Adaptive Evolution in Rapid Assessments: A 25-Year Perspective.

OBJECTIVES: This article retrospectively examines the evolution of rapid assessments (RAs) produced by the Health Technology Assessment (HTA) Program at the Institute of Health Economics over its 25-year relationship with a single requester, the Alberta Health Ministry (AHM). METHODS: The number, types, and methodological attributes of RAs produced over the past 25 years were reviewed. The reasons for developmental changes in RA processes and products over time were charted to document the push-pull tension between AHM needs and the HTA Program's drive to meet those needs while responding to changing methodological benchmarks. RESULTS: The review demonstrated the dynamic relationship required for HTA researchers to meet requester needs while adhering to good HTA practice. The longstanding symbiotic relationship between the HTA Program and the AHM initially led to increased diversity in RA types, followed by controlled extinction of the less fit (useful) "transition species." Adaptations in RA methodology were mainly driven by changes in best practice standards, requester needs, the healthcare environment, and staff expertise and technology. CONCLUSIONS: RAs are a useful component of HTA programs. To remain relevant and useful, RAs need to evolve according to need within the constraints of HTA best practice.

Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review.

BACKGROUND AND OBJECTIVES: In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities. RESEARCH DESIGN AND METHODS: A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively. RESULTS: The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor. DISCUSSION AND IMPLICATIONS: Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.

Guidelines for investigating stillbirths: an update of a systematic review.

OBJECTIVE: To identify formal, publicly available guidelines for stillbirth investigation and to identify the most appropriate clinical practice guideline (or component of a guideline) for use in Alberta. METHODS: A systematic literature search was conducted to identify primary and secondary research studies published between January 1985 and August 2006 and formal, publicly available guidelines on the subject of stillbirth investigation. The Cochrane Library, PubMed, EMBASE, CINAHL, HealthSTAR, Science Citation Index, BIOSIS, and the NHS and CRD databases were searched. The methodological quality of the selected primary research studies was assessed according to specific criteria. RESULTS: All six of the publicly available clinical practice guidelines selected for this review outlined similar steps in the stillbirth investigation but differed about which tests to include and which components should be core or additional investigations. They agreed on including several elements for routine investigation, such as complete autopsy and detailed examination of the cord and placenta. Of 61 retrieved primary research studies, only seven met the inclusion criteria. No studies compared the value of specific guidelines. Although reviewed evidence highlights the value of fetal autopsy and placental examinations as integral components of stillbirth investigation, the value of other components is still not clear. CONCLUSIONS: No firm scientific judgement could be made about which clinical practice guideline for stillbirth investigation is the most appropriate or which components are essential. Currently here is no generally accepted reference guideline for stillbirth investigation. Fetal autopsy and placental examination remain important components, assuming the postmortem examination is of high quality. These data may be helpful in counselling parents who are considering whether or not to consent to a postmortem examination.

Mentoring a developing health technology assessment initiative in Romania: an example for countries with limited experience of assessing health technology.

OBJECTIVES: The aim of this study was to assist and facilitate introduction and development of a health technology assessment (HTA) program in Romania. METHODS: Mentoring of an initiative group in Romania was provided by an HTA program in Canada. Mentoring activities included provision of HTA materials, participation in local seminars, facilitating contact with HTA and funding organizations, and in-house training of a professional from Romania. RESULTS: Since 1998, when the relationship was initiated, the Romanian group has been successful in developing an understanding of HTA and awareness of its utility among various decision-makers in the health system. Currently, although the need for HTA in Romania exists and interest in developing this activity has been officially expressed, HTA is still early in its development phase. The mentoring support helped to identify and define the need for HTA in Romania. Continuation of the existing relationship can be expected to strengthen the expertise in this country. However, while mentoring has been a valuable activity, it is not, by itself, sufficient to ensure development of an HTA program in Romania. The actions and decisions that could lead to implementing HTA in Romania depend on the local context. CONCLUSIONS: Mentoring services assisted the initiative group in promoting HTA in Romania. The implementation of HTA in Romania has not happened yet, and efforts need to continue to sustain the existing momentum. However, success in implementing an HTA program will depend on essential factors such as local political, economical, and educational support for this initiative and others like it.

The cost of major comorbidity in people with diabetes mellitus.

BACKGROUND: People with diabetes mellitus are more likely to have cardiovascular, renal and ophthalmic comorbidity than those without diabetes. Information on the economic impact of diabetes and its complications on the Canadian health care system is limited. METHODS: To estimate health care expenditures for diabetes and its major complications, we identified people with diabetes in 1996 in Saskatchewan, using the administrative databases of Saskatchewan Health. We grouped utilization and expenditure data for prescription drugs, physician services, hospitalizations, day surgery procedures and dialysis services according to cardiovascular, renal and ophthalmic services, according to billing codes and the American Hospital Formulary Services classification for prescription drugs. RESULTS: Of the 38 124 people identified (48.5% female and 9.7% registered Indians), 46.6% had cardiovascular-related records, 19.8% ophthalmic-related records and 6.6% renal-related records. Registered Indians had significantly fewer (p < 0.001) cardiovascular-related records than the rest of the diabetic population (35.1% v. 47.9%, respectively) but more renal- related records (11.7% v. 6.0%, respectively). The total 1996 Saskatchewan Health expenditure for the study group, within the observed categories, was estimated to be $134.3 million, of which $35.5 million (26.4%) was for cardiovascular-related services, $10 million (7.5%) for renal-related services and $3.3 million (2.5%) for ophthalmic-related services. INTERPRETATION: In 1996, 36.4% of health care expenditures for people with diabetes was attributable to major comorbidity. Actions to prevent or control such comorbidity will yield significant cost savings.