The clinical-economic trial: Promise,problems, and challenges

The clinical-economic trial is a study design that is appearing with greater frequency in medical and public health literature. Some experienced investigators view these trials with skepticism; to policy makers they represent a promising step in the control of rising health care costs. The success of clinical-economic trials in meeting the important goal of more rational and efficient use of health care resources will depend on the strengths and limitations of the research method. As part of a report to the Office of Technology Assessment of the U.S. Congress on new health care assessment techniques, we describe the reasons why economic data collection and analysis are being considered in clinical trials, identify and discuss various designs and methods for gathering economic trial data, and evaluate the strengths and limitations of different methods for providing sound data for decision making on appropriate use of health care interventions. Because of the potential significance and increasing visibility of such research, experts in research methods should give more attention to methodological research for clinical-economic trials. Future efforts should be directed at comparing different techniques for collecting data, examining the incremental value of precision in economic measurements and ensuring appropriate interpretation of data from clinical-economic trials.     

Cost analyses in assistive technology research

Economic evaluation has become one of the principal methodologies in outcomes research within the health care field in general and specifically in assistive technology. Efforts to define and develop a consistent methodology for assistive technology economic evaluations have been hampered by lack of familiarity with the various terms and concepts associated with cost analysis, an essential aspect of economic evaluations. Adapting these concepts, which were constructed to suit a medical model, to the needs of the assistive technology field has been a challenge as well. This article outlines terms and concepts basic to cost analysis. The authors then consider five studies that relate costs to outcomes in order to illustrate the challenges, choices, and trade-offs researchers make when adapting this methodology to assistive technology. The article concludes by seeking to stimulate further discussion of the complexity inherent in assessing costs in assistive technology outcomes research and calling for the development of a standardized and consistent economic evaluation methodology.     

Cost Analyses in Assistive Technology Research

Economic evaluation has become one of the principal methodologies in outcomes research within the health care field in general and specifically in assistive technology. Efforts to define and develop a consistent methodology for assistive technology economic evaluations have been hampered by lack of familiarity with the various terms and concepts associated with cost analysis, an essential aspect of economic evaluations. Adapting these concepts, which were constructed to suit a medical model, to the needs of the assistive technology field has been a challenge as well. This article outlines terms and concepts basic to cost analysis. The authors then consider five studies that relate costs to outcomes in order to illustrate the challenges, choices, and trade-offs researchers make when adapting this methodology to assistive technology. The article concludes by seeking to stimulate further discussion of the complexity inherent in assessing costs in assistive technology outcomes research and calling for the development of a standardized and consistent economic evaluation methodology.     

Beyond "compliance" is "adherence". Improving the prospect of diabetes care

The purpose of this study is to evaluate existing research in the area of patient "compliance," to endorse reconceptualizing "compliance" in terms of "adherence," and to discuss the benefits of such a change for medical practitioners. This study critically reviews existing medical, nursing, and social scientific research in the area of patient "compliance." We assert that the literature reviewed is flawed in its focus on patient behavior as the source of "noncompliance," and neglects the roles that practitioners, the American medical system, and patient-practitioner interaction play in medical definitions of "compliance." The term "compliance" suggests a restricted medical-centered model of behavior, while the alternative "adherence" implies that patients have more autonomy in defining and following their medical treatments. We suggest that while the change in terminology is minor, it reflects an important paradigmatic shift for thinking about the delivery of health care. By enabling practitioners to more accurately identify patients' social and economic constraints and to provide them with more efficient educational and financial resources, this type of change will improve patient care. In general, by moving to a more social paradigm for understanding patient behavior, practitioners can expand the types of explanations, and therefore the types of solutions, they have for therapeutic adherence.     

胃肠镜检查中舒适医疗相关因素分析

目的：探讨胃肠镜检查中舒适医疗的相关因素，为舒适医疗的发展提供依据。方法将503例胃肠镜检查者中行麻醉检查者设为研究组(286例)，非麻醉检查者设为对照组(217例)。对两组的临床资料进行对比分析，并进行多因素 logistic 回归分析。结果两组文化程度、经济状况、心理状态、痛苦程度及满意度比较差异有显著性(P <0.05或0.01)，性别、职业类型、检查项目比较差异无显著性(P >0.05)。回归分析显示文化程度、经济状况、心理状态对舒适医疗有显著影响，选择麻醉对降低检查痛苦度和提高满意度有独立影响。结论胃肠镜检查中舒适医疗的影响因素较多，应通过多种途径促进舒适医疗的进一步发展。     

北京协和医院复合型医学精英人才培养体系的探索与实践

随着我国社会经济水平的显著提高,人民群众对高质量医疗服务的需求快速增长,亟需更多基础扎实、技术精良、综合素质高的临床医师.北京协和医院不断传承创新优秀医学人才的培养模式,根据前期经验、文献检索分析及调研结果,自2016年起探索实施"临床医学博士后培养项目",这是我国毕业后医学教育改革的创新模式之一,旨在高效、持续强化学...     

Cost-effectiveness analysis of treatment of renal-artery stenoses by medication,angioplasty, stenting and surgery

This study analysed the cost-effectiveness of four different treatment modalities (medical therapy, PTA with and without stent, and surgery) for the therapy of renal-artery stenoses in hypertensive patients in Germany. A computerised, predictive decision-analytic model, based on economic input data and the cost of medical care in Germany, and the results of published data from prospective clinical trials, was developed. The economic analysis was performed from the perspective of a third-party payer. The base-case analysis showed that the primary end-point (major vascular bleeding, stroke, dialysis, or repeat arterial revascularisation) was reached at 36 months by 82.4% of the patients in the medical treatment group, 81.4% in the angioplasty group, 52.9% in the surgical group and 27.7% in the stent group. The average reimbursed treatment cost per patient after 3 years was € 9121 (medication), € 17 164 (surgery), € 14 670 (PTA), and € 8437 (stent). This resulted in a cost-effectiveness ratio of € 51 752 (medical treatment), € 36 454 (surgery), € 78 766 (PTA), and € 11 663 (stent) per event-free patient at 3 years. The accelerated cost-development after balloon dilatation was caused by higher rates of restenosis compared with primary stent implantation. The analysis of published prospective clinical data and current economic variables for renovascular interventions leads to the conclusion that a strategy using primary stent implantation is more cost-effective than stand-alone balloon dilatation. Both medical therapy and surgery offer a better cost-effectiveness ratio than PTA treatment alone.     

Principles of economic evaluation for interventions of chronic musculoskeletal pain

Economic evaluation is attracting increasing attention to inform policy makers, insurers and other payers of the value of existing and new treatment modalities. Hence, it is desirable to assess not only the medical but also the economic consequences the new treatments produce. The available literature on economic evaluation revealed an urgent need for sound economic evaluation studies in the field of chronic musculoskeletal pain. Due to the generally weak methodology, the intended purpose of economic evaluation to help set funding priorities has often been bypassed. Although in general therapists have no direct responsibility for allocating scarce resources in the field of musculoskeletal pain, they are confronted with the results of these decisions in their everyday work. A clear understanding of the main principles of economic evaluation studies might therefore be advantageous. This paper addresses important methodological issues in economic evaluation research, such as the techniques for economic evaluation studies and the analytic perspective. In addition, the paper pays attention to the inclusion of costs and outcomes in economic evaluation research, sensitivity analysis, discounting, incremental analysis and ratios, and collecting of data.Further emphasis is placed on the transparent reporting of methods and study results. A clear reporting may help therapists and other researchers interpret the results of published studies and apply them to their own studies, and it may help decision makers generalize results from one setting to another.     

医学伦理学学科、功能与发展之一:中外医学伦理学文献计量比较研究

目的借鉴循证医学系统研究和文献分析方法,定量与定性分析系统检出的"医学伦理学"中外文献,以剖析其学科发展规律及趋势,为相关决策和后续研究提供基线数据和决策参考。方法计算机检索PubMed和CNKI中与医学伦理学相关的主题词和关键词,检索时限均从建库至2012年1月1日,用共词分析法建立共现矩阵、聚类分析,绘制国内外医学伦理主题图、研究领域关系图和医学伦理战略坐标图。结果从PubMed检获的相关研究文献是CNKI的6倍(26646 vs. 4419篇)。我国医学伦理学领域研究较国外起步晚近35年,尚处在研究初期阶段。国外研究已形成职业道德、伦理审查、医患关系、临床试验、安乐死、教育教学、临床伦理和卫生政策8个研究主题,而国内研究现只涉及职业道德、医患关系、教育教学、生命伦理和医学研究5个研究主题。结论国外重视如何运用医学伦理去解决医疗及医学研究出现的新问题(如偏重伦理审查研究),研究网络中心集中在职业道德、伦理审查、医患关系3个主题;而国内更重视探讨医学职业道德及其教育,研究网络中心集中在职业道德领域。我国应尽快从单纯道德教育研究逐渐拓展到伦理审查、医学教育为主的应用性研究,尽快缩小与国外研究的差距。     

家属行为对老年患者院前急救的影响因素分析

目的探讨家属行为对老年患者院前急救的影响因素,为制定相应对策提供依据。方法对205例老年患者院前急救的病例进行回顾性分析。结果家属行为与老年患者的院前急救的成功与否密切相关。影响较大的正性因素依次为:呼救及时、积极协助抢救、对患者进行心理安慰、信任医护人员、抢救现场有序、经济状况较好;负性因素依次为:呼救不及时、自行进行错误处理、急救知识知晓率低、不信任医护人员、在患者身边谈论病情、抢救现场拥挤混乱。结论大力普及急救知识,加强与患者家属的沟通,稳定家属情绪,引导家属面对现实,与医护人员密切配合,对院前急救可起到积极作用。     

滇东南地区新生儿延迟就医影响因素的质性研究

目的 深层分析滇东南地区新生儿延迟就医的影响因素,为制定干预策略提供依据.方法 2020年11月至2021年2月,采用目的抽样法选取12名滇东南地区的儿科医务人员进行半结构式访谈,以Colaizzi 7步分析法分析资料.结果 新生儿延迟就医分为"寻求照护决策的延迟""到达医疗卫生机构的延迟""获得充分和适当治疗的延迟"...     

阿莫西林/克拉维酸序贯治疗小儿肺炎的成本-效果分析

目的:对小儿肺炎的两种治疗方案即阿莫西林/克拉维酸连续静脉滴注(A)组和阿莫西林/克拉维酸静脉滴注转口服序贯治疗(B)组的临床疗效及医疗费用进行药物经济学评价。方法:采用前瞻性、随机对照的临床研究方法及药物经济学的最小成本分析法。结果:两组在临床效果、细菌清除率及不良反应发生率方面差异无显著性(P>0.05),但B组的医疗总费用及抗生素费用明显低于A组(P<0.001)。结论:小儿肺炎采用序贯治疗不但安全、有效,而且更加经济合理。     

Medical sociology for whom?

This article defines the role of a medical sociologist in a medical institution concerned with health care delivery. The role in applied research and teaching is also discussed. The distinction is made between sociology in medicine and sociology of medicine. Five broad areas of research included under the category of sociology of medicine are the consumer of health care; the social, cultural, and economic enviroments as they relate to health and illness; health and illness behavior; patient education; and the evaluation of services provided to the consumer. Research methodologies utilized by sociologists are briefly presented, and research issues of concern in the sociology of medicine are outlined. The knowledge and information provided by a medical sociologist are supplemental to the physician's practice and are expressed ultimately as a benefit for the patient.     

The state of health economic and pharmacoeconomic evaluation research in Zimbabwe: A review

BACKGROUND: Economic evaluation of health care has developed into a substantial body of work, and its contribution to medical decision making is increasingly being recognized.OBJECTIVE: The aim of the study was to describe the characteristics and quality of health economic (including pharmacoeconomic) evaluation research studies related to Zimbabwe.METHODS: A review of the literature was conducted to identify published health economic evaluation studies related to Zimbabwe. HEED, PubMed, MEDLINE, HealthSTAR, EconLit, and PsycINFO databases and sociological and dissertation abstracts were used to search for economic analyses. The searches used the following terms alone and in combination: costs, budgets, fee, economics, health, pharmacy, pharmacy services, medicines, drugs, health economics, cost-effectiveness, cost-benefit, cost-minimization, cost utility analysis, and Zimbabwe. Only original applied economic evaluations addressing a health-related topic pertaining to Zimbabwe and published in full were included. Two reviewers independently evaluated and scored each study in the final sample using the data collection form designed for the study.RESULTS: Fifty-nine studies were identified in the database searches, 18 of which were excluded because they were not about Zimbabwe (3 studies) or were not health related (15). Of the 41 remaining studies, 8 were excluded after further review because they were not original research, 6 because they were not economic analyses, and 1 because it was not about Zimbabwe. The final 26 studies appeared in 13 different journals (based mostly [17 (65%)] outside of Zimbabwe). The mean (SD) number of authors of each study was 3.36 (2.13); most of the authors had medical/clinical training. The number of studies peaked between 1994 and 1997. Based on a 10-point scale, with 10 indicating the highest quality, the mean (SD) quality score for all studies was 5.40 (1.56); 8 of the studies (31%) were considered to be of poor quality (score ≤4). The quality of the studies reviewed was significantly (all, P < 0.05) associated with the country in which the journal was based (non-Zimbabwe = higher), the primary health intervention (services>pharmaceutical interventions), the number of authors (more authors = higher), and year of publication (more recent = higher).CONCLUSION: This study indicated that the use of health economic (including pharmacoeconomic) evaluation research in Zimbabwe was low, and 31 % of the studies were of poor quality. More and better quality health economic research in Zimbabwe is warranted.     

多模态深度学习及其在眼科人工智能的应用展望

深度学习的强学习能力和高易用性使其成为当前主流机器学习算法和医学人工智能的核心技术。鉴于医学影像在健康筛查、疾病诊断、精准治疗、预后评估等诸多任务中的关键作用,用于医学影像结构分析与语义理解的深度学习正成为重要的交叉学科研究方向。在临床场景中,医生为了实现更精准的诊断,往往需要同时参考不同类型、不同模态的影像样本进行综合分析和判断。本文介绍面向此类场景的多模态深度学习的基本概念和工作原理,结合具体案例分析多模态深度学习在眼科领域的研究进展、应用情况及技术挑战,并对该技术的应用前景作出展望。     

Survival analysis

Aims and objectives. This paper describes when and why survival analysis is used and describes the use and interpretation of the techniques most commonly encountered in medical literature. This is performed using examples taken from core medical journals. Background. Survival analysis is widely used in clinical and epidemiological research: in randomised clinical trials for comparing the efficacy of treatments and in observational (non-randomised) research to determine and test the existence of epidemiological association. Design. This paper introduces the principles, practice and terminology of survival analysis. Methods. References are made to examples from open-access medical journals. Results. Survival analysis is a well-established series of methodologies that are widely encountered in medical literature for both observational and randomised studies. Conclusions. Survival analysis represents a more efficient use of clinical data than other forms of analysis which rely on fixed time periods. One of the most widely used techniques is that developed by Kaplan and Meier. This involves the creation of life tables and the plotting of survival curves with comparison made between two or more groups. The log-rank test is commonly used to establish whether there is a statistically significant difference between these groups. The Multivariate Cox proportional hazards extend this approach to give an estimate of effect size (the Hazards Ratio) and can adjust for any potential confounding variables. In this model, the assumption of proportional hazards is of key importance and should always be checked. More advanced techniques are the use of time-dependent variables and the less widely used parametric survival techniques. Care should always be taken when considering the assumptions involved when using such methods. Relevance to clinical practice. As survival analysis is widely used in clinical research, it is important that readers can critically evaluate the use of this technique.     

Cost of healthcare for patients with migraine in five European countries: results from the International Burden of Migraine Study (IBMS)

Migraine is a disabling neurological disease that affects 14.7 % of Europeans. Studies evaluating the economic impact of migraine are complex to conduct adequately and with time become outdated as healthcare systems evolve. This study sought to quantify and compare direct medical costs of chronic migraine (CM) and episodic migraine (EM) in five European countries. Cross-sectional data collected via a web-based survey were screened for migraine and classified as CM (≥15 headache days/month) or EM (<15 headache days/month), and included sociodemographics, resource use data and medication use. Unit cost data, gathered using publicly available sources, were analyzed for each type of service, stratified by migraine status. Univariate and multivariate log-normal regression models were used to examine the relationship between various factors and their impact on total healthcare costs. This economic analysis included data from respondents with migraine in the UK, France, Germany, Italy, and Spain. CM participants had higher level of disability and more prevalent psychiatric disorders compared to EM. CM participants had more provider visits, emergency department/hospital visits, and diagnostic tests; the medical costs were three times higher for CM than EM. Per patient annual costs were highest in the UK and Spain and lower in France and Germany. CM was associated with higher medical resource use and total costs compared to EM in all study countries, suggesting that treatments that reduce headache frequency could decrease the clinical and economic burden of migraine in Europe. Comparing patterns of care and outcomes among countries may facilitate the development of more cost-effective care, and bring greater recognition to patients affected by migraine.     

医学信息学在罕见病诊疗中的研究进展及应用

罕见病种类繁多、表型复杂,存在遗传异质性和临床异质性,故其诊断极具挑战,且治疗方面缺乏有效药物。随着临床语义系统研究、二代测序、影像组学数据分析、多组学融合分析等医学信息学技术研究的不断深入,罕见病在数据共享、科学研究等方面的限制正在逐步被打破。整合和研究不同来源的罕见病相关共享数据,有利于更多致病位点的发现和孤儿药的开发,可促进罕见病的诊断和治疗。本文旨在介绍医学信息学技术在罕见病领域的研究进展及应用, 以期推动医学信息学在罕见病诊疗方面的发展。     

脑卒中患者早期强化康复治疗的卫生经济学评价

目的:中国的脑卒中康复缺少强化康复与一般康复的对照研究,亦无早期康复的卫生经济学评价。对脑卒中患者早期康复进行卫生经济学评价,观察早期强化康复后患者能否缩短住院日,减少医疗费用。方法:用分层区组随机法将患者分入两组。用成本效果分析进行卫生经济学评价。结果:强化康复组患者神经功能缺损积分每减少1分、总的生活能力每提高1级、日常生活活动能力每提高1分需分别花费人民币1267.8元、6508.0元和411.0元。而一般康复组则分别需花费1875.4元、10462.4元和2422.1元。2组患者住院时间及医疗费用无显著性差异。结论:早期强化康复在降低患者神经功能缺损积分、提高患者总的生活能力等级及日常生活活动能力上较一般康复有更好疗效。强化康复在脑卒中早期康复中更为经济。