剂量舒芬太尼复合氟比洛芬酯的应用效果。方法回顾性分析德州市妇女儿童医院2014年10月-2016年10月收治的88例子宫切除术患者的临床资料,所有患者均实施术后患者自控静脉镇痛,并给予不同的药物剂量,其中对照组45例给予50μg舒芬太尼+150 mg氟比观察组43例给予150μg舒芬太尼+150 mg氟比洛芬酯。术后术后2 h、术后4 h、术后6 h、术后8 h分别对两组进行疼痛评分判定,比较两组的不良反应发生情况。结果两组患者子宫切除手术相关指标比较,差异无统计学意义(均P0.05);观察组术后不同时间点疼痛评分显著低于对照组(均P0.05);两组患者均出现恶心、呕吐等不良反应,但观察组的不良反应发生率明显低于对照组(P0.05)。结论子宫切除术后患者自控静脉镇痛中应用不同剂量舒芬太尼复合氟比洛芬酯的镇痛效果不同,给予150μg舒芬太尼+150 mg氟比洛芬酯镇痛效果更好,不良反应更轻微。     

预先镇痛对全子宫切除术后全麻恢复期病人意识恢复的影响

目的:观察预先镇痛是否影响术后病人意识恢复。方法:选择40例ASAI～Ⅲ级行全子宫切除术的病人,随机分为对照组(n=20)和预先镇痛组(n=20),所有病人均在静-吸复合麻醉下完成手术。预先镇痛组在手术开始前使用曲马多1.5mg/kg。两组术后入苏醒室,记录OAA/S镇静评分、VAS镇痛评分、BIS和术后寒颤和躁动的发生率。结果:①VAS,预先镇痛组优于对照组(P<0.05);②OAA/S评分和BIS,在5min和10min两个时间点,预先镇痛组低于对照组(P<0.05);③术后寒颤和躁动的发生率,预先镇痛组明显低于对照组。结论:预先镇痛能够使患者的意识恢复程度有一定程度的延长,但不会造成苏醒延迟。     

连续静脉镇痛泵用于开胸手术后止痛治疗的评估

目的 观察连续静脉镇痛泵止痛治疗和间断镇痛剂药物治疗开胸术后胸痛的疗效和副作用.方法 210例常规后外侧切口开胸手术的患者,随机分成I组和D组,分别采用连续镇痛泵治疗和间断镇痛剂药物治疗,比较患者术后的疼痛程度,分别记录2 h、4 h、12 h、24 h、48 h时的VAS评分,镇静程度评分以及恶心、呕吐、头晕、呼吸抑制的发生情况以及术后肺部感染、肺不张和心律失常等的发生率.结果 两组中I组止痛镇静效果较好,围手术期并发症的发生率较低,而副反应的发生率两组则无显著性差异.结论 持续静脉镇痛泵治疗开胸手术后疼痛优于间断镇痛剂药物治疗.     

罗哌卡因浸透的明胶海绵切口皮下植入对子宫切除术后疼痛的影响

目的 探讨罗哌卡因浸透的明胶海绵切口皮下植入对子宫切除术后的镇痛效果.方法 选取2016年1月至2016年10月在海南省妇幼保健院接受择期子宫切除术的240例患者,采用随机数字表法分为A、B、C三组各80例,A组采用罗哌卡因浸透的明胶海绵切口皮下植入进行术后镇痛,B组术后直接静脉滴注0.5%罗哌卡因镇痛,C组置入明胶海绵后注射0.9%生理盐水,监测并对比三组术后疼痛、血流动力学等指标.结果 A、B两组患者术后1、4、8、12、24、48h的疼痛程度评分均低于同一时间点C组患者(F=51.204,P<0.05),A、B两组患者术后各时间点疼痛程度评分差异均无统计学意义(F=1.276,均P>0.05);A、B、C三组患者T0、T1、T2、T3、T4时刻的血氧饱和度(SpO2)水平差异无统计学意义(F=2.057,均P>0.05);A、C组患者T1、T2、T3、T4时刻的平均动脉压(MAP)、心率(HR)监测值与本组T0时刻比较差异均无统计学意义(F值分别为2.684、1.419,均P>0.05),B组患者患者T1、T2时刻的MAP、HR监测值与本组T0时刻比较降低(t值分别为13.085、10.684,均P<0.05);A、C组患者的恶心呕吐、头痛发生率均低于B组(χ2值分别为18.279、10.833,均P<0.05);A组的恶心呕吐发生率高于C组(χ2=4.498,均P<0.05).结论 罗哌卡因浸透的明胶海绵切口皮下植入对子宫切除术后的镇痛效果显著,血流动力学影响小,具有较高的临床推广价值.     

Optimisation versus certainty: understanding the issue of heterogeneity in economic evaluation

This paper considers how the information provided by economic evaluation for decision-makers can fail to optimise use of health resources and how assessment of the relative cost-effectiveness of health care interventions can be misleading unless heterogeneity within populations is taken into account. The cost-effectiveness of an intervention is not a point estimate but an average chosen from within a distribution of different results. The normal interpretation of the distribution around that point is often mistakenly assumed to be the 'white noise' of measurement error. In reality this variance is a combination of measurement error and true heterogeneity of results. There remains an overemphasis on pursuing certainty which stems from the fact that the methods involved were originally devised to measure dichotomous outcomes not continuous ones such as cost-effectiveness ratios. It is argued in this paper that more consideration be given to the heterogeneous nature of costs and effects across populations in analysis and policy making.     

An economic evaluation comparing two schedules of antenatal visits

OBJECTIVES: To conduct an economic evaluation comparing a traditional antenatal visiting schedule (traditional care) with a reduced schedule of visits (new style care) for women at low risk of complications. METHODS: Economic evaluation using the results of a randomised controlled trial, the Antenatal Care Project. This took place between 1993 and 1994 in antenatal clinics in South East London and involved 2794 women at low risk of complications. RESULTS: The estimated baseline costs to the UK National Health Service (NHS) for the traditional schedule were 544 Pounds per woman, of which 251 Pounds occurred antenatally, with a range of 327-1203 Pounds per woman. The estimated baseline costs to the NHS for the reduced visit schedule was 563 Pounds per woman, of which 225 Pounds occurred antenatally, with a range of 274-1741 Pounds per woman. Savings from new style care that arose antenatally were offset by the greater numbers of babies in this group who required special or intensive care. Sensitivity analyses based on possible variations in unit costs and resource use and modelled postnatal stay showed considerable variation and substantial overlap in costs. CONCLUSIONS: Patterns of antenatal care involving fewer routine visits for women at low risk of complications are unlikely to result in savings to the Health Service. In addition, women who had the reduced schedule of care reported greater dissatisfaction with their care and poorer psychosocial outcomes which argues against reducing numbers of antenatal visits.     

An economic evaluation of "Health for All".

The World Health Organization's 'Global Strategy' is an ambitious vision, but to achieve its goals it must first be implemented. Implementation will require careful and detailed planning. This paper evaluates the possibilities of transforming the Global Strategy from a laudable policy initiative into an actual 'Plan for Health', from the point of view of a health economist. This economic evaluation assesses the probable costs of implementing various activities of the Strategy, and the likelihood that developing countries will be able to afford these costs, either on their own, or with the assistance of the developed countries. A final section considers the current global situation and presents trends over the last two decades. The numbers of countries that have already achieved the goals of the Strategy, that can be expected to achieve the goals of the Strategy by the year 2000, and that are unlikely to achieve these goals (on the basis of current trends) are shown. The WHO 'success indicator' based on numbers of countries is compared to a more epidemiological one based on deciles of the world's population. It is argued that, even several years after the initiation of the Global Strategy, insufficient information exists on the next logical step of transforming the Policy into a Plan. Unless adequate attention is paid to this vital step, implementation of the Strategy will inevitably be ad hoc and patchy. Further research on the costs of the activities proposed by the Global Strategy, and the probable effects on health of those activities, is desperately needed.