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PubMed2006

The use of filters with small infants.

The use of breathing system filters may be particularly beneficial in small infants, compared with older children and adults, because of their greater need for warming and humidification of inspired gases as well as their increased susceptibility to lower respiratory tract contamination. The only evidence available regarding the safety and efficacy of breathing system filters in small infants comes from a few small studies conducted on intensive care patients, however. These studies have suggested that the use of HME filters may be effective in preserving body temperature and airway humidity while decreasing fluid build-up in the breathing system and therefore reducing breathing system contamination. Nonetheless, the use of filters has not been shown to decrease the incidence of VAP in small infants. In contrast,their use in adult intensive care patients, particularly those requiring prolonged ventilation, has been associated with a decrease in the infection rate. The use of breathing system filters is not associated with a statistically significant increase in the rate of complications, despite the potentially greater hazards associated with their use in small infants compared with older children and adults. In practice the use of breathing system filters, even in small infants, rarely causes any major clinical problems that cannot be prevented with a high degree of vigilance and appropriate monitoring. This vigilance is particularly important to prevent the serious morbidity and even mortality that may result from filter occlusion; when subjected to excessive loading, smaller filters are more prone to obstruction than are their larger counterparts. The increased resistance provided by smaller filters should not translate into a clinically significant increase in the work of breathing during general anesthesia, because it is common practice to ventilate small infants for all but the shortest of surgical procedures. An increase in the work of breathing may, however, become more significant when spontaneous ventilation is established at the end of a surgical case. It remains unclear whether the use of filters allows the safe reuse of breathing systems in small infants. None of the breathing system filters tested by the MHRA had a zero-percent penetrance to sodium chloride particles, and pediatric filters generally had a higher penetrance than their adult counterparts. This finding suggests that there is a potential, albeit small, risk of cross-contamination. The exact risk depends on the type of filter used and on the particular patient undergoing anesthesia or ventilation in the ICU. Although no evidence has been published showing cross-infection occurring when any filter has been used in the anesthesia breathing system for adults or small infants, the level of filtration performance required to allow the safe reuse of anesthesia breathing systems in small infants remains unanswered. Because the incidence of lower respiratory tract colonization is low in unselected small infants, a study with sufficient power to answer accurately the questions regarding the safety of breathing system reuse in small infants would be very difficult to conduct. The effect of filters on post operative infection rates may in fact be of less significance than the adoption of adequate standards of hygiene (eg, hand washing and the use of gloves).Further research is needed to determine if the variations in filtration efficiency demonstrated by the MHRA have any effects on patient outcome. This research might allow setting an effective minimal level of filtration performance for breathing system filters for use in small infants. On a practical note, the publication of the MHRA assessments of breathing system filters provides a useful tool for objective comparison of the different filters available for use in small infants, even though the relevance of the flow used to test pediatric filters has been criticized. Individual institutions will need to formulate policies for the use of breathing system filters for clinical reasons as well as for cost containment or logistical reasons. These policies should be within the frameworks set out by their regulatory agencies. Any problems arising from policies that are in breach of these frame works will remain the responsibility of the individual clinicians caring for these small infants.

Anesthesia, Inhalation↗

PubMedDate not supplied

An iterative Bayesian approach to health technology assessment: application to a policy of preoperative optimization for patients undergoing major elective surgery.

PURPOSE: This article presents an iterative framework for managing the dynamic process of health technology assessment. The framework uses Bayesian statistical decision theory and value of information (VOI) analysis to inform decision making regarding appropriate patient management and to direct future research effort over the lifetime of a technology. Within the article, the framework is applied to a policy decision regarding preoperative patient management before major elective surgery, for which trial data are available. METHOD: The evidence available prior to the trial is used to determine the appropriate method of patient management and to ascertain whether, at the time of commissioning, the trial was potentially worthwhile. The prior information is then updated with the trial data via a Bayesian analysis using informative priors. This post trial information set is then used to reassess the appropriate method for patient management and to determine whether there is a requirement for any further research. RESULTS: Prior to the trial, preoperative optimization with dopexamine is identified as the appropriate method of patient management. The results of the VOI analysis suggest that a short-term trial was potentially worthwhile (population expected value of perfect information [EVPI] = 48 million pounds sterling). Following the trial, the uncertainty surrounding the choice of appropriate patient management and the potential worth of further research had increased (population EVPI = 67 million pounds sterling). CONCLUSIONS: The article demonstrates the value and practicality of applying the iterative framework to the dynamic process of health technology assessment. It is only by formally incorporating all of the information available to decision makers, through informed priors, that the appropriate decisions can be made.

Aged↗

PubMed1995

Canadian immigration policy: the effectiveness of the point system and other instruments.

"This paper examines the effects of changes in Canadian immigration policy on the occupational composition of immigration. We focus on 1967 changes that created a regulatory system, including the point system, that still forms the framework of Canadian immigration policy. We find that the point system provides some control over occupational composition but that its effectiveness in fine tuning is limited by the large number of other characteristics it seeks to control. We also find that entry class and source country composition of inflow have impacts that have swamped the effects of the point system in the last two decades." (SUMMARY IN FRE)

Americas↗

PubMed2000

Social ecology and behavioral medicine: implications for training, practice, and policy.

Social ecology offers a conceptual framework for understanding the etiology of multiple health problems and a basis for designing broad-gauge educational, therapeutic, and policy interventions to enhance personal and community well-being. Implications of social ecology for behavioral medicine are considered in relation to the development of diagnostic and therapeutic practices, professional training programs, and health policies implemented at municipal, state, and national levels. By influencing the training and practices of healthcare professionals and the decisions of corporate and community leaders, behavioral medicine can expand the scope and impact of future interventions beyond the health gains achievable through provision of direct services to patient populations. Potential barriers to establishing ecologically based health programs and policies and directions for research at the interface of behavioral medicine, social ecology, and public health are discussed.

Behavioral Medicine↗

PubMed2006

[The Danish Health Technology Assessment model. A systematic review of Danish HTAs published by CEMTV from 1998 to 2004].

INTRODUCTION: A common, broad definition of health technology assessment (HTA) has been agreed upon at the international level. The aim of this study was to investigate whether Danish HTA studies actually use this definition in practice. MATERIALS AND METHODS: The study was conducted as a systematic literature review of the 27 HTA reports published by CEMTV from 1998 to 2004. The reports were analysed according to the four main components of the Danish HTA definition: technology, economics, the patient and the organisation, as well as various descriptive variants. RESULTS: The study showed that the broad definition of HTA is widely used in Denmark and that the partial use of the HTA concept is not used. All the Danish HTA studies included assessments of both technology and economic factors and from a variety of standpoints, and more than 90% also included assessments of patient and organisational factors. The literature review was the most commonly applied assessment method, while RCT and meta-analysis were rarely used. Two-thirds of the HTA studies provided direct policy recommendations. CONCLUSION: In a policy decision-making framework, the Danish HTA reports were found to be more satisfactory than international HTA reports because of their extensive information content and the conscious effort to inform policy decision making.

Decision Making↗

PubMed2003

Determinants of health policy impact: comparative results of a European policymaker study.

OBJECTIVES: This article will use a new theoretical framework for the analysis of health policy impact introduced by Rütten et al. (2003). In particular, it will report on a comparative European study of policymakers' perception and evaluation of specific determinants of the policy impact, both in terms of output (implemented measures) and outcome (health behaviour change). Policy determinants investigated are goals, resources, obligations and opportunities as related to the policymaking process. METHODS: Theory is applied to a comparative analysis of prevention and health promotion policy in Belgium, Finland, Germany. The Netherlands, Spain and Switzerland. The study is MED2-part of a project that has developed a Methodology for the Analysis of the Rationality and Effectiveness of Prevention and Health Promotion Strategies (MAREPS) within the EU-BIO-program. A mail survey of 719 policymakers on the executive and administrative level selected by a focused sample procedure was conducted. This survey used policymakers' experience and evaluative expertise to analyse determinants of policy output and outcome. RESULTS: Regression analyses reveal differential predictive power of policy goals, resources, obligations, as well as of political, organisational and public opportunities. For instance, whereas resources, concreteness of goals, and public opportunities have significant importance for health outcome of policy, obligations and organisational opportunities significantly predict policy output. CONCLUSIONS: Results are discussed in terms of rationality and effectiveness of health policy. They indicate that six sensitising constructs derived from the theoretical framework represent equivalent structures across nations. They comprise a validated instrument that can be used for further comparative health policy research.

Europe↗

PubMed1988

Pew Memorial Trust policy synthesis: 5. State coverage for organ transplantation: a framework for decision making.

Transplantation of hearts and livers for both adults and children is increasingly viewed as therapeutic and lifesaving, but access to these procedures is impeded by their high cost as well as by a limited supply of organs. In the absence of comprehensive federal coverage, pressure is being brought to bear on states to provide broader access to these procedures. This synthesis provides a framework for the consideration of coverage decisions at the state level. While there are no "right" answers about whether a state should support such coverage, the analytic tools of cost analysis, demand estimation, and assessment of capacity described in this synthesis can better inform the decision-making process.

Adult↗

PubMed2004

What's in a name? Policy transfer in Mozambique: DOTS for tuberculosis and syndromic management for sexually transmitted infections.

A common assumption is that international health policies are imposed on developing countries, owing to their high level of dependence on international aid. In reality, the process is likely to be complex. Drawing on analytical frameworks developed to study policy transfer between jurisdictions, this paper explores how far two globally promoted infectious disease policies (DOTS for tuberculosis and syndromic management for sexually transmitted infections) were voluntarily or coercively transferred in one particular setting, Mozambique. The paper suggests that guidelines emanating from these policies were not imposed, but evolved in the 1980s through technical networks of national and international experts. Further, that it was experience at the country level that fed into the globally promoted policies of the 1990s. By the time the policies were transferred by WHO and other international organisations to developing countries in the 1990s, Mozambique had already adopted their guidelines for good practice.

Directly Observed Therapy↗

PubMed1991

Assessing the impacts of community-based health care policies and programs for older adults.

This article presents a framework for evaluating long-term care policies and programs to determine how well community-based programs benefit the older adult population. Equity, accessibility, quality, and efficiency are identified as core criteria for implementing and evaluating long-term care policy. Special problems with conducting process and/or outcome evaluation of community-based programs are noted, and findings of evaluation research on community-based health care programs are reviewed. Most previous research indicates that community-based health programs for older adults are not a substitute for institutional care and do not reduce either informal caregiving or ambulatory medical services. The article concludes with policy implications.

Aged↗

PubMed1999

The communicable disease impact of eliminating publicly funded prenatal care for undocumented immigrants.

OBJECTIVES: In 1996, California proposed regulations to eliminate publicly funded prenatal care for undocumented immigrants. Prenatal treatment of sexually transmitted infections (STIs) can prevent STI-related adverse outcomes of pregnancy (AOP). The study assessed the STI-related health and economic impact of the proposed regulations in Los Angeles County (LAC). METHODS: We modeled excess STI-related AOPs and associated costs that would occur in LAC as if the regulations were implemented in 1995. Using attributable fractions in the exposed for five STIs and their associated AOPs, we calculated excess STI-related AOPs and their costs that would result from the regulations and the degree to which excess morbidity would offset gross savings. RESULTS: The model indicates that, depending on regulatory level, 74, 110, or 132 excess AOPs would occur subsequent to the regulations, representing lost prevented morbidity. These excess AOPs would cost $5.1, $7.6, or $9.2 million dollars in direct medical expenses, offsetting anticipated savings by 19.2%, 29.0%, or 34.9%. This analysis does not include other costs of these STIs or costs associated with non-STI-related sequelae of diminished prenatal care, all of which could further offset anticipated savings. CONCLUSIONS: The proposed regulations would likely lead to increased STI-related morbidity and costs, thereby offsetting anticipated savings. Health departments are in a special position to promptly respond to policy issues affecting vulnerable populations. The development of a practical and rational framework for local-level policy assessment can be important for encouraging good scientific approaches that respond to calls for reductions in basic preventive health services.

California↗

PubMed2001

Comparative institutional response to economic policy managed competition and governmentality.

This article provides a comparative conceptual framework for understanding why so many governments found economic policies based on managed competition attractive and yet dangerous to implement. The framework conceptualizes governments as a kind of organizational complex and thus governments as an international population of organizations, each embedded in a state that tries to harness and direct behaviour through what Foucault called "governmentality". This nascent concept is made more robust here and joined with Fligstein's historical research on the response of leading organizations when fundamental change threatens a population of organizations, by embracing a new conception of control that allows them to re-establish their control and pre-eminence. Fligstein studied corporations, but his model can be fruitfully extended to governments. Economic sociology has not to date been able to do much comparative research on institutional responses to economic policy; but this set of case studies and conceptual framework provide such an opportunity.

Developed Countries↗

PubMedDate not supplied

Optimal ordering policies for continuous review perishable inventory models.

This paper extends the notions of perishable inventory models to the realm of continuous review inventory systems. The traditional perishable inventory costs of ordering, holding, shortage or penalty, disposal and revenue are incorporated into the continuous review framework. The type of policy that is optimal with respect to long run average expected cost is presented for both the backlogging and lost-sales models. In addition, for the lost-sales model the cost function is presented and analyzed.

Costs and Cost Analysis↗

PubMedDate not supplied

The sector-wide approach in health: what is it? Where is it leading?

This paper describes early experience with the Sector-Wide Approach (SWAp), an emerging trend in development practice in low-income countries. The paper describes what a SWAp is, and why it is now being pursued. The SWAp is characterized as a sustained government-led partnership with donor agencies and other groups. By applying sector-wide policies to an expenditure framework and national implementation systems, explicit health sector reforms are undertaken to meet sectoral and national development objectives. The approach has changed the dynamic between governments and donor agencies, requiring systemic changes in policy-making and management in both governments and donor agencies. With the SWAp, ongoing joint assessment and negotiations around sectoral plans and review of performance replaces the old way of preparing and supervising projects. Early experiences in countries undergoing SWAps are discussed, including the problem of reconciling priority programs and old practices with broader health sector reforms and new ways of managing development assistance. The paper concludes by identifying some of the key challenges for the future of SWAps.

Developing Countries↗

PubMed2002

The EU Water Framework Directive--a key to catchment-based governance.

The principles of good water governance require an effective water policy with a clear legal framework and institutional structure for managing river basins and aquifers. Integrated water resources management is essential and decision-making processes must be participatory and transparent. The development of the European Union's Water Framework Directive is outlined, and it is shown how it can serve as the basis of catchment-based governance for the successful management of water quality and quantity in transboundary river basins.

Conservation of Natural Resources↗

PubMed2006

EU biotech crop regulations and environmental risk: a case of the emperor's new clothes?

European Union Commissioner for the Environment Stavros Dimas recently hailed 'upgraded' non-genetically modified (GM) crops as an alternative to GM crops. A comparative analysis of the environmental risks associated with such non-GM herbicide-resistant crops and GM herbicide-resistant crops is presented here. The analysis highlights serious weaknesses in the European Union (EU) regulatory framework, and the contradictory policy of the EU Commission on the precautionary principle is also shown. The continued political stance of ignoring these regulatory and policy inconsistencies is examined and found to be flawed. It is postulated that, even in the face of these flaws and coupled with recent statements from the UK drawing attention to inconsistencies in the EU regulatory framework, the EU will continue to ignore the real and present environmental risks associated with upgraded non-GM crops for biopolitical reasons.

Agriculture↗

PubMed1994

Towards a comprehensive national policy on drug abuse.

Drug abuse is complex in its causation and ramifications. No country has been able to respond successfully to the problems brought in the wake of drug abuse by having recourse to a single strategy. In 1987 the United Nations adopted a comprehensive multidisciplinary outline for future activities in drug abuse control. This provided, for the first time, a comprehensive framework within which countries can elaborate policies and programmes tailor-made to national situations. However, in order to facilitate the development and implementation of such policies and programmes it is essential that certain conditions exist: strong political will at national level; recognition of the need for an integrated policy; adequate legal framework and enforcement capability; coordinated response at international, national and local level; and recognition of drug abuse in planning changes in different sectors.

Adolescent↗

PubMed1998

From efficacy to effectiveness: selecting indicators for a community-based lactational amenorrhoea method promotion programme.

This paper reviews the results of clinical trials and community studies of lactational amenorrhoea and its role as a contraceptive method (LAM). Indicators which are used in efficacy trials and effectiveness interventions are compared and sets of indicators of effectiveness appropriate to community-based LAM programmes are recommended. A five-tiered ecological framework is used to facilitate selection of indicators which range from individual to policy level outcomes. The indicator framework is intended as a tool for health practitioners in family planning and maternal and child health service delivery settings who are interested in designing programmatic interventions for the promotion of LAM, particularly among less well-educated women of lower socioeconomic communities.

Amenorrhea↗

PubMed1988

Policymaking cycles in mental health: critical examination of a conceptual model.

Analysts have frequently used the concept of a cycle to describe the historical development of mental health policy in the United States. According to the "cyclical" perspective, the mental health system alternates between crests of high policy and program activity and troughs of stagnation and decline. Analysts also observe that past policy themes are periodically rediscovered, only to eventually lose favor and recede into the background once again. This article critically examines the cyclical model of mental health policymaking, placing it within a context of broader theoretical work on the dynamics of public policy formation. The purpose is to organize in a conceptually coherent way what has emerged as the leading theoretical approach to understanding the evolution of the mental health system; to identify major issues and ambiguities in the application of the cyclical framework to mental health policy analysis; and to derive some general insights about problems and possibilities in modeling policy change.

Community Mental Health Services↗