Cost-utility analysis of pacemakers for the treatment of vasovagal syncope.

Dual-chamber pacing is a promising treatment for patients with very frequent vasovagal syncope, but its cost utility is unknown. We report that the incremental cost per quality-adjusted life-year gained is $13,159 Canadian dollars (about $8,600 US dollars), and therefore this pacemaker therapy for vasovagal syncope has a favorable cost-utility ratio.

Recruiting research participants: a comparison of the costs and effectiveness of five recruitment strategies.

Among the major costs associated with conducting survey research are the time and money spent recruiting a large and racially representative sample. Contrasted here are the costs of different recruitment strategies (agencies, support groups, snowballs, media, mass mailings) in terms of project time, supplies (e.g., postage, support materials), and staff time as they bear on the costs of recruiting 841 older mothers of offspring with lifelong disabilities. Results indicate that the costs of recruitment vary by method and race. Whereas agencies, support groups, and snowball recruitment were low- to moderate-cost strategies, they were less effective for recruiting African Americans than were media and demographic sampling unit strategies. These analyses suggest that with appropriate planning, funding, and implementation, nonprobability sampling methods can be used successfully to recruit a large and diverse sample. Suggestions for improving the implementation of future recruitment campaigns are also offered.

Assessment of lack of fit in simple linear regression: an application to serologic response to treatment for syphilis.

A patient treated for infectious syphilis is cured when serologic tests become non-reactive, which may take years to achieve. Our objective is to develop a method to determine, within months, whether the patient has responded adequately to treatment. Previous research and our exploratory graphical analysis suggested that treatment response is linear when we applied logarithmic transformations of the axes. If the response to treatment is linear, titres recorded within the first few months of treatment will determine the slope of the line and one can develop an action line in future research. We used a non-parametric method to assess whether the logarithmic transformation improved the linearity and then we applied three different methods of testing lack of fit in linear regression. Based upon a sample size that reflects a clinically reasonable number of data points, the results of these tests provided no evidence against linearity.

Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment.

Data from 50 residents of a long-term care facility were used to examine the extent to which performance on a brief, objective inventory could predict a clinical psychologist's evaluation of competence to participate in decisions about medical care. Results indicate that the competence to participate in medical decisions of two-thirds of the residents could be accurately assessed using scores on a mental status instrument and two vignette-based measures of medical decision-making. These procedures could enable nursing home staff to objectively assess the competence of residents to participate in important decisions about their medical care.

Falls among nursing home residents: an examination of incident reports before and after restraint reduction programs.

OBJECTIVE: To examine changes in the rate of falling of an experimental group of restrained subjects who underwent restraint reduction, and to compare their rate of falling with a group of subjects who did not have restraint orders during the study period. DESIGN: A quasi-experimental, multiple time-series study utilizing the principles of single-subject design. Each subject was followed for 25 weeks before and 25 weeks after initiation of the intervention. SETTING: Seven nursing homes. INTERVENTION: Formal programs aimed at reducing all bed and chair restraints were initiated in all sites after staff received education and training. Multidisciplinary teams implemented the restraint reduction process on a case-by-case basis, beginning with 1 unit/floor at a time in each site. Most experimental subjects reached their optimum restraint-elimination/reduced status within 2 weeks of intervention initiation. The implementation periods ranged from 4 months to more than a year. PARTICIPANTS: Subjects with chart orders for restraints at the start of the study comprised the experimental group and participated in the restraint reduction program (184 subjects). Subjects with no orders for restraints during the study period comprised the nonequivalent control group (111 subjects) and, therefore, did not undergo the intervention. MEASUREMENTS: Incident reports documenting all falls during the study period were examined. Falls, the dependent variable, were classified as serious or nonserious. The independent variable (intervention) was the restraint reduction program offered to experimental subjects. Based on the principles of single subject design, the impact of the intervention on falls was calculated before and after the date the restraint reduction process was initiated for an individual (experimental group) subject. For the control group, the pre- and posttest period was calculated from the start date of the restraint reduction program on the unit on which each subject resided. RESULT: Serious falls did not increase, but nonserious falls increased significantly after restraints were removed or reduced in experimental subjects. The total mean weekly fall rate for this group increased from 1.87% of residents falling per week during preintervention to 3.01% during postintervention. The mean weekly fall rate of the control group was 3.18% at pretest and did not change statistically over time. CONCLUSIONS: The increase in nonserious falls among the experimental group may be attributed to restraint reduction. The mean weekly fall rate in the experimental group postintervention (25 weeks) became comparable to the mean weekly fall rate for the control group during the entire study period (50 weeks). In light of such findings, policy makers have to confront the ethical choice between tying some frail, elderly subjects to beds and chairs versus exposing them to the risks of freedom in their old age.

Application of TQM principles to the utilization management process.

Application of the philosophy and principles of TQM and CQI to utilization management within an institution necessitates an in-depth review of the systems and processes of the flow of inpatients throughout their stay. This encompasses a total systems perspective, beginning with the admitting process and going through the discharge process. TQM and CQI philosophies identify that the most significant and costly inefficiencies are due to faulty systems and processes, not individuals. Applying this management strategy to a health care institution requires a detailed review and analysis of processes by which service is delivered and requires evaluation of the outcomes of patient care and patient satisfaction.