医院所有制与效率：以德国为关注重点的研究回顾

德国医院市场在过去20年里进行了一揽子医疗改革,特别是在2004年引进了疾病诊断相关分组——以期提高医院效率。本文旨在回顾近期就比较德国公立医院、私立非营利医院和私立营利医院效率所开展的研究。尽管研究结果错综复杂,但结合其他国家,特别是美国的研究证据,德国方面的研究结果表明:与公立医院相比,私立医院(私立非营利和私立营利医院)的运营效率并不一定就高。由于私立营利医院通常都会被认为是最有效率的所有制形式,因此本研究结果对很多决策者来说也许有些意外。     

Social capital and self-rated health--a study of temporal (causal) relationships

Despite the vast amount of research over the past fifteen years, there is still lively debate surrounding the role of social capital on individual health outcomes. This seems to stem from a lack of consistency regarding the definition, measurement and plausible theories linking this contextual phenomenon to health. We have further identified a knowledge gap within this field - a distinct lack of research investigating temporal relationships between social capital and health outcomes. To remedy this shortfall, we use four waves of the British Household Panel Survey to follow the same individuals (N = 8114) between years 2000 and 2007. We investigate temporal relationships and association between our outcome variable self-rated health (SRH) and time-lagged explanatory variables, including three individual-level social capital proxies and other well-known health determinants. Our results suggest that levels of the social capital proxy 'generalised trust' at time point (t - 1) are positively associated with SRH at subsequent time point (t), even after taking into consideration levels of other well-known health determinants (such as smoking status) at time point (t - 1). That we investigate temporal relationships at four separate occasions over the seven-year period lends considerable weight to our results and the argument that generalised trust is an independent predictor of individual health. However, lack of consensus across a variety of disciplines as to what generalised trust is believed to measure creates ambiguity when attempting to identify possible pathways from higher trust to better health.     

Integrating virtual patients into courses: follow-up seminars and perceived benefit

Medical Education 2012: 46 : 417–425 Context The use of virtual patients (VPs) suggests promising effects on student learning. However, currently empirical data on how best to use VPs in practice are scarce. More knowledge is needed regarding aspects of integrating VPs into a course, of which student acceptance is one key issue. Several authors call for looking beyond technology to see VPs in relation to the course context. The follow‐up seminar is proposed as an important aspect of integration that warrants investigation. Methods A cross‐sectional explanatory study was performed in a clinical clerkship introduction course at four teaching hospitals affiliated to the same medical faculty. The VP‐related activities were planned collaboratively by teachers from all four settings. However, each setting employed a different strategy to follow up the activity in the course. Sixteen questionnaire items were grouped into three scales pertaining to: perceived benefit of VPs; wish for more guidance on using VPs, and wish for assessment and feedback on VPs. Scale scores were compared across the four settings, which were ranked according to the level of intensity of students’ processing of cases during VP follow‐up activities. Results The perceived benefit of VPs and their usage were higher in the two intense‐use settings compared with the moderate‐ and low‐intensity settings. The wish for more guidance was high in the low‐ and one of the high‐intensity settings. Students in all settings displayed little interest in more assessment and feedback regarding VPs. Conclusions High case processing intensity was related to positive perceptions of the benefit of VPs. However, the low interest in more assessment and feedback on the use of VPs indicates the need to clearly communicate the added value of the follow‐up seminar. The findings suggest that a more intense follow‐up pays off in terms of the benefit perceived by students. This study illustrates the need to consider VPs from the perspective of a holistic course design and not as isolated add‐ons.     

Modeling overdispersed longitudinal binary data using a combined beta and normal random-effects model

Background

In medical and biomedical areas, binary and binomial outcomes are very common. Such data are often collected longitudinally from a given subject repeatedly overtime, which result in clustering of the observations within subjects, leading to correlation, on the one hand. The repeated binary outcomes from a given subject, on the other hand, constitute a binomial outcome, where the prescribed mean-variance relationship is often violated, leading to the so-called overdispersion.

Methods

Two longitudinal binary data sets, collected in south western Ethiopia: the Jimma infant growth study, where the child’s early growth is studied, and the Jimma longitudinal family survey of youth where the adolescent’s school attendance is studied over time, are considered. A new model which combines both overdispersion, and correlation simultaneously, also known as the combined model is applied. In addition, the commonly used methods for binary and binomial data, such as the simple logistic, which accounts neither for the overdispersion nor the correlation, the beta-binomial model, and the logistic-normal model, which accommodate only for the overdispersion, and correlation, respectively, are also considered for comparison purpose. As an alternative estimation technique, a Bayesian implementation of the combined model is also presented.

Results

The combined model results in model improvement in fit, and hence the preferred one, based on likelihood comparison, and DIC criterion. Further, the two estimation approaches result in fairly similar parameter estimates and inferences in both of our case studies. Early initiation of breastfeeding has a protective effect against the risk of overweight in late infancy (p = 0.001), while proportion of overweight seems to be invariant among males and females overtime (p = 0.66). Gender is significantly associated with school attendance, where girls have a lower rate of attendance (p = 0.001) as compared to boys.

Conclusion

We applied a flexible modeling framework to analyze binary and binomial longitudinal data. Instead of accounting for overdispersion, and correlation separately, both can be accommodated simultaneously, by allowing two separate sets of the beta, and the normal random effects at once.     

Fulminant Crohn's colitis after allogeneic stem cell transplantation

We report a case of fulminant Crohn's colitis that occurred following non-myeloablative allogeneic stem cell transplantation for Hodgkin's lymphoma. Adoptive transfer of inflammatory bowel disease by haematopoietic cells is recognised in several animal models of inflammatory bowel disease and remission of Crohn's disease has been reported in patients who have received a bone marrow transplant. However, adoptive transfer of Crohn's disease susceptibility leading to phenotypic manifestation of the disease after transplantation has not been previously reported. Having ruled out an infective cause of a colitis in this case, we speculated that adoptive transfer of Crohn's disease may have occurred and performed a genetic analysis of known susceptibility loci for significant donor-recipient mismatches. The donor and recipient had several haplotype mismatches in HLA class III genes at the IBD3 locus. In addition, the donor (but not the recipient) had a polymorphism of the 5' UTR of NOD2/CARD15 that may be associated with Crohn's disease. This case highlights the question of whether adoptive transfer of Crohn's disease can occur between allogeneic stem cell transplant donor and recipient, in a similar fashion to that reported for other autoimmune diseases. This report should also stimulate debate regarding the need for stem cell transplant donor screening for inflammatory bowel disease.     

Swedish guidelines for the management of community-acquired pneumonia in immunocompetent adults

This document presents the evidence-based guidelines of the Swedish Society of Infectious Diseases for the management of adult immunocompetent patients with community-acquired pneumonia (CAP), who are assessed at hospital. The prognostic score 'CURB-65' is recommended for all CAP patients in the emergency room. The score provides an assessment tool for the decision regarding outpatient treatment or level of hospital supervision, the choice of microbiological investigations, and empirical antibiotic treatment. In patients with non-severe CAP (CURB-65 score 0-2) we recommend initial narrow-spectrum antibiotic treatment, orally or intravenously, primarily directed at Streptococcus pneumoniae. In those with CURB-65 score 3, penicillin G or a cephalosporin intravenously is recommended. For CURB-65 score 0-3 atypical pathogens should be covered only when they are suspected on clinical or epidemiological grounds. In patients with CURB-65 score 4-5 intravenous combination therapy with either cephalosporin/macrolide or penicillin G/fluoroquinolone is recommended. Efforts should be made to identify the CAP aetiology in order to support the ongoing antibiotic treatment or to suggest treatment alterations. Recommended measures for prevention of CAP include influenza -- and pneumococcal -- vaccination to risk groups and efforts for smoking cessation.