Housing quality and mental health.

This study examined the potential link between housing quality and mental health. First, the development of a psychometrically sound, observer-based instrument to assess physical housing quality in ways conceptually relevant to psychological health is reported. Then 2 different studies, including a prospective longitudinal design, demonstrate that physical housing quality predicts mental health. Possible underlying psychosocial processes for the housing quality-psychological distress link are discussed.

Effectiveness of eletriptan in reducing time loss caused by migraine attacks.

BACKGROUND: The growing literature on the economics of migraine and its treatment generally indicates that the direct healthcare costs of managing the disorder are relatively low compared with the personal and societal burdens resulting from the disruption to normal functioning caused by migraine attacks. OBJECTIVE: To investigate the effectiveness of eletriptan, a new selective serotonin (5-hydroxytryptamine; 5-HT)5-HTIB/ID agonist, in reducing both the patient-focused burden of migraine and the amount of work time foregone during a single attack. DESIGN: In a phase III, multinational, randomised clinical trial, 692 patients treated a migraine attack with eletriptan 40 mg or 80 mg, or placebo. Patients responded to a questionnaire seeking information concerning the amount of time lost from usual activities during the attack. Time loss assessments were made 24 hours after the last dose taken and recorded in a diary. MAIN OUTCOME MEASURES AND RESULTS: Patients receiving either dose of the active compound were unable to perform their usual activities for a median period of 4 hours compared with 9 hours experienced by those taking placebo. This difference was highly statistically significant (p < 0.001). The time saving associated with eletriptan usage reflected the differences in efficacy findings in the clinical component of the study. CONCLUSION: In this placebo-controlled trial, eletriptan produced a significant reduction in the loss of usual functioning time associated with a migraine attack. This gain clearly represents a substantial benefit to patients with migraine irrespective of how it might most appropriately be valued in monetary terms. Further methodological progress in this area is warranted.

The relevance and application of disease management and pharmacoeconomics to migraine.

Disease management is a comprehensive approach to improving the outcomes for patients suffering from chronic disease. It has frequently been applied to diseases like diabetes and asthma but, to date, has not widely been regarded as particularly relevant to migraine. Yet a number of factors suggest that this view might usefully be reconsidered, notably the dissatisfaction with migraine control expressed by many patients and the inconsistencies in treatment patterns observed across clinical practice. Another factor is the growing range of therapeutic options available to manage the disorder. In this latter respect, decision-making must not only be governed by individual patient needs, but also by considerations of clinical cost effectiveness. Pharmacoeconomic analysis can play a useful role in determining the relative value for money offered by different treatments and is increasingly being applied in migraine. It is clear, however, that full realisation of its potential contribution requires progress to be made in a number of key areas, perhaps most importantly agreement on the definition of successful treatment.

A cost analysis on the pattern of asthma prescribing in the UK.

There is a need to establish the proportion of adult asthmatics at each step of the recommended asthma management guidelines, the cost of their prescribed treatment, and a revised cost of treatment assuming patients who were suboptimally controlled were moved up a step. Actual prescription and cost figures and a theoretical projection of an ideal scenario was calculated from a sample of general practices in Great Britain from the Doctors Independent Network. They comprised 102 nationally distributed practices and 17,206 adult patients with a diagnosis of, and prescription related to, asthma recorded between October 1993 and March 1994. Ninety-one per cent of patients received treatment within a recognized step of the guidelines. Of these, 80% were at steps 1 and 2. Employing excess inhaled beta-agonist use as a proxy for control of asthma, between 55% and 69% of patients at Steps 1-3 should receive treatment at a higher step. This could lead to an increased expenditure of up to Pound Sterling 4.66 per adult patient per month. This would imply a rise in the annual UK cost of antiasthma prescriptions for adults from Pound Sterling 388m to a possible Pound Sterling 533m. The United Kingdom Government audit commission has suggested that current expenditure on asthma treatment appears to be insufficient. Using an entirely different approach this study has confirmed that a significant increase in asthma prescribing costs is likely to be needed if optimal control of asthma is to be achieved.

Past, present, and future directions for Alzheimer research.

To understand the current thinking and future research directions in Alzheimer disease (AD), it is essential to examine the breadth of research into AD. AD was identified as a distinct disease process early in this century and research into its etiology and treatment has a short, but active, history. This paper emphasizes past, present, and future biomedical research for the goal of stimulating research to solve some of the unanswered questions to ultimately help the victims of Alzheimer disease. The "hot" topics today for biomedical researchers include early diagnosis, presymptomatic markers, the role of presenilins, amyloid, protein precursor processing, and continued exploration for genetic and environmental risk factors.

Nursing research and solving problems of Alzheimer disease.

This article discusses the applied science of the nursing discipline and nursing issues related to Alzheimer disease. Three models are presented and illustrated with interdisciplinary research ideas to improve the care of persons who suffer from dementia of the Alzheimer type (DAT). Phases of Nursing Research is a five-component model to (1) identify problems, (2) conduct the study, (3) disseminate results, (4) utilize findings that are to the central component, (5) practical knowledge. Promoting evidence-based care for making a recommendation against artificial feeding and providing the tools to promote natural feeding illustrates the Interdisciplinary Collaboration model. The Program of Research model is described by studies of late-stage DAT, intercurrent infections, and decision making. Issues framing nursing research are discussed and specific suggestions for research projects developed from recent funding priorities of the National Institutes of Health are given.

The grant application: making yours stand out across the review cycle.

This article provides an overview of the grant application during the review process. Three levels of review occur once a grant is submitted-administrative, scientific, and programmatic. The purposes of each level of review are different, but the overall goal for the funding agency is to fund grant applications that address important research topics, are scientifically meritorious, and assist the agency in meeting their goals and objectives.

Idea to application: you are in charge.

The grant writing process can be daunting to a novice investigator. This article focuses on three inter-related activities that lead to a completed grant application. The first activity involves developing the research team. Selection of colleagues who will strengthen and support the research ideas is an early first step to developing a competitive grant application. It is important to communicate clearly the roles and responsibilities of each team member. The second activity is development of the scientific plan-the research proposal-from specific aims to plans for data analysis. Strategies used to review the literature, synthesize existing knowledge, develop the argument for the research proposal, and select the most appropriate method are discussed. The third activity involves developing a business plan-the budget-that demonstrates clearly the investigator's ability to complete the proposed research. These three activities are set within a timeline to guide investigators in successful completion of a grant application.

Structure and process of federal funding for AD research.

This paper outlines the structure of the National Institute on Aging (NIA), the National Institutes of Health (NIH) agency that funds a majority of Alzheimer disease (AD) research, and the process of submitting a federal grant application. The multiple steps of the grant application process, both for the investigator preparing the application and the review process at NIH, are described. The importance of speaking with a program officer from an institute and incorporating reviewers' comments into grant applications to strengthen the proposal is stressed.

An explanatory model of the dental care utilization of low-income children.

OBJECTIVES: Factors related to the utilization of dental care by 5- to 11-year-old children from low-income households were investigated using a comprehensive multivariate model that assessed the contribution of structure, history, cognition, and expectations. The influence of dentist-patient interactions, psychosocial and health beliefs, particularly fear of the dentist, on utilization were investigated. METHODS: Children were chosen randomly from public schools, and 895 mothers were surveyed and their children were interviewed in the home. Utilization was studied during the 1991-1992 school year, including a 6-month follow-up period after the interview. RESULTS: The overall utilization rate was 63.2%, and the rate for nonemergent (preventive) visits was 59.9%. Utilization was unrelated to actual oral health status. Race and years the guardian lived in the United States were predictive of an episode of care. Preventive medical visits and perceived need were strong predictors of a visit to the dentist, as were beliefs in the efficacy of dental care. Mothers who were satisfied with their own care and oral health and whose children were covered by insurance were more likely to utilize children's dental care. In contrast, child dental fear and absences from school for family problems were associated with lower rates of utilization. CONCLUSIONS: Mutable factors that govern the use of care in this population were identified. These findings have implications for the design of dental care delivery systems for children and their families.

Clinical economics review: irritable bowel syndrome.

The ubiquitous nature of irritable bowel syndrome (IBS), coupled with a lack of good treatment options, has created the impression that the condition must represent a large drain on health-care resources. The literature certainly appears to support this view but is largely based on patients seen in referral centres (10-15%) and it may not be appropriate to extrapolate these data to the IBS population as a whole (85-90%). In addition to reviewing such literature that exists on the economics of IBS, this paper contains some new data, which suggest that the direct costs of the condition, certainly in the UK, may not be quite as high as has previously been assumed. This may be partly due to factors such as the low cost of the drugs used to treat the condition and the tendency for many patients to stop consulting because of disenchantment with the inadequacies of current therapy. Conversely, the indirect and intangible costs of the disorder appear to be much greater, but these burdens obviously do not have such an impact on those responsible for purchasing and providing health care for IBS sufferers. Paradoxically, if a new, effective therapy for IBS were forthcoming, the situation could change dramatically, especially if it involved a new drug. Any such agent would inevitably be more expensive than anything available today, leading to a potentially dramatic escalation in the direct costs of this disorder.

Role transition: from clinical nurse specialist to clinical nurse specialist/case manager.

Changes in the healthcare environment provide the impetus to look closely at the way in which patient care is delivered. Complex health problems, requiring the expertise of multiple healthcare specialists, coupled with complex hospital systems, result in fragmented care that is confusing to patients and their families. Case management by nurses working closely with physicians in hospitals is one strategy that can reduce fragmentation of care. Case management also facilitates the delivery of cost-effective patient-focused care. Because of his her expertise, the clinical nurse specialist (CNS) is an ideal choice for the role of case manager. The authors describe the role transition of nurses from CNS to CNS case manager over a 2-year period and identify the key system supports required to ensure successful evolution into this expanded role.

A comparison of the cost effectiveness of alternative prophylactic therapies in childhood asthma.

An economic analysis was conducted comparing the cost effectiveness of fluticasone propionate with that of sodium cromoglycate (cromolyn sodium) in a group of children aged 4 to 12 years old with asthma, who required inhaled prophylactic therapy. Over an 8-week study period, 115 patients received sodium cromoglycate 20mg 4 times daily, via the spin operated dry powder inhaler, and 110 patients received fluticasone propionate 50 micrograms twice daily, via the Diskhaler (trademark held by the Glaxo Wellcome Group of Companies). Patient healthcare resource use was examined in terms of study medication, the use of rescue medication [salbutamol (albuterol) 200 micrograms] and the number of hospitalisations. The effectiveness of both treatments was examined over a range of success and failure criteria embracing peak expiratory flow rate (PEFR) improvement, symptom control and the level of adverse events related to the study medication. Results indicate that, for each UK pound spent, fluticasone propionate was associated with twice as many successfully treated patients as sodium cromoglycate, using a range of outcomes based on the goals of treatment defined in the British Thoracic Society's asthma guidelines. It is concluded that fluticasone propionate was more cost effective than sodium cromoglycate in improving PEFR and symptom control in this group of children with asthma who had a clinical requirement for prophylactic therapy.

Economic and social impact of migraine.

We sent an anonymous self-administered questionnaire to 4200 employees of a Trust hospital, 1903 of whom returned it. We identified 158 migraine sufferers according to International Headache Society (IHS) criteria. These sufferers estimated 2.0 days/year absence from work, and an equivalent of 5.5 days/year lost by reduced effectiveness at work, caused by their migraine at an estimated financial cost of over 50,000 pounds to the Trust. An additional 220 individuals who had received a diagnosis of migraine from a doctor but fulfilled only 3/4 IHS criteria lost the equivalent of 6.7 days off work at a further cost of 63,000 pounds). Few patients had consulted their general practitioner about their migraines in the last 3 months. Most (78%) were using only over-the-counter medication. Migraine patients should be encouraged to seek medical attention.

Lower extremity burns and Unna paste: can we decrease health care costs without compromising patient care?

OBJECTIVE: To compare an alternative treatment for lower extremity burns with the standard in-hospital treatment, in an attempt to shorten hospital stay. DESIGN: A case-control series. SETTING: A university-affiliated hospital. PATIENTS: All patients with a burn isolated to a lower extremity were treated over an 8-month period with split-thickness skin grafting (STSG), Unna paste dressing, immediate mobilization and early discharge. This group was compared with matched controls from the preceding 8 years treated with STSG, occlusive burn gauze dressing, bed rest and hospitalization. MAIN OUTCOME MEASURES: Duration of hospital stay and graft viability. RESULTS: Thirteen patients with an average wound size of 131 cm2 were treated with Unna paste and had a graft viability of greater than 95% and a burn-scar rating equivalent to that of patients treated with the earlier regimen. The duration of hospital stay decreased from a mean of 12.9 days to 1.4 days, with no complications. This translated into a saving of $10,350 per patient. CONCLUSIONS: This alternative treatment is safe, inexpensive and effective and is recommended as the treatment of choice for uncomplicated, noncircumferential lower extremity burns.

The real costs of emesis--an economic analysis of ondansetron vs. metoclopramide in controlling emesis in patients receiving chemotherapy for cancer.

The cost effectiveness of ondansetron was compared with that of metoclopramide in the prevention of acute emesis due to highly emetogenic chemotherapy in an open, randomised, parallel group pilot study. Ondansetron was given as three 8 mg intravenous doses (0, 4 and 8 h) and metoclopramide as an intravenous loading dose (3 mg/kg) followed by a maintenance dose of 0.5 mg/kg/h for 8 h. Therapeutic outcomes and full utilisation costs, that is nursing time, material costs, in addition to drug acquisition prices were recorded for each antiemetic for 24 h following chemotherapy. The cost per successfully treated patient (< or = 1 emetic episode and no adverse events) was 95.20 pounds for ondansetron and 92.18 pounds for metoclopramide. The results of the study therefore suggest that for the control of acute emesis due to highly emetogenic chemotherapy ondansetron and metoclopramide are equally cost-effective treatments.