Are economic evaluations and health technology assessments increasingly demanded in times of rationing health services? The case of the Argentine financial crisis

OBJECTIVES: After 4 years of deepening recession, Argentina's economy plummeted after default in 2002. This crisis critically affected health expenditures and triggered acute rationing. Our objective was to explore health decision-makers' knowledge and attitudes about economic evaluations (EE) and whether health technology assessment (HTA) were increasingly used for decision making. METHODS: A qualitative design based on semistructured interviews and focus groups was used to explore how decision makers belonging to different health sectors implement resource allocation decisions. RESULTS: Informants were mostly unaware of EE. The most important criteria mentioned to adopt a treatment were evidence of effectiveness, social/stakeholder demand, or resource availability. Despite general positive attitudes about EE, knowledge was rather limited. Although cost considerations were widely accepted by purchasers and managers, clinicians argued about these issues as interfering with the doctor-patient relationship. Other important perceived barriers to HTA use were lack of confidence in the transferability of studies conducted in developed countries and institutional fragmentation of the Argentine healthcare system. The new macroeconomic context was cited as a justification of implicit rationing measures. Although explicit priority setting was implemented by many purchasers and managers, HTA was not used to improve technical and/or allocative efficiency. CONCLUSIONS: The crisis seems to be a strong incentive to extend the use of HTA in Argentina, provided decision makers are aware as well as involved in the generation of local studies.     

Health consequences of the increasing caesarean section rates

Caesarean section (C-section) rates are rising in many middle- and high-income countries, with the justification that higher rates of C-section are associated with better outcomes. A review of 79 studies comparing outcomes of elective caesarean sections with vaginal deliveries, including both observational studies and randomized trials, suggests that caesarean sections may have substantially greater risks than vaginal deliveries. In this issue of Epidemiology, Leung and colleagues present data from Hong Kong on morbidity in offspring related to C-section. Such studies are needed to widen the scope of possible health outcomes related to elective C-sections, including such endpoints as maternal satisfaction and women's relationship with their child. Testing of interventions to reduce unnecessary C-sections is also needed, with strategies to enhance the role of women in the process of their obstetric care.     

Examination of the variations of lateral femoral cutaneous nerves: report of two cases

The origins, courses and relations of lateral femoral cutaneous nerves (LFCNs) were examined bilaterally in 28 cadavers, and the variations were observed in two. On the right side of one cadaver, the ventral rami of the first and second lumbar spinal nerves were united and then this nerve was divided into four branches. From medial to lateral, these branches were the obturator nerve, the femoral nerve, the medially located LFCN and the laterally located LFCN. On the left side of another cadaver, there were three LFCNs. All of these nerves pierced the psoas major muscle anterolaterally. Two of these nerves, which pierced the psoas major muscle more proximally than the third, united with each other by a communicating branch anterior to the iliacus muscle. These types of variations are very important, especially in the presence of paresthesias or pain in the anterior thigh, lateral thigh and gluteal region. In these cases, surgeons must always remember the possible variations of the LFCN during surgical procedures in order to prevent injury and the occurrence of meralgia paresthetica.