Can economic evaluation in telemedicine be trusted? A systematic review of the literature

Background

Chronic diseases, represented mainly by cardiovascular disease (CVD) and cancer, are increasing in developing countries and account for 53% of chronic diseases in Argentina. There is strong evidence that a reduction of 50% of the deaths due to CVD can be attributed to a reduction in smoking, hypertension and hypercholesterolemia. Generalized cost-effectiveness analysis (GCE) is a methodology designed by WHO to inform decision makers about the extent to which current or new interventions represent an efficient use of resources. We aimed to use GCE analysis to identify the most efficient interventions to decrease CVD.

Methods

Six individual interventions (treatment of hypertension, hypercholesterolemia, smoking cessation and combined clinical strategies to reduce the 10 year CVD Risk) and two population-based interventions (cooperation between government, consumer associations and bakery chambers to reduce salt in bread, and mass education strategies to reduce hypertension, hypercholesterolemia and obesity) were selected for analysis. Estimates of effectiveness were entered into age and sex specific models to predict their impact in terms of age-weighted and discounted DALYs saved (disability-adjusted life years). To translate the age- and sex-adjusted incidence of CVD events into health changes, we used risk model software developed by WHO (PopMod). Costs of services were measured in Argentine pesos, and discounted at an annual rate of 3%. Different budgetary impact scenarios were explored.

Results

The average cost-effectiveness ratio in argentine pesos (ARS$) per DALY for the different interventions were: (i) less salt in bread $151; (ii) mass media campaign $547; (iii) combination drug therapy provided to subjects with a 20%, 10% and 5% global CVD risk, $3,599, $4,113 and $4,533, respectively; (iv) high blood pressure (HBP) lowering therapy $7,716; (v) tobacco cessation with bupropion $ 33,563; and (iv) high-cholesterol lowering therapy with statins $ 70,994.

Conclusion

Against a threshold of average per capita income in Argentina, the two selected population-based interventions (lowering salt intake and health education through mass-media campaigns) plus the modified polypill strategy targeting people with a 20% or greater risk were cost-effective. Use of this methodology in developing countries can make resource-allocation decisions less intuitive and more driven by evidence.     

Is it time to drop the ‘knowledge translation’ metaphor? A critical literature review

The literature on 'knowledge translation' presents challenges for the reviewer because different terms have been used to describe the generation, sharing and application of knowledge and different research approaches embrace different philosophical positions on what knowledge is. We present a narrative review of this literature which deliberately sought to highlight rather than resolve tensions between these different framings. Our findings suggest that while 'translation' is a widely used metaphor in medicine, it constrains how we conceptualise and study the link between knowledge and practice. The 'translation' metaphor has, arguably, led to particular difficulties in the fields of 'evidence-based management' and 'evidence-based policymaking' - where it seems that knowledge obstinately refuses to be driven unproblematically into practice. Many non-medical disciplines such as philosophy, sociology and organization science conceptualise knowledge very differently, as being (for example) 'created', 'constructed', 'embodied', 'performed' and 'collectively negotiated' - and also as being value-laden and tending to serve the vested interests of dominant élites. We propose that applying this wider range of metaphors and models would allow us to research the link between knowledge and practice in more creative and critical ways. We conclude that research should move beyond a narrow focus on the 'know-do gap' to cover a richer agenda, including: (a) the situation-specific practical wisdom (phronesis) that underpins clinical judgement; (b) the tacit knowledge that is built and shared among practitioners ('mindlines'); (c) the complex links between power and knowledge; and (d) approaches to facilitating macro-level knowledge partnerships between researchers, practitioners, policymakers and commercial interests.     

Can the school make a difference? A multilevel analysis of adolescent risk and health behaviour

The main aim of this article is to assess the relationship between the structural and (health) policy variables of the school and characteristics of the individual on the risk and health behaviour of adolescents. Individual and school level effects on seven health-related behaviours are simultaneously estimated, using multilevel modelling. The data are from the Flemish health behaviour in school-aged children study in Belgium. Data are used from 29 Flemish schools in which students (N=3225), school administrators (N=29) and teachers (N=1132) were surveyed with anonymous written questions. The analysis confirms previous findings concerning individual level effects. Although differences between schools in risk and health behaviour were found to originate mainly from differences in pupil characteristics, substantial variation between schools remained with regard to regular smoking, drinking habits and tooth brushing after controlling for individual effects. A wide range of school structure and policy variables were taken into account, but only few of them were found to influence the health and risk behaviour of young people. Moreover, the study could not detect an effect of health promotion policy at school. The analysis therefore only partially confirms the hypothesis that the school has an impact on the health behaviour of young people. The findings demonstrate the need for a more thorough examination of the paths by which schools can influence the health behaviour of their pupils.     

What's cooking for dietetics? A review of the literature

Aim: There are issues surrounding the apparent decline and devaluing of cooking skills in the population, potential health impacts and the role of dietitians. The present paper aims to outline several arguments and raise questions on the relationship between cooking and dietetics. Methods: Evidence from dietetics and nutrition journals and other sources is used to develop positions for dietetics and its relationship to cooking and cooking skills Results: The historical relationship between dietetics and home economics has seen dietetics professionally distance itself by its scientific education on food and nutrition, rather than actual involvement with cooking. In pursuing this rational scientific approach there are concerns that dietitians have inadvertently supported the growth of the functional and convenience food market, particularly given the demise of home economics as a skill-based curricula in schools in several states. There is a need to consider what role cooking skills could have in dietetics training as a professional competency for practice, particularly for public health interventions. This is in the light of Commonwealth government funding that is legitimising cooking skill interventions as a policy response to obesity. There may be a role for dietitians to develop partnerships and train a new professional category or paraprofessionals and/or peer educators to deliver cooking skill interventions Conclusion: There is a need for research on dietitian's views and use of cooking skill interventions. This would help answer whether we should consider cooking and cooking skills as part of our professional practice and whether cooking should be a dietetic competency.     

Can observations of workplace bullying really make you depressed? A response to Emdad et al.

Background

A recent study by Emdad and colleagues published in International Archives of Occupational and Environmental Health concluded that being a bystander to workplace bullying is related to future symptoms of depression. In this response to the authors, we argue, through the use of empirical evidence, that this relationship can be explained by the observers own exposure to bullying. Furthermore, by also investigating the reversed association between the variables, we show that observations of workplace bullying can be influenced by symptoms of psychological distress.

Method

A reanalysis of prospective questionnaire survey data with a two-year time lag based on a representative sample of Norwegian employees was used to determine long-term relationships between observed bullying, self-reported exposure to bullying, and psychological distress.

Results

Bivariate, baseline observations of others being bullied were significantly associated with subsequent symptoms of psychological distress. Yet, this association disappeared when controlling for the observers own exposure to bullying. Analyzing reversed relationship between the variables, baseline symptoms of distress predicted being a bystander at follow-up.

Conclusion

By showing that the relationship between being a bystander to bullying and distress can be fully explained by the observers own exposure to bullying, our results question the conclusion by Emdad et al. (Int Arch Occup Environ Health. doi:10.1007/s00420-012-0813-1, 2012) that observed bullying in itself is related to subsequent distress. Together with the finding that psychological distress predicts subsequent observations of bullying, it is concluded that future research on observers should always take the observers’ own exposure to bullying, as well as negative perceptions biases, into account.     

Does money really matter? A review of the literature on the relationships between healthcare organization finances and quality

The authors review empirical literature from 1980 to 2005 on relationships between healthcare organizations' finances and quality of care. They found only 16 studies of this topic that employed statistical methods. This research indicates cumulatively that expenses, fiscal margin, and asset and liability management all affect healthcare outcome quality. There is less evidence about how organizational finance factors affect structural or process quality, and there is no information about how structural or process quality mediates between finances and outcomes. The authors note what patterns have emerged from previous studies and make specific suggestions about what future research is necessary and why.     

Psychological workload and body weight: is there an association? A review of the literature

BACKGROUND: According to Karasek's Demand/Control Model, workload can be conceptualized as job strain, a combination of psychological job demands and control in the job. High job strain may result from high job demands combined with low job control. Aim To give an overview of the literature on the association between obesity and psychological workload. METHOD: We carried out a review of the associations between psychological workload and body weight in men and women. In total, 10 cross-sectional studies were identified. RESULTS: The review showed little evidence of a general association between psychological workload and body mass index. Only weak positive associations were found, and only between elements of psychological workload and overall body weight. For body fat distribution, two out of three studies showed a positive association in men, but the associations became insignificant after adjustment for education. For women, there was no evidence of a consistent association. CONCLUSION: The reviewed articles were not supportive of any associations between psychological workload and either general or abdominal obesity. Future epidemiological studies in this field should be prospective or experimental, and should examine how chronic work stress affects eating and to what extent initial body weight is a predictor for individual differences in perceived psychological workload.     

Do economic evaluation studies inform effective healthcare resource allocation in Iran? A critical review of the literature

To aid informed health sector decision-making, data from sufficient high quality economic evaluations must be available to policy makers. To date, no known study has analysed the quantity and quality of available Iranian economic evaluation studies. This study aimed to assess the quantity, quality and targeting of economic evaluation studies conducted in the Iranian context.The study systematically reviewed full economic evaluation studies (n?=?30) published between 1999 and 2012 in international and local journals. The findings of the review indicate that although the literature on economic evaluation in Iran is growing, these evaluations were of poor quality and suffer from several major methodological flaws. Furthermore, the review reveals that economic evaluation studies have not addressed the major health problems in Iran.While the availability of evidence is no guarantee that it will be used to aid decision-making, the absence of evidence will certainly preclude its use. Considering the deficiencies in the data identified by this review, current economic evaluations cannot be a useful source of information for decision makers in Iran. To improve the quality and overall usefulness of economic evaluations we would recommend; 1) developing clear national guidelines for the conduct of economic evaluations, 2) highlighting priority areas where information from such studies would be most useful and 3) training researchers and policy makers in the calculation and use of economic evaluation data.     

Can alcohol promote aromatization of androgens to estrogens? A review

Increased aromatization may be a mechanism for feminization of some male alcoholics, as well as for the reported increases in plasma estrogen levels in postmenopausal women subjected to moderate alcohol consumption. Alcohol consumption-related increases in estrogen levels may in turn be partially responsible for the associated decreased risk for coronary artery disease and osteoporosis, as well as for increased risk for breast cancer. The purpose of this review is to evaluate the literature to determine whether alcohol can promote aromatization of androgens to estrogens. In male rats, chronic heavy alcohol administration (36% of total calories=12-18 g/kg/day) led to increased aromatization of androgen in the liver, but the results were equivocal for the hypothalamus. In female rats, chronic heavy alcohol administration did not promote aromatization in the hypothalamus exposed to alcohol in utero. In human placental tissue, although ex vivo alcohol administration (less or more than 72 g/day) did not affect the rate of aromatization, in vitro incubation of choriocarcinoma cells with 5-50 mM of alcohol increased estradiol secretion, which could be due to increased aromatization. In in vitro human ovarian granulosa cell studies, alcohol increased, had no effect on, or decreased estradiol secretion, and in one study, 20 mM of alcohol significantly increased aromatization of androstenedione to estrogens. These results may not be fully relevant to normal human ovary because in both studies cells were heavily luteinized by gonadotropins. A study of ovariectomized rats shows that only heavy chronic alcohol intake (4.4 g/kg/day) for 10 weeks can increase plasma estradiol levels and uterine weight, which could be due to increased aromatization or delayed clearance of estradiol. In conclusion, chronic heavy alcohol administration can result in aromatization of androgens in male rat liver. It is not clear whether moderate alcohol intake can produce a similar effect in the liver nor whether alcohol can potentiate aromatization of androgens in other tissue or organs of male rats. In females, the available information is not adequate to evaluate the effect of alcohol on aromatization. Further studies are required in both genders to evaluate the ability of alcohol (moderate vs. heavy dose) to promote aromatization of androgens to estrogens.     

Is freezing in the vaccine cold chain an ongoing issue? A literature review

Vaccine exposure to temperatures below recommended ranges in the cold chain may decrease vaccine potency of freeze-sensitive vaccines leading to a loss of vaccine investments and potentially places children at risk of contracting vaccine preventable illnesses.This literature review is an update to one previously published in 2007 (Matthias et al., 2007), analyzing the prevalence of vaccine exposure to temperatures below recommendations throughout various segments of the cold chain. Overall, 45 studies included in this review assess temperature monitoring, of which 29 specifically assess ‘too cold’ temperatures. The storage segments alone were evaluated in 41 articles, 15 articles examined the transport segment and 4 studied outreach sessions. The sample size of the studies varied, ranging from one to 103 shipments and from three to 440 storage units. Among reviewed articles, the percentage of vaccine exposure to temperatures below recommended ranges during storage was 33% in wealthier countries and 37.1% in lower income countries. Vaccine exposure to temperatures below recommended ranges occurred during shipments in 38% of studies from higher income countries and 19.3% in lower income countries.This review highlights continuing issues of vaccine exposure to temperatures below recommended ranges during various segments of the cold chain. Studies monitoring the number of events vaccines are exposed to ‘too cold’ temperatures as well as the duration of these events are needed. Many reviewed studies emphasize the lack of knowledge of health workers regarding freeze damage of vaccines and how this has an effect on temperature monitoring. It is important to address this issue by educating vaccinators and cold chain staff to improve temperature maintenance and supply chain management, which will facilitate the distribution of potent vaccines to children.     

Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature

Background

There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries. The private sector represents an important source of care for all socioeconomic groups, including the poorest and substantial concerns have been raised about the quality of care it provides. Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals. Limited information is available on the extent to which these interventions have successfully expanded access to quality health services for poor and disadvantaged populations. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor.

Methods

The search topic of the systematic literature review was the effectiveness of interventions working with the private for-profit sector to improve utilization of quality health services by the poor. Interventions included social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The search for published literature used a series of electronic databases including PubMed, Popline, HMIC and CabHealth Global Health. The search for grey and unpublished literature used documents available on the World Wide Web. We focused on studies which evaluated the impact of interventions on utilization and/or quality of services and which provided information on the socioeconomic status of the beneficiary populations.

Results

A total of 2483 references were retrieved, of which 52 qualified as impact evaluations. Data were available on the average socioeconomic status of recipient communities for 5 interventions, and on the distribution of benefits across socioeconomic groups for 5 interventions.

Conclusion

Few studies provided evidence on the impact of private sector interventions on quality and/or utilization of care by the poor. It was, however, evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people. Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn.

     

Play as a coping strategy?: A review of the relevant literature

Despite the fact that coping and play are both considered essential elements of child development, their relationship has seldom been investigated. The present review examines the assessment of children’s coping skills in general and the specific use of play as a coping skill in studies involving children aged 5–12 years. Forty studies published between 2000 and 2013 were analyzed. The review shows that play is not incorporated in 40% of the children’s coping skills instruments. Even when a coping instrument recognized play, it was classified as either an avoidant or distracting activity. Future research should investigate children’s play as a coping strategy for managing difficult and stressful situations. Overlooking play as a coping strategy may lead to underestimating its developmental and social potential in pediatric health care.     

Room for one more? A review of the literature on ‘inappropriate’ admissions to hospital for older people in the English NHS

This paper reports the findings of a review of the literature on emergency admissions to hospital for older people in the UK, undertaken between May and June 2014 at the Health Services Management Centre, University of Birmingham. This review sought to explore: the rate of in/appropriate emergency admissions of older people in the UK; the way this is defined in the literature; solutions proposed to reduce the rate of inappropriate admissions; and the methodological issues which particular definitions of ‘inappropriateness’ raise. The extent to which a patient perspective is included in these definitions of inappropriateness was also noted, given patient involvement is such a key policy priority in other areas of health policy. Despite long‐standing policy debates, relatively little research has been published on formal rates of ‘inappropriate’ emergency hospital admissions for older people in the UK NHS in recent years. What has been produced indicates varying rates of in/appropriateness, inconsistent ways of defining appropriateness and a lack of focus on the possible solutions to address the problem. Significantly, patient perspectives are lacking, and we would suggest that this is a key factor in fully understanding how to prevent avoidable admissions. With an ageing population, significant financial challenges and a potentially fragmented health and social care system, the issue of the appropriateness of emergency admission is a pressing one which requires further research, greater focus on the experiences of older people and their families, and more nuanced contextual and evidence‐based responses.     

Informed choice in screening programmes: do leaflets help? A critical literature review

BACKGROUND: Screening programmes aim to maximise population benefit by maximizing uptake but must also allow informed choice about participation. Many programmes provide potential participants with information leaflets. This article reviews studies of the effectiveness of leaflets in promoting informed choice in screening. METHODS: I searched 15 electronic databases and the websites of UK screening programmes, searched the bibliographies of identified studies and contacted experts in the field. Randomized controlled trials (RCTs) and controlled clinical trials where an attempt had been made to determine the contribution of leaflets to the exercise of informed choice in screening decisions were included. RESULTS: I identified nine trials from various screening programmes. Outcome measures included knowledge, attitudes to screening, intention to be screened, uptake, anxiety, satisfaction with decision-making, discussions about screening with care providers and agreement that enough information had been provided to allow informed choice. Most studies demonstrated that providing written information increased knowledge, but evidence that this promoted informed choice was poor. CONCLUSIONS: Research into informed choice in screening is hampered by the lack of agreement about its definition and measurement. The most effective way for screening programmes to achieve informed choice is unclear. Programmes should not rely solely on providing written information but should explore additional ways to promote informed choice.     

Why use placebos in clinical trials? A narrative review of the methodological literature

Researchers have a number of different options for their choice of control or comparison intervention in randomized trials. We surveyed the methodological literature looking for reasons why a researcher might choose to administer a placebo (i.e., a mimic intervention) to control subjects. Two implicit assumptions were that the issue of placebo is pertinent only to drug trials and that the nonplacebo effect of a treatment is the "real" or "true" effect. Explicit reasons given in the literature for the use of placebos were facilitating blinding and controlling for the placebo effect. The importance of the latter was often inadequately argued. Reasons to avoid placebos in controlled trials, other than ethics and feasibility, are that placebos do not inform real decisions, and may interfere with accurate estimation of effect size and with nonspecific aspects of treatment. Placebo-controlled trials have high internal validity but may be difficult to apply to clinical practice; the situation is reversed for trials without placebo control.     

Should family members be present during cardiopulmonary resuscitation? A review of the literature

During resuscitation, family members are often escorted out of the room for fear of immediate and long-term consequences to the family, the patient, and the physician. However, mounting evidence suggests that family presence during resuscitation could, in fact, be beneficial. The Emergency Nurses Association and the American Heart Association endorse family-witnessed resuscitation and the development of hospital policies to facilitate this process. However, the opinions on family-witnessed resuscitation vary widely, and few hospitals in the United States have developed formal policies on the presence of families during cardiopulmonary resuscitation. In this article, we review the current status of family-witnessed resuscitation and provide recommendations on the development of hospital policies for family-witnessed resuscitation.     

Can worksite nutritional interventions improve productivity and firm profitability? A literature review

AIMS: This paper investigates whether and how worksite nutrition policies can improve employee productivity. METHODS: The questions are pursued through a literature review, including a systematic search of literature--combined with literature identified from backward references--on randomized controlled or quasi-experimental worksite intervention trials and observational cross-sectional studies. Studies were selected on the basis of topic relevance, according to publication title and subsequently according to abstract content. A quality appraisal of the studies was based on study design and clarity in definition of interventions, as well as environmental and outcome variables. Results: The search identified 2,358 publications, 30 of which were found suitable for the review. Several of the reviewed studies suggest that diet-related worksite interventions have positive impacts on employees' nutritional knowledge, food intake and health and on the firm's profitability, mainly in terms of reduced absenteeism and presenteeism. Conclusions: Well-targeted and efficiently implemented diet-related worksite health promotion interventions may improve labour productivity by 1%-2%. On larger worksites, such productivity gains are likely to more than offset the costs of implementing such interventions. These conclusions are subject to some uncertainty due to the relatively limited amount of literature in the field.