Medicare's use of cost-effectiveness analysis for prevention (but not for treatment)

ContextMedicare currently pays for 23 preventive services in its benefits package, the majority of which were added since 2005. In the past decade, the program has transformed from one essentially administering treatment claims, to one increasingly focused on health promotion and maintenance. What is largely unappreciated is the role cost-effectiveness analysis has played in the coverage of preventive services.MethodsWe review the role of cost-effectiveness analysis in Medicare coverage of preventive services and contrast it to the lack of such consideration in the coverage of treatments.FindingsWhile not considered for coverage of treatment, cost-effectiveness analysis played a role in the coverage of nine preventive services, and was evaluated in a number of instances when the service was not added. Pneumococcal vaccine, the first preventive service added to the benefit (1981), followed a Congressionally requested cost-effectiveness analysis, which showed it to be cost-saving. More recently, the Centers for Medicare and Medicaid Services (CMS) reviewed cost-effectiveness evidence when covering preventive services such as HIV screening (2010) and screening and behavioral counseling for alcohol misuse (2011) (studies reported cost-effectiveness ratios of $55,440 per QALY, and $1755 per QALY, respectively).ConclusionsCost-effectiveness analysis has played a longstanding role in informing the addition of preventive services to Medicare. It offers Medicare officials information they can use to help ensure health gains are achieved at reasonable cost. However, limiting cost-effectiveness evidence to prevention and not treatment is inconsistent and potentially inefficient.     

Evaluating Quality in Adult Cardiac Surgery

National and institutional quality initiatives provide benchmarks for evaluating the effectiveness of medical care. However, the dramatic growth in the number and type of medical and organizational quality-improvement standards creates a challenge to identify and understand those that most accurately determine quality in cardiac surgery. It is important that surgeons have knowledge and insight into valid, useful indicators for comparison and improvement. We therefore reviewed the medical literature and have identified improvement initiatives focused on cardiac surgery. We discuss the benefits and drawbacks of existing methodologies, such as comprehensive regional and national databases that aid self-evaluation and feedback, volume-based standards as structural indicators, process measurements arising from evidence-based research, and risk-adjusted outcomes. In addition, we discuss the potential of newer methods, such as patient-reported outcomes and composite measurements that combine data from multiple sources.     

社区护士应对突发公共卫生事件救援能力评价指标的构建

目的 构建社区护士应对突发公共卫生事件救援能力评价指标。方法 基于文献研究、理论分析、质性访谈初步拟订评价指标,2020年8月—9月采用德尔菲法对20名专家进行2轮咨询,结合层次分析法和平均分配法计算各级指标权重。 结果 2轮专家咨询的问卷回收率为90%、100%,有效率均为100%;专家权威系数均为0.866;专家意见协调系数分别为0.174、0.224,均具有统计学意义（P<0.001）。最终确立的社区护士应对突发公共卫生事件救援能力评价指标包括突发公共卫生事件预防能力、突发公共卫生事件救援准备能力、突发公共卫生事件救援能力和突发公共卫生事件恢复能力4个一级指标、15个二级指标和51个三级指标。 结论 该研究构建的社区护士应对突发公共卫生事件救援能力评价指标,专家意见统一,为评估社区护士应对突发公共卫生事件救援能力提供了工具,同时为进一步优化社区护士应急培训模式提供参考。     

Professor James M. Tanner and the sport sciences

Background: Although Tanner was not directly involved in physical education or the sport sciences, several of his papers addressed issues related to research in the area.

Aim: To consider the implications of selected papers and research projects for the sport sciences.

Papers and Implications: Several early papers addressed ratio standards, somatotype and total cholesterol, and anthropometric and somatotype changes associated weight training and cessation of training in young adult men. The papers have, respectively, implications for current studies of allometric scaling, physique and risk factors for cardiovascular and metabolic complications, and responses to training. The survey of athletes at the 1960 Rome Olympic Games not only added to the literature but to some extent also set the stage for subsequent surveys of Olympic athletes in 1968, 1972 and 1976. Although not directly involved in the mixed-longitudinal study of Training of Youth Athletes (TOYA) in several sports, it was conducted in his department. Results from TOYA indicated no influence of systematic training for sport on growth in height, young adult height and sexual maturation. Growth at Adolescence was also a fixture in many graduate programs.

Conclusion: Though not a sport scientist, Tanner contributed directly and indirectly to the field.     

Human Biological Surveys

Abstract

Background: In 2006, the World Health Organization published universal growth standards for all children from birth to 5 years of age, based on a sample of breastfed children.

Aims: The present study documented breastfeeding prevalence in the Flemish Growth Survey 2004, and compared growth of exclusively breastfed children in Flanders with local reference charts and WHO growth standards.

Subjects and methods: A subset of 3287 children 0–3 years of age from the Flemish reference population was studied. Prevalence and duration of breastfeeding were estimated with the status quo method. SD scores (SDS) of length/height, weight, BMI, and head circumference were plotted by age.

Results: Breastfeeding is initiated for 68.2% of children, and approximately 25% were exclusively breastfed until at least 6 months of age. Breastfed children grow according to a typical pattern that deviates from the local reference curve. The average length of breastfed children is reasonably close to the WHO growth standard, but this does not hold for weight, BMI, or head circumference. In Flanders, breastfed children are more comparable to the local reference than to the WHO growth standards.

Conclusions: Growth of breastfed children is similar to the WHO standards for length, but not for other traits. In Flanders, the use of the recent local growth reference is advised for both breastfed and formula-fed children.     

Festschrift in honor of the 65th birthday of Dr John L. Brash. Part 2

Adsorption of fibrinogen from buffer as a single protein and from plasma to four materials has been studied. The two NIH-NHLBI primary reference standards, filler free polydimethylsiloxane and low density polyethylene, were used along with polyvinylchloride and cellulose materials supplied by the IUPAC Working Party. The materials were examined in both film and tubing form, except for polydimethylsiloxane which was studied only in tubing form. Adsorption was measured at room temperature using ¹²⁵I-Iabelled fibrinogen. The order of adsorbed amounts in the single protein experiments was found to be: cellulose < PVC < PE = PDMS. Apparent adsorption affinities are in the same order. In plasma, all surfaces except cellulose showed maxima in adsorption as a function of plasma concentration after 5 min contact. This is indicative of initial adsorption followed by displacement of fibrinogen (the Vroman effect). Cellulose showed very low adsorption of fibrinogen from plasma. The Vroman maxima were more pronounced on the tubing samples than on the films, and, as for the single protein experiments, adsorption was found to be less on tubing than on film samples. A tentative interpretation of the Vroman effect data suggests that the order of procoagulant activity of the materials may be: PDMS = PE < PVC < cellulose.     

中国药典气体灭菌法质量标准的分析与现状思考

目的 分析中国药典气体灭菌法质量标准与国外药典的差异以及对现状的思考,探索进一步提高和完善中国药典气体灭菌法标准的路径。方法 将美国药典、欧洲药典、日本药局方与中国药典收载的气体灭菌法质量标准进行比对,同时采取参阅其他文献和企业调研的方式展开研究。结果 中国药典与国外药典在气体灭菌法的质量控制上整体要求是一致的,但在一些方面还存在一定的差异性,如气体灭菌法的定义和范畴、生物指示剂的菌株种类和编码、物理化学指示剂的分类和异常说明、验证方法、灭菌剂残留的解析和检测等,需要通过充分的技术评估和可行性分析来逐步完善;此外我国大部分企业的硬件水平差距较为明显,如气体浓度探头的使用、灭菌柜循环系统的配备、热解析室的建立等,其根源很大程度上在于企业成本和发展观念的制约。结论 应根据我国实际情况,进一步完善我国气体灭菌法的国家标准,同时以提高技术标准为依托,推动我国气体灭菌企业转变思维模式和观念,不断优化工艺,提高整体行业水平。     

Anti-Müllerian Hormone Levels in the Follicular Fluid of the Preovulatory Follicle: A Predictor for Oocyte Fertilization and Quality of Embryo

This prospective study investigated the relationship between anti-Müllerian hormone (AMH) level in the follicular fluid (FF) and the quality of the oocyte and embryo. A total of 65 FF samples from 54 women were included in this study. FF was collected from the largest preovulatory follicle sized≥20 mm of mean diameter from each ovary. Samples were divided into 3 groups according to the FF AMH levels: below the 33th percentile (low group, FF AMH<2.1 ng/mL, n=21), between the 33th and the 67th percentile (intermediate group, FF AMH=2.1-3.6 ng/mL, n=22), and above the 67th percentile (high group, FF AMH>3.6 ng/mL, n=22). The quality of the ensuing oocytes and embryos was evaluated by fertilization rate and embryo score. FF AMH levels correlated positively with the matched embryo score on day 3 after fertilization (r=0.331, P=0.015). The normal fertilization rate was significantly lower in the low group than in the intermediate group (61.9% vs. 95.5% vs. 77.3%, respectively, P=0.028). Our results suggest that the FF AMH level could be a predictor of the ensuing oocyte and embryo quality.

Graphical Abstract

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