Priority setting in health authorities: a novel approach to a historical activity

As resources in health care are scarce, health authorities and other health organizations are charged with determining how best to spend limited resources. While a number of formal approaches to priority setting within health authorities have been used internationally, there has been limited success with such activity, particularly across major service portfolios. This participatory action research project instituted a novel priority setting framework, coined macro-marginal analysis (MMA), in a fully integrated urban health region in Alberta, Canada. The focus of MMA is on identifying areas for service growth and areas for resource release, then determining, based on pre-defined, locally generated criteria, if actual shifts or re-allocation of resources should occur. For fiscal year 2002/03, the Calgary Health Region identified over 40 M dollars in resource releases (approximately 3% of the total budget), which were made available for servicing the deficit, and more importantly for our purposes, re-investing in service growth areas. The MMA framework is pragmatic in nature and has the ability to incorporate relevant evidence directly into the decision-making process. This work constitutes a significant advancement in health economics, and responds where previous priority setting approaches have failed in that it allows decision-makers to achieve genuine re-allocation of resources with the aim of improving population health or better meeting other important criteria.     

Declining trends in work-related morbidity and disability, 1993-1998: a comparison of survey estimates and compensation insurance claims

OBJECTIVES: This study compared trends in the incidence of work-related morbidity and disability across 3 sources of surveillance data in a Canadian province. METHODS: Time series estimates of workplace injuries and work-related disability based on 2 panel surveys in the province of Ontario, Canada, for the period 1993-1998 were compared with rates of work-related injury and illness compensation claims during the same period. RESULTS: Lost-time compensation claims declined by 28.8% over this 6-year period. The incidence of self-reported work-related injury declined by 28.2%, and the self-reported incidence of work absence for work-related causes declined by 32.2%. CONCLUSIONS: Parallel reductions in work-related morbidity were seen in 3 independent data sources. These results support an interpretation that there has been an important reduction in injury risk in Ontario workplaces over the past decade.     

Synthesis and evaluation of imidazole acetic acid inhibitors of activated thrombin-activatable fibrinolysis inhibitor as novel antithrombotics

Thrombin-activatable fibrinolysis inhibitor (TAFI) is an important regulator of fibrinolysis, and inhibitors of this enzyme have potential use in antithrombotic and thrombolytic therapy. Appropriately substituted imidazole acetic acids such as 10j were found to be potent inhibitors of activated TAFI and selective versus the related carboxypeptidases CPA, CPN, and CPM but not CPB. Further, 10j accelerated clot lysis in vitro and was shown to be efficacious in a primate model of thrombosis.     

The burnout in nursing academicians in Turkey

The purpose of this study was to determine the level of burnout in nursing academicians in Turkey and to investigate the variables which are strongly correlated with the burnout nursing education settings in Turkey. The sample of the study consisted of the nursing academicians working in the schools of nursing at the different universities in Turkey. Although the total number of nursing academicians in Turkey was 179, the subjects who agreed to participate in the research was 135. The Maslach Burnout Inventory (MBI) was used to measure burnout, after having been statistically tested for its validity and reliability in nursing education settings in Turkey. The multiple regression analysis was carried out in order to determine the main variables correlated with burnout, namely "the predictors" of each of the three components (emotional exhaustion (EE), depersonalization (DP), personal accomplishment (PA)) of burnout. The results indicated that the most significant predictor of EE was work-setting satisfaction, of DP was job pressure, and of PA was job satisfaction in nursing education settings in Turkey. Finally, these findings were compared with of those previous studies in the field.     

Costs of rheumatoid arthritis: new estimates from the human capital method and comparison to the willingness-to-pay method.

BACKGROUND: Individuals' valuation of changes in health states in monetary terms have been measured by examining changes in the direct and indirect costs of disease and by the willingness-to-pay (WTP) methodology. METHODS: In 2002, a 2-part study was conducted in Quebec. In one part of the study, 121 rheumatoid arthritis (RA) patients from the McGill University Health Centre were mailed the Stanford Cost Assessment Questionnaire, which enabled the elicitation of direct costs and indirect costs, according to the friction cost and the human capital methods. The other part was a phone survey conducted in a representative sample of the general population and in the same sample of patients, aiming to elicit the societal WTP for a complete cure of RA in the context of 2 different scenarios: a public coverage or private insurance. These estimates were then compared. RESULTS: Estimates of the cost of illness of RA ranged from 11,717 to 28,498 Canadian Dollars (CAD) depending on the method. These estimates are higher than those previously published in Canada from the 1990s, which is partly due to the recent and costly biological therapies and to a change in the measurement of productivity losses. These estimates are somewhat lower than the societal WTP elicited from the WTP survey, that is, 26,717 and 36,817 CAD per RA case, depending on the public or private health insurance context in which the cure would be available. CONCLUSION: Given that neither method is ideal, data from both methods would provide an important sensitivity analysis when monetary estimates of health state changes are required.     

Tamoxifen and risk of large bowel cancer in women with breast cancer

Background: The increasingly consistent association between estrogen replacement therapy and colorectal cancer suggests that the anti-estrogen tamoxifen may also be associated with large bowel cancer incidence.Methods: Women with new diagnoses of breast cancer were identified from the Surveillance Epidemiology and End Results (SEER) Program, a set of geographically defined, population based cancer registries representing approximately ten percent of the U.S. population. Of 85,411 women with local or regional breast cancer diagnosed from 1983–90, 14,984 women were reported to have received hormonal therapy and 70,427 were not known to have received hormonal therapy. Subsequent cancer diagnoses were identified in this cohort beginning 6 months after initial breast cancer diagnosis until death, or December 31, 1994. Multivariate Cox proportional hazards models were used to estimate the risk of developing colorectal cancer and other second cancers according to hormonal therapy use.Results: Over the follow-up period 793 colorectal, 2,648 contralateral breast, 506 endometrial, 250 ovarian, 98 gastric, and 1,765 other cancers were identified in the study cohort. While overall there was no association between hormonal therapy use and colorectal cancer (relative risk (RR) 1.09, 95% confidence interval (CI) 0.88–1.35), in the period five or more years after diagnosis, risk was increased significantly by about 50% (95% CI 1.00–2.15). As expected, based upon clinical trials data, cancers of the contralateral breast were significantly decreased, and cancers of the uterine endometrium were significantly increased. No other meaningful associations were observed. When women were excluded for whom hormonal therapy might represent therapy other than tamoxifen (premenopausal women and those who received chemotherapy), this did not meaningfully alter these estimates.Conclusions: The results of this large population based cohort study suggest that tamoxifen therapy may modestly increase risk of large bowel cancer in women, but only after 5 years following initiation of breast cancer therapy.     

Willingness to pay for what? A note on alternative definitions of health care program benefits for contingent valuation studies.

The authors examine a number of ways in which willingness to pay (WTP) can be defined for measurement and use in a cost-benefit analysis (CBA) of a collectively funded health care program. They show how ambiguous specification of the program consequences that respondents should consider in their WTP responses can lead to problems of double counting or zero countingin a subsequent CBA. An example is whether the value of lost time from work because of poor health should be included by a CBA analyst (e.g., valued at the wage rate) as a separate cost item or whether this has already been monetized and included in respondents' WTP data. The authors highlight how differences in assumed or actual institutional structures are often ignored in measures of WTP and the consequences of this for the interpretation of WTP data.     

Possible cause of failure after McCall culdoplasty

Objective  

To evaluate prospectively the rate of postoperative failure of McCall culdoplasty and the presence of a history of vaginal delivery of macrosomic infants as risk factors in patients with stage III or symptomatic stage II apical prolapse without any other pelvic floor defects.     

Response patterns of the Spanish version of the 49-item short form of the Addiction Research Center Inventory after the use of sedatives, stimulants, and opioids.

This report examines the validity of the Spanish version of the 49-item short form of the Addiction Research Center Inventory (ARCI) for measuring subjective effects after the use of sedatives, stimulants, and opioids. Data from four clinical trials in which this questionnaire was used have been analyzed. The Spanish ARCI short form was found to be sensitive in measuring subjective effects after the administration of alcohol, triazolam, and flunitrazepam (sedatives), cocaine (stimulants), and morphine, pentazocine, and naloxone (opioids) and to distinguishing among them. The response patterns were similar to those previously reported for the same drugs with the English version of ARCI. It is concluded that Spanish version of the 49-item short form of ARCI is a valid instrument for assessing the subjective effects of psychoactive drugs in the Spanish-speaking population context.     

Frontal sinus osteoma in a skull found in the archeological excavations at the old Louvre

A skeleton dating 8th-9th centuries exhumed from the Napoleon square at the Louvre, presents a voluminous ivory or benign osteomata at its frontal sinus. Anthropological and pathological studies give matter to introduce this osteomata on the morphological and demographic problematica ot the benign tumours.