Applying health technology assessment to pharmaceutical care: pitfalls and future directions

It has been argued in previous issues of this journal that health technology assessment can be used as a tool to assess the efficiency of pharmaceutical care by linking its impact on clinical and humanistic outcomes to the resources required to achieve these outcomes. Additionally, as policy-makers appreciate the need to evaluate projects on the basis of their costs and benefits, the application of health technology assessment to pharmaceutical care may serve as a way of communicating with policy-makers and informing policy on pharmaceutical care.This article elaborates on this idea by arguing that policy-makers will be more likely to appreciate the value of pharmaceutical care if researchers pay more attention to some methodological principles underlying health technology assessment in the context of pharmaceutical care, and if they take into account the decision-making context facing policy-makers. In order to raise the methodological quality of studies, researchers need to take care to define better the pharmaceutical care intervention; to evaluate the costs of the intervention and its impact on the utilization of other health services; and to aggregate the various clinical and humanistic outcome measures that are commonly used in this type of research. In order to increase the usefulness of study findings to policy-makers, researchers need to identify the multiple objectives that policy-makers pursue, and show how study findings will aid policy-makers in attaining these objectives.     

Evidence-based health promotion for older people and instrumentalisation: comparing the influence of policy contexts in Austria and England

Health promotion (HP) amongst older people is an increasingly prominent policy concern for governments. The development of an evidence-base and the advocacy of effective interventions in the light of this act as legitimation tools for the overall HP phenomenon – assisting the growth of state and non-state funding for public health initiatives for older people. In structuring decision-making as to which individual projects/initiatives receive funding, frameworks for acknowledging efficacy impact on formats of HP work both positively and negatively. Drawing on recent research across the EU and focusing on the specific national contexts of Austria and England, this comparative policy analysis triangulates best-practice modelling, evaluation data and interviews with project coordinators to explore how policy contexts impact on the nature and format of HP interventions. Amidst a developing awareness of what effective practice looks like, successful HP initiatives must advocate their legitimacy within narrow rules of quality, where measurable outcomes have become the keys which unlock financial resources. Findings across both countries suggest that this instrumentalisation of legitimation, driven by economic pressures and bureaucratic generalisability, threatens the rationality of HP. From a Habermasian perspective, tensions emerge between projects’ remaining reflexive towards processes and their need to articulate the ‘success’ of the interventions in a language of outcomes. Over time, in an era where resources are increasingly scarce and competition over these intensifies, a danger exists whereby the instrumentality of HP begins to separate from, and impinge upon, the capacity for projects to think and act holistically.     

Nursing and the Emergence of Egoless Care: A Discussion on Social Engineering in Mental Health

The narrowing of the diverse fields of psychiatry to just the single dimension of the biomedical model has resulted in a situation where professions with a focus on curing (psychiatrists and psychologists) are favoured over those with a focus on caring and encouraging near communities to care for each other (nurses). The social engineering of mental problems leads to a state of helplessness. This paper contributes to an understanding of the barriers to utilise the social resources of people with mental health problems and argues for forms of “indirect social engineering” and “egoless care,” and, ultimately, a rediscovery of nursing, using the mental health care in the Netherlands as a case study.     

Deficiencies in the transfer and availability of clinical trials evidence: a review of existing systems and standards

ABSTRACT: BACKGROUND: Decisions concerning drug safety and efficacy are generally based on pivotal evidence provided by clinical trials. Unfortunately, finding the relevant clinical trials is difficult and their results are only available in text-based reports. Systematic reviews aim to provide a comprehensive overview of the evidence in a specific area, but may not provide the data required for decision making. METHODS: We review and analyze the existing information systems and standards for aggregate level clinical trials information from the perspective of systematic review and evidence-based decision making. RESULTS: The technology currently used has major shortcomings, which cause deficiencies in the transfer, traceability and availability of clinical trials information. Specifically, data available to decision makers is insufficiently structured, and consequently the decisions cannot be properly traced back to the underlying evidence. Regulatory submission, trial publication, trial registration, and systematic review produce unstructured datasets that are insufficient for supporting evidence-based decision making. CONCLUSIONS: The current situation is a hindrance to policy decision makers as it prevents fully transparent decision making and the development of more advanced decision support systems. Addressing the identified deficiencies would enable more efficient, informed, and transparent evidence-based medical decision making.     

Simple posterior vestibuloplasty for central introital dyspareunia

The aim of this study is the evaluation of a simple surgical widening plasty of the posterior vestibulum for central introital dyspareunia. This study takes place in gynecological infectious diseases clinic in secondary and tertiary care centers. The subjects are one hundred forty-five consecutive patients with introital pain during or when attempting sexual intercourse. One-digit examination of the posterior hymenal rim of the vulva elicits the specific pain and clinical examination reveals nothing abnormal or only focal redness on the central posterior vestibulum. This condition should be clearly differentiated from the focal-provoked vestibulodynia, although mixed forms are frequent. A questionnaire was composed to assess the level of pain experienced during intercourse and of satisfaction of their sexual life in general at 1 to 3?years after the intervention. After a mean of 3?years, 90% of the patients were very satisfied with the improvement of the sexual health due to the intervention. Eighty percent had less pain during intercourse. The proportion of patients forced to interrupt sexual intercourse because of pain dropped from 64% to 26% (p?<?0.0001). The number of women only having infrequent intercourse (once a month or less) decreased more than fourfold and the mean number of occasions that sexual intercourse took place increased by 27% after the intervention. Simple surgical widening plasty of the posterior vestibulum without excision of tissue led to a significant improvement of the sex life of at least 80% of a group of women with primary and secondary central introital dyspareunia of any cause. Correct and specific diagnosis is crucial prior to any intervention.