Is there scope for improving the cost-effective prescribing of nonsteroidal anti-inflammatory drugs?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used widely throughout the world to relieve the symptoms of musculoskeletal disorders, in particular osteoarthritis and rheumatoid arthritis. These drugs have significant adverse effects, including gastrointestinal ulceration and the associated complications of perforation and bleeding. The relative toxicity of competing forms of branded and generic NSAIDs varies considerably. Their acquisition cost also varies considerably, sometimes with relatively more toxic drugs being more expensive. Thus, it may be possible to reduce both adverse effects and pharmaceutical expenditures associated with NSAIDs, if doctors' prescribing behaviour can be changed. A tentative exploration of alternative patterns of NSAID use demonstrates that it may be possible to reduce expenditures on NSAIDs in the UK to below the 1994 level, and reduce adverse events. If prescribing of NSAIDs was reduced by 25%, average dosage reduced by 10% and patients switched to less toxic NSAIDs, up to 86 million pounds sterling could be saved per year in the UK, the number of serious adverse events per year reduced by 189 (from a baseline figure of around 500) and the annual number of gastrointestinal complications reduced by 127 (from a baseline figure of around 315). Such results may be achieved without reductions in the quality of life of patients using these drugs. The available clinical and economic information about NSAIDs is limited, and the publication of numerous poor quality studies has corrupted the knowledge base. Despite these problems, there appears to be enough evidence to indicate that expenditure on NSAIDs could be considerably reduced and significant adverse effects could be avoided if general practitioners were persuaded to change their prescribing behaviour. Inefficient and inappropriate prescribing of these often beneficial, but sometimes dangerous, drugs appears to be wasting scarce UK National Health Service resources and harming patients.     

Pricing, demanders, and the supply of health care.

This paper is divided into three substantive sections. In the first section the conventional neoclassical paradigm is augmented by consideration of the agency relationship in which the physician is considered not only as the agent who controls the supply of health care, but also as the decision maker who articulates demand because patients forego this role and rely on "expert" advice. The next section is concerned with the effects of pricing on consumer demand and draws on the available empirical evidence to present estimates of price elasticity, cross elasticity, and other characteristics of the choice process. This analysis is completed by integrating the agency relationship into the discussion and arguing that if the policy objectives are expenditure containment and greater efficiency in resource utilization, the price mechanism should be used to affect the behavior of the primary demander and the supplier: the physician. In the final section the implications of this analysis are discussed in the contexts of two competing perspectives: the liberal market perspective and the collective "needology" perspective, and an attempt is made to distinguish some of the characteristics of the two views of the world.     

Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion

This article describes Posttraumatic Stress Disorder (PTSD) symptomatology in 69 sixth-grade youths who resided within 100 miles of Oklahoma City at the time of the 1995 bombing of the Alfred P. Murrah Federal Building. These youths neither had any direct physical exposure nor personally knew anyone killed or injured in the explosion. A survey conducted two years after the bombing assessed exposure, PTSD symptoms, and functioning. PTSD symptom frequency was measured with the Impact of Event Scale--Revised. Our BCD criteria for defining PTSD caseness was modeled after DSM-IV B, C, and D criteria requiring one reexperiencing, three avoidance/numbing, and two arousal symptoms for diagnosis. Those who met our BCD criteria had significantly higher PTSD symptom scores than those who did not. Both increased mean PTSD symptom score and meeting our caseness definition were associated with increased functioning difficulties. Media exposure and indirect interpersonal exposure (having a friend who knew someone killed or injured) were significant predictors of symptomatology. These findings suggest that children geographically distant from disaster who have not directly experienced an interpersonal loss report PTSD symptoms and functional impairment associated with increased media exposure and indirect loss.     

Insulin-like growth factor (IGF)-1, IGF-binding protein-3, and pancreatic cancer in male smokers.

To investigate whether insulin-like growth factor (IGF)-1 and IGF-binding protein-3 (IGFBP-3) are prospectively associated with exocrine pancreatic cancer, we conducted a nested case-control study within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study cohort of 29,133 male Finnish smokers, aged 50-69 years. To avoid the potential influence of subclinical cancer on IGF-1 and IGFBP-3, all subjects in this study were alive without clinical evidence of cancer during their 5th year of the cohort follow-up. Four hundred randomly selected cohort controls and 93 incident pancreatic adenocarcinoma cases that occurred between their 5th follow-up year through 1997 (i.e., up to 12.7 years of follow-up) were included in this study. Concentrations of IGF-1 and IGFBP-3 were measured in serum samples obtained at baseline using ELISA. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models, adjusted for confounders. Neither IGF-1, IGFBP-3, nor the IGF-1:IGFBP-3 molar ratio was significantly associated with pancreatic cancer: highest compared to lowest tertile, OR = 0.67, 95% CI 0.37-1.21, P trend = 0.17; OR = 0.70, 95% CI 0.38-1.27, P trend = 0.12; and OR = 0.85, 95% CI 0.50-1.46, P trend = 0.54, respectively. Our results do not support the hypothesis that serum IGF-1 and IGFBP-3 concentrations are associated with pancreatic cancer risk among male smokers. Further studies are necessary to evaluate these associations in other populations.     

Foetal cystic abdominal masses

Foetal abdominal cysts are frequently found on routine antenatal ultrasound. Various sonographic features might help in their differential diagnosis. However, a definitive diagnosis is often not made until postnatal life, and detection of an intra‐abdominal cyst antenatally rarely alters obstetric management. A review of possible causes of a foetal abdominal cyst is presented.     

Reducing weight gain in children through enhancing physical activity and nutrition: the APPLE project.

OBJECTIVE: Community-based lifestyle intervention may offer the best means of reducing the global epidemic of childhood obesity and its consequences, yet few successful interventions have been reported. The objective was to determine whether increasing extra-curricular levels of activity could reduce weight gain in children. METHODS: A controlled intervention study was conducted using standardised methods to assess outcomes. Two comparable relatively rural communities in Otago, New Zealand formed intervention and control settings. Height, weight, waist circumference and participation in physical activity (by accelerometry) were measured at baseline and at 1 year in 384 children aged 5 to 12 years representing the majority of children in this age group in intervention and control communities. Community Activity Co-ordinators were employed at each school in the intervention area. Their brief was to widen exposure to activity and engage children not interested in traditional sporting activities by encouraging lifestyle-based activities (e.g. walking) and non-traditional sports (e.g. golf and taekwondo) during extra-curricular time at school, after school and during vacations. Simple dietary advice was offered and the wider community was encouraged to participate. RESULTS: Average accelerometry counts at 1 year were 28% (95% CI: 11 to 47%) higher in intervention compared with control children after adjusting for age, sex, baseline values and school. Intervention children spent less time in sedentary activity (ratio 0.91, p = 0.007) and more time in moderate (1.07, p = 0.001) and moderate/vigorous (1.10, p = 0.01) activity. Adjusted mean BMI Z-score was lower in intervention relative to control children by -0.12 units (95% CI: -0.22 to -0.02). CONCLUSION:. An intervention designed to maximise opportunities for physical activity during extra-curricular time at school and during leisure time through the provision of community-based Activity Co-ordinators significantly increased participation in physical activity and slowed unhealthy weight gain in primary school-aged children.     

Systems Mapping of the New Zealand Free and Healthy School Lunch Programme: Perspectives from Lunch Providers

As part of the COVID-19 economic recovery package, the Aotearoa New Zealand Government rolled out a universal free and healthy lunch programme to the 25% least advantaged schools nationwide. This study explored experiences of school lunch providers in the Hawke’s Bay region. The aim was to create a systems map identifying points of intervention through which the lunch programme could be improved to meet the goal of reducing child food insecurity. Twelve lunch providers were interviewed to generate casual loop diagrams which were examined and integrated to form a single systems map. Seven themes arose during analysis: teacher support, principal support, nutrition guidelines and government support, supply chain, ingredient suppliers, student feedback and food waste. Teacher support was important for getting students to try new foods and eat the nutritious lunches. Principal support was a strong theme impacting opportunities for broader student engagement. This study employed systems science to highlight the importance of support from different stakeholders within the lunch programme to achieve the goal of reduced child food insecurity. Further work is needed to ensure the programme meets the wider goals of the government and community, and to determine the potential broader benefits of the programme.