Induction of labour up to thirty-six weeks.
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Female↗
Biomedical subjects
J Gardiner
Publications and source records attributed to J Gardiner.
Cost-effectiveness analysis in heart disease, Part II: Preventive therapies.
Cost-effectiveness analysis of preventive therapies are reviewed in the following categories: lipid lowering, hypertension, smoking cessation, exercise, and anticoagulation. From review of 8 analyses, cost-effectiveness of primary prevention via cholesterol lowering drugs is generally expensive, whereas that of secondary prevention generally is favorable. However, targeting by age, coexisting risk factors, and gender strongly influence results that are also sensitive to drug costs. Treatment of hypertension (5 analyses) is cost-effective in virtually all patient populations and circumstances and for a wide variety of drugs. It is more so with coexisting risk. Issues relating to compliance and drug costs are important. Smoking cessation (4 analyses) is highly cost-effective and worthwhile. However, data on recidivism are incomplete, and cessation may be more difficult to achieve in the general population versus study patients. In one analysis, an exercise program was found to be cost-effective in prevention of coronary heart disease. Anticoagulants have been analyzed in various circumstances. Their cost-effectiveness is favorable for prosthetic valves, although sensitive to imprecision in monitoring. It is also favorable for mitral stenosis in the presence of atrial fibrillation but not normal sinus rhythm. Cost-effectiveness of heparinization for prosthetic valve patients undergoing surgery is rather variable and depends on type of surgery (major versus minor) and type of valve. Many topics in anticoagulant therapy remain to be explored from a cost-effectiveness point of view.
Adult↗
Cost-effectiveness analysis in heart disease, Part III: Ischemia, congestive heart failure, and arrhythmias.
Cost-effectiveness analyses were reviewed in the following diagnostic and treatment categories: acute myocardial infarction (MI) and diagnostic strategies for coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA), congestive heart failure (CHF), and arrhythmias. In the case of acute MI, coronary care units, as presently used, are rather expensive but could be made much more efficient with more effective triage and resource utilization; reperfusion via thrombolysis is cost-effective, as are beta-blockers and angiotensin-converting enzyme (ACE) inhibitors post-MI in appropriate patients. Cost-effectiveness of CAD screening tests depends strongly on the prevalence of disease in the population studied. Cost-effectiveness of CABG surgery depends on targeting; eg, it is highly effective for such conditions as left-main and three-vessel disease but not for lesser disease. PTCA appears to be cost-effective in situations where there is clinical consensus for its use, eg, severe ischemia and one-vessel disease, but requires further analysis based on randomized data; coronary stents also appear to be cost-effective. In preliminary analysis, ACE inhibition for CHF dominates, ie, saves both money and lives. Cardiac transplant appears to be cost-effective but requires further study. For arrhythmias, implantable cardioverter defibrillators are cost-effective, especially the transvenous device, in life-threatening situations; radiofrequency ablation is also cost-effective in patients with Wolff-Parkinson-White syndrome apart from asymptomatic individuals; and pacemakers have not been analyzed except in the case of biofascicular block, where results were variable depending on the situation and preceding tests.
Angioplasty, Balloon, Coronary↗
Cost-effectiveness analysis in heart disease, Part I: General principles.
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Bias↗
Evaluation of the effectiveness of following up laboratory reports of elevated blood leads in adults.
The usefulness of a statewide laboratory-based blood lead surveillance system to initiate workplace enforcement inspections was studied. In particular, the effectiveness of inspection of companies in which at least one worker had a blood lead level (BLL) 30-39 microg/dL but no greater than 39 microg/dL was considered. The surveillance system identified all individuals who had been tested for blood lead. Adults with BLLs > or =30 microg/dL were interviewed. Companies where lead exposures occurred were identified and enforcement inspections performed there. Companies were grouped into four categories: one or more employees with BLL > or =50 microg/dL; one or more employees with highest BLL of 40-49 microg/dL; one or more employees with highest BLL of 30-39 microg/dL; and companies that used lead but from which no blood lead reports were received. The number of citations and amounts of penalties, and BLLs before and after, were compared among the three blood lead groups and with a control group of no lead-using companies. A cost-benefit analysis was performed. Citations and penalties did not differ among the three blood lead groups but were markedly increased compared with the lead using but no blood lead group. Violations of specific lead standard components were similar among the three blood lead groups. Blood lead companies had increased citations and penalties as compared with nonusing lead control companies. No significant decrease in blood leads was seen postinspection. Total cost to identify lead-exposed workers at problem work sites was $125 ($53-$459) per lead-exposed worker. Followup of companies identified through the surveillance system was an effective method to target workplace inspections. It is recommended that routine inspection be instituted for all companies in which an employee is reported to have a blood lead of 30 microg/dL or greater.
Adult↗
Confidence intervals for cost-effectiveness ratios.
The problem of variability in computed cost-effectiveness ratios (CERs) is usually addressed by performing sensitivity analyses to determine the effects on these ratios of plausible ranges of values of input parameters. However, the sampling variation that exists in these estimated parameters can be utilized to obtain confidence intervals for cost-effectiveness ratios. As cost-effectiveness analysis becomes more widely used, new techniques need to be developed for establishing when a difference in strategies evaluated is meaningful. A first step is to establish the precision of the CER itself. The authors estimate the precision of a CER in the context of a statistical model in which the primary outcome is survival, with cost and effectiveness defined in terms of the underlying survival distribution (S). Effectiveness (alpha) is measured by life expectancy, restricted to a finite time horizon and discounted at a fixed rate r, alpha = integral of e-rtS(t)dt. Cumulative cost (beta) per patient is regarded as resource utilization and incurred randomly over time depending on the survival experience of the patient, beta = integral of e-rtS(t)dC(t), where C(t) is the total potential resources utilized up to time t. Average cost-effectiveness (ACE) of a single strategy is beta/alpha, and when comparing two strategies, the CER is delta beta/delta alpha, the ratio of the incremental cost to the difference in mean survival. Utilizing the sampling distribution of the Kaplan-Meier estimate of S yields standard errors and confidence intervals for ACE and CER. The technique is applied to survival data from 218 previously studied patients to assess 95% confidence intervals for the CER and ACE of the implantable cardioverter defibrillator as compared with electrophysiology-guided therapy.
Confidence Intervals↗
The management of dural puncture in obstetrics and the efficacy of epidural blood patches.
Epidural blood patch is the definitive treatment for post dural puncture headaches (PDH), providing acceptable short-term relief. Disappointingly however debate exists as to their long-term success. To investigate their efficacy in our practice, a retrospective audit of all epidural blood patches performed over a four year period was performed. Patients were subsequently followed up using a postal questionnaire and persistent symptom relief and patient satisfaction was measured. During the study period 87 patients required an epidural blood patch, 11 required repeat patches. 71.26% of patients had complete symptom resolution on discharge. The response rate to follow up survey was 73.26% with the majority, 57.44%, replying that their symptoms returned following their discharge home. Only 25.53% said they would have an epidural or spinal anaesthetic for future deliveries. Epidural blood patches provide excellent short-term relief but long-term results are disappointing. Patients receiving epidural blood patches need improved long-term follow up.
Adult↗
Resuscitation in special circumstances.
Basic and Advanced Life Support Guidelines should be followed as normal in cardiorespiratory arrest where there are 'special circumstances' such as near drowning, hypothermia, electrocution, poisoning, anaphylaxis and pregnancy. In order to increase the chances of a successful outcome there are specific considerations and actions that need to be taken. These will be discussed in this paper, the fifth in our resuscitation series.
Drowning↗
Use of skin-cancer prevention strategies among farmers and their spouses.
Epidemiologic studies show that farmers are at increased risk of skin cancer, presumed to be secondary to the increased time they spend outdoors with exposure to the sun. We surveyed a random sample of farmers and their spouses 40 years of age or older from four rural counties in Michigan on their knowledge, attitudes, and behavior regarding protection of their skin from the sun and screening medical exams for skin cancer. Questionnaires were completed by 1,342 farmers and their spouses. This was a response rate of 63.5%. Eighty to ninety percent knew the changes in the skin that could indicate cancer and required medical follow-up. Only 40% of the men and 65% of the women were likely to protect their skin when they went outdoors. Increasing age and personal history of skin cancer increased the likelihood of both men and women protecting their skin when they went outside. Additionally, higher-income women were likely to use sun protection. Despite the fact that 90% of the respondents had had a physical examination in the last three years, less than one third reported ever having had their skin examined for cancer. Increasing age, income, and education increased the likelihood of having had such an exam. The majority of those who had had a skin exam had the exam for a particular skin problem, and not as part of a routine physical examination. Farmers and their spouses need to increase their use of sun protection when going outside. Additionally, health care providers need to routinely include examination of the skin for skin cancer and alert their patients that it is being performed.
Adult↗