Economic evaluation of the "paramedics and palliative care: bringing vital services to Canadians" program compared to the status quo.

OBJECTIVE: Based on programs implemented in 2011-2013 in three Canadian provinces to improve the support paramedics provide to people receiving palliative care, the Canadian Partnership Against Cancer and Healthcare Excellence Canada provided support and funding from 2018 to 2022 to spread this approach in Canada. The study objectives were to conduct an economic evaluation of "the Program" compared to the status quo. METHODS: A probabilistic decision analytic model was used to compare the expected costs, the quality-adjusted life years (QALYs) and the return on investment associated with the Program compared to the status quo from a publicly funded healthcare payer perspective. Effectiveness data and Program costs, expressed in 2022 Canadian dollars, from each jurisdiction were supplemented with literature data. Probabilistic sensitivity analyses varying key model assumptions were conducted. RESULTS: Analyses of 5416 9-1-1 calls from five jurisdictions where paramedics provided support to people with palliative care needs between April 1, 2020 and March 31, 2022 indicated that 60% of the 9-1-1 calls under the Program enabled people to avoid transport to the emergency department and receive palliative care at home. Treating people at home saved paramedics an average of 31 min (range from 15 to 67). The Program was associated with cost savings of $2773 (95% confidence interval [CI] $1539-$4352) and an additional 0.00069 QALYs (95% CI 0.00024-0.00137) per 9-1-1 palliative care call. The Program return on investment was $4.6 for every $1 invested. Threshold analyses indicated that in order to be cost saving, 33% of 9-1-1 calls should be treated at home under the Program, the Program should generate a minimum of 97 calls per year with each call costing no more than $2773. CONCLUSION: The Program was cost-effective in the majority of the scenarios examined. These results support the implementation of paramedic-based palliative care at home programs in Canada.

RéSUMé: OBJECTIFS: En fonction des programmes mis en œuvre en 2011-2013 dans trois provinces canadiennes pour améliorer le soutien que les ambulanciers paramédicaux fournissent aux personnes recevant des soins palliatifs. le Partenariat canadien contre le cancer et Excellence des soins de santé Canada a fourni un soutien et du financement de 2018 à 2022 pour diffuser cette approche au Canada. Les objectifs de l'étude étaient d'effectuer une évaluation économique du « programme ¼ par rapport au statu quo. MéTHODES: Un modèle probabiliste d'analyse décisionnelle a été utilisé pour comparer les coûts prévus, les années de vie ajustées en fonction de la qualité (AVAQ) et le rendement du capital investi associés au Programme par rapport au statu quo du point de vue des payeurs de soins de santé financés par l'État. Les données sur l'efficacité et les coûts du Programme, exprimés en dollars canadiens de 2022, de chaque administration ont été complétées par des données documentaires. Des analyses probabilistes de sensibilité ont été effectuées en fonction de diverses hypothèses clés du modèle. RéSULTATS: Des analyses de 5416 appels 9-1-1 provenant de cinq administrations où des ambulanciers paramédicaux ont fourni du soutien aux personnes ayant des besoins en soins palliatifs entre le 1er avril 2020 et le 31 mars 2022 ont indiqué que 60 % des 9Les appels 1-1 dans le cadre du Programme ont permis aux gens d'éviter le transport vers les urgences et de recevoir des soins palliatifs à domicile. Le traitement à domicile a permis aux ambulanciers paramédicaux d'économiser en moyenne 31 minutes (de 15 à 67 minutes). Le programme a permis de réaliser des économies de 2 773 $ (intervalle de confiance [IC] de 95 %, de 1 539 $ à 4 352 $) et de 0,00069 AVAQ supplémentaires (IC à 95 %, de 0,00024 à 0,00137) par appel de soins palliatifs 9-1-1. Le rendement du capital investi du Programme était de 4,6 $ pour chaque dollar investi. Les analyses des seuils ont indiqué que pour réaliser des économies, 33 % des appels 9-1-1 devraient être traités à domicile dans le cadre du Programme, le Programme devrait générer un minimum de 97 appels par année, chaque appel ne dépassant pas 2773 $. CONCLUSION: Le Programme a été rentable dans la majorité des scénarios examinés. Ces résultats appuient la mise en œuvre de programmes de soins palliatifs paramédicaux à domicile au Canada.

Calculating the affordability of antiretrovirals in St Lucia.

The cost of antiretrovirals is borne by donors in many low- and middle-income countries, including St Lucia. Although donor involvement has facilitated access to antiretrovirals, donor engagement in HIV/AIDS has changed over the years. This paper assesses the affordability of antiretrovirals at the individual level if donors were no longer available to fund the cost of first and second-line antiretrovirals and a prospective third-line regimen. Various conceptions of affordability are reviewed using different assumptions of what is required to maintain a standard of living that would avoid individuals descending into poverty as a result of antiretroviral purchases. These concepts of affordability are operationalized using data from the Household Budgeting Survey conducted in St Lucia in 2005/2006. While there is a range of results for the affordability of first and second-line antiretrovirals depending on which standard of affordability is used, third-line antiretrovirals are unaffordable to more than 80% of the population across the four standards of affordability used - the national poverty line, 50% of median annual consumption, 10% of annual consumption and a proposed reasonable minimum standard.

The 2018 decision to establish an Advisory Council on adding pharmaceuticals to universal health coverage in Canada.

Canada is the only Universal Health Insurance country in the OECD without universal insurance for outpatient prescription drugs, a situation generally perceived as unfair and inefficient. In June 2018, the federal government launched an Advisory Council on the Implementation of National Pharmacare, to report in 2019 on the best strategy to implement a national Pharmacare program that would provide all Canadians access to affordable outpatient prescription drugs. The Council was asked to consider three options: a universal public plan for all Canadians; a public catastrophic insurance plan that would kick off once spending on prescription drugs reaches a given threshold; and a more modest patching of existing gaps, providing coverage to those who are not eligible to any form of insurance. Beyond the relative consensus around the ideas that gaps in coverage should be filled to make drugs affordable to all, and that the costs of drugs are too high in Canada, the Council faces the challenge of addressing three underlying issues: 1) what amount of income redistribution will result from each of the three options; 2) how much savings would the implementation of a single payer generate? 3) what role restricting a national formulary would play in achieving those savings, and what would be the political consequences of narrowing the formulary?

Moral hazard, doctors, and absenteism in France. Preliminary analysis based on aggregate data.

This article provides a simple and preliminary study of variations in the number of days of work lost to illness and injury in France, over time and across jurisdictions. We test the hypothesis that workers use their physicians to cheat the system and increase their leisure time paid for by the sickness fund. Firstly, using time series analysis, we check that change in the unemployment rate correlates unequivocally and negatively with the absence rate. We then show, based on geographical aggregate level data, that physicians' density is not positively correlated to sick leaves, which runs contrary to the idea of cheating helped by doctors. We suggest and test for alternative factors, such as baseline population health. If the increase in the number of days lost to illness is seen as a matter of concern, our recommended policy would be to target demand side as well as supply side in the labour market.

[The effect of dilutions of Apis mellifica and Apium virus on ultraviolet light-induced erythema in the guinea pig]. / Mise en évidence des effets de dilutions d'Apis mellifica et d'Apium virus vis-à-vis de l'érythème provoqué par un rayonnement UV chez le cobaye.

Dilutions of Apis mellifica (obtained from the whole bee) and Apium virus (obtained from bee venom) are used classically in homeopathy for inflammatory symptoms with edema, erythema and pruritus (Lewis triad). Using a method examining the evolution of UV induced erythema in the guinea pig, the authors show the following dilutions of Apis mellifica 7 CH(10(-14)), 9 CH(10(-18)) and of Apium virus 5 CH(10(-10)), 7 CH(10(-14)), 9 CH(10(-18)) exert an action on experimental erythema. The results are statistically significant for the dilutions at the 48th hour after irradiation.

Calculating the affordability of antiretrovirals in St Lucia / Cálculo de la asequibilidad de los antirretrovirales en Santa Lucia

The cost of antiretrovirals is borne by donors in many low- and middle-income countries, including St Lucia. Although donor involvement has facilitated access to antiretrovirals, donor engagement in HIV/AIDS has changed over the years. This paper assesses the affordability of antiretrovirals at the individual level if donors were no longer available to fund the cost of first and second-line antiretrovirals and a prospective third-line regimen. Various conceptions of affordability are reviewed using different assumptions of what is required to maintain a standard of living that would avoid individuals descending into poverty as a result of antiretroviral purchases. These concepts of affordability are operationalized using data from the Household Budgeting Survey conducted in St Lucia in 2005/2006. While there is a range of results for the affordability of first and second-line antiretrovirals depending on which standard of affordability is used, third-line antiretrovirals are unaffordable to more than 80% of the population across the four standards of affordability used - the national poverty line, 50% of median annual consumption, 10% of annual consumption and a proposed reasonable minimum standard.

El costo de los antirretrovirales descansa sobre los hombros de los donantes en muchos países de ingresos medios y bajos, incluyendo Santa Lucia. Aunque la involucración de los donantes ha facilitado el acceso a los antirretrovirales, el compromiso de aquellos con respecto al VIH/SIDA ha cambiado con los años. Este trabajo evalúa la asequibilidad de los antirretrovirales a nivel individual, en caso de que no hubiera ya más donantes disponibles para financiar el costo de los antirretrovirales de primera y segunda línea, y un régimen prospectivo de tercera línea. Se examinan varias concepciones en torno a su asequibilidad a partir de diferentes supuestos de lo que se requiere para mantener un determinado nivel de vida, sin que las personas caigan en la pobreza como resultado de la compra de antirretrovirales. Estos conceptos de asequibilidad se operacionalizan usando datos de la Encuesta de Presupuestos de Hogares realizada en Santa Lucía en 2005/2006. Si bien hay una gama de resultados para la asequibilidad de los antirretrovirales de primera y segunda línea, en dependencia de cual estándar de asequibilidad se utilice, los antirretrovirales de tercera línea son inasequibles para más del 80% de la población en los cuatro estándares de accesibilidad utilizados: la línea de pobreza nacional, el 50% del consumo anual promedio, el 10% del consumo anual, y un estándar mínimo razonable propuesto.

Ultrastructural study of the mast cells of the human duodenal mucosa.

The ultrastructure of the process of degranulation of mast cells of human duodenal mucosa was examined. In normal controls little degranulation was seen, but in persons with false food allergy (pseudo-allergy) considerable degranulation of mast cells was detected. This is consistent with the hypothesis that some persons have an abnormal fragility of duodenal mast cells in the presence of histamine-releasing substances. Incubation of duodenal biopsy material with various histamine-releasing agents (compound 48/80, Concanavalin A, the calcium ionophore A 23187, and anti-IgE) confirmed the susceptibility of duodenal mast cells for antigen non-specific release of histamine, or that mediated by IgE. In a group of patients with immediate-type, anaphylactic, food allergy, mast cells in the absence of antigen are in a normal state, but degranulation occurs on exposure in vitro or in vivo to specific antigen. The susceptibility to degranulation continues in persons cured of their food allergy. This suggests that a clinical cure is not due to a change of susceptibility of duodenal mast cells to release histamine, but is possibly associated with formation of blocking antibodies, and/or a modification in reactivity of basophils and mast cells of other organs.

[Toxicity and pharmacokinetics of zirconium oxychloride in mice and rats]. / Toxicité et pharmacocinétique de l'oxychlorure de zirconium chez la souris et chez le rat.

The experimental toxicity of zirconium compounds is examined in the Mouse (acute toxicity) and in the Rat (short time toxicity). The absorption, the distribution and the elimination of zirconium are evaluated by zirconium cation assay in some biological fluids and tissues. After a single oral dose, zirconium oxyd is not toxic, zirconium oxychlorure slightly toxic and zirconium chlorure moderately toxic. At certain concentrations, cerebral and pulmonary disorders are observed, particularly with zirconium chlorure. In considering molar toxicity, the studied zirconium compounds are more toxic than certain aluminium salts mentioned in the literature. The zirconium oxychlorure doesn't influence the growth curve after iterative administrations (0.23 g zirconium/kg/day). Only a weak fraction of administered zirconium is absorbed and is electively fixed in the ovaries, in a lesser degree in the lung and the bone. In the ovary the zirconium induces vascular variation (hypervascularization) which appear one month after the end of the treatment. The absorbed zirconium is eliminated by the urinary tract. The fecal elimination can be essentially explained by an important quantity of non absorbed zirconium.

Sideroblastic anaemia during fusidic acid treatment.

OBJECTIVES AND METHODS: To describe cases of fusidic acid-associated sideroblastic anaemia from the French Pharmacovigilance database. RESULTS: Six cases of sideroblastic anaemia associated with oral fusidic acid treatment were retrieved. Four females and two males (mean age 65.3 yr) developed severe anaemia (mean haemoglobin level: 6.9 g/dL) within 32-190 d (mean: 81 d) of treatment. Bone marrow aspirates showed dyserythropoiesis and ringed sideroblasts in all patients. Four patients required repeated blood transfusions. After fusidic acid discontinuation in five patients, complete recovery was obtained. In one patient, rechallenge with fusidic acid resulted in recurrence of anaemia that resolved after definitive discontinuation of the drug. CONCLUSION: Our data indicate that fusidic acid should be added to the list of drugs that can cause sideroblastic anaemia.