Is clinical pathology accreditation worth it? A survey of CPA-accredited laboratories

Following two pilot studies, Clinical Pathology Accreditation (CPA) accreditation was introduced to UK pathology laboratories in 1992. Since then, significant numbers of laboratories have undergone accreditation but many have never applied. We carried out a postal survey of 145 accredited laboratories in the UK to independently determine the opinions of laboratory managers/clinicians about CPA and whether accreditation had produced any significant benefits to pathology services. Ninety-three replies were received (64 per cent) a good response to an unsolicited questionnaire. Most laboratories felt accreditation by CPA had resulted in better laboratory performance with more documentation and better health and safety and training procedures. CPA accreditation was believed to provide useful information by approximately 50 per cent of laboratories but was also felt by a significant proportion of laboratories to be over-bureaucratic, inefficient and expensive (46 of 93 respondents). Many complaints were voiced about the excessive paperwork that CPA generated and there was also a significant body of opinion that felt that CPA assessed areas were the domain of other regulatory bodies such as the CPSM, IBMS and HSE.     

Is it worth the risk? A systematic review of instruments that measure risk propensity for use in the health setting

In this era of shared doctor-patient decision-making, eliciting and incorporating patients' treatment choices is essential to ensure all patients receive the treatment that is right for them. Clinicians and researchers should fully understand the many factors that influence and guide patients in their preferences for treatment. One of these influences is an individual's general risk propensity or willingness to take risks, yet there is little in the literature about methods for measuring risk propensity. A systematic review was undertaken to identify instruments that measure risk propensity and to appraise their validity and relevance for a clinical setting. Of 3546 articles, 139 were potentially relevant. From these, 14 instruments were identified. Eight measured risk propensity, whereas six measured personality traits associated with risk propensity. Most instruments demonstrated good internal reliability but their appropriateness for patients, particularly older adults, remains unclear. While no instrument was specific to or tested in a clinical setting, instruments that directly measured risk propensity were considered to be the most useful for clinical populations. The further adaptation and validation of these instruments among older adults are important avenues for future research.     

Clarifying the scope of Italian NHS coverage. Is it feasible? Is it desirable?

The reduction in National Health Service (NHS) expenditure as a share of total health care expenditure, the fragmentation of the NHS into 21 regional systems and the implementation of a 'quasi-market' on the provider side of the system has pressed the government to define and specify, in detail, the set of services that are to be guaranteed by the public sector. To understand whether rationing can be more rational and explicit in the Italian NHS, the following are analysed: (i) the new positive list of drugs, as a major example of limiting and making more rational NHS pharmaceutical coverage; (ii) the Di Bella case, as an example of the difficulties of rational policy-making on sensitive issues; (iii) what Italian people think about health care rationing and priority setting (using the 1998 Eurobarometer Survey);( iv) the criteria defining the set of 'essential services' to be guaranteed to all Italian citizens, which are contained in the recently released National Health Plan. The 'revolution' that has taken place in the pharmaceutical sector shows it is feasible to limit, in an explicit and rational way, the extent of NHS coverage. However, the re-classification of the positive list should be regarded as an exceptional event in the history of Italian social policy. The 'Di Bella' case, on the contrary, shows that limiting NHS coverage can be very unpopular, and that the Italian cultural and social context can be unfavourable for the implementation of hard choices. Public attitude toward rationing seems to confirm that Italians are not familiar with rationing issues. Thus, it is very difficult to predict whether the national government will really go ahead with the implementation of a 'list of essential services' and whether this attempt will be successful. Rationing and priority setting should be discussed in the context of a general debate concerning the future of the Italian NHS.     

Can statin therapy reduce the risk of melanoma? A meta-analysis of randomized controlled trials

A growing body of literature suggests that statins may have a chemopreventive potential against melanoma through pleiotropic anti-inflammatory, immunomodulatory, and antiangiogenesis mechanisms. Our aim was to examine this association through a detailed meta-analysis of randomized controlled trials (RCTs). A comprehensive search for trials published up to June 2009 was performed, reviews of each study were conducted and data were abstracted. Prior to meta-analysis, the studies were evaluated for publication bias and heterogeneity. Pooled relative risk estimates (RR) and 95% confidence intervals (CIs) were calculated using the fixed- and the random-effects models. Subgroup and sensitivity analyses were also conducted. Sixteen RCTs of statins for cardiovascular outcomes, involving 62,568 individuals with a mean age of 60 years and an average follow-up of nearly 4.7 years, contributed to the analysis. We found no evidence of publication bias (P = 0.47) or heterogeneity among the studies (P = 0.25). Statin use did not significantly affect the risk of developing melanoma assuming either a fixed- (RR = 0.92, 95% CI: 0.67–1.26), or a random-effects model (RR = 0.92, 95% CI: 0.62–1.36). This neutral effect was further supported by the results of subgroup and sensitivity analyses. Our findings do not support a protective effect of statins against melanoma.     

Is a management degree worth the investment for physicians? A survey of members of the American College of Physician Executives

In a survey of 568 physician members of the American College of Physician Executives (ACPE), most of whom had advanced management degrees (MBA, MMM, MPH), approximately 90% of respondents reported that their investment in the education was "worth it." The return on investment was independent of the quality of the academic institution, although primary care physicians stood to gain more relative to specialists. Salary comparisons showed that female physicians had approximately 20% lower incomes than male physicians, confirming the presence of a "glass ceiling" for female physician executives as seen in other medical specialties. These findings have implications for early and mid-career physicians and physician recruiters.     

Treatment of obesity with intragastric injection of botulinum toxin. Is it worth the pinch? An overview of systematic reviews and meta-analysis.

Background and aimsΑvaialble evidence regarding the effectiveness of intragastric injection of botulinum toxin in reducing anthropometric indices of subjects with obesity is conflicting. We evaluated the existing evidence and perform a meta-analysis to assess the efficacy of intragastric botulinum toxin in treating obesity.MethodsWe identified published systematic reviews evaluating the efficacy of intragastric injection of botulinum toxin in patients with overweight or obesity and additionally performed a systematic literature search to retrieve randomized controlled trials on this topic. A random-effects meta-analysis was performed to synthesize the existing studies.ResultsA total of four systematic reviews were included in our overview of systematic reviews and six randomized controlled trials were included in our meta-analysis. Compared to placebo, intragastric injection of botulinum toxin was ineffective in reducing body weight and body mass index after the application of the Knapp-Hartung adjustment (MD = −2.41 kg, 95%CI = −5.21 to 0.38, I² =59% and MD = −1.43 kg/m², 95%CI = −3.04 to 0.18, I² =62%, respectively). Moreover, treatment with intragastric injection with botulinum toxin was not superior to placebo in decreasing waist and hip circumference.ConclusionsBased on the available evidence, intragastric injection with botulinum toxin is an ineffective procedure in reducing body weight and body mass index when the Knapp-Hartung method was applied.     

Is it time to reassess the categorization of disease burdens in low-income countries?

The classification of disease burdens is an important topic that receives little attention or debate. One common classification scheme, the broad cause grouping, is based on etiology and health transition theory and is mainly concerned with distinguishing communicable from noncommunicable diseases. This may be of limited utility to policymakers and planners. We propose a broad care needs framework to complement the broad cause grouping. This alternative scheme may be of equal or greater value to planners. We apply these schemes to disability-adjusted life year estimates for 2000 and to mortality data from Tanzania. The results suggest that a broad care needs approach could shift the priorities of health planners and policymakers and deserves further evaluation.     

Is there evidence for recommending needleless closed catheter access systems in guidelines? A systematic review of randomized controlled trials

A systematic review was conducted to determine whether certain vascular access policies are better than others in terms of prevention of catheter-related infections. Publications were retrieved by a search of Medline, the Cochrane Library and Embase up to May 2005. All randomized trials and systematic reviews/meta-analyses of randomized trials evaluating the effect of vascular access policies (i.e. needleless closed systems, conventional closed systems or conventional open systems) on catheter-related infection in hospitalized patients with intravascular catheters in situ were selected. Two reviewers independently assessed trial quality and extracted data. Data from the original publications were used to calculate the relative risk or the incidence-density relative rate of catheter-related infection. Data for similar outcomes were combined in the analysis where appropriate using a random-effects model. Of the six studies reviewed, one was excluded. Five randomized controlled trials were included in the review. The quality of the trials and the way they were reported were generally unsatisfactory. Four trials compared needleless closed systems with conventional open systems. There was a trend for an advantage of the needleless closed devices in terms of less catheter-associated bloodstream infection, less catheter tip colonization and less hub inlet colonization. There were no possibilities for combining data because of clinical heterogeneity. One trial compared needleless closed systems with conventional closed systems and the evidence was inconclusive. From the point of view of infection prevention, there are no objections to use these new systems. However, there is insufficient evidence at this stage to recommend the needleless closed vascular devices.     

Can a health advocate for homeless families reduce workload for the primary healthcare team? A controlled trial

The objective of the present study was to determine whether provision of health advocacy for homeless patients would reduce the burden of care for a primary healthcare team. The impact of a health advocacy intervention was assessed in a quasi-experimental, three-armed controlled trial. Homeless patients registering at an inner-city health centre were allocated in alternating periods to health advocacy (with or without outreach registration) or 'usual care' over a total intake period of 3 years. The client group were homeless people in hostels or other temporary accommodation in the Liverpool 8 area of the UK. The majority of participants (n = 400) were women (76%) in their twenties (mean age = 26.6 years). Most (63%) were temporarily housed at either one of the women's refuges or Liverpool City Council family hostels, and all were registered with an inner-city health centre. Data on health service utilisation over a 3-month period was collected for all clients recruited to the study and direct health service costs were measured. Homeless adults who were proactively registered by the health advocate on outreach visits to hostels made significantly less use of health centre resources whilst having more contact with the health advocate than patients who registered at the health centre at a time of need. There was no reduction in health centre workload when the offer of health advocacy was made after registration at the health centre. The additional costs of providing health advocacy were offset by a reduction in demand for health-centre-based care. The results demonstrate that health advocacy can alter the pattern of help-seeking by temporarily homeless adults. The intervention was cost-neutral. The short-term health service workload associated with symptomatic homeless patients requiring medication was not reduced, but outreach health advocacy was used successfully to address psycho-social issues and reduce the workload for primary care staff.     

Is prevention of suicide worth less? A comparison of the value per statistical life

The European Journal of Health Economics - This paper compares the value per statistical life (VSL) in the context of suicide prevention to that of prevention of traffic fatalities. We conducted...     

Is Regret Theory an alternative basis for estimating the value of healthcare interventions?

This paper presents an argument for the existence of "regret' influencing the valuation of alternative outcomes when making treatment decisions in healthcare. It is argued that valuation techniques as currently formulated rely upon the axioms of Expected Utility Theory (transitivity and independence). This potentially leads to a misrepresentation of the respondents true preferences over treatment alternatives, and thus results in the potential for "irrational' decisions being observed. A modified version of Regret Theory is outlined, and the results of a tentative empirical analysis provided to illustrate the importance of accounting for regret in the valuation of health states. It is concluded that regret is an important element in individual valuation and decision making in health care.