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The outcomes utility index: will outcomes data tell us what we want to know?

PURPOSE: To propose an approach to the evaluation of the utility of an outcome measure for use in making comparisons among health plans, hospitals, networks, or other accountable entities. METHOD: Seven components are recommended for evaluation: whether the outcome is a health outcome; the extent to which expectations for performance can be defined; the role medical care plays in achieving the outcome; the relative complexity of events that produce the outcome; the degree to which attribution can reasonably be made; the suitability of risk adjustment for limiting external sources of variation; and the likelihood that the measure provides perverse behavioral incentives. RESULTS: Illustrative examples are given in each area for scoring the performance of measures on the component. CONCLUSION: Outcomes measurement is of great interest to a variety of potential users. The approach proposed here is intended to provoke discussion and more rigorous development of tools that will help to identify the measures that are likely to produce the most useful information for making comparisons among accountable entities in the health system.

Benchmarking↗

Randomized, double-blind study of grepafloxacin versus amoxycillin in patients with acute bacterial exacerbations of chronic bronchitis.

This randomized, multicentre, double-blind, double-dummy study compared the efficacy and safety of grepafloxacin and amoxycillin in acute bacterial exacerbations of chronic bronchitis (ABECB). Patients were randomized to receive grepafloxacin 400 mg or 600 mg od, or amoxycillin 500 mg tds, for 7 or 10 days. The trial recruited 656 patients, of whom 566 (86%) completed the study. Clinical success rates at the 2 week follow-up visit for the population evaluable for clinical efficacy were 82% (165/202 patients) in the grepafloxacin 400 mg group, 85% (175/206) in the grepafloxacin 600 mg group and 85% (172/203 patients) in the amoxycillin group. The 95% confidence interval confirmed the equivalence of the two grepafloxacin doses and amoxycillin, with no significant difference between the grepafloxacin groups. The microbiological success rates at follow-up showed equivalence between the grepafloxacin 400 mg and amoxycillin groups: 86% (144/168 isolates) and 83% (162/195), respectively. The grepafloxacin 600 mg group achieved a statistically significantly higher eradication rate (92%, 150/164; 95% CI 2.0%, 16.1%) than the amoxycillin group in the follow-up assessment for microbiological and clinical efficacy (evaluable population). There was no significant difference between the two grepafloxacin treatment groups (95% CI -13.3%, 0.9%; P= 0.087). All three treatment regimens successfully eradicated the pathogens most commonly isolated during the study, including Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae. Grepafloxacin had a good safety profile, comparable to that of amoxycillin, although grepafloxacin 600 mg was associated with a higher incidence of nausea, dyspepsia and taste perversion than amoxycillin. It can be concluded that grepafloxacin 400 mg or 600 mg od is as effective as amoxycillin 500 mg tds in the treatment of ABECB.

Adolescent↗

Unusual deaths associated with polyphagia.

Perversion of appetite may be manifest in either qualitative (pica), quantitative (polyphagia), or combined derangements of eating. Ingested materials are capable of serving as dangerous physical agents through interference with normal cardiac and/or respiratory function. Since the mechanisms of injury are similar to those that might occur as a result of violence or serious natural disease, a thorough investigation of the history and circumstances immediately preceding the final event is warranted in addition to a complete autopsy. Three cases of asphyxia of unusual etiology are presented along with a rationale regarding the mechanisms believed to be involved. In case 1, sudden subdiaphragmatic viscus expansion with resultant lung volume displacement and impediment of venous return from the lower half of the body are believed to have been operative. In cases 2 and 3, both asphyxial loci are infraglottic. The common denominator in all of these fatalities is the physical impairment of vital air exchange as a complication of an abnormal eating pattern.

Adult↗

A sadistic homicide.

Sadistic homicides are probably more common than would be expected from reading the literature, where only a few cases are mentioned. Most forensic pathologists and forensic psychiatrists have had experience with one or more cases, but they do not usually share their experience with their colleagues. This article describes in detail a typical mutilation pattern. Also, the clinical description, including the psychiatric evaluation, of the perpetrator is presented. Not infrequently, the perversion develops gradually as in the present case, and the perpetrator is known to the police for minor sex crimes before the final sadistic homicide. This observation must be kept in mind if society hopes to stop the sadistic perpetrator prior to his final crime.

Adult↗

A case of necrophilia in Medunsa.

Necrophilia is the erotic attraction to or a sexual interest in corpses. It is a rare sexual perversion that is seldom reported to police, published in the journals, or found in the forensic literature. It usually involves people who work with cadavers at mortuaries and funeral parlors. This case involved a teenage girl who had already been examined at autopsy.

Adult↗

Eating the curriculum.

The alimentary metaphor--learning as ingestion--is well established in medical education: students are spoonfed, forcefed; they cram, digest, and metabolize information; and they regurgitate it on tests. In the author's experience, these metaphors are inextricably bound with the attitudes and information they describe, organize, and sometimes generate in medical education. Alimentary imagery shapes discussions of the curriculum, and its perversities characterize and help perpetuate much that needs changing in North American medical education. Medical school teachers speak of their life's work as feeding students, not as chiefs but as the anxious caretakers of problem eaters, and the images used most often to describe the teacher-learner relationship suggest an underlying infantilization of medical students. Alimentary metaphors are not in themselves evil. A closer look at medicine's uses of the metaphor of learning as eating suggests a healthier educational philosophy. Despite the "full plate" that students are served, they are metaphorically starving. Fundamental curriculum reform should help them learn to be healthy eaters-using lessons from parents, pediatricians, and child psychologists about how to do this, which are discussed in detail. The difficult-to-achieve but imperative goal of medical education should be to put students in charge of their own "eating" and thereby produce intellectually curious, self-motivated, active, and "well-nourished" physicians who know how to feed themselves in the right amounts and at reasonable levels, maintain a healthy skepticism about the information they consume, and periodically check that information for freshness.

Curriculum↗

Contrast agents for magnetic resonance imaging: safety update.

Magnetic resonance contrast agents, particularly the gadolinium-based agents, are extremely safe and lack the nephrotoxicity associated with iodinated contrast media. Currently, seven gadolinium agents are available in one or more countries of the world, of which only four are available for clinical use in the United States. Minor adverse effects associated with each of these agents occur infrequently and include nausea, headache, and taste perversion. Whereas the gadolinium agents cannot be differentiated on the basis of these mild adverse effects, recent studies have brought to light the issue of chelate stability, and in particular, clinical observations associated with the least stable of these agents. This review briefly discusses the most recent safety issues concerning the gadolinium agents. A brief review of safety issues concerning the non-gadolinium agents is also provided.

Contrast Media↗

A phase I clinical trial with gadodiamide injection, a nonionic magnetic resonance imaging enhancement agent.

Twenty adult male volunteers were studied in an unblinded, ascending-dose study to evaluate the safety, tolerance, and pharmacokinetics of intravenously administered nonionic gadodiamide injection. Dosages administered were 0.05, 0.1, 0.2, and 0.3 mmol/kg. Subjects were monitored from 36 hours before, through 72 hours after administration. There were no clinically relevant changes in vital signs or electrocardiograms. No clinically significant changes occurred in blood or urine laboratory parameters, although a tendency for minor, transient elevations in serum iron levels 8 to 48 hours after administration was noted. These changes were not dose-related. Nine of 20 subjects reported at least one adverse event; all events were transient and of mild intensity, the most common being dizziness/lightheadedness and perversion of taste or smell. One subject reported discomfort consisting of mild stinging at the injection site during administration. Gadodiamide was excreted unmetabolized in the urine with greater than 95% recovery at 72 hours after administration. The serum elimination half-life was approximately 70 minutes.

Adult↗

Zopiclone and triazolam in insomnia associated with generalized anxiety disorder: a placebo-controlled evaluation of efficacy and daytime anxiety.

In a double-blind placebo-controlled study, following a 1 week washout, 75 outpatients suffering from generalized anxiety disorder with severe insomnia as the target symptom were randomly assigned to 4 weeks of treatment with zopiclone 7.5 mg, triazolam 0.5 mg or placebo at bedtime. Zopiclone was significantly better than placebo on most sleep parameters. Triazolam tended to be superior to placebo, but its superiority was significant only on the sleep induction factor. Triazolam-treated patients presented significantly more day-time-interdose anxiety than zopiclone as assessed by the weekly HARS and Clinical Global Assessment of Anxiety. Although daytime-interdose anxiety was observed with both drugs, this treatment emergent symptom was more frequent and severe with triazolam. Side-effects were of a mild to moderate intensity for both zopiclone and triazolam; however, taste perversion frequently appeared with zopiclone. Although both drugs share similar pharmacological properties and bind to benzodiazepine receptors, they differ significantly with respect to side-effects and daytime anxiety.

Adult↗

Pedophilia occurring after onset of cognitive impairment.

Four married patients are reported who first manifested pedophilia and other signs of disinhibition after sustaining illnesses that led to cognitive impairments. Although pedophilia may often be related to a long-standing inadequacy of sexual functioning, the onset of pedophilia in an individual without a previous histroy of sexual perversion may indicate the presence of recently sustained cognitive impairments.

Adult↗

Patterns of ambulatory health care in five different delivery systems.

Few empirical investigations permit systematic comparison of the impact of widely-varying delivery systems within a single population sample. This study provides such a comparison, describing patterns of ambulatory care among patients using five different systems in Washington, D.C. as a regular source of health care: solo practice, fee-for-service group practice, prepaid group practice, public clinics, and hospital outpatient departments or emergency rooms. Comparisons are adjusted statistically to account for major patient group variations, and the results reveal substantial differences among the five systems. Sources used primarily by the poor--hospital outpatient departments, emergency rooms, and public clinics--contained important structural and financial barriers, and had the lowest rates of patient-initiated use. The prepaid system, in contrast, maximized patient's access to both preventive care and symptomatic care, and did not seem to inhibit physician-controlled follow-up care. The results suggest some perverse effects of fee-for-service payment: patients, especially poor patients, appeared to be deterred from seeking preventive and symptomatic care, while physicians were encouraged to expand follow-up services. Moreover, services in fee-for-service systems were distributed less equitably relative to both income and medical need than in the prepaid system. These findings have direct implications for policy decisions concerning organizational and financial arrangements for the delivery of ambulatory care.

Adult↗

Economic incentives in health manpower policy.

Policymakers have evidenced continued concern with the issue of maldistribution of physicians among specialties and locations. Many of the recent policy proposals in this area have involved increasing the financial rewards to primary care specialization and to location of practice in underserved areas. This article examines the evidence on current economic incentives to specialize and to locate, including income and the hours of work needed to produce income. Findings suggest that current distributions of physicians among locations and specialties are more consistent with a decision to minimize hours worked, rather than an income maximization rule. Policy implications are discussed with respect to potentially perverse results which may occur if consideration is not given to this aspect of career decisions.

Health Policy↗

Self-reported symptoms and medication side effects influence adherence to highly active antiretroviral therapy in persons with HIV infection.

OBJECTIVES: To identify variables predictive of nonadherence to highly active antiretroviral therapy (HAART) and to assess whether self-reported symptoms or medication side effects are related to adherence. DESIGN: Cross-sectional multicenter study Adherence Italian Cohort Naive Antiretrovirals [AdICONA] within the Italian Cohort Naive Antiretrovirals (ICONA). METHODS: Participants receiving HAART completed a 16-item self-administered questionnaire to assess nonadherence in the last 3 days as well as the type and intensity of 24 common HIV- and HAART-related symptoms experienced during the last 4 weeks. RESULTS: From May 1999 to March 2000, 358 persons were enrolled: 22% reported nonadherence and were less likely to have HIV RNA <500 copies/ml (odds ratio = 0.51; 95% confidence interval: 0.31-0.85). Frequency of moderate/severe symptoms or medication side effects in nonadherent participants ranged from 3.6% to 30%. On univariate analysis, nausea, anxiety, confusion, vision problems, anorexia, insomnia, taste perversion, and abnormal fat distribution were significantly associated with nonadherence. Nonadherent persons had a higher mean overall symptom score (12.3 +/- 9.2 versus 8.1 +/- 6.6; p <.001) and mean medication side effect score (2.9 +/- 2.7 versus 1.9 +/- 1.9; p <.001) when compared with adherent participants. In the multivariate analysis, nausea ( p =.003); anxiety ( p =.006); younger age ( p =.007); unemployment ( p <.001); not recalling name, color, and timing of drugs ( p =.009); running out of pills between visits ( p =.002); and being too busy ( p =.03) were independently associated with nonadherence in the last 3 days. CONCLUSIONS: In addition to patient characteristics, medication-related variables, and reasons for nonadherence, patient-reported symptoms and medication side effects were significantly associated with adherence to HAART.

Adult↗

The community psychiatrist of the future.

PURPOSE OF REVIEW: The potential contributions of the community psychiatrist are described, via the interdisciplinary team, to individuals and families dealing with mental illness, and to the communities of the future, along with the opportunities for, and barriers to, effective teamwork and community collaborations. RECENT FINDINGS: Health and medical training systems still provide perverse incentives deterring psychiatrists from becoming adequately trained in community psychiatry and full members of interdisciplinary teams, and skilled partners in improving the mental health of the whole community. Sources of potential role conflict should be resolved, and advantages of community collaborations, interdisciplinary leadership, support of teamwork, division of labour, cross-fertilization and hybrid vigour should be realized. SUMMARY: Truly essential and desirable roles and the skill base of community psychiatrists in interdisciplinary teams and local communities could be developed and strengthened by changes in basic and advanced psychiatric training, and by psychiatric professional bodies and training programmes placing greater emphasis and value upon the roles of a community psychiatrist.

Attitude to Health↗

The role of multilateral institutions.

In line with its mission of alleviating poverty through support for environmentally and socially sustainable economic development, The World Bank (along with some other multilateral development banks) is working to help developing countries capture a share of the emerging global market in greenhouse-gas-emissions reductions ('carbon trading'). Under the Kyoto Protocol of the United Nations Framework Convention on Climate Change (UNFCCC), the Joint Implementation instrument and the Clean Development Mechanism now provide an opening for substantial international resource transfers and potential for supporting sustainable development through the transfer of cleaner technologies or sustainable forestry and agro-forestry practices. For example, carbon sequestration represents a non-extractive non-consumptive sustainable use of living natural resources that can be incorporated within a multiple-use 'integrated ecosystem management' approach. The World Bank initiated the Prototype Carbon Fund (PCF) in April 2000, to help spur the development of a global carbon market and to 'learn by doing' how to use carbon-purchase transactions across a range of energy-sector technologies (and some forestry applications) to achieve environmentally credible and cost-effective emissions reductions that benefit developing countries and economies in transition. Building on the success of the PCF ($145 million raised from public and private-sector investors), The World Bank expects to launch two new funds in 2002: the Biocarbon Fund and the Community Development Carbon Fund. These funds will target synergies between carbon markets and objectives such as biodiversity conservation, combating desertification and small-scale community-driven development. Experience from the PCF shows that developing countries can have a comparative advantage in supplying this global market, as emissions reductions can be achieved in developing countries in the range of $3-$5 per ton of CO(2) equivalent, compared with a marginal abatement cost of $10-$15 per ton of CO(2) equivalent in most countries within the Organization for Economic Cooperation and Development. However, realizing this economic potential over the next decade, and targeting the market to the rural poor, will require substantial assistance with project development and government legal and institutional capacity building. Specific needs include raising awareness of the potential of carbon markets at all levels (particularly in energy and land-use sectors), clarifying property rights, particularly in the case of communally held land and resources, ensuring the existence of an attractive investment climate, eliminating policies that create perverse incentives and constraints, and mitigating logistical, political and 'reputational' risks that could deter private-sector investors. It will also be necessary to find ways to reconcile the short-term needs of the rural poor and the typically long-term revenue stream associated with carbon sequestration.

Air Pollution↗

Designing a carbon market that protects forests in developing countries.

Firmly incorporated into the Kyoto Protocol, market mechanisms offer an innovative and cost-effective means of controlling atmospheric concentrations of greenhouse gases. However, as with markets for many other goods and services, a carbon market may generate negative environmental externalities. Possible interpretations and application of Kyoto provisions under COP-6bis and COP-7 raise concerns that rules governing forestry with respect to the Kyoto carbon market may increase pressure on native forests and their biodiversity in developing countries. In this paper, we assess the following two specific concerns with Kyoto provisions for forestry measures. First, whether, under the Clean Development Mechanism (CDM), by restricting allowable forestry measures to afforestation and reforestation, and explicitly excluding protection of threatened native forests, the Kyoto Protocol will enhance incentives for degradation and clearing of forests in developing countries; second, whether carbon crediting for forest management in Annex I (industrialized) regions under Article 3.4 creates a dynamic that can encourage displacement of timber harvests from Annex I countries to developing nations. Given current timber extraction patterns in developing regions, additional harvest pressure would certainly entail a considerable cost in terms of biodiversity loss. In both cases, we find that the concerns about deleterious impacts to forests and biodiversity are justified, although the scale of such impacts is difficult to predict. Both to ensure reliable progress in managing carbon concentrations and to avoid unintended consequences with respect to forest biodiversity, the further development of the Kyoto carbon market must explicitly correct these perverse incentives. We recommend several steps that climate policymakers can take to ensure that conservation and restoration of biodiversity-rich natural forests in developing countries are rewarded rather than penalized. To correct incentives to clear natural forests through CDM crediting for afforestation and reforestation, we recommend for the first commitment period that policymakers establish an early base year, such as 1990, such that lands cleared after that year would be ineligible for crediting. We further recommend an exception to this rule for CDM projects that are explicitly designed to promote natural forest restoration and that pass rigorous environmental impact review. Restoration efforts are typically most effective on lands that are adjacent to standing forests and hence likely to have been recently cleared. Thus, we recommend for these projects establishing a more recent base year, such as 2000. For the second and subsequent commitment periods, we recommend that climate policymakers act to restrain inter-annex leakage and its impacts by ensuring that crediting for forest management in industrialized countries is informed by modelling efforts to anticipate the scale of leakage associated with different Annex I 'Land use, land-use change and forestry' policy options, and coupled with effective measures to protect natural forests in developing countries. The latter should include expanding the options permitted under the CDM to carbon crediting for projects that protect threatened forests from deforestation and forest degradation. Ultimately, carbon market incentives for forest clearing can be reduced and incentives for forest conservation most effectively strengthened by fully capturing carbon emissions associated with deforestation and forest degradation in developing countries under a future emissions cap. Finally, we note that these recommendations have broader relevance to any forest-based measures to reduce greenhouse-gas emissions developed outside of the specific context of the Kyoto Protocol.

Air Pollution↗

Quality in provision of forensic psychiatric services: room for improvement.

Highlights some of the tensions which impede the development of an effective and efficient system of service delivery in forensic psychiatry. Reports on an investigation exploring the quality of care in a relatively small unit providing forensic psychiatric care in a secure setting and the constraints which impede the development of such services. Discusses the findings from the investigation which point to the need for the organizational structure surrounding forensic psychiatric care to be altered so that there are no perverse incentives for purchasers of services and to enable the contracting process, considering both cost and quality issues, to take place on a level playing field.

Australia↗

Physician responses to global physician expenditure budgets in Canada: a common property perspective.

Global expenditure budgets in the fee-for-service physician sector create management problems for both funders and physicians. Global expenditure cap policies must be designed, and appropriate institutional structures created, to mitigate perverse utilization incentives, manage collective utilization, and diffuse the internal professional and the funder-profession tensions created by a capped budget. Two Canadian provinces that adopted different approaches to the design of their physician expenditure cap policies experienced different outcomes in utilization growth. The outcomes, however, are the opposite to what one would predict based on an analysis of the incentive structures embodied in the two provinces' policies. An analytic framework developed for the study of common-property resources is applied to the differing physician responses to global budgets across the two provinces. The insights offered by this framework can guide policy design for global physician budgets, and they indicate the critical importance of physician acceptance of such a policy.

Alberta↗