Public involvement in health care priority setting: an economic perspective

Background  Public involvement in health care decision making and priority setting in the UK is being promoted by recent policy initiatives. In 1993, the British Medical Association called for public consultation where rationing of services was to be undertaken. The approach to priority setting advocated by many health economists is the maximization of quality adjusted life years (QALYs). Typically, for a particular health care programme, the QALY calculation takes account of four features: (1) the number of patients receiving the programme, (2) the survival gain, (3) the gain in quality of life and, (4) the probability of treatment success. Only one feature, that relating to quality of life, is based upon public preferences. If the QALY is to be used as a tool for health care resource allocation at a societal level then it should incorporate broader societal preferences.
Methods  This study used an interview-based survey of 91 members of the general public to explore whether the traditional QALY maximization model is a good predictor of public responses to health care priority setting choices.
Results and conclusions  Many respondents did not choose consistently in line with a QALY maximization objective and were most influenced by quality of life concerns. There was little support for health care programmes that provided a prognostic improvement but left patients in relatively poor states of health. The level of respondent engagement in the survey exercise was not sensitive to the provision of supporting clinical information.     

Totally laparoscopic aortobifemoral bypass grafting in an experimental model: Description of technique with initial surgical results

Our aim was to examine the feasibility of a totally laparoscopic insertion of a bifurcated aortofemoral bypass graft in a canine model and to compare the surgical results with those in control animals undergoing standard grafting and laparoscopic-assisted bypass procedures. Using a six-port approach, we exposed and cross clamped the aorta, tunneled a bifurcated Dacron graft, and performed an end-to-end aortic anastomosis while maintaining pneumoperitoneum by means of CO₂. Proximal anastomoses were performed with 4/0 double-ended continuous Prolene sutures and distal anastomoses were performed through standard groin incisions. Total operating and aortic cross-clamp times were measured as was the total blood loss for each procedure. Clinical outcome was also documented. Eight female laboratory-bred hounds underwent successful totally laparoscopic aortobifemoral bypass grafting, eight underwent open grafting, and eight underwent laparoscopic-assisted bypass. Mean operating time was 193 minutes in the animals undergoing totally laparoscopic insertion vs. 156 minutes in the open group and 180 minutes in the laparoscopic-assisted group. Aortic cross-clamping time was also significantly longer at 87 minutes vs. 43 minutes (p < 0.001)=" in=" the=" totally=" laparoscopic=" group,=" but=" blood=" loss=" was=" less.=" all=" eight=" laparotomy=" and=" laparoscopic-assisted=" dogs=" were=" still=" alive=" with=" no=" complications=" at=" 28=" days,=" whereas=" three=" of=" the=" eight=" in=" the=" totally=" laparoscopic=" group=" showed=" evidence=" of=" temporary=" paraplegia.=" this=" experimental=" study=" demonstrates=" that=" a=" totally=" laparoscopic=" approach=" can=" be=" used=" to=" insert=" a=" bifurcated=" aortofemoral=" bypass=" with=" a=" proximal=" end-to-end=" anastomosis=" but=" currently=" does=" not=" save=" time=" and=" may=" increase=" the=" risk=" of=" neurologic=">Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

STDs and family planning clinics: a regional program for Chlamydia control that works

Joint meetings between the members of the US Family Planning Services Program and the STD Program of Region X (comprising Alaska, Idaho, Oregon, and Washington) from fall 1986 through spring 1987 led to the screening and treatment of patients with chlamydia. Samples from patients were sent to state health department laboratories in Idaho, Washington, and Oregon. A direct fluorescent antibody (DFA) slide technique was used to process the cervical smears. Clinic visit record (CVR) information and laboratory results were collected by a central data management company, and sent to CDC and Region X researchers. 6 clinics in 3 of the states collected 2 cervical samples from each of 3000 patients, 1 for smear (DFA slide) and 1 for tissue culture over a 4-month period. During the 1988-1990 period, 136 clinics in the region supplied patient information and test results on over 300,000 samples. Overall, positive rates for chlamydia in the region went from a high of 10.9% in the 1st quarter of 1988 to 6.8% in the last quarter of 1990, with an overall declining trend. This amounted to an almost 37% decrease within the region. When analyzed by state, the positivity rates and decreases were relatively similar: Alaska, 12.2% to 10.0% positivity (18% decrease); Idaho, 10.5% to 8.0% (24% decrease); Oregon, 8.9% to 6.9% (22% decrease); and Washington, 9.3% to 6.6% (29% decrease). In patients 17 years of age and younger, positive rates for chlamydia fell 19%, from 12.2% in 1988 to 9.9% in 1990. In women 18-19 years old and women 20-24 years old, the rates fell 24% and 31%, respectively. Larger decreases in chlamydia rates were found among women in the 25-29 year age group (31% reduction) and in those 30 years old and older (44% reduction). Infection rates decreased in all race/ethnic groups, except Asians. Approximately 2/3 of the women with positive chlamydia tests had no apparent symptoms of disease. Conversely, the presence of certain clinical indicators seemed to correlate with the probability of a positive test result.     

From Vineberg to bypass: a "second-hand" internal mammary artery.

A patient operated upon 20 years ago for myocardial revascularization with two Vineberg procedures and one coronary artery bypass graft (CABG) on the right coronary artery had a recurrence of unstable angina due to the thrombosis of the left internal mammary artery (IMA) and the right CABG. The right IMA was patent but stenosed distally. Reoperation was performed with a direct end to side anastomosis of the patent right IMA onto the left anterior descending artery and a saphenous vein graft as a CABG on the marginal branch. We comment on the choice of this "second hand" IMA graft and the pathological appearances of the patent IMA.     

Technical Points in Vertical Gastroplasty for Morbid Obesity

The success of vertical gastroplasty may be jeopardized by gastric leakage or ulceration due to failure of the technique. Reports of band erosion and staple-line leakage have led us to seek technical improvements to reduce technical failures. We describe a modification to the technique of band placement and a manoeuvre to aid the placement of staples when the TA90 staple gun is used.     

Modification of Gastric Banding,Using a Fundal Suture

Many forms of gastric banding have been described and high reoperation rates reported. These can be mainly attributed to excess vomiting associated both with and without stenosis. Reflux oesophagitis and the ‘sump’ effect may be other causes. This paper examines the problems associated with banding leading to revisional surgery and introduces a new technique, ‘fundal supporting suture’, to correct these problems. Preliminary results on 126 bandings without the modification and 22 with the modification are presented.     

Increased placental apoptosis in intrauterine growth restriction

OBJECTIVES: Our purpose was to investigate a possible role for apoptosis in the pathophysiologic mechanisms of intrauterine growth restriction. STUDY DESIGN: Placental samples were obtained from 43 uncomplicated third-trimester pregnancies and from 26 pregnancies complicated by intrauterine growth restriction. The definition used to identify cases of intrauterine growth restriction depended on three criteria: clinical evidence of suboptimal growth, ultrasonographic evidence of deviation from an appropriate growth percentile, and individualized birth weight ratios <10th percentile. Light microscopy was used to quantify the incidence of apoptosis. Electron microscopy and TUNEL (terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick end labeling) staining were used to confirm the occurrence of apoptosis. RESULTS: Quantification of apoptosis (medians and interquartile ranges) resulted in the following values: normal third trimester (n = 43) 0.14% of cells (0.08% to 0.20%) and intrauterine growth restriction third trimester (n  = 26) 0.24% of cells (0.16% to 0.29%). The incidence of apoptosis was significantly higher in placentas from pregnancies with intrauterine growth restriction compared with normal third-trimester placentas (p < 0.01, Mann Whitney U test). CONCLUSIONS: These results suggest that apoptosis may play a role in the pathophysiologic mechanisms of intrauterine growth restriction.(Am J Obstet Gynecol 1997;177:401)     

Congenital tuberculosis

Congenital tuberculosis is a rare disease. The non-specific nature of presenting signs and symptoms (because of the lack of host response) and the fatal outcome in the absence of early therapy all underscore the importance of early diagnosis and treatment in infants. Recognition requires awareness that tuberculosis at this age has manifestations not found in older children. Here a case of congenital tuberculosis is presented, where changes were confined only to the thorax. Tuberculosis in the mother could be diagnosed only retrospectively.