Do budget-holding physicians respond to price? the case of fundholding in the UK.

In an effort to improve the efficiency of the healthcare sector, some countries have experimented with various forms of 'internal market' in public healthcare provision. In some models, policymakers have assumed that actors will behave, as in a retail market, by responding to price in the course of seeking the best 'value for money' from healthcare providers. In the study reported here we examined the responsiveness of general practitioners to price during the British experiment in general practice (GP) fundholding. The study analysed routine data on 29 423 referrals for elective care made by 129 practices in one city to two competing providers of secondary care. Indices of price responsiveness were calculated for each practice from their manifest referral behaviour. These were then used to compare fundholding and non-fundholding practices. The results showed no difference between these groups in their propensity to respond to published procedure prices, even when potential savings were very large. Our findings are consistent with the reported views of fundholding GPs that price was a secondary consideration in their referral behaviour, and provides further evidence that healthcare markets cannot be understood in simplistic terms.     

Roentgen stereophotogrammetric analysis of metal-backed hemispherical cups without attached markers

A method for the detection of micromotion of a metal-backed hemispherical acctabular cup is presented and tested. Unlike in conventional roentgen stereophotogrammetric analysis, the cup does not have to be marked with tantalum markers: the micromotion is calculated from the contours of the hemispherical part and the base circle of the cup. In this way two rotations (tilt and anteversion) and the translations along the three cardinal axes are obtained. In a phantom study, the maximum error in the position of the cup's centre was 0.04 mm. The mean error in the orientation of the cup was 0.41 with a 95% confidence interval of 0.28-0.54°. The in vivo accuracy was tested by repeated measurement of 21 radiographs from seven patients. The upper bound of the 95% tolerance interval for the translations along the transversal, longitudinal, and sagittal axes was 0.09. 0.07. and 0.34 mm. respectively: for the rotation, this upper bound was 0.39°. These results show that the new method, in which the position and orientation of a metal-backed hemispherical cup is calculated from its projected contours, is a simple and accurate alternative to attaching markers to the cup.     

Results of the tension-free vaginal tape procedure for stress incontinence: Patient''s perspective

BACKGROUND: To evaluate the results of the tension-free vaginal tape procedure (TVT) from a patient's perspective. METHODS: Between May 1999 and January 2002, 90 patients underwent a TVT for genuine stress incontinence (GSI) and mixed incontinence. Prior to the procedure, GSI was confirmed by clinical examination and urodynamic studies. Results were then audited from patient notes and the same patients were sent questionnaires to examine results from a patient perspective. RESULTS: Overall response rate to the questionnaire was 70 (77%). The mean age of the patients was 50.4 years (range 31-83 years). Sixty-one patients had spinal anesthesia, seven had general anesthesia and two had local anesthesia. Mean hospital stay was 3.36 days (range 2-14 days) and mean period from the operation to the time of the survey and audit was 16.34 months (range 3-28; SD 6.92). Thirty-nine (56%) of the 70 patients who answered said that the operation had cured their incontinence, 16 (23%) had an improvement in their symptoms, 7 (10%) had worsening of their symptoms and 8 (11%) felt that the operation did not make any difference. The overall success rate according to the patients' perspective was 79%, whereas our audit showed an overall success rate of 86% (77% and 82%, respectively, when we compared only the 66 patients who had both notes and replies available for analysis). CONCLUSION: Although a patient's perception regarding the success of TVT tends to differ from that of a clinician, it was not found to be statistically significant (P = 0.22, McNemar test). The TVT is a very successful operation, but realistic cure rates should be offered to patients.     

Hodgkin disease: CT of the thymus

The computed tomography (CT) scans in two groups of patients with Hodgkin disease were reviewed to determine the frequency of thymic enlargement. In 50 CT scans from 50 patients with evidence of thoracic disease on CT scans who were examined for primary staging, the thymus was enlarged in 15 of 50 (30%). Fifty CT scans were obtained from 44 patients at the time of 50 separate episodes of known or suspected relapse. Relapse occurred in the mediastinum in 12 episodes, lung parenchyma in five, and both sites in one. Thymic enlargement thought to be due to involvement by disease was present in seven of 18 (38%). Mediastinal disease was associated with thymic enlargement in all but one patient in whom a thymic cyst developed after radiation therapy. Differentiation of thymic enlargement from enlarged superior mediastinal lymph nodes was easily made in all but two patients. Thymic enlargement in the absence of lymph node enlargement may indicate a different disease, since isolated Hodgkin disease of the thymus is uncommon. Primary thymic tumor should be considered initially, whereas after treatment, rebound hyperplasia of the thymus may be the cause of enlargement.     

Solid and papillary epithelial neoplasms of the pancreas: CT findings

Five female patients and one male patient with solid and papillary epithelial neoplasms of the pancreas were examined with computed tomography (CT). The mean age of the patients was 27 years (range, 13-46 years). All cases showed well-encapsulated, round or lobulated masses consisting of both cystic and solid areas. Cystic portions showed CT numbers that suggested hemorrhagic necrosis. There were no internal septations within the masses. In three tumors located in the head of the pancreas, dilatation of the biliary tree was absent or minimal, although the masses were large. Two tumors contained calcifications. One tumor demonstrated metastatic deposits in liver and lymph nodes. Metastatic masses appeared similar to the primary pancreatic mass. Solid and papillary neoplasm of the pancreas should be the primary diagnostic consideration when characteristic CT findings are detected in a young female patient.     

Elastic strain energy in the low back muscles during human walking

Summary A simple model of the thorax, pelvis and three columns of the intrinsic lumbar back muscles (=ILBM) was constructed. The model was used to study the length of the ILBM during the different stages of the walking cycle. The length of the right ILBM (especially the lateral column) was largest at right toe off, exactly the stage of the walking cycle in which most force was needed to prevent the torso from falling forwards and laterally.     

Variable selection under multiple imputation using the bootstrap in a prognostic study

Background  

Missing data is a challenging problem in many prognostic studies. Multiple imputation (MI) accounts for imputation uncertainty that allows for adequate statistical testing. We developed and tested a methodology combining MI with bootstrapping techniques for studying prognostic variable selection.     

Clinical and genetic features of variegate porphyria in a Chinese patient

Acute porphyria is rare in orientals. We describe a Chinese woman with recurrent generalised tonic-clonic seizures and abdominal pain. Genomic DNA studies identified a heterozygous base substitution from guanine to adenine at nucleotide position 503, resulting in substitution of arginine by histidine at position 168 of the protein (R168H). This genetic abnormality is similar to the mutation reported in Caucasians with variegate porphyria. To the best of our knowledge, this is the first report in the English literature a Chinese patient with variegate porphyria with an identifiable mutation. A brief review of porphyria is presented.