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PubMed1994

[Automated peritoneal dialysis (APD). Experience in 42 patients].

Automated peritoneal dialysis (APD) is currently considered as one of the most attractive home treatments for uremic patients. However, relevant costs and the presence of a dialysis machine prevent a wider diffusion of this technique. In this work we discuss the results obtained in 42 patients (12 females, 30 males) treated by two dialysis units of the Piedmont Region. Patients' characteristics. Eighty-three percent of the females and 66.5% of the males are under 65 years of age; glomerulo-nephritis and nephroangiosclerosis account for the most frequent renal diseases (28.5 each); a high risk condition is recorded in 52.5% of cases. Twenty-two patients were transferred to APD from CAPD (patient's request in 59% of cases, clinical problems in the remaining). RESULTS. Forty-five percent of cases are working full or part-time, 12% are not caring for self. Peritonitis rate accounts for 1 episode every 42 patient-months. Biochemical control is satisfactorily achieved (mean values: urea 137.8 mg/dl, creatinine 11 mg/dl, calcium 10.2 mg/dl, phosphate 5.7 mg/dl, albumin 4.3 g/dl, cholesterol 234 mg/dl, triglycerides 195 mg/dl). Technical assistance was requested on average once every 16 months of treatment. CONCLUSION. Negative drawbacks of APD, mainly related to elevated costs and technical complexity, are fully counterbalanced by satisfactory social and clinical rehabilitation, wider indications to peritoneal dialysis with respect to CAPD, lower rates of peritonitis and limited technical needs.

Adult↗
PubMed1993

Technological advances in the clinical diagnosis of periodontal diseases.

Traditional diagnostic procedures for periodontal disease, such as probing and radiographic assessment, supply information on previous disease experience but not of present site-specific activity nor of possible future attachment loss. Although the newer automatic probes which record data electronically give higher resolution and accuracy than their manual counterparts, their use in clinical practice is only of value in longitudinal clinical trials. In general clinical practice, manual probing is adequate provided probing technique and probe tine characteristics are within acceptable limits. It is suggested that the general practitioner could use the CPITN method for screening purposes because of its relative speed and ease. This must, however, be supplemented by comprehensive probing in each sextant with advanced disease. The humble bitewing radiograph is likewise adequate for the assessment of alveolar bone loss in normal clinical practice but if refined data of bone loss over time is required, subtraction radiography is recommended. Currently, other forms of imaging technology have limited value in clinical practice because of technical complexity, access and cost. A number of other electronic devices are available which make the accurate assessment of mobility and occlusal function possible but, because the relationship between these signs and periodontitis is still equivocal, the general use of such apparatus is not indicated. The advent of a battery of easily performed chairside tests shows considerable promise for the future, particularly those tests that are becoming commercially available for the assay of host and bacterial markers of site-specific disease in the crevicular fluid. The clinical value and the cost-benefit of these assays need further investigation before they can be recommended for general use. Clinical practice objectives differ from those required for research projects and therefore the required sensitivity, specificity and predictive value of diagnostic tests must be in keeping with the intended purpose to justify the cost involved.

Cost-Benefit Analysis↗
PubMed1993

Functional neuroimaging with single photon emission computed tomography (SPECT).

Single photon emission computed tomography (SPECT) is a technique for producing regional maps of the in vivo distribution of radioactively labelled tracers without either the complexity or the cost of positron emission tomography (PET). Use of commercially available single photon emitting tracers such as 99mTc, 123I, or 201Th with longer half-lives than positron emitters eliminates the need for an on-site cyclotron and greatly simplifies the radiopharmacy requirements. In addition, the ability to produce images using gamma cameras which are routinely available in most nuclear medicine departments has considerably reduced the capital asset cost of imaging. SPECT is not an inexpensive procedure but it is much cheaper than PET. It is not possible to use the ideal biological labels of carbon, nitrogen, or oxygen with SPECT or to measure metabolic rates for oxygen or glucose. It is, however, now possible to image the distribution of cerebral blood flow with a reasonably well-validated technique, to investigate tumour viability, and to study an ever-increasing range of neurotransmitter receptor systems using SPECT. SPECT may have its technical limitations but it is the functional imaging technique which is likely to be available to most clinicians and, as experience with its application to a variety of pathological conditions grows, a much broader benefit from functional neuroimaging than could be produced by PET alone will result. The purpose of this review is not to compare SPECT with PET, but to give an overview of how SPECT works and what has been established in studies of various pathologies. In some cases, the clinical role of SPECT has already been established and in some it is emerging, but in other cases SPECT is a measurement tool for research purposes which is unlikely ever to be used routinely.

Animals↗
PubMed1996

Integrating data from natural language processing into a clinical information system.

Demographic data extracted from discharge summaries by natural language processing was compared to data gathered by a conventional hospital admitting system. Discrepancies in data were noted in names, age, sex, race, and ethnicity. Some differences are attributable to errors in collection: interaction with patient, dictation, transcription, and data entry. Very few differences were due to errors in natural language processing. Other differences can be used to critique existing data, or to enhance data with more detailed information. Discrepancies in data as elementary as patient demographics raise the issue of resolving conflicts when neither source of data is known to be more reliable. Clinical repositories can represent conflicting data from multiple sources, but clinical information systems must bear the cost of increased complexity in the application programs that will use the data.

Evaluation Studies as Topic↗
PubMed1997

[Medical liability in the treatment of intensive care unit patients].

Critical care medicine was practiced informally during several years, specially during war periods. Nowadays it is, however, a fundamental part of health systems in which patients attain care facilities of increasing complexity in a cost effective manner, according to their needs. The importance of this discipline in Chile, during its 30 years of development, has progressively increased and at the present time, intensive care units represent up to 30% of the total number of beds in some hospitals. Even though these units require great budgets and many resources, their place and the role of physicians who work in them has not been recognized adequately by the national medical community. The present document presents the official position of the Chilean Society of Intensive Medicine on the general objectives of this discipline. It indicates the scope of action of the specialty and the role of intensive care physicians, their relationship with other specialties, their duties and responsibilities with their patients.

Chile↗
PubMed1998

Extracorporeal gas exchange.

The high mortality associated with acute respiratory failure and further exacerbation of the lung injury by mechanical ventilation continues to pose a challenge in the management of critically ill patients. By providing total gas exchange and complete lung rest, extracorporeal membrane oxygenation (ECMO) has improved the survival rate of selected neonatal, pediatric, and adult patients. Arteriovenous carbon dioxide removal (AVCO2R) was developed as a less labor intensive, less costly, and less complex technique of extracorporeal gas exchange, allowing near total CO2 removal.

Extracorporeal Membrane Oxygenation↗
PubMed1998

[Capitation contract financing of primary health care: a possible alternative to traditional payment for service--part 1].

Worldwide health systems are faced with additive and complex problems: a cost containment willingness, growing expenses for the health care budgets particularly in relation with the new technologies, questioning about true quality of provided care from results indicators. Health care financing is one of the major determinants of the nature and the comprehensive quality of the system: its aim to promote suitable processes and behaviors, to dissuade inadequate ones, in a context of efficiency (efficacy with minimal cost), as for politic decidors, as for the patients, as for the providers, as for the insurers/funders. A comparative and critical approach of the international scientific literature shows that partial fixed capitation payment is an interesting alternative for the total fee for service. Taking into account many experiences, a proposal for a cumulated financing for the practices is made: a structural part, a fixed capitation payment (the most important), a fee for service one, a target payment one, and a patient personal participation.

Belgium↗
PubMed1998

Simulating patients with Parallel Health State Networks.

The American Board of Family Practice is developing a computer-based recertification process to generate patient simulations from a knowledge base. Simulated patients require a stochastically generated history and response to treatment, suggesting a Monte Carlo-like patient generation process. Knowledge acquisition experiments revealed that description of a patient's overall health as a node in a Monte Carlo model was difficult for domain experts to use, severely limited knowledge reusability, and created a plethora of awkwardly defined health states. We explored a model in which patients traverse several parallel health state networks simultaneously, so that overall health is a vector describing the current nodes from every Parallel Network. This model has a reasonable biological basis, more easily defined data, and greatly improved reuse potential, at the cost of more complex simulation algorithms. Experiments using osteoarthritis stages, weight classification, and absence or presence of gastric ulcers as three Parallel Networks demonstrate the feasibility of this approach to simulating patients.

Algorithms↗
PubMed2003

Ethical exploration of the least restrictive alternative.

Although there have been critiques about the application of the "least restrictive alternative" to mental health policies in the past three decades, no critical analysis of the ethical logic of this principle has been put forward. The author explores three main ethical theories-liberalism, utilitarianism, and communitarianism-and explains how liberalism and subjective utilitarianism, which evidently uphold the least restrictive alternative in the name of individual rights and preference for liberty, effectively disenfranchise patients and members of their family. Contrarily, objective utilitarianism, with its highlight on cost-effectiveness analysis, would actually lay solid ground for mental health policies that attend not simply to ideological belief but rather to the question of which treatments can most cost-effectively meet the complex needs of patients. In addition, under communitarianism the evidence derived from cost-effectiveness analysis can be used to reinterpret the traditional value in mental health policies and thereby lead to the policy in favor of the most cost-effective alternative.

Continuity of Patient Care↗
PubMed1995

Quality of life and cost of therapy in reflux disease.

UNLABELLED: BACKGROUND AND RESULTS IN THE LITERATURE: Reflux symptoms are common, with an incidence of up to 40% monthly and 7% daily in the general adult population. The duration of symptoms in patients seeking help for reflux is often in excess of 5 years in an unselected population. A majority, 70%, of those with daily symptoms do not have esophagitis at endoscopy but still require regular medication for symptom control. After treatment, relapse is seen in a majority of cases in whom esophagitis is present at start of therapy. Symptoms of reflux and upper abdominal dyspepsia affect several aspects of daily living. Consequently quality of life (QoL) is low in patients with reflux esophagitis and upper dyspepsia. Values normalize during medical treatment or after surgery for reflux esophagitis. Cost of treatment is complex. Evaluations in patients with reflux esophagitis are based on the effectiveness and cost of the drug, the cost of investigations and time lost from work. In comparisons based on the results of clinical healing trials, omeprazole has been found the most cost-effective drug for treatment of reflux esophagitis. There are as yet no evaluations made for patients with reflux symptoms only. CONCLUSIONS: The consequences for the patient and society regarding QoL and costs for reflux symptoms should be evaluated more closely to optimize future therapy.

Adult↗
PubMed1990

Estimating costs in the economic evaluation of medical technologies.

The complexities and nuances of evaluating the costs associated with providing medical technologies are often underestimated by analysts engaged in economic evaluations. This article describes the theoretical underpinnings of cost estimation, emphasizing the importance of accounting for opportunity costs and marginal costs. The various types of costs that should be considered in an analysis are described; a listing of specific cost elements may provide a helpful guide to analysis. The process of identifying and estimating costs is detailed, and practical recommendations for handling the challenges of cost estimation are provided. The roles of sensitivity analysis and discounting are characterized, as are determinants of the types of costs to include in an analysis. Finally, common problems facing the analyst are enumerated with suggestions for managing these problems.

Cost-Benefit Analysis↗
PubMed1999

Panel on cost-effectiveness in health and medicine recommendations: identifying costs.

The assignment of costs in a cost-effectiveness analysis is a complex and disputed issue. The Panel on Cost-Effectiveness in Health and Medicine was convened to discuss standards that could be applied across a range of areas of cost-effectiveness. Additionally, the Panel had a mandate to resolve some controversial issues about the practice of cost-effectiveness that created difficulty in making comparisons across studies. The Panel proposed these guidelines: (1) Do at least some of the analysis from a social perspective; (2) Assign values to resources that reflect their opportunity costs; (3) Avoid zero counting of resources; (4) Avoid double counting of resources; (5) Make analyses only as exacting as necessary in a study. Difficulties in data collection were discussed. Among other questions considered by the panel were how to assign a value to the patient's time and which productivity costs to include in a cost-effectiveness analysis. With tools and suggestions from the Panel on Cost-Effectiveness in Health and Medicine, the cost analyst can report costs accurately and provide accurate comparisons of cost performance across states, trial modalities, or diseases.

Cost of Illness↗
PubMed1993

Affinity and specificity of serine endopeptidase-protein inhibitor interactions. Empirical free energy calculations based on X-ray crystallographic structures.

An empirical function was used to calculate free energy change (delta G) of complex formation between the following inhibitors and enzymes: Kunitz inhibitor (BPTI) with trypsin, trypsinogen and kallikrein; turkey ovomucoid 3rd domain (OMTKY3) with alpha-chymotrypsin and the Streptomyces griseus protease B; the potato chymotrypsin inhibitor with the protease B; and the barely chymotrypsin inhibitor and eglin-c with subtilisin and thermitase. Using X-ray coordinates of the nine complexes, we estimated the contributions that hydrophobic effect, electrostatic interactions and side-chain conformational entropy make towards the stability of the complexes. The calculated delta G values showed good agreement with the experimentally measured ones, the only exception being the kallikrein/BPTI complex whose X-ray structure was solved at an exceptionally low pH. In complexes with different enzymes, the same inhibitor residues contributed identically towards complex formation (delta G(residue) Spearman rank correlation coefficient 0.7 to 1.0). The most productive enzyme-contacting residues in OMTKY3, eglin-c, and the chymotrypsin inhibitors were found in analogous positions on their respective binding loops; thus, our calculations identified a functional (energetic) motif that parallels the well-known structural similarity of the binding loops. The delta G values calculated for BPTI complexed with trypsin (-21.7 kcal) and trypsinogen (-23.4 kcal) were similar and close to the experimental delta G value of the trypsin/BPTI complex (-18.1 kcal), lending support to the suggestion that the 10(7) difference in the observed stabilities (KA) of these two complexes reflects the energetic cost of conformational changes induced in trypsinogen during the pre-equilibrium stages of complex formation. In almost all of the complexes studied, the stabilization free energy contributed by the inhibitors was larger than that donated by the enzymes. In the trypsin-BPTI complex, the calculated delta G contribution of the amino group from the BPTI residue Lys15 (9.7 kcal) was somewhat higher than that arrived at in experiments with semisynthetic inhibitor analogs (7.5 kcal). In OMTKY3, different binding loop residues are known to affect differently the binding (delta delta G) to alpha-chymotrypsin and protease B; a good qualitative agreement was found between the calculated delta G(residue) estimates and the experimental delta delta G data (correlation coefficient 0.7). Large variations were observed in local surface complementarity and related interfacial volume in the two OMTKY3 complexes (by 20 to 60% for some side-chains).(ABSTRACT TRUNCATED AT 400 WORDS)

Amino Acid Sequence↗
PubMed2006

Physiological improvements and health benefits during an exercise-based comprehensive rehabilitation program in medically complex patients.

OBJECTIVES: To determine the effects of an exercise-based comprehensive rehabilitation program on the physiological, health, and cost benefit in medically complex patients. DESIGN: Case series SETTING: Comprehensive rehabilitation centers. PARTICIPANTS: Elderly chronically ill men (n = 39, age = 75.3 +/- 1.4) and women (n = 74, age = 76.5 +/- 0.9 years). INTERVENTION: Patients participated in individualized physical therapy with therapeutic exercises (stretching, strengthening, endurance, balance, sitting and standing dynamic exercises) three times/week for three months under the supervision of a physician. MEASUREMENTS: Upper (back) and lower (leg flexors) extremity strength, aerobic power as measured by metabolic equivalents (METS) at 80% of age predicted maximal heart rate (APMHR), physical functioning and mental health as assessed by the Short Form-36 (SF-36) questionnaire, and medical events (falls, physician visits, and hospitalizations) questionnaire was collected at baseline and after three months of the program. RESULTS: Strength measures improved by approximately 30% (P < 0.05) as well as aerobic power improved by approximately 25% (P < 0.05) over the three-month period. There were significant improvements in two of the SF-36 Physical Component Scales: Physical Functioning (P < 0.05) and Role Physical (P < 0.05); plus, there were significant improvements in all four of the Mental Component Scales: Vitality (P < 0.05), Social Functioning (P < 0.05), Role Emotional (P < 0.05), and Mental Health (P < 0.05). There were significant reductions in fall rate (P < 0.05), physician visits (P < 0.05), and hospitalizations (P < 0.05). CONCLUSION: Patients improve physical capacity, which result in improvements in health status with concurrent reductions in healthcare utilization during a comprehensive rehabilitation program.

Aged↗
PubMed2004

Use of risk assessment in attaining and maintaining oral health.

The cost of health care is increasing rapidly. A transition from the "repair" to a "wellness" model of oral health care that minimizes the occurrence of disease and the need for complex treatment may reduce costs and improve oral health. Quantification of risk is essential for successful use of the wellness model. Subjective risk assessment by expert clinicians is too variable to be useful in clinical decision making. However, user-friendly Internet-based technology has been developed that provides a consistently accurate and valid quantified risk assessment for periodontitis, as well as a quantified measure of disease severity and extent. The numeric information helps clinicians and patients make diagnoses and generate individual, needs-based treatment plans. This technology enables successful application of the wellness model of care in day-to-day dental practice. Use of the wellness model may result in more uniform and accurate periodontal clinical decision making, improved oral health, less need for complex periodontal therapy, lower oral health care costs, and improved clinician productivity and income.

Adult↗
PubMed2004

Assessing the value of antipsychotics for treating schizophrenia: the importance of evaluating and interpreting the clinical significance of individual service costs.

Schizophrenia is a serious and complex disorder, with treatment requiring a large number and wide range of health and social service resources. This paper addresses one challenge for assessing the direct costs of antipsychotic treatments - that of interpreting both cost and effectiveness implications of specific components of service use. Information collected on direct component costs has frequently been analysed and reported only in total. Results of several published studies provide evidence that the total direct medical costs associated with atypical antipsychotics appear to be at least equivalent to, and in some cases lower than, those associated with conventional agents. An important implication of this cost-equivalency finding is that treatment involving higher medication costs have led to offsets in certain medical service costs. Results from several studies demonstrate a shift of cost components, primarily from more expensive inpatient to less expensive outpatient care. Although the common inpatient versus outpatient dichotomy is useful, the complexities of schizophrenia and the heterogeneity of outpatient service provision are likely to warrant greater specificity. Published schizophrenia treatment guidelines can assist researchers to more fully understand and meaningfully interpret the possible relationship of antipsychotic effectiveness to the use of particular outpatient services. Because the disease requires comprehensive and continuous care, outpatient treatment costs may be better conceptualised as baseline or expectable costs necessary in the maintenance phase of treatment. Lack of expectable costs may represent poor patient outcomes and increased intangible costs. In contrast, reductions in acute outpatient service costs may provide important markers of treatment effectiveness. A small number of studies have examined the use of crisis services, but additional work is needed to differentiate treatments vis-à-vis the need for intensive (acute) interventions. The assessment and clinical interpretation of individual cost components may offer an important opportunity to build upon initial results focusing on total costs and tailor analyses to the complexities of the disorder and the treatment process. Research able to incorporate clinical acumen into cost analyses will enhance the ability of healthcare policy makers to make informed decisions regarding the value of different antipsychotic medications for the treatment of schizophrenia.

Ambulatory Care↗
PubMed2004

Cost-effectiveness of sirolimus-eluting stents for treatment of complex coronary stenoses: results from the Sirolimus-Eluting Balloon Expandable Stent in the Treatment of Patients With De Novo Native Coronary Artery Lesions (SIRIUS) trial.

BACKGROUND: Recently, sirolimus-eluting stents (SESs) have been shown to dramatically reduce the risk of angiographic and clinical restenosis compared with bare metal stent (BMS) implantation. However, the overall cost-effectiveness of this strategy is unknown. METHODS AND RESULTS: Between February and August 2001, 1058 patients with complex coronary stenoses were enrolled in the SIRIUS trial and randomized to percutaneous coronary revascularization with either a SES or BMS. Clinical outcomes, resource use, and costs were assessed prospectively for all patients over a 1-year follow-up period. Initial hospital costs were increased by 2881 dollars per patient with SESs. Over the 1-year follow-up period, use of SESs led to substantial reductions in the need for repeat revascularization, including repeat percutaneous coronary intervention and bypass surgery. Although follow-up costs were reduced by 2571 dollars per patient with SESs, aggregate 1-year costs remained 309 dollars per patient higher. The incremental cost-effectiveness ratio for SES was 1650 dollars per repeat revascularization event avoided or 27,540 dollars per quality-adjusted year of life gained, values that compare reasonably with other accepted medical interventions. Under updated treatment assumptions regarding available stent lengths and duration of antiplatelet therapy, use of SESs was projected to reduce total 1-year costs compared with BMSs. CONCLUSIONS: Although use of SESs was not cost-saving compared with BMS implantation, for patients undergoing percutaneous coronary intervention of complex coronary stenoses, their use appears to be reasonably cost-effective within the context of the US healthcare system.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

[Cost involved in retrieving multiple organs].

UNLABELLED: The process of organ donation and retreat is complex and involves a high cost for hospitals that do it. PURPOSE: to survey the expenses with the process of donation and retreat of organs. METHODS: retrospective study based on medical records of 32 donors, admitted in the Search Organs Organisation do Instituto Dante Pazzanese de Cardiologia, during the period from January to December of 1999. RESULTS: the process is complex and involves a special structure as well as 24 hours of activities, making it costly. Expenses were related with the following items: human resources, permanent material, public utilities, complementary examinations, depreciation of equipment and transportation. A comparison with the values reimbursed by the Single Health System (SUS) followed. CONCLUSION: the total cost was high than the reimbursement provided by SUS, showing the necessity of research about cost of procedures and the reinvestment margin.

Adolescent↗