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.     

Occupational therapy in mental health: challenges and opportunities

The National Mental Health Policy and National Mental Health Plan published in 1992 provided directions for the reform of mental health services in Australia. They stated that mental health services should be part of the mainstream health system and that integrated mental health programmes should be developed to cover the full range of specialist mental health services, focusing on improved quality of service, the consumers, equity of access, continuity of care and redistribution of resources. The Queensland Mental Health Plan published in 1994 set out specific objectives and strategies for implementing mental health service reform in Queensland. In Queensland there has been a concentration on developing core mental health services involving the reorientation of service delivery from institutions to the community, based on the principles of integration, mainstreaming and regional self-sufficiency. Major restructuring of mental health services is taking place, which has meant changes in service development, organizational structures and work practices. There has been a significant impact on the roles and skills required by the mental health workforce in the context of today's mental health services climate. There is a focus on staff providing individualized assessment and continuing treatment using a case management approach, within a continuum of care. Implications for occupational therapists include developing a generic skill base in preparation for broad-spectrum mental health professional roles while maintaining their professional identity. It is recommended that research be conducted to examine the capacity of occupational therapists to adapt to the changing mental health environment. Copyright © 1999 Whurr Publishers Ltd.     

Health and development: knowledge systems and local practice in rural Thailand

The specific framing of health within a development context has implications for constructions of wellness and illness and how people react in times of ill health. In Thailand, recent national HIV/AIDS education-prevention campaigns commonly use topdown relay of public health information. This pattern replicates numerous development projects that aim to bring useful and beneficial knowledge to rural villagers. How villagers integrate this information depends, in part, on previous experiences with development programs in general and public health programs in particular. This paper considers the political economy of medical knowledge and multiple local health strategies in rural Northeast Thailand as a background to the contingent response to public health directives.     

Anaesthetic management of a parturient with severe muscular dystrophy,lumbar lordosis and a difficult airway

Purpose

This case describes the management of a 19-yr-old wheelchair bound primigravida with severe muscular dystrophy who presented for Caesarean section after spontaneous rupture of membranes. Anaesthesia was influenced by several features of her systemic disease which were impediments to both neuraxial and general anaesthesia.

Clinical features

Other than for a prenatal record and the history obtainable from the patient, little additional medical information was available. Physical examination showed diffuse muscular weakness and an anatomically abnormal airway. Examination of the spine showed slight 10–15° thoracolumbar scoliosis and > 45° lumbar lordosis. Fetal assessment was normal. Echocardiography revealed mildly decreased left ventricular function and was consistent with pulmonary hypertension. After discussion with the patient and her obstetrician, elective Caesarean delivery was deemed the best management. Neuroaxial anaesthesia was at an increased risk of failure due to the profound lumbar lordosis. A plan for awake intubation and general anaesthesia was described to the patient in case regional anaesthesia could not be initiated. A fibreoptic bronchoscope and difficult intubation kit were made available. General anaesthesia was expected to have increased risk of postoperative pulmonary complications, hence epidural anaesthesia was attempted. After difficult catheter insertion, a sensory block was titrated to a T₄ level. This was well tolerated by both mother and fetus. A healthy baby was delivered with Apgar scores of 9 and 9. Postoperatively the mother was transferred to the intensive care unit. After 72 hr, the patients respiratory status allowed transfer to the ward.

Conclusion

This case illustrates the use of epidural anaesthesia in the successful management of a severely compromised patient with limb-girdle muscular dystrophy undergoing elective Caesarean section.     

First experience in healthy volunteers with technetium-99m l,l-ethylenedicysteine,a new renal imaging agent

Animal studies have indicated that technetium-99m l,l-ethylenedicysteine (^99mTc-l,l-EC) may be a promising tracer agent for renal function studies. We have performed a paired study with ^99mTc-mercaptoacetyltriglycine (^99mTc-MAG₃) and ^99mTc-l,l-EC in six male volunteers. In both cases, iodine-131-labelled o-iodohippurate was co-injected as an internal biological standard. The analog images between 0 and 30 min p.i. were of identical diagnostic value for both tracer agents. The two renograms were similar in all volunteers. The mean 1-h plasma clearance for ^99mTc-MAG₃ and 99 mTc-l,l-EC was significantly different, respectively 382.9 ± 17.1 ml/min per 1.73 m² versus 460.2 ± 47.7 ml/min per 1.73 m² (P<0.003). The urinary excretion after 30 min p.i. was 69.4% ± 5.6% of the injected dose for ^99mTc-MAG₃ versus 66.5% ± 2.5% for ^99mTc-l,l-EC (P>0.05) and after 60 min p.i. respectively 83.1% ± 3.9% versus 79.8 % ± 4.3 % (P > 0.05). ^99mTc-l,l-EC has a very low plasma protein binding (31% ± 6.8%) as compared to ^99mTc-MAG₃ (88% ± 5.2%) and a larger volume of distribution. Although the exact mechanism responsible for the high plasma clearance of ^99mTc-l,l-EC is not yet fully known, we conclude that this new agent merits further clinical evaluation in patients to establish its value as a renal radiopharmaceutical. Correspondence to: A. Verbruggen     

Comparative assessment of bone mineral density of the forearm using single photon and dual X-ray absorptiometry

Summary Forearm bone mineral density (BMD) was measured at proximal and distal sites by ¹²⁵I single photon absorptiometry (SPA) and by dual energy X-ray absorptiometry (DXA) in 67 consecutive subjects, aged 18–75 years. Correlations and regression equations between these two techniques were determined. All forearm measurements were significantly correlated with each other (r=0.599–0.926; P0.0001). Although SPA and DXA correct for fat in different ways, we found similar correlation and regression equations in women with body mass index measurements above and below the mean. In addition, forearm measurements by both techniques were moderately correlated with vertebral spine and hip BMD. We conclude that overall, SPA forearm measurements in a population can be calibrated to DXA measurements if necessary, and that DXA forearm measurements are as predictive of the remainder of the skeleton as SPA measurements.     

The CINOD, AZD3582, exhibits an improved gastrointestinal safety profile compared with naproxen in healthy volunteers

COX-inhibiting nitric oxide donators (CINODs) are a new class of drugs in development for the treatment of acute and chronic pain. They comprise a COX-inhibiting moiety linked to a nitric-oxide-donating component and are designed to provide an innovative mechanism of action of balanced COX inhibition and controlled nitric oxide donation. Through these pathways, CINODs should provide analgesic and anti-inflammatory efficacy, while offering gastrointestinal safety through the tissue-protective effects of nitric oxide donation. AZD3582 [4-(nitrooxy)butyl-(2S)-2-(6-methoxy-2-naphthyl)propanoate] is the first agent in the CINOD class to enter extensive clinical development. Pre-clinical studies demonstrate that AZD3582 has a superior gastrointestinal safety profile to naproxen, while demonstrating analgesic and anti-inflammatory efficacy. In healthy human volunteers, AZD3582 caused little gastrointestinal damage compared with equimolar doses of naproxen. Studies to evaluate the longer-term gastrointestinal safety of AZD3582, alongside its efficacy in alleviating chronic and acute pain, are ongoing.