Biomedical subjects
A Mills
Publications and source records attributed to A Mills.
The contribution of economics to health service planning.
The increased emphasis on the need consciously to plan the future development of the NHS has, in recent years, focused attention on the availability of skills and techniques which might help planners in their attempts to elucidate objectives and the best way of achieving them. This paper sets out the contribution economics can make to health service planning and reviews some of the recent developments in this field.
Experimental treatments in end-stage leukaemia.
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Measuring the outcome of contact tracing. 1. A description of the patient and contact populations studied.
A standard system for health workers to record and handle information on patients and contacts was introduced to five clinics. Information on all the patients interviewed during the first quarter of 1975 was collected and analysed. An analysis of the characteristics of these patients showed variation between the clinics. However, regardless of what was being measured, there were always differences between men and women. It was found that not all infected patients were interviewed about their contacts. Unless or until contact tracing includes all infected patients, the effect of contact tracing on the control of the sexually transmitted diseases will be of limited value and difficult to assess.
Measuring the outcome of contact tracing. 2. The responsibilities of the health worker and the outcome of contact investigations.
The previous paper (Satin and Mills, 1978) concerned information on patients who were interviewed by health workers in five selected clinics; information on the contacts named by these patients was similarly analysed. This paper describes and evaluates the activities of the health workers and the outcome of contact investigations. At all stages of the contact tracing process, differences were observed between men and women. It was found that more than half of the male contacts and half the female contacts were known to have been examined. Of those contacts examined, at least two-thirds of them attended the same clinic as the patient who had named them, and 85% of these contacts were found to have a treatable condition. It will be seen that the concept of success or effectiveness of contact tracing is complex in definition and measurement.
'Atypical' mycobacteria isolated in Rhodesia.
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Mycobacterium rhodesiae sp. nov. A new species of rapid-growing scotochromogenic mycobacteria.
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Why the poor pay more: household curative expenditures in rural Sierra Leone.
This paper draws on data from Sierra Leone, and secondary data from elsewhere, to show that the rural poor can be disproportionately disadvantaged by user charges for health care, paying a higher percentage of their incomes for health care than wealthier households. Cost sharing systems at primary care level should include exemptions for the poor, but rarely succeed in consistently protecting them. The regressivity of health expenditures also results from lack of protection from the higher costs of less-frequently used, expensive providers. In Sierra Leone, the burden of curative treatment costs for all groups came mainly from private and NGO providers. Proximity to facilities appeared a more important factor in their use than average price levels. Even if a perfect exemption system existed at government primary care facilities, it would not have had much overall effect because of their relatively small contribution to household health expenditures. The financial burden on households could be relieved by making basic health facilities more accessible and at hospital level using additional resources generated through improved efficiency and cross-subsidization to provide exemptions. Also, pricing policy should take into account local economic conditions. Insurance/prepayment schemes covering the cost of hospitalization would come closer to an ideal solution, but have been implemented in very few of the poorer countries.
Health policy in less developed countries: past trends and future directions.
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The cost-effectiveness of chemoprophylaxis with Maloprim administered by primary health care workers in preventing death from malaria amongst rural Gambian children aged less than five years old.
In recent trials in The Gambia, mass chemoprophylaxis with Maloprim administered over several years by primary health care workers to children aged 3-59 months has reduced both mortality and morbidity without inducing impairment of natural immunity or significant development of drug resistance. Taking expenditure of both time and money, by both public authorities and village volunteers, into account, the costs and the cost effectiveness of such mass chemoprophylaxis are estimated here. The cost per child protected per season was (1990 US) $2.84; the cost per childhood death averted was $143. Both costs compare favourably with those of permethrin bed net impregnation. So in some circumstances where malaria is holoendemic, control of childhood malaria by chemoprophylaxis may be more economically efficient than provision of impregnated bed nets.
Health sector reforms in sub-Saharan Africa: lessons of the last 10 years.
Over the past 10 years the poorest countries, especially in Africa, have struggled with worsening economic conditions and reduced public finance for health services. Some governments have responded in a piecemeal fashion, reacting to internal and external pressures. Others have embarked on major reforms of various aspects of their health systems. This paper reviews two specific types of strategy that have been initiated by governments: reform of financing strategies, and reform of public sector organization and procedures. Particular attention is paid to the experience of introducing user fees, community financing and decentralization since these have been some of the most popular strategies. The paper describes the nature, objectives and extent of reforms. It then presents an evaluation framework related to the criteria of efficiency and equity, and evaluates current reform experience using this framework. It concludes that assessment of the potential impact of reforms on efficiency and equity is undermined by the limited duration of many reforms and the limited nature of existing evaluations. It is clear, however, that a policy package is required rather than implementation of isolated reform strategies, and that in order to design an effective policy package, more needs to be known about the implementation and operation of reforms--particularly with respect to the influence of context, actors and processes.
Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania.
BACKGROUND: A community-randomised trial was undertaken to assess the impact, cost, and cost-effectiveness of averting HIV-1 infection through improved management of sexually transmitted diseases (STDs) by primary-health-care workers in Mwanza Region, Tanzania. METHODS: The impact of improved treatment services for STDs on HIV-1 incidence was assessed by comparison of six intervention communities with six matched communities. We followed up a random cohort of 12,537 adults aged 15-54 years for 2 years to record incidence of HIV-1 infection. The total and incremental costs of the intervention were estimated (ingredients approach) and used to calculate the total cost per case treated, the incremental cost per HIV-1 infection averted, and the incremental cost per disability-adjusted life-year (DALY) saved. FINDINGS: During 2 years of follow-up, 11,632 cases of STDs were treated in the intervention health units. The baseline prevalence of HIV-1 infection was 4%. The incidence of HIV-1 infection during the 2 years was 1.16% in the intervention communities and 1.86% in the comparison communities. An estimated 252 HIV-1 infections were averted each year. The total annual cost of the intervention was US$59,060 (1993 prices), equivalent to $0.39 per head of population served. The cost for STD case treated was $10.15, of which the drug cost was $2.11. The incremental annual cost of the intervention was $54,839, equivalent to $217.62 per HIV-1 infection averted and $10.33 per DALY saved (based on Tanzanian life expectancy) or $9.45 per DALY saved (based on the assumptions of the World Development Report). In a sensitivity analysis of factors influencing cost-effectiveness, cost per DALY saved ranged from $2.51 to $47.86. INTERPRETATION: Improved management of STDs in rural health units reduced the incidence of HIV-1 infection in the general population by about 40%. The estimated cost-effectiveness of this intervention ($10 per DALY) compares favourably with that of, for example, childhood immunisation programmes ($12-17 per DALY). Cost-effectiveness should be further improved when the intervention is applied on a larger scale. Resources should be made available for this highly cost-effective HIV control strategy.
Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment.
Predisposing factors contributing to the development of first carpometacarpal (CMC) osteoarthritis include an inherent laxity or incongruency of this joint, a shallow trapezium saddle, and heavy stresses placed on the joint with pinching and grasping. Splinting is a common mode of conservative treatment for CMC osteoarthritis. This study assessed the objective and subjective responses of patients with CMC osteoarthritis who wore short and long opponens splints, as well as radiographic changes associated with wearing of the splints. The study evaluated 26 hands. Each patient was assigned at random to wear the long or the short splint first. Patients wore the splints for one week. They then documented function in their splints (on 22 activities of daily living) and rated splint satisfaction and pain levels on visual analog scales. One week after application of the first splint, the second splint was applied and worn for one week, and all measures were repeated. On the final visit, tip pinches were evaluated and x-rays were taken to assess subluxation. One-way repeated-measure analysis and paired comparison were used to analyze the pinch, pain, radiographic, and splint-rating measures. Descriptive statistics were used to assess activity-of-daily-living function and splint preference. Both splints appear to reduce subluxation at the first CMC joint in patients with grades 1 and 2 osteoarthritis. The majority of the patients picked the short splint when asked at the end of the study which splint they preferred. The splints do not appear to increase pinch strength or affect pain levels associated with the performance of pinch strength measurements. This study supports anecdotal evidence that patients with CMC osteoarthritis get pain relief with splinting.
Avoiding problems in clinical practice after the pill scare.
The publications of 1995 and 1996 on the risk of venous thrombosis associated with the use of the combined oral contraceptive pill (COC) suggested that the risks were lower than previous estimates. The debate, which ensued, ensured that the safety of the COC with regard to arterial and venous disease was reassessed. This review details the importance of contraception for public health. It reassesses critically current prescribing practice in the light of the new publications on Factor V Leiden, arterial and venous disease. Methods of communicating information about the COC are assessed, and the difficulties of transmitting complex scientific data to health care professionals and the general public are debated. The importance of attempting to quantify the benefits and risks of the COC and explaining them in the context of other life events is emphasized.
High-level expression of G protein-coupled receptors with the aid of the Semliki Forest virus expression system.
The expression of two G protein-coupled receptors was studied in several cell lines using the Semliki Forest virus expression system. Human neurokinin-2 and dopamine D3 receptor cDNAs were introduced into the pSFV1 vector. In vitro transcribed RNAs were coelectroporated with pSFV-Helper RNA into BHK cells resulting in in vivo packaging of high titer SFV-NK-2 and SFV-D3 virus stocks, respectively. Infection of BHK, HOS and CHO cells with the recombinant NK-2 virus resulted in high levels of receptor expression as detected by metabolic labelling with [35S]-methionine. The expression of the NK-2 receptors in the cell membrane was demonstrated by Flow cytometry experiments on infected BHK and CHO cells with fluoresceinyl-NKA as the ligand. Saturation binding assays on membranes prepared from SFV-NK-2 infected CHO cells with [3H] GR100679 showed maximum receptor densities of 6.5 pmol receptor/mg protein. Additionally, the expressed NK-2 receptors were able to stimulate Ca2+ mobilization in CHO cells indicating functional coupling to G proteins. CHO cells infected with SFV-D3 also produced high levels of receptor as evidenced by both [35S]methionine labelling and [3H]spiperone binding.
Incident reports in secure psychiatric units.
In 1995 Sir Louis Blom-Cooper observed a 'picture of increasing violence in British psychiatric hospitals in recent years, although the rate of serious violence is mercifully low' (Blom-Cooper et al 1995). In the following report, the author examines the incidence and management of violent incidents in three secure psychiatric units in the West Country.
Helping male victims of sexual abuse.
The author recounts his experience of working in an extra care psychiatric unit in which a proportion of the male attenders had been subject to sexual abuse as children. While there is a paucity of literature on the subject of male sexual abuse, his experience of looking after victims suggests that many commonalities with female sexual abuse survivors exist. A model is presented as guidance for practitioners in helping men who have suffered sexual abuse as children.