EURIPA: EUROPEAN RURAL AND ISOLATED PRACTITIONERS ASSOCIATION

Abstract

Point-of-care tests are biomedical tests on patients’ specimens like blood, saliva, urine or faeces, which can be used near the patient, without interference of a laboratory. The use of these tests, many of which have been recently developed, is increasing in general practice, where they add to the GP's set of diagnostic instruments. The question is, however, whether they always contribute to an effective and high-quality diagnostic process by GPs. We present a set of criteria that can be used by guideline developers, regional primary care organizations and individual GPs to evaluate a new point-of-care test in a practice setting. These criteria do not relate only to their use and quality. A point-of-care test needs to be evaluated in the right population and for the right indications, and GPs then need to use them for the indications for which they were evaluated. Expanding the range of indications can lead to an increase in false-positive and false-negative test results.     

Cost-Effectiveness of Midazolam Versus Haloperidol Versus Olanzapine for the Management of Acute Agitation in the Accident and Emergency Department

ObjectivesA multicenter randomized clinical trial in Hong Kong Accident and Emergency (A&E) departments concluded that intramuscular (IM) olanzapine is noninferior to haloperidol and midazolam, in terms of efficacy and safety, for the management of acutely agitated patients in A&E setting. Determining their comparative cost-effectiveness will further provide an economic perspective to inform the choice of sedative in this setting.MethodsThis analysis used data from a randomized clinical trial conducted in Hong Kong A&E departments between December 2014 and September 2019. A within-trial cost-effectiveness analysis comparing the 3 sedatives was conducted, from the A&E perspective and a within-trial time horizon, using a decision-analytic model. Sensitivity analyses were also undertaken.ResultsIn the base-case analysis, median total management costs associated with IM midazolam, haloperidol, and olanzapine were Hong Kong dollar (HKD) 1958.9 (US dollar [USD] 251.1), HKD 2504.5 (USD 321.1), and HKD 2467.6 (USD 316.4), respectively. Agitation management labor cost was the main cost driver, whereas drug costs contributed the least. Midazolam dominated over haloperidol and olanzapine. Probabilistic sensitivity analyses supported that midazolam remains dominant > 95% of the time and revealed no clear difference in the cost-effectiveness of IM olanzapine versus haloperidol (incremental cost-effectiveness ratio 667.16; 95% confidence interval ?770.89, 685.90).ConclusionsIM midazolam is the dominant cost-effective treatment for the management of acute agitation in the A&E setting. IM olanzapine could be considered as an alternative to IM haloperidol given that there is no clear difference in cost-effectiveness, and their adverse effect profile should be considered when choosing between them.     

Cervical cancer and the global health agenda: Insights from multiple policy-analysis frameworks

Cervical cancer is the second leading cause of cancer deaths for women globally, with an estimated 88% of deaths occurring in the developing world. Available technologies have dramatically reduced mortality in high-income settings, yet cervical cancer receives considerably little attention on the global health policy landscape. The authors applied four policy-analysis frameworks to literature on global cervical cancer to explore the question of why cervical cancer may not be receiving the international attention it may otherwise warrant. Each framework explores the process of agenda setting and discerns factors that either facilitate or hinder policy change in cases where there is both a clear problem and a potential effective solution. In combination, these frameworks highlight a number of crucial elements that may be needed to raise the profile of cervical cancer on global health agendas, including improving local (national or sub-national) information on the condition; increasing mobilisation of affected civil society groups; framing cervical cancer debates in ways that build upon its classification as a non-communicable disease (NCD) and an issue of women's rights; linking cervical cancer screening to well-funded services such as those for HIV treatment in some countries; and identifying key global policy windows of opportunity to promote the cervical cancer agenda, including emerging NCD global health discussions and post-2015 reviews of the Millennium Development Goals.     

Consumer Participation in Identifying Research and Development Priorities for Power Wheelchair Input Devices and Controllers

A focus group comprised of persons who use power wheelchairs and professionals working in the field were asked to participate in a brainstorming session to determine priorities for the development and application of power mobility input devices and control concepts. The group consensus was that durability and reliability are the most important criteria. Essentially, the expectation is that a power wheelchair must work everyday in the way a person needs it and wants it. At the same time, there is a desire to enhance and advance the features of input devices and control systems. Many would say these changes constitute designing “smarter” power wheelchairs, such as systems that can independently detect obstacles and can provide users with more feedback. This paper presents the rationale behind forming this focus group and details of the results of a brainstorming session where ideas were generated and prioritized. The five most important issues as determined by the group are discussed in depth.     

Risk resistance: constructing home birth as morally responsible on an online discussion group

In hegemonic risk discourses, hospital obstetric units are represented as the safest and best birth settings; however, a minority of women in England and Wales (2.3% in 2014) still opt for home birth. In this article, I analyse pro-home birth discourses on a UK-based online discussion group for pregnant women covering the period 2010–2015 and collected in March 2016, to identify how individuals making pro-home birth posts on the site represented home birth as a morally responsible choice. Using Foucauldian discourse analysis, I identify three main themes: home births as a normal process, representing an intimate, existential life moment which meets women’s needs for care and personal autonomy, and is convenient and relatively safe, in contrast to hospital births which are characterised as risky; home births as morally legitimate and justified by discourses of evidence-based risk assessment, woman centredness and empowerment; and home birth as not risky and the mothers who opt for it were not taking unnecessary risks but were acting responsibly. In this article, I examine the ways in which the online setting can be used to resist dominant risk discourses. I show how the participants in the online discussion group in my study used available discursive resources to challenge hegemonic risk discourses regarding birth setting, making resistance to dominant risk discourses possible, as pro-home birth discourses legitimised ‘nonconformist’ decisions regarding birth setting. The focus on the ‘risk-takers’ in this article is valuable for healthcare practitioners seeking to improve their communication about birth setting choices with pregnant women.     

A Bayesian Approach for Benefit-Risk Assessment

An important aspect of the drug evaluation process is to have an integrated benefit-risk assessment to determine, using some quantitative measures, whether the benefit outweighs the risk for the target population. Chuang-Stein et al. proposed a five-category random variable along with three global measures of benefit-risk assessment. Assuming the cell probabilities follow a multinomial distribution, we propose a Bayesian approach for the longitudinal assessment of benefit-risk using these three global measures and a new measure. A Dirichlet distribution is used as the natural conjugate prior for multinomial cell probabilities, and the posterior distributions of cell-probabilities are recursively derived as the data from multiple visits become available. In a more generalized approach, a power prior is used through the likelihood function to discount the information from previous visits, and, again, the posterior distributions of the cell-probabilities at multiple visits are derived. The estimates of the posterior means and credible intervals for the four global measures are derived, and the decision rules based on the credible intervals are applied for the assessment of the four global measures. Using two simulated datasets generated under two different scenarios—one where benefit outweighs risk and the other where benefit does not outweigh risk—the performances of the four measures are evaluated using a Markov chain Monte Carlo (MCMC) technique. We illustrate of the methodology using clinical trial data.     

Goal setting practice in chronic low back pain. What is current practice and is it affected by beliefs and attitudes?

Introduction: Goal setting, led by the patient, is promising as an effective treatment for the management of chronic low back pain (CLBP); however, little is known about current practice. The aims of the study were to explore (1) current goal setting practice in CLBP among physiotherapists; (2) perceived barriers to goal setting in CLBP; and (3) relationship between clinician’s attitudes and beliefs and goal setting practice. Method: A cross-sectional observational survey. Results: The majority of respondents used goal setting with the main aim of facilitating self-management. The greatest number of goals were set with 50% therapist/50% patient involvement. The most common perceived barriers to goal setting related to time constraints and lack of skill and confidence. A higher biomedical score for treatment orientation of the therapist was associated with a lower patient involvement score. Conclusion: Goal setting is common practice for CLBP and is perceived as a high priority. It is more often a collaboration between therapist and patient rather than patient-led with treatment orientation of the physiotherapist a predictor of patient involvement. Education of healthcare professionals needs to include better understanding of chronic pain to orient them away from a biomedical treatment approach, as well as to enhance skills in facilitating patient involvement in goal setting.