Patterns of health service use in community living older adults with dementia and comorbid conditions: a population-based retrospective cohort study in Ontario, Canada.

BACKGROUND: Patients with dementia have increased healthcare utilization and often have comorbid chronic conditions. It is not clear if the increase in utilization is driven by dementia, the comorbidities or both. The objective of this study was to describe the number and types of comorbid conditions in a population-based cohort of older adults with dementia and how the level of comorbidity impacts dementia-related and non-dementia-related health service utilization. METHODS: This study is a retrospective cohort study using multiple linked administrative databases to examine health service utilization and costs of 100,630 community-living older adults living with pre-existing dementia in Ontario, Canada. Comorbid conditions and health service utilization were measured using administrative data (physician visits, emergency department visits, hospitalizations, and homecare contacts). RESULTS: Nearly all, 96.3 %, had at least one comorbid condition, while 18.4 % had five or more comorbid conditions. The most common comorbid conditions were hypertension (77.8 %), and arthritis (66.2 %). All types of utilization increased consistently with the number of comorbid conditions. The average number of dementia-related services tended to be similar across all levels of comorbidity while the average number of non-dementia related visits tended to increase with the level of comorbidity. CONCLUSIONS: Comorbidities in community-living older adults with dementia are common and account for a substantial proportion of health service use and costs in this population. Our results suggest that comprehensive programs that take a holistic view to identify the needs of patients in the context of other comorbidities are required for persons with dementia living in the community.

Decision aid on radioactive iodine treatment for early stage papillary thyroid cancer: update to study protocol with follow-up extension.

BACKGROUND: Patient decision aids (P-DAs) are used to inform patients about healthcare choices, but there is limited knowledge about their longer term effects, beyond the time period of decision-making. METHODS/DESIGN: We developed a computerized P-DA that explains the choice of radioactive iodine (RAI) adjuvant treatment or no RAI, for patients with low risk papillary thyroid cancer after total thyroidectomy. The original protocol for a randomized controlled trial, comparing the use of the P-DA (with usual care) to usual care alone, has been published in Trials http://www.trialsjournal.com/content/11/1/81. We found that P-DA (with usual care) significantly improved patients' medical knowledge at the time of decision-making (primary outcome) compared to usual care alone (control). In this update, we present the protocol for an extended follow-up study (15 to 23 months post-randomization), including qualitative and quantitative methods. The patient outcomes evaluated using quantitative questionnaires include: the degree to which patients feel well-informed about their RAI treatment choice, decision satisfaction, decision regret, cancer-related worry, mood, and trust in the treating physician. The qualitative component explores the experiences of RAI treatment decision-making, treatment satisfaction, and trial participation in a representative subgroup of patients. Extended follow-up study results will be described for the entire study population, and data will be compared between the P-DA and control groups. RESULT AND CONCLUSION: This mixed methods extended follow-up study will provide data on long term outcomes, relating to the use of a computerized P-DA in decision-making about adjuvant RAI treatment in early stage papillary thyroid cancer. DISCUSSION: Our results are intended to inform future research in this area, particularly relating to long term effects of the use of P-DAs in making healthcare choices. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01083550, registered 24 February 2010 and last updated 5 January 2015.

Exploring the relationship between patients' information preference style and knowledge acquisition process in a computerized patient decision aid randomized controlled trial.

BACKGROUND: We have shown in a randomized controlled trial that a computerized patient decision aid (P-DA) improves medical knowledge and reduces decisional conflict, in early stage papillary thyroid cancer patients considering adjuvant radioactive iodine treatment. Our objectives were to examine the relationship between participants' baseline information preference style and the following: 1) quantity of detailed information obtained within the P-DA, and 2) medical knowledge. METHODS: We randomized participants to exposure to a one-time viewing of a computerized P-DA (with usual care) or usual care alone. In pre-planned secondary analyses, we examined the relationship between information preference style (Miller Behavioural Style Scale, including respective monitoring [information seeking preference] and blunting [information avoidance preference] subscale scores) and the following: 1) the quantity of detailed information obtained from the P-DA (number of supplemental information clicks), and 2) medical knowledge. Spearman correlation values were calculated to quantify relationships, in the entire study population and respective study arms. RESULTS: In the 37 P-DA users, high monitoring information preference was moderately positively correlated with higher frequency of detailed information acquisition in the P-DA (r = 0.414, p = 0.011). The monitoring subscale score weakly correlated with increased medical knowledge in the entire study population (r = 0.268, p = 0.021, N = 74), but not in the respective study arms. There were no significant associations with the blunting subscale score. CONCLUSIONS: Individual variability in information preferences may affect the process of information acquisition from computerized P-DA's. More research is needed to understand how individual information preferences may impact medical knowledge acquisition and decision-making.

The cost implications of an early versus delayed invasive strategy in Acute Coronary Syndromes: the TIMACS study.

BACKGROUND: The Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial demonstrated that early invasive intervention (within 24 hours) was similar to a delayed approach (after 36 hours) overall but improved outcomes were seen in patients at high risk. However, the cost implications of an early versus delayed invasive strategy are unknown. METHODS AND RESULTS: A third-party perspective of direct cost was chosen and United States Medicare costs were calculated using average diagnosis related grouping (DRG) units. Direct medical costs included those of the index hospitalization (including clinical, procedural and hospital stay costs) as well as major adverse cardiac events during 6 months of follow-up. Sensitivity and sub-group analyses were performed. The average total cost per patient in the early intervention group was lower compared with the delayed intervention group (-$1170; 95% CI -$2542 to $202). From the bootstrap analysis (5000 replications), the early invasive approach was associated with both lower costs and better clinical outcomes regarding death/myocardial infarction (MI)/stroke in 95.1% of the cases (dominant strategy). In high-risk patients (GRACE score ≥141), the net reduction in cost was greatest (-$3720; 95% CI -$6270 to -$1170). Bootstrap analysis revealed 99.8% of cases were associated with both lower costs and better clinical outcomes (death/MI/stroke). LIMITATIONS: We were unable to evaluate the effect of community care and investigations without hospitalization (office visits, non-invasive testing, etc). Medication costs were not captured. Indirect costs such as loss of productivity and family care were not included. CONCLUSIONS: An early invasive management strategy is as effective as a delayed approach and is likely to be less costly in most patients with acute coronary syndromes.

Patients' with obstructive sleep apnoea syndrome (OSAS) preferences and demand for treatment: a discrete choice experiment.

RATIONALE: Despite its high level of effectiveness, initial acceptance of continuous positive airway pressure (CPAP) and regular use in patients with obstructive sleep apneoa syndrome (OSAS) are still an issue. Alternatively, oral appliances (OAs) can be recommended. To improve patient engagement in their treatment, physicians are advised to take into account patient preferences and to share the therapeutic decision. We aimed to determine patients' preferences for OSAS treatment-related attributes, and to predict patients' demand for both CPAP and OAs. METHODS: A discrete choice experiment (DCE) was performed in 121 newly diagnosed patients consecutively recruited in a sleep unit. RESULTS: Regression parameters were the highest for impact on daily life and effectiveness ahead of side effects. In the French context, the demanding probabilities for CPAP and OAs were 60.2% and 36.2%, respectively. They were sensitive to the variation in the amount of out-of-pocket expenses for both CPAP and OAs. CONCLUSIONS: This first DCE in OSAS emphasises the importance to communicate with patients before the implementation of treatment.

Randomized controlled trial of a computerized decision aid on adjuvant radioactive iodine treatment for patients with early-stage papillary thyroid cancer.

PURPOSE: Decision-making on adjuvant radioactive iodine (RAI) treatment for early-stage papillary thyroid cancer (PTC) is complex because of uncertainties in medical evidence. Using a parallel, two-arm, randomized, controlled trial design, we examined the impact of a patient-directed computerized decision aid (DA) on the medical knowledge and decisional conflict in patients with early-stage PTC considering the choice of being treated with adjuvant RAI or not. The DA describes the rationale, possible risks and benefits, and the medical evidence uncertainty relating to the choice. PATIENTS AND METHODS: We recruited 74 patients with early-stage PTC after thyroidectomy. Participants were assigned by using 1:1 central computerized randomization to either the DA group with usual care (intervention) or usual care alone (control). Medical knowledge about PTC and RAI treatment (the primary outcome), as well as decisional conflict (a secondary outcome), were measured by using validated questionnaires, and the respective scores were compared between groups. RESULTS: Consistent with PTC epidemiology, 83.8% (62 of 74) of the participants were women, and the mean age was 45.8 years (range, 19 to 79 years). Medical knowledge about PTC and RAI treatment was significantly greater and decisional conflict was significantly reduced in the DA group compared with the control group (respective P values < .001). The use of adjuvant RAI treatment was not significantly different between groups (DA group, 11 of 37 [29.7%]; controls, seven of 37 [18.9%]; P = .278). CONCLUSION: A computerized DA improves informed decision making in patients with early-stage PTC who are considering adjuvant RAI treatment. DAs are useful for patients facing decisions subject to medical evidence uncertainty.

Outcomes and metrics: measuring the impact of a comprehensive adolescent and young adult cancer program.

Against a background of poorly coordinated provision of holistic care to the adolescent and young adult (AYA) cancer population, the Canadian National Task Force on Adolescent and Young Adult Oncology, which is supported by the Canadian Partnership Against Cancer and the C17 network, convened a workshop to formulate the components of a systematic approach to care for this age group. Because such a program will deflect scarce resources, it must be validated and justified by reproducible metrics. A subgroup of experts was convened, comprising attendees at the AYA workshop, including AYA cancer survivors. A substantial number of key, feasible, and consistent metrics were identified and are systematized, justified, and presented in this article. Prioritization from within this range will be necessary.

A usability study of a computerized decision aid to help patients with, early stage papillary thyroid carcinoma in, decision-making on adjuvant radioactive iodine treatment.

OBJECTIVE: We tested the usability of a patient-directed decision aid (DA), intended for patients with early stage papillary thyroid carcinoma (PTC) deciding to accept or reject adjuvant radioactive iodine (RAI) treatment. This decision is complicated by uncertainty of the medical evidence relating to potential treatment benefits. METHODS: The DA was tested by 12 thyroid cancer survivors, 7 thyroid specialty physicians, and 30 lay individuals with no history of thyroid cancer. The participants completed the System Usability Scale for human-computer interaction questionnaire. The medical knowledge of lay participants was assessed before and after DA exposure. Qualitative participant feedback was obtained by thinking aloud during DA use, as well as from interviews. RESULTS: Participants generally found the usability of the DA acceptable. The DA significantly increased medical knowledge. In spite of some physicians' concerns about disclosure of treatment controversy and evidence uncertainty, it was found to be acceptable to non-physicians. CONCLUSION: A computerized DA on RAI treatment is acceptable to physicians and non-physicians and can improve medical knowledge. PRACTICE IMPLICATIONS: In counseling patients about complex medical decisions, disclosure of uncertainty related to medical evidence may be acceptably conveyed using a DA.

Decision aid on radioactive iodine treatment for early stage papillary thyroid cancer--a randomized controlled trial.

BACKGROUND: Patients with early stage papillary thyroid carcinoma (PTC), are faced with the decision to either to accept or reject adjuvant radioactive iodine (RAI) treatment after thryroidectomy. This decision is often difficult because of conflicting reports of RAI treatment benefit and medical evidence uncertainty due to the lack of long-term randomized controlled trials. METHODS: We report the protocol for a parallel, 2-arm, randomized trial comparing an intervention group exposed to a computerized decision aid (DA) relative to a control group receiving usual care. The DA explains the options of adjuvant radioactive iodine or no adjuvant radioactive iodine, as well as associated potential benefits, risks, and follow-up implications. Potentially eligible adult PTC patient participants will include: English-speaking individuals who have had recent thyroidectomy, and whose primary tumor was 1 to 4 cm in diameter, with no known metastases to lymph nodes or distant sites, with no other worrisome features, and who have not received RAI treatment for thyroid cancer. We will measure the effect of the DA on the following patient outcomes: a) knowledge about PTC and RAI treatment, b) decisional conflict, c) decisional regret, d) client satisfaction with information received about RAI treatment, and e) the final decision to accept or reject adjuvant RAI treatment and rationale. DISCUSSION: This trial will provide evidence of feasibility and efficacy of the use of a computerized DA in explaining complex issues relating to decision making about adjuvant RAI treatment in early stage PTC. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT01083550.

A scoping review of strategies for the prevention of hip fracture in elderly nursing home residents.

BACKGROUND: Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear. OBJECTIVE: We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes. METHODS: We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate. FINDINGS: We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7--vitamin D (n = 12,875 participants), 2--sunlight exposure (n = 522), 1--alendronate (n = 327), 1--fluoride (n = 460), 4--exercise or multimodal interventions (n = 8,165), and 5--hip protectors (n = 2,594). Vitamin D, particularly vitamin D(3) > or = 800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC. CONCLUSIONS: The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed.

Family physician attitudes about prescribing using a drug formulary.

BACKGROUND: Drug formularies have been created by third party payers to control prescription drug usage and manage costs. Physicians try to provide the best care for their patients. This research examines family physicians' attitudes regarding prescription reimbursement criteria, prescribing and advocacy for patients experiencing reimbursement barriers. METHODS: Focus groups were used to collect qualitative data on family physicians' prescribing decisions related to drug reimbursement guidelines. Forty-eight family physicians from four Ontario cities participated. Ethics approval for this study was received from the Hamilton Health Sciences/Faculty of Health Sciences Research Ethics Board at McMaster University. Four clinical scenarios were used to situate and initiate focus group discussions about prescribing decisions. Open-ended questions were used to probe physicians' experiences and attitudes and responses were audio recorded. NVivo software was used to assist in data analysis. RESULTS: Most physicians reported that drug reimbursement guidelines complicated their prescribing process and can require lengthy interpretation and advocacy for patients who require medication that is subject to reimbursement restrictions. CONCLUSION: Physicians do not generally see their role as being cost-containment monitors and observed that cumbersome reimbursement guidelines influence medication choice beyond the clinical needs of the patient, and produce unequal access to medication. They observed that frustration, discouragement, fatigue, and lack of appreciation can often contribute to family physicians' failure to advocate more for patients. Physicians argue cumbersome reimbursement regulations contribute to lower quality care and misuse of physicians' time increasing overall health care costs by adding unnecessary visits to family physicians, specialists, and emergency rooms.

The impact of thyroid cancer and post-surgical radioactive iodine treatment on the lives of thyroid cancer survivors: a qualitative study.

BACKGROUND: Adjuvant treatment with radioactive iodine (RAI) is often considered in the treatment of well-differentiated thyroid carcinoma (WDTC). We explored the recollections of thyroid cancer survivors on the diagnosis of WDTC, adjuvant radioactive iodine (RAI) treatment, and decision-making related to RAI treatment. Participants provided recommendations for healthcare providers on counseling future patients on adjuvant RAI treatment. METHODS: We conducted three focus group sessions, including WDTC survivors recruited from two Canadian academic hospitals. Participants had a prior history of WDTC that was completely resected at primary surgery and had been offered adjuvant RAI treatment. Open-ended questions were used to generate discussion in the groups. Saturation of major themes was achieved among the groups. FINDINGS: There were 16 participants in the study, twelve of whom were women (75%). All but one participant had received RAI treatment (94%). Participants reported that a thyroid cancer diagnosis was life-changing, resulting in feelings of fear and uncertainty. Some participants felt dismissed as not having a serious disease. Some participants reported receiving conflicting messages from healthcare providers on the appropriateness of adjuvant RAI treatment or insufficient information. If RAI-related side effects occurred, their presence was not legitimized by some healthcare providers. CONCLUSIONS: The diagnosis and treatment of thyroid cancer significantly impacts the lives of survivors. Fear and uncertainty related to a cancer diagnosis, feelings of the diagnosis being dismissed as not serious, conflicting messages about adjuvant RAI treatment, and treatment-related side effects, have been raised as important concerns by thyroid cancer survivors.

Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial.

OBJECTIVE: To determine if a complex nursing and midwifery intervention in hospital labour assessment units would increase the likelihood of spontaneous vaginal birth and improve other maternal and neonatal outcomes. DESIGN: Multicentre, randomised controlled trial with prognostic stratification by hospital. SETTING: 20 North American and UK hospitals. PARTICIPANTS: 5002 nulliparous women experiencing contractions but not in active labour; 2501 were allocated to structured care and 2501 to usual care. INTERVENTIONS: Usual nursing or midwifery care or a minimum of one hour of care by a nurse or midwife trained in structured care, consisting of a formalised approach to assessment of and interventions for maternal emotional state, pain, and fetal position. MAIN OUTCOME MEASURES: Primary outcome was spontaneous vaginal birth. Other outcomes included intrapartum interventions, women's views of their care, and indicators of maternal and fetal health during hospital stay and 6-8 weeks after discharge. RESULTS: Outcome data were obtained for 4996 women. The rate of spontaneous vaginal birth was 64.0% (n=1597) in the structured care group and 61.3% (n=1533) in the usual care group (odds ratio 1.12, 95% confidence interval 0.96 to 1.27). Fewer women allocated to structured care (n=403, 19.5%) rated staff helpfulness as less than very helpful than those allocated to usual care (n=544, 26.4%); odds ratio 0.67, 98.75% confidence interval 0.50 to 0.85. Fewer women allocated to structured care (n=233, 11.3%) were disappointed with the amount of attention received from staff than those allocated to usual care (n=407, 19.7%); odds ratio 0.51, 98.75% confidence interval 0.32 to 0.70. None of the other results met prespecified levels of statistical significance. CONCLUSION: A structured approach to care in hospital labour assessment units increased satisfaction with care and was suggestive of a modest increase in the likelihood of spontaneous vaginal birth. Further study to strengthen the intervention is warranted. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16315180.

An updated systematic review and commentary examining the effectiveness of radioactive iodine remnant ablation in well-differentiated thyroid cancer.

Radioactive iodine remnant ablation (RRA) is used to destroy residual normal thyroid tissue after complete gross surgical resection of papillary or follicular thyroid cancer. The article updates a prior systematic review of the literature to determine whether RRA decreases the risk of thyroid cancer-related death or recurrence at 10 years after initial surgery, including data from 28 studies. No long-term randomized trials were identified, so the review is limited to observational studies. The incremental benefit of RRA in low risk patients with well-differentiated thyroid cancer after total or near-total thyroidectomy who are receiving thyroid hormone suppressive therapy remains unclear.

Basis for physician recommendations for adjuvant radioiodine therapy in early-stage thyroid carcinoma: principal findings of the Canadian-American thyroid cancer survey.

OBJECTIVE: To explore physician recommendations regarding radioiodine remnant ablation (RRA) as adjuvant treatment in early-stage well-differentiated thyroid carcinoma (WDTC), their rationale for administration of RRA, and their willingness to involve patients' opinions in decision making about the use of RRA. METHODS: We surveyed a representative sample of specialty physicians in Canada and the United States and asked survey participants whether they would recommend adjuvant RRA after thyroidectomy for a 1.6-cm papillary thyroid carcinoma (Likert scale of agreement responses from 1 to 7; strong agreement >or=6). Factor analysis was performed to explore the rationale for recommendations. We asked whether physicians accepted the role of patients' preferences in decision making about administration of RRA, and backward conditional logistic regression analysis was used to identify predictors of strong acceptance. RESULTS: The effective response rate for the survey was 56.3% (486 of 864), with 62.8% (295 of 470 respondents) strongly recommending RRA. Strong RRA recommendations were founded in opinions that RRA (1) decreases WDTC-related mortality and recurrence and (2) facilitates WDTC follow-up at low risk of adverse effects. Approximately a third of the survey respondents (152 of 474) strongly agreed with incorporation of patients' preferences in decision making regarding the use of RRA. Physicians without firm convictions about the efficacy of RRA in decreasing disease-related outcomes and those practicing in the United States were most likely to indicate strong support for incorporating patients' preferences in decision making about RRA. CONCLUSION: The recommendations of physicians regarding use of adjuvant RRA are founded in beliefs in intervention efficacy and follow-up practices. Physicians in medical practice in the United States and those without strong convictions about RRA efficacy are most likely to incorporate patients' views in individualizing decisions about RRA therapy.

Regional differences in opinions on adjuvant radioactive iodine treatment of thyroid carcinoma within Canada and the United States.

OBJECTIVE: To identify regional differences in recommendations for radioactive iodine remnant ablation (RRA) in early stage well-differentiated thyroid carcinoma (WDTC) within Canada and the United States. DESIGN: A cross-sectional written survey of a sample of physicians in specialties potentially involved in thyroid cancer care was performed in 2006. Participants were asked if they recommended RRA for a hypothetical 38-year-old woman with a solitary, 1.6-cm papillary carcinoma resected by total thyroidectomy. Exploratory regional comparisons were performed using Student t tests or analysis of variance. The regions studied were western Canada, eastern Canada (Ontario, the Maritimes), Quebec, the northeastern United States, the western and midwestern United States, and the southern United States. In a secondary multivariable logistic regression analysis, we explored potential relationships between individual respondent characteristics RRA recommendations. MAIN OUTCOME: Agreement with case-based RRA recommendations was measured on a Likert scale of 1 to 7 (7 = strongest agreement). RESULTS: The effective response rate was 56.3% (486/864). There were significant differences in RRA recommendations among the regions studied (F = 11.99, 5 df, p < 0.001); national boundaries did not explain regional variations. For the sample case, the strongest support for RRA was in Quebec and the southern United States, intermediate support in eastern Canada and the northeastern United States, and the least support in western Canada and the western and midwestern United States. Academic affiliation and surgical specialty were independently inversely associated with strong RRA recommendations. CONCLUSIONS: There are significant regional differences in physician-based RRA recommendations in early stage WDTC within Canada and the United States. Physician specialty and practice characteristics may influence RRA recommendations.

Capacity planning for cardiac catheterization: a case study.

BACKGROUND: Excessive waiting for procedures such as cardiac catheterization is an important issue for health care systems. Delays are generally attributed to a mismatch between demand and available capacity. Furthermore, due to the dynamic nature of short-term referral rates, procedure times, and patients' medical urgency, all of which are important contributors to the problem of excessive waiting time, it has been difficult to predict capacity needs accurately. The objective of our paper is to demonstrate how such calculations could be performed. METHODS: After constructing a patient flow model and populating it with appropriate data from 16 consecutive months of operations (n=6215 referrals) of a regional cardiac centre in Ontario, we used computer simulation to simulate the operations of catheterization laboratories in several "what-if" scenarios. We divided the patients into three urgency categories: U1--hospitalized patients, U2--urgent outpatients, U3--elective outpatients. We tested the accuracy of the model by comparing a 1-year sample of computer simulation with actual data which resulted in a highly significant correlation of 0.94. RESULTS: We observed from the referral cohort that waiting times were long, both overall and within each urgency category. We observed from the simulation models that: (1) a one-time infusion of capacity to clear the backlog failed to reduce the waiting times; (2) targeting extra capacity to highest urgency categories reduced waiting times overall and also benefited low urgency patients for whom specific increased capacity was not earmarked; (3) there were no significant effects on waiting times if in some cases patients or referring physicians were able to choose their cath physician; and (4) in situations where the arrival rates increased overall or within specific urgency categories, waiting times increased dramatically and failed to return to baseline for several months to years for the low urgency patients. Efficiency of the labs within the existing capacity could be improved by: (1) reducing changeover time between cases (2) externalizing and standardizing many of the pre- and post-procedural management of the patients, and (3) more carefully balancing the booking to reduce both slack and overtime. INTERPRETATION: Capacity determination is a complex and dynamic process. A combination of available clinical and administrative data, along with a computer simulation model, helps predict capacity needs and is the most appropriate strategy to minimize waiting of patients for procedures. This approach is generalizable and can lead to more effective management of waiting lists for a variety of procedures.

The biggest bang for the buck or bigger bucks for the bang: the fallacy of the cost-effectiveness threshold.

It has been suggested that scepticism among decision-makers about using cost-effectiveness analysis (CEA) is caused in part by the low level of the cost-effectiveness "thresholds" in the economic evaluation literature. This has led Ubel and colleagues to call for higher threshold values of US$200,000 or more per quality-adjusted life-year. We show that these arguments fail to identify the objective of CEA and hence do not consider whether or how the threshold relates to this objective. We show that incremental cost-effectiveness ratios (ICERs) cannot be used to identify an efficient use of resources--the "biggest bang for the bucks"--allocated to health care. On the contrary, the practical consequence of using the ICER approach is shown to be an increase in health care expenditures, or "bigger bucks for making a bang", without any evidence of the bang being bigger (i.e. that this leads to an increase in benefits to the population). We present an alternative approach that provides an unambiguous method of determining whether a new intervention leads to an increase in health gains from whatever resources are to be made available to health care decision-makers.

Treatment decision aids: conceptual issues and future directions.

BACKGROUND: In the last 10 years, there has been a major growth in the development of treatment decision aids. Multiple goals have been identified for these tools. However, the rationale for and meaning of these goals at the conceptual level, the mechanisms through which decision aids are intended to achieve these goals, and value assumptions underlying the design of aids and associated values clarification exercises have often not been made explicit. OBJECTIVE: In this paper, we present ideas to help inform the future development and evaluation of decision aids. RESULTS: We suggest, (i) that the appropriateness of using any decision aid be assessed within the context of the wider decision-making encounter within which it is embedded; (ii) that goal setting activities drive measurement activities and not the other way round; (iii) that the rationale for and meaning of goals at the conceptual level, and mechanisms through which they are intended to have an impact be clearly thought through and made explicit; (iv) that value assumptions underlying both decision aids and associated values clarification exercises be communicated to patients; (v) that taxonomies developed and used to classify various types of decision aids include a section on value assumptions underlying each tool; (vi) that further debate and discussion take place on the role of explicit values clarification exercises as a component of or adjunct to treatment decision aids and the feasibility of implementing valid measures. CONCLUSION: Further debate and discussion is needed on the above issues.