Mapping of Family Reported Outcome Measure (FROM-16) scores to EQ-5D: algorithm to calculate utility values.

OBJECTIVE: Although decision scientists and health economists encourage inclusion of family member/informal carer utility in health economic evaluation, there is a lack of suitable utility measures comparable to patient utility measures such those based on the EQ-5D. This study aims to predict EQ-5D-3L utility values from Family Reported Outcome Measure (FROM-16) scores, to allow the use of FROM-16 data in health economic evaluation when EQ-5D data is not available. METHODS: Data from 4228 family members/partners of patients recruited to an online cross-sectional study through 58 UK-based patient support groups, three research support platforms and Welsh social services departments were randomly divided five times into two groups, to derive and test a mapping model. Split-half cross-validation was employed, resulting in a total of ten multinomial logistic regression models. The Monte Carlo simulation procedure was used to generate predicted EQ-5D-3L responses, and utility scores were calculated and compared against observed values. Mean error and mean absolute error were calculated for all ten validation models. The final model algorithm was derived using the entire sample. RESULTS: The model was highly predictive, and its repeated fitting using multinomial logistic regression demonstrated a stable model. The mean differences between predicted and observed health utility estimates ranged from 0.005 to 0.029 across the ten modelling exercises, with an average overall difference of 0.015 (a 2.2% overestimate, not of clinical importance). CONCLUSIONS: The algorithm developed will enable researchers and decision scientists to calculate EQ-5D health utility estimates from FROM-16 scores, thus allowing the inclusion of the family impact of disease in health economic evaluation of medical interventions when EQ-5D data is not available.

Strategies to expand corporate autonomy by the tobacco, alcohol and sugar-sweetened beverage industry: a scoping review of reviews.

BACKGROUND: Noncommunicable diseases contribute to over 70% of global deaths each year. Efforts to address this epidemic are complicated by the presence of powerful corporate actors. Despite this, few attempts have been made to synthesize existing evidence of the strategies used to advance corporate interests across industries. Given this, our study seeks to answer the questions: 1) Is there an emergent taxonomy of strategies used by the tobacco, alcohol and sugar-sweetened beverage (SSB) industries to expand corporate autonomy? 2) How are these strategies similar and how are they different? METHODS: Under the guidance of a framework developed by Arksey and O'Malley, a scoping review was carried out whereby six databases were searched in June 2021 to identify relevant peer-reviewed literature. To be included in this review, studies had to explicitly discuss the strategies used by the tobacco, alcohol, and/or sugar-sweetened beverage multinational corporations and be considered review articles aimed to synthesize existing evidence from at least one of the three industries. Eight hundred and fifty-eight articles were selected for full review and 59 articles were retained for extraction, analysis, and categorization. RESULTS: Results identified six key strategies the industries used: 1) influencing government policy making and implementation, 2) challenging unfavorable science, 3) creating a positive image, 4) manipulating markets, 5) mounting legal challenges, and 6) anticipating future scenarios. Despite these similarities, there are few but important differences. Under the strategy of influencing government policy making and implementation, for example, literature showed that the alcohol and SSB industries have been "privileged with high levels of participation" within international public health organizations. CONCLUSIONS: Understanding how industries resist efforts to control them is important for public health advocates working to reduce consumption of and death and diseases resulting from harmful commodities. Moreover, there is a greater need for the public health community to generate consensus about how to ethically engage or not engage with industries that produce unhealthy commodities. More studies are also needed to build the evidence base of industry tactics to resist regulation, particularly in the case of SSB, and in low-and middle-income countries.

Assessment of human exposures to animal vaccines using poison control records, 2000-2009.

To characterize human exposures to vaccines intended for animals, evaluate the human risk due to these exposures and determine whether there is sufficient surveillance in place to monitor them. Retrospective analysis of surveillance data (2000-2009). Information collected by poison specialists during calls reporting human exposure to an animal vaccine product, made to one of the 57 United States Poison Control Centers. Data from the National Poison Data System were analysed to determine the number of calls due to human exposures to animal vaccines, and descriptive statistics were generated to characterize the exposures by age, gender, medical outcome, exposure site, exposure route, vaccine type and intended species, aetiologic agent, call date and exposure reason. Overall, the human health effects were minor, primarily due to unintentional parenteral exposure. Less than 15% of the reports were classified as occupational, and 80% of the exposures took place outside of a workplace or healthcare facility. Almost 60% of calls were due to exposure to the West Nile Virus vaccine; the others distributed among a variety of vaccines. Unintentional exposure to animal vaccines appears to occur almost exclusively among untrained individuals who may benefit from more effective education about the risks and benefits of administering vaccines. Improved reporting of adverse outcomes is essential to adequately define the extent of human exposure and risks associated with availability of new vaccines.

The multi-stakeholder movement for primary care renewal and reform.

A multi-stakeholder movement for primary care renewal and reform has emerged in the United States, out of recognition that the achievement of an efficient, effective, and sustainable health system requires a vibrant primary care sector. We describe the case for reform from the perspective of private purchasers, government, consumers, and clinicians; the principles around which these stakeholders have coalesced; the groundswell of primary care reform initiatives taking place across the country; and the prospects for this coalition to reshape the character of U.S. health care on a stronger foundation of primary care.

Access to orthopedic care for children with medicaid versus private insurance in California.

OBJECTIVE: To compare the availability of timely orthopedic care to a child with a fractured arm insured by Medi-Cal (California state Medicaid) and by private insurance. STUDY DESIGN: Fifty randomly chosen offices of orthopedic surgeons were telephoned with the following scenario: "My 10-year-old son broke his arm last week during a vacation" followed by a request for an appointment that week. Each office was called twice with an identical script except for insurance status: once with Medi-Cal and once with private insurance. RESULTS: All 50 offices offered an appointment to see the child with private insurance within 7 days. Only 1 of the same 50 offices offered an appointment to see the child with Medi-Cal within 7 days. Of the offices that would not see a child with Medi-Cal, 87% were unable to recommend an orthopedic office that accepted Medi-Cal. CONCLUSIONS: Timely access to orthopedic care was available in 100% of offices polled to a child with private insurance versus in 2% of offices to a child with Medi-Cal. This is a significant difference. Lack of timely orthopedic care may result in poor outcome, ie, if a fracture is not properly aligned in the first few weeks, a permanent deformity may result. Although causation cannot be established from this study, we suspect that Medi-Cal reimbursement rates below the cost of office overhead may be of significance. Although federal guidelines require that payments must be sufficient to enlist enough providers so that services to Medi-Cal recipients are available to the same extent as those available to the general population, this study finds that that children with Medi-Cal insurance have significantly less access to timely orthopedic care.

Balancing the perfect scorecard. Inquiry as intervention in physician practice management.

We describe how inquiry into several operational aspects of health care delivery in the Division of Medicine at the Cleveland Clinic Foundation improved clinical and administrative functions, demonstrating the principle that inquiry is intervention. The process of inquiry displays data on a "performance wheel" that summarizes several indicators, allowing easy comprehension of performance in various operational aspects and a visual appreciation of the interaction among these operational aspects.

Comparison of direct hospital costs and length of stay for radical nephrectomy versus nephron-sparing surgery in the management of localized renal cell carcinoma.

OBJECTIVES: Recent work has demonstrated comparable surgical results and 5-year cancer-specific survival rates between radical nephrectomy and nephron-sparing surgery (NSS) in the treatment of patients with small (4 cm or smaller) solitary renal cell carcinomas (RCCs). However, differences exist in the intraoperative management and postoperative care of patients undergoing NSS versus radical nephrectomy, and we sought to compare direct hospital costs and length of stay (LOS) between these two groups to determine whether either treatment imparts a specific cost advantage. METHODS: Data were retrieved from medical records and administrative data sets containing billing encounters for all costs incurred during hospitalization at the Cleveland Clinic Foundation. Individual costs were grouped together using nine cost center categories encompassing every aspect of direct hospital care, including anesthesiology, laboratory, radiology, nursing, pharmaceutical, and emergency services, and medical care, surgical care, and miscellaneous costs. Each cost center was further subdivided, and a total of 52 cost subcategories were assessed. The total direct costs of hospitalization were compared using a multivariate regression model in which patient demographics and tumor characteristics, type and year of surgery, LOS, and cost center categories were assessed as single and interactive factors. Postoperative complication and cancer-specific survival rates were also compared to identify any potential therapeutic differences between the two groups. RESULTS: Between 1991 and 1995, 80 patients underwent surgery at the Cleveland Clinic Foundation for solitary RCCs 4 cm or smaller, including 52 partial and 28 radical nephrectomies. We found no difference in the postoperative complication rate or cancer-specific survival rate between the two surgical groups. Total direct hospital costs and LOS were not statistically different between the NSS and radical nephrectomy groups (P >0.05). This was further supported by our multivariate model, which accounted for 61% of the observed variance in the total costs (F = 12.11, P = 0.0001). The type of surgery was not associated with total cost when controlling for all other factors, including age, sex, year of surgery, tumor size, grade, and stage, and postoperative complications (P = 0.7). There was no significant interaction between the type of surgery and the LOS (P = 0.5). CONCLUSIONS: This study demonstrated that elective NSS can be performed with equivalent direct hospital costs and LOS when compared with patients undergoing radical nephrectomy for small solitary RCCs. These data have significant economic implications for the comparison of competing surgical treatment strategies for localized RCC.

Variability in the assessment of acetabular index.

This study was undertaken to assess the inter- and intraobserver variability associated with the assessment of acetabular index. Five readers (three senior orthopaedic residents and two pediatric orthopaedic attendings) read each of 24 films on three separate occasions (360 total readings). An independent observer who was blinded to the results of the study assessed whether the radiographs would result in a reproducible acetabular index. Variability was increased for the radiographs that were deemed poorly reproducible by the independent observer. Interobserver variability exceeded intraobserver variability. Variability was comparable for senior orthopaedic residents and attending pediatric orthopaedic surgeons. Even in the group with the least variability (intraobserver variability for reproducible radiographs), the 95% tolerance interval was 8.35 degrees. The results of this study cast doubt on the reliability of the acetabular index based on a single reading.

Maintaining quality of care and patient satisfaction with radical prostatectomy in the era of cost containment.

OBJECTIVES: To determine the effect of shortened hospital stay after radical retropubic prostatectomy on costs, adverse surgical outcomes, and patient satisfaction. METHODS: The effect of changes in preoperative counseling, perioperative care, and analgesic management on hospital length of stay; mean cost per case and cost per hospital day; and 30-day complication, hospital readmission, and mortality rates were analyzed for a consecutive sample of 374 patients undergoing radical prostatectomy between July 1989 and November 1995. Satisfaction with length of stay, analgesic regimen, and surgical outcome was assessed in a random subset of 150 patients by anonymous questionnaire. RESULTS: Length of stay (LOS) was shortened from a median 7 to 2 nights after surgery during the study (P < 0.0001), whereas the acute complication, 30-day readmission, and 30-day mortality rates remained constant. Reducing LOS resulted in a 43% decrease in mean cost per case while mean cost per day increased by 22% to 35%. Overall patient satisfaction was high, with 83.5% of patients rating LOS as "just right" and 89.2% reporting they were "satisfied" or "very satisfied" with their pain control after surgery. CONCLUSIONS: Shortened LOS after radical retropubic prostatectomy can be accomplished safely and can meet with high levels of patient satisfaction while significantly reducing hospital-related costs. The potential for further incremental reductions in cost with reductions in LOS to less than 2 nights appears to be small, and future efforts at cost reduction for this procedure should center on decreasing the intensity of care during hospitalization.

Spiral computed tomography angiography in the assessment of middle cerebral artery occlusive disease.

There has been no report on the use of spiral computed tomography angiography (CTA) in the investigation of intracranial cerebral artery stenosis. A prospective pilot study was conducted to investigate the feasibility of CTA in the diagnosis of intracranial occlusive disease and its correlation with transcranial Doppler. With transcranial Doppler, 10 patients with acute ischaemic stroke with middle cerebral artery stenosis or occlusion were identified. There were seven middle cerebral artery stenoses and five middle cerebral artery occlusions. The CTA confirmed all diagnoses by transcranial Doppler except in one patient with middle cerebral artery occlusion in whom the embolus had probably propagated. The results showed that CTA is feasible and potentially useful in the diagnosis of middle cerebral artery occlusive disease. Further studies are required to assess its validity, sensitivity, and specificity in the diagnosis of middle cerebral artery occlusive disease.

Outcomes of elderly stroke patients. Day hospital versus conventional medical management.

BACKGROUND AND PURPOSE: Much controversy exists over the value of geriatric day hospitals in the rehabilitation of elderly patients, and cerebrovascular accident is a particularly common diagnosis among patients referred to these day hospitals. We carried out a prospective, randomized study to compare the outcomes of elderly stroke patients managed by a geriatric team using a day hospital facility versus conventional medical management. METHODS: One hundred twenty elderly patients with acute stroke were randomized to inpatient care on a stroke ward under the care of either a neurologist or a geriatric team. Those under the care of neurologists were hospitalized until the attending physician felt that the patients had reached full rehabilitation potential. Patients under the care of the geriatric team were discharged home as soon as the team felt they were able to cope and given follow-up rehabilitation at the day hospital. Family or community support was arranged when necessary for both treatment groups. On recruitment, patient demographics, medical history, clinical features related to stroke, and functional ability as measured by the Barthel Index were noted. Subjects were reviewed at 3 and 6 months to assess functional level, hospital and outpatient services received, general well-being, mood, and level of satisfaction. Costs of treatment of the two groups were also compared. RESULTS: Functional improvement (Barthel Index score) was greater in the group managed by the geriatricians with a day hospital facility compared with the conventional group at 3 months (P = .03). There were also fewer outpatient visits among the day hospital patients at 6 months (P = .03). No significant difference was found in costs between the two treatment groups. CONCLUSIONS: Compared with conventional medical management, care in the geriatric day hospital hastened functional recovery and reduced outpatient visits in elderly stroke patients without additional cost.

Utilizing physician leadership to reduce length of stay.

With the proliferation of prospective payment, managed care and the concomitant shift in risk from payer to provider, hospitals are investing in utilization management programs to reduce cost per case while maintaining or improving clinical quality. This article discusses a major component of the utilization management program at the Cleveland Clinic Foundation: the use of physician champions. Overall, the length of stay reduction initiative resulted in a shorter average length of stay by 1.8 days (22 percent).

Mortality of patients transferred to a tertiary care hospital.

BACKGROUND: Seriously ill patients are often transferred from community hospitals to tertiary care hospitals. OBJECTIVES: To review the numbers, sources, and outcomes of patients transferred to the Cleveland Clinic Hospital from 1989 through 1992. METHODS: Retrospective analysis. RESULTS: Compared with the Cleveland Clinic's overall hospital mortality rate of 3.09% (3760 of 121,014 patients) during this period, the mortality rate among transferred patients was 8.26% (1092 of 13,226 patients). Although transferred patients accounted for only 10.9% of the total admissions, they represented 29.0% of the deaths. Transfers from other hospitals in the Cleveland Health Quality Choice (HQC) program, a community-wide quality-assessment project, increased 40.2% in 1992 (during the initial data collection period for the HQC program), while those from non-HQC hospitals increased only 0.9%. CONCLUSIONS: Patients transferred to a tertiary care hospital from other acute care hospitals have a 2.7-fold greater chance of dying in the hospital than nontransferred patients. Public scrutiny of quality may increase the likelihood of transfer of seriously ill patients to tertiary care centers.

Survival, disability, and residence 20 months after acute stroke in a Chinese population: implications for community care.

A total of 304 Chinese patients with acute stroke were assessed at 3 and 20 months to determine survival, disability, and place of residence, and so to provide an estimate of the impact on community care resources. Approximately 30% of patients had died by 3 months; thereafter the mortality rate decreased, with a further 13% dying by 20 months. Age, rather than stroke subtype, determined the likelihood of death. Fifty-seven per cent of 3-month survivors were independent at 20 months, with only 18% moderately to severely disabled (Barthel Index less than 15). Thirteen per cent of patients improved and 14% deteriorated between 3 and 20 months. Older subjects had a lower Barthel Index at 20 months, and were more likely to show deterioration. Seventeen per cent of patients were living in institutions by 20 months, predisposing factors being age and mental test score. Although a low Barthel Index was a factor in univariate analysis, it did not contribute to the discriminant function model for predicting institutionalization, and nor did previous stroke, coexisting cardiovascular diseases, or diabetes mellitus influence eventual placement. Approximately 30% of patients were readmitted during the follow-up period, particularly elderly patients and those with a Barthel Index less than 15. Although only 9% of the original cohort required institutional care by 20 months, approximately half of all the government nursing home places in Hong Kong are likely to be taken up by these patients because of the large number of strokes occurring each year.

The validity of inferences based on incomplete observations in disease state models.

In many survival time studies or studies on the progression of a disease, information is often incomplete in the sense that it is known only that a patient has been in certain disease states at several time points. In this paper, conditions concerning the interrelationship between the disease process and the examination scheme (i.e., the pattern of examination times) are derived under which a valid statistical inference is possible. These conditions are confronted with examination schemes that are of practical importance in clinical research. A cancer marker study is used as an example to estimate the magnitude of the potential bias when the conditions derived are violated.

Microalgae as food and supplement.

The microalgae Chlorella spp., Dunaliella spp., and Scenedesmus spp., and the cyanobacteria Spirulina spp., and Aphanizomenon flos-aquae, are being used as nutrient-dense foods and sources of fine chemicals. They have significant amounts of lipid, protein, chlorophyll, carotenoids, vitamins, minerals, and unique pigments. They may also have potent probiotic compounds that enhance health. Their historical and current use are reviewed in this article.

Is routine examination of the male partner of any prognostic value in the routine assessment of couples who complain of involuntary infertility?

The purpose of this study was to determine whether routine examination of the male partner is of value in assessing couples complaining of involuntary infertility. The relationship between male age, a previous paternity, male physical characteristics, and fertility outcome was examined. Life table analysis was performed after accounting for known female factors. Five hundred forty-four couples were recruited to the study. All conceptions were independent of treatment to either partner in which the female partner was found to be "normal" on investigation. Although male age and several physical characteristics were related to fertility outcome when all couples were examined, this was, by virtue of these variables, being related to female age and the length of involuntary infertility before investigation. When only those couples were examined in which the female partner was normal on investigation (n = 250), past paternity (x1(2) = 4.21, P = 0.040, RR = 1.81) was the only variable that retained a significant relationship to fertility outcome. It was concluded that routine examination of the male partner is of no prognostic value for couples complaining of involuntary infertility.