Interlaboratory variability in assessment of the model of end‐stage liver disease score

Background: The model of end‐stage liver disease (MELD) score is nowadays widely used to prioritize patients for liver transplantation. Aims: To assess the contribution of the individual components of the MELD score in interlaboratory variability. Methods: We sent 15 samples from patients listed for liver transplantation to seven different European laboratories who were asked to measure all three variables. In addition, 10 samples from patients on oral anticoagulant treatment were sent to the same labs for the international normalised ratio (INR) measurement. Results and Conclusions: In all 15 samples, a substantial and clinically relevant variation in the calculated MELD score was observed between laboratories. The mean difference in the MELD score between the highest‐ and the lowest‐scoring laboratory was 4.8. The variation in creatinine measurements resulted in differences of up to three MELD points in a single patient when comparing the highest and the lowest scoring lab. The variation in bilirubin measurements only accounted for a difference of one point between the highest‐ and the lowest‐scoring laboratory, but the variation in INRs resulted in differences of 2 to 12 MELD points. MELD scores or INR values were not substantially different in laboratories that used the Owren instead of the more widely used Quick methodology for INR measurements. The variability in the INR in patients on oral anticoagulants was substantially less as compared with the variability in patients with liver disease. In conclusion, we observed a large interlaboratory variation in the MELD score. This variation in the MELD score is primarily caused by the INR.     

Clinical prioritizations and contextual constraints in nursing homes – a qualitative study

Scand J Caring Sci; 2010; 24; 533–540
Clinical prioritizations and contextual constraints in nursing homes ‐ a qualitative study Aim: The aim of the study was to describe nurses’ and physicians’ experiences of prioritization factors in nursing homes. Background: What are the experiences of health care personnel when prioritizing treatment and care for elderly residents in nursing homes? Little research has been done in this area, yet with the growing elderly population and limited health care budgets there can be little doubt about its relevance. Method: The study was conducted through semi‐structured interviews with 13 physicians and nurses in six nursing homes. The interviews were analysed by manifest content analysis based on first‐ and second‐level categories describing relevant factors. The categories were developed after preliminary readings of the texts. Results: This study revealed that there was a complex set of contextual constraints which influenced the care provided. There were three main findings: (i) some overall challenges related to providing good care to nursing home residents; these in turn influenced (ii) prioritizing dilemmas and (iii) factors influencing prioritization decisions. Discussion: Contextual constraints and higher level prioritizations seem to play a key role in clinical prioritizations in nursing homes. The combination of implicit rationing and the factors described as most predominant in the clinical prioritizations in nursing homes may result in inadequate and unjust health care services for some of the nursing home residents. In particular, those patients who do not speak up or do have comprehensive needs are at risk of being neglected.     

Importance of Different Types of Prior Knowledge in Selecting Genome‐Wide Findings for Follow‐Up

Biological plausibility and other prior information could help select genome‐wide association (GWA) findings for further follow‐up, but there is no consensus on which types of knowledge should be considered or how to weight them. We used experts’ opinions and empirical evidence to estimate the relative importance of 15 types of information at the single‐nucleotide polymorphism (SNP) and gene levels. Opinions were elicited from 10 experts using a two‐round Delphi survey. Empirical evidence was obtained by comparing the frequency of each type of characteristic in SNPs established as being associated with seven disease traits through GWA meta‐analysis and independent replication, with the corresponding frequency in a randomly selected set of SNPs. SNP and gene characteristics were retrieved using a specially developed bioinformatics tool. Both the expert and the empirical evidence rated previous association in a meta‐analysis or more than one study as conferring the highest relative probability of true association, whereas previous association in a single study ranked much lower. High relative probabilities were also observed for location in a functional protein domain, although location in a region evolutionarily conserved in vertebrates was ranked high by the data but not by the experts. Our empirical evidence did not support the importance attributed by the experts to whether the gene encodes a protein in a pathway or shows interactions relevant to the trait. Our findings provide insight into the selection and weighting of different types of knowledge in SNP or gene prioritization, and point to areas requiring further research.     

Prioritizing patients for prostatectomy: balancing clinical and psychosocial factors

BACKGROUND: The aim of this study was to develop a points-based approach to prioritize patients for elective transurethral resection of the prostate and to determine the relative contributions that clinical and psychosocial characteristics should make to a measurement of urgency for surgery. Another objective was to measure the agreement between urologists, other medical practitioners and laypersons in assessing the major determinants of priority. METHODS: A focus group of urologists and epidemiologists developed a standard questionnaire identifying relevant clinical and psychosocial factors in men with benign prostatic hypertrophy. The questionnaire was used to interview 48 men with benign prostatic hypertrophy being placed on waiting lists for transurethral resection of the prostate at four Victorian public hospitals. Individual patient case vignettes were produced using the answers to the interview questions. Members of an assessor panel comprising six laypeople, six non-urologist medical practitioners, and five urologists individually reviewed the vignettes and assigned urgency ratings and rankings to each patient. The urgency ratings and rankings were used to derive weightings for the clinical and psychosocial factors that were then incorporated into a prioritization tool framework. RESULTS: The assessor panel perceived a broad spread of urgency for surgery among the patients. Agreement on rankings and urgency ratings was moderate among assessors. Linear regression showed that the effect of clinical symptoms and psychosocial disturbance held approximately equal-strength independent associations with perceived urgency for all groups of assessors. CONCLUSION: Urologists, non-urologist medical practitioners and laypeople considered the severity of benign prostatic hypertrophy symptoms and any resulting psychosocial disturbance as equally important in establishing priority for transurethral resection of the prostate. New prioritization tools should take both into consideration and weight them equally.     

Pesticide prioritization for a case-control study on childhood leukemia in Costa Rica: a simple stepwise approach

Multiple exposures and rapidly changing use patterns are obstacles for adequate recall of pesticide exposures in epidemiologic studies. We present a simple stepwise approach for prioritization of pesticides as part of the exposure assessment strategy in an ongoing case-control study on pesticides and childhood leukemia in Costa Rica. Pesticide imports between 1977 and 2000, approximately the pertinent exposure period, were surrogates for use data. In the first phase, 323 active ingredients were identified, of which 219 were eliminated based on low usage and absence or negative results in a preliminary search in three major toxicity databases. In the second phase, the remaining 104 pesticides underwent scoring for their toxicodynamic potential (TDP) with regard to carcinogenicity, mutagenicity, and teratogenicity, weighted in this order. Bioavailability was assessed when TDP was multiplied by a weight for persistence and bioaccumulation, producing the intrinsic toxic potential (ITP). ITP was multiplied by an index of quantity (QI) of pesticide used in the exposure period, resulting in a weighted toxic potential (WTP). The top 25 positions in each of the four rankings (TDP, ITP, QI, and WTP) yielded together 64 highest-priority pesticides. This prioritization process has to be complemented with a further breakdown into crop-, time-, and biocide-specific shortlists to achieve a recall tool suitable for developing countries. Different parameters for prioritization assure inclusion of all relevant pesticides with regard to toxicity and bioavailability. The method contributes to cancer epidemiology in developing countries with access to basic use data and the Internet. The method is adaptable to other health outcomes.     

Thinking about equity in health care

Public health care systems such as the British National Health Service typically profess two principal objectives: to improve the health of the whole population; and to reduce inequalities in health within it. Given scarce resources, these objectives are often in conflict. Much attention has justifiably been paid, by health economists, to addressing the former objective with methods of economic appraisal. My intention is to focus on the more difficult issue of the pursuit of 'equity' in health care, specifically the desire to reduce inequalities in health. This raises philosophical and policy questions about what makes some people more deserving of care than others, and whether or not society should adopt a forgiving stance towards those who have compromised their health status in some way, and offer access to treatment. Also, decision-makers may need to distinguish between the goal of raising the level of those worse-off and reducing inequality across society as a whole. Moreover, it is important to clarify what we wish to be made less unequal within the realm of health care provision. Tough decisions like these are based on value judgements and trading off one priority against another. In the interests of equity, such decisions need to be transparent and based on the preferences of society as a whole rather than covert and capricious. No manager needs reminding that resources are limited or that if more favourable treatment is accorded to some, inevitably less favourable treatment is accorded to others. Policy-making for a whole unit requires a nurse manager to offer a perspective on multidisciplinary matters and engage in wider public policy issues facing the team. As circumstances change, existing practice may be challenged as unfair, inefficient, or failing to account for important patient characteristics which make them different. Here, thinking clearly about equity is very important, and nurse managers are important as clarifiers of the thinking about what should be considered when making these difficult decisions.     

Priority assessment of patients for elective general surgery: game on?

Background: Clinical priority assessment criteria (CPAC) are used to generate a score by which patients are prioritized and rationed for elective surgery. It is widely believed that surgeons elevate scores to ensure their patients’ acceptance for elective surgery, colloquially called gaming. The purpose of the present paper was therefore to investigate whether there was a temporal trend to an increase in the assigned priority score from the inception of CPAC to the present. Methods: Priority and weighted inlier equivalent separations (WIES) scores between 23 April 1999 and 23 July 2002 were collected for elective general surgical cases at Auckland Hospital. A total of 5440 cases was retrospectively analysed using multiple regression techniques. Priority score was included as the dependent variable and time as an independent variable. Any change in case complexity over that period was accounted for by including the WIES score as a covariate. Multiple regression was undertaken for the combined surgeons and for individuals. Results: The combined model was statistically significant but accounted for only 17% of the priority score variance. An increase of one WIES unit leads to an increase of 2.7 in priority score (P = 0.0001). The relationship of priority score with time was dependent on the surgeon performing the prioritization. However, only half the surgeons had individual models that indicated gaming. Conclusions: The results show that gaming is occurring but that not all surgeons participate in this. The difference between surgeons’ participation in gaming is a potential source of practice variation in the prioritization process.     

New treatments for advanced cancer: an approach to prioritization

The allocation of funding for new anticancer treatments within the UK has not kept pace with demand. Clinicians find themselves restricted in the use of licensed drugs which they feel are in the best interests of individual patients. Against this, health authorities have a duty to ensure that scarce resources are used equitably to meet the needs of the local population as a whole. Differential levels of funding for new treatments across the country have led to concerns about rationing by postcode. This paper outlines an approach to the prioritization of new treatment for advanced cancer developed jointly by clinicians and health authorities in South London. The approach involves evidence reviews and consensus meetings. Existing and new treatments are rated on a four-point 'relative effectiveness scale', which takes account of the impact of the treatment on quality of life and on survival. The strength of evidence supporting each effectiveness rating is also classified. Health Authorities have used these ratings to determine overall funding levels, while leaving decisions on individual patients to the relevant Trusts.