Health care technology: how can we tell if we can afford it? A Canadian viewpoint

Major changes are reshaping the economic, political, and social climate in which Canada's health care systems operate. Cost containment has become an essential element of that climate. The perception is that health care technology is a major contributor to health care costs, and this has served as the impetus for a call for assessment and evaluation of all health care technology. While the need for health technology assessment is valid, such assessments must be much broader than simple economic assessments. A complete cost-benefit analysis of the clinical use of a given technology, including consideration of possible alternatives and the implications of rejection of that technology in certain circumstances, is complex. If we are to utilize the results of these analyses to effect important changes in health care delivery, studies must include the science behind the technology, the technology itself, the devices resulting from the technology, the medical outcome, and the societal impact in addition to pure cost considerations. Only then will we be able to properly assess the effectiveness and efficiency of health care technology in society and decide whether we can afford it.     

Comparative effectiveness research: what is it and why do we need it in nephrology?

The USA leads other industrialized countries in health care spending but lags behind in terms of health outcomes. There has been growing interest in comparative effectiveness research (CER) as a means to identify best practices to create a more efficient and effective health care system. Two key concepts of CER are that it should (i) compare two or more alternative tests, therapies or procedures and (ii) be conducted in persons, clinical settings and conditions that are representative of the real world. The goal of CER is to provide evidence for clinicians, patients, policy makers and others to make informed decisions that will ultimately improve the overall health of specific subgroups and of the population as a whole. In this narrative review, we first describe the strengths and limitations of various types of studies that constitute CER, including randomized clinical trials, observational studies and systematic reviews, providing examples from the nephrology literature. Because of the concerns regarding confounding in observational CER, we also provide an overview of methods to reduce confounding in these types of studies. Finally, we will discuss why CER pertaining to kidney disease care needs to be a top priority in order to move our field from a largely opinion-based specialty to an evidence-based specialty.     

Late presenters: what can we do?

Late presentation represents a major problem for patients with HIV infection. Actually, it should be made a distinction between late testers and late presenters since the strategies to reduce the percentage of these two groups of subjects could be different. Indeed, the first population is represented by individuals unaware of their serological status, while in the second case the problem is related to engagement and retention in care. Concerning the first population, it has been shown that most of the patients had been seen by their family doctor or admitted to hospital during the year before HIV diagnosis. Indeed, this is a relevant problem, and new strategies to increase the level of suspicion of HIV infection among doctors who are non‐HIV specialists are needed, as testing in presence of indicator diseases, should be applied. Concerning the population of late presenters, American data showed a percentage of engagement in care ranging between 50 and 59%. These low percentages could be due to the American Health System, while in a public health system setting, the percentage of patients not engaged in care or lost to follow‐up could be lower, even if still relevant. Another important factor that should be considered in both populations is stigma. Indeed, many patients that present late, either late testers or late presenters, are immigrants and have important cultural barriers to disclose their HIV serostatus to family members and friends. Obviously, all subjects unaware or refusing their HIV infection could potentially infect their partners. In conclusion, all efforts should be made to reduce the phenomenon of late presentation since these two populations represent an epidemiological problem not only for the prognosis of the single patient but also for the treatment as prevention strategy.     

Sportsman hernia: what can we do?

Introduction  

Sportsman (sports) hernia is a medially located bulge in the posterior wall of the inguinal canal that is common in football players. About 90% of cases occur in males. The injury is also found in the general population.     

Triplane fractures: do we need cross-sectional imaging?

Introduction

Diagnosis of Triplane fractures remains difficult in common practice. Aim of the study was the evaluation of the fracture pattern and the benefit of cross-sectional imaging in classification of Triplane-fractures.

Material and Methods

A total of 27 pediatric patients treated for ankle fractures were identified from patient charts. Radiographic images of epiphyseal fractures (X-rays and additional cross-sectional imaging) were blinded evaluated by 13 observers to answer a specific questionnaire regarding type or fracture and treatment suggestion.

Results

There were seven Triplane-I and eight Triplane-II fractures. The other physeal ankle fracture group consisted of four patients with a Twoplane-fracture, five Salter-and-Harris (SH) II, one SH-III, and two SH-IV fracture. Accuracy of classification improved considerably depending on the experience of the observer in pediatric trauma care. Surgeons specialized in pediatric trauma care classified correctly with conventional X-rays in 48.1 % of all cases presented versus 31.5 % appropriate diagnosis by younger fellows. Accuracy in exact specification of Triplane-fractures was comparable lesser in younger fellows (31.1 vs. 22 %). Cross-sectional imaging improved classification of all fractures in both groups (75.6 % specialized vs. 47.3 % non specialized). Whereas availability of cross-sectional imaging improved treatment recommendation in specialized surgeons this benefit was not detectable for the doctors without specialization. Evaluation of fracture pattern showed a relatively stereotypical fracture pattern in Triplane-II fractures, whereas Triplane-I fractures were more variable.

Conclusion

The additional information of cross-sectional imaging seems helpful for any physician in finding the right classification of a pediatric ankle fracture. However, the additive information appears especially viable for experienced surgeons to suggest the appropriate treatment.