Showing papers on "Cost effectiveness published in 2006"

ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

Abstract: It is important that the medical profession plays a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines, whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. The Task Force is pleased to have this guideline developed in conjunction with the European Society of Cardiology (ESC). Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop or update written recommendations for clinical practice. Experts in the subject under consideration have been selected from all 3 organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular tests or therapies are considered as well as frequency of follow-up and cost effectiveness. When available, information from studies on cost will be considered; however, review …

Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies.

Abstract: No consensus on the indications for surgical resection of colorectal liver metastases exists. This systematic review has been undertaken to assess the published evidence for its efficacy and safety and to identify prognostic factors. Studies were identified by computerised and hand searches of the literature, scanning references and contacting investigators. The outcome measures were overall survival, disease-free survival, postoperative morbidity and mortality, quality of life and cost effectiveness, and a qualitative summary of the trends across all studies was produced. Only 30 of 529 independent studies met all the eligibility criteria for the review, and data on 30-day mortality and morbidity only were included from a further nine studies. The best available evidence came from prospective case series, but only two studies reported outcomes for all patients undergoing surgery. The remainder reported outcomes for selected groups of patients: those undergoing hepatic resection or those undergoing curative resection. Postoperative mortality rates were generally low (median 2.8%). The majority of studies described only serious postoperative morbidity, the most common being bile leak and associated perihepatic abscess. Approximately 30% of patients remained alive 5 years after resection and around two-thirds of these are disease free. The quality of the majority of published papers was poor and ascertaining the benefits of surgical resection of colorectal hepatic metastases is difficult in the absence of randomised trials. However, it is clear that there is group of patients with liver metastases who may become long-term disease- free survivors following hepatic resection. Such survival is rare in apparently comparable patients who do not have surgical treatment. Further work is needed to more accurately define this group of patients and to determine whether the addition of adjuvant treatments results in improved survival.

ASAS/EULAR recommendations for the management of ankylosing spondylitis

Abstract: OBJECTIVE: To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism. METHODS: Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise. RESULTS: The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion. CONCLUSION: Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

Global epidemiology, ecology and control of soil-transmitted helminth infections

Abstract: Soil-transmitted helminth (STH) infections are among the most prevalent of chronic human infections worldwide. Based on the demonstrable impact on child development, there is a global commitment to finance and implement control strategies with a focus on school-based chemotherapy programmes. The major obstacle to the implementation of cost-effective control is the lack of accurate descriptions of the geographical distribution of infection. In recent years, considerable progress has been made in the use of geographical information systems (GIS) and remote sensing (RS) to better understand helminth ecology and epidemiology, and to develop low-cost ways to identify target populations for treatment. This review explores how this information has been used practically to guide large-scale control programmes. The use of satellite-derived environmental data has yielded new insights into the ecology of infection at a geographical scale that has proven impossible to address using more traditional approaches, and has in turn allowed spatial distributions of infection prevalence to be predicted robustly by statistical approaches. GIS/RS have increasingly been used in the context of large-scale helminth control programmes, including not only STH infections but also those focusing on schistosomiasis, filariasis and onchocerciasis. The experience indicates that GIS/RS provides a cost-effective approach to designing and monitoring programmes at realistic scales. Importantly, the use of this approach has begun to transition from being a specialist approach of international vertical programmes to becoming a routine tool in developing public sector control programmes. GIS/RS is used here to describe the global distribution of STH infections and to estimate the number of infections in school-age children in sub-Saharan Africa (89.9 million) and the annual cost of providing a single anthelmintic treatment using a school-based approach (US$5.0-7.6 million). These are the first estimates at a continental scale to explicitly include the fine spatial distribution of infection prevalence and population, and suggest that traditional methods have overestimated the situation. The results suggest that continent-wide control of parasites is, from a financial perspective, an attainable goal.

The World Health Organization and the Transition From “International” to “Global” Public Health

Abstract: Even a quick glance at the titles of books and articles in recent medical and public health literature suggests that an important transition is underway. The terms ‘global’, ‘globalization’, and their variants are everywhere, and in the specific context of international public health, ‘global’ seems to be emerging as the preferred authoritative term.1 As one indicator, the number of entries under the rubrics ‘global’ and ‘international’ health in PubMed shows that ‘global’ health is rapidly on the rise, seemingly on track to overtake ‘international’ health at some point in 2005 (see Table 5.1). Although universities, government agencies, and private philanthropies are all using the term in highly visible ways, the origin and meaning of the term ‘global health’ are still unclear.2

Nanoporous Membranes with Ultrahigh Selectivity and Flux for the Filtration of Viruses

Abstract: The filtration, separation, and isolation of viruses are critical issues for controlling blood-borne viral infections and for viral research. Membrane-based technology has been identified as a useful method for the separation of biomaterials including viruses, owing to its efficiency, ease of implementation, and cost effectiveness. Several types of membranes have been employed for virus filtration. For example, microfiltration (MF) membranes show a relatively high flux and good retention of viruses on the membrane due to the presence of electrostatic interactions under appropriate conditions. However, the pore size of MF membranes is typically much larger than the size of the virus particles, which limits their applicability to biomaterials that are tens of nanometers in size. Ultrafiltration membranes with smaller pore sizes have also been employed for the separation of viruses. However, they have not been very effective, since the virus particles permeate into a small number of abnormally largesized pores. Track-etched polycarbonate (PC) and anodized aluminum oxide (AAO) membranes with a uniform pore size have also been studied for the separation of viruses. While the pore size distributions are narrow for these membranes, both types of membranes show a very low flux for virus separation. Thus, a new type of membrane, providing both high selectivity and high flux, is needed to filter viruses. Here, we introduce a new membrane with an asymmetric film geometry, which shows both high selectivity and flux. This membrane consists of a thin nanoporous layer, prepared from a blockcopolymer template, and a support membrane that provides mechanical strength. This asymmetric membrane shows ultrahigh selectivity while still maintaining a high flux for the separation of human rhinovirus type 14 (HRV14), which has a diameter of ∼ 30 nm and is a major pathogen for the common cold in humans. Since the pore diameter in the top layer can be tuned from 10 to 40 nm, the cutoff size of the membrane filter can be precisely controlled. With these pore sizes, this membrane allows biomolecules such as proteins present in the unfiltered solution to pass through the membrane, while only the viruses are screened. This unique characteristic of the new membrane filter eliminates the risk of contamination from viruses while processing biotherapeutic proteins such as vaccines and hormones. Therefore, this new membrane can be used to develop new types of bloodfiltering systems, such as a haemodialysis membrane that is free of the risk of viral infection. Moreover, this membrane provides an easy means to increase the concentration of the virus, thereby making it possible to investigate virus cultivation and the morphologies of unknown viruses. Figure 1 shows a schematic depiction of the fabrication of asymmetric nanoporous membranes. The top separation layer (∼ 80 nm thick) is made from a thin film of a mixture of polystyrene-block-poly(methyl methacrylate) copolymer (PS-b-PMMA), with cylindrical microdomains of PMMA, on a ∼ 100 nm thick sacrificial silicon oxide layer. As previously reported, when the PMMA homopolymer is added to PS-b-PMMA, the cylindrical nanodomains orient normal to the surface in films of up to ∼ 300 nm thickness on surfaces where the interfacial interactions have been balanced (Fig. 1a). This thin film can be removed from the substrate by using a buffered HF solution to dissolve the oxide layer. The film is then transferred onto the MF polysulfone (PSU) membrane, which acts as a support (Fig. 1b). The adhesion between the block-copolymer-mixture film and the PSU membrane is sufficient to maintain the mechanical integrity of the system during the fabrication and filtration experiments. Porous thin films of the upper layer can be prepared by selectively removing the PMMA homopolymer from the cylindrical PMMA microdomains with acetic acid (Fig. 1c). This produces a well-ordered array consisting of ∼ 15 nm diameter pores with a narrow pore size distribution (see Fig. S1, Supporting Information), which completely prevents the HRV14 virus (colored green) from penetrating into the pores, while proteins, such as bovine serum albumin (BSA) (colored yelC O M M U N IC A IO N S

The Survival Benefits of AIDS Treatment in the United States

Abstract: BACKGROUND As widespread adoption of potent combination antiretroviral therapy (ART) reaches its tenth year, our objective was to quantify the cumulative survival benefits of acquired immunodeficiency syndrome (AIDS) care in the United States. METHODS We defined eras corresponding to advances in standards of human immunodeficiency virus (HIV) disease care, including opportunistic infection prophylaxis, treatment with ART, and the prevention of mother-to-child transmission (pMTCT) of HIV. Per-person survival benefits for each era were determined using a mathematical simulation model. Published estimates provided the number of adult patients with new diagnoses of AIDS who were receiving care in the United States from 1989 to 2003. RESULTS Compared with survival associated with untreated HIV disease, per-person survival increased 0.26 years with Pneumocystis jiroveci pneumonia prophylaxis alone. Four eras of increasingly effective ART in addition to prophylaxis resulted in per-person survival increases of 7.81, 11.05, 11.57, and 13.33 years, compared with the absence of treatment. Treatment for patients with AIDS in care in the United States since 1989 yielded a total survival benefit of 2.8 million years. pMTCT averted nearly 2900 infant infections, equivalent to 137,000 additional years of survival benefit. CONCLUSIONS At least 3.0 million years of life have been saved in the United States as a direct result of care of patients with AIDS, highlighting the significant advances made in HIV disease treatment.

The High/Scope Perry Preschool Program Cost–Benefit Analysis Using Data from the Age-40 Followup

Abstract: This paper presents an updated cost-benefit analysis of the High/Scope Perry preschool Program, using data on individuals aged 40. Children were randomly assigned to a treatment or control group. Program costs are compared against treatment impacts on educational resources, earnings, criminal activity, and welfare receipt. Net present values are calculated for participants, the general public, and society. The treatment group obtains significantly higher earnings. For the general public, higher tax revenues, lower criminal justice system expenditures, and lower welfare payments easily outweigh program costs; they repay $12.90 for every $1 invested. However, program gains come mainly from reduced crime by males.

Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries

Abstract: The ongoing policy debate about the value of communications technology in promoting development objectives is diverse. Some view computer/web/phone communications technology as insufficient to solve development problems while others view communications technology as assisting all sections of the population. This paper looks at evidence to support or refute the idea that fixed and mobile telephones is, or could be, an effective healthcare intervention in developing countries. A Web-based and library database search was undertaken including the following databases: MEDLINE, CINAHL, (nursing & allied health), Evidence Based Medicine (EBM), POPLINE, BIOSIS, and Web of Science, AIDSearch (MEDLINE AIDS/HIV Subset, AIDSTRIALS & AIDSDRUGS) databases. Evidence can be found to both support and refute the proposition that fixed and mobile telephones is, or could be, an effective healthcare intervention in developing countries. It is difficult to generalize because of the different outcome measurements and the small number of controlled studies. There is almost no literature on using mobile telephones as a healthcare intervention for HIV, TB, malaria, and chronic conditions in developing countries. Clinical outcomes are rarely measured. Convincing evidence regarding the overall cost-effectiveness of mobile phone " telemedicine" is still limited and good-quality studies are rare. Evidence of the cost effectiveness of such interventions to improve adherence to medicines is also quite weak. The developed world model of personal ownership of a phone may not be appropriate to the developing world in which shared mobile telephone use is important. Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy, but its magnitude is unknown. One advantage, however, of telephones with respect to adherence to medicine in chronic care models is its ability to create a multi-way interaction between patient and provider(s) and thus facilitate the dynamic nature of this relationship. Regulatory reforms required for proper operation of basic and value-added telecommunications services are a priority if mobile telecommunications are to be used for healthcare initiatives.

Planned missing data designs in psychological research.

Abstract: The authors describe 2 efficiency (planned missing data) designs for measurement: the 3-form design and the 2-method measurement design. The 3-form design, a kind of matrix sampling, allows researchers to leverage limited resources to collect data for 33% more survey questions than can be answered by any 1 respondent. Power tables for estimating correlation effects illustrate the benefit of this design. The 2-method measurement design involves a relatively cheap, less valid measure of a construct and an expensive, more valid measure of the same construct. The cost effectiveness of this design stems from the fact that few cases have both measures, and many cases have just the cheap measure. With 3 brief simulations involving structural equation models, the authors show that compared with the same-cost complete cases design, a 2-method measurement design yields lower standard errors and a higher effective sample size for testing important study parameters. With a large cost differential between cheap and expensive measures and small effect sizes, the benefits of the design can be enormous. Strategies for using these 2 designs are suggested.

Good Practice Guidelines for Decision-Analytic Modelling in Health Technology Assessment: A Review and Consolidation of Quality Assessment

Abstract: The use of decision-analytic modelling for the purpose of health technology assessment (HTA) has increased dramatically in recent years. Several guidelines for best practice have emerged in the literature; however, there is no agreed standard for what constitutes a 'good model' or how models should be formally assessed. The objective of this paper is to identify, review and consolidate existing guidelines on the use of decision-analytic modelling for the purpose of HTA and to develop a consistent framework against which the quality of models may be assessed. The review and resultant framework are summarised under the three key themes of Structure, Data and Consistency. 'Structural' aspects relate to the scope and mathematical structure of the model including the strategies under evaluation. Issues covered under the general heading of 'Data' include data identification methods and how uncertainty should be addressed. 'Consistency' relates to the overall quality of the model. The review of existing guidelines showed that although authors may provide a consistent message regarding some aspects of modelling, such as the need for transparency, they are contradictory in other areas. Particular areas of disagreement are how data should be incorporated into models and how uncertainty should be assessed. For the purpose of evaluation, the resultant framework is applied to a decision-analytic model developed as part of an appraisal for the National Institute for Health and Clinical Excellence (NICE) in the UK. As a further assessment, the review based on the framework is compared with an assessment provided by an independent experienced modeller not using the framework. It is hoped that the framework developed here may form part of the appraisals process for assessment bodies such as NICE and decision models submitted to peer review journals. However, given the speed with which decision-modelling methodology advances, there is a need for its continual update.

A systematic review of the effectiveness of adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis in adults and an economic evaluation of their cost-effectiveness.

Abstract: OBJECTIVES This report reviews the clinical effectiveness and cost-effectiveness of adalimumab, etanercept and infliximab, agents that inhibit tumour necrosis factor-alpha (TNF-alpha), when used in the treatment of rheumatoid arthritis (RA) in adults. DATA SOURCES Electronic databases were searched up to February 2005. REVIEW METHODS Systematic reviews of the literature on effectiveness and cost-effectiveness were undertaken and industry submissions to the National Institute for Health and Clinical Excellence (NICE) were reviewed. Meta-analyses of effectiveness data were also undertaken for each agent. The Birmingham Rheumatoid Arthritis Model (BRAM), a simulation model, was further developed and used to produce an incremental cost-effectiveness analysis. RESULTS Twenty-nine randomised controlled trials (RCTs), most of high quality, were included. The only head-to-head comparisons were against methotrexate. For patients with short disease duration (

Bayesian methods for evidence synthesis in cost-effectiveness analysis

Abstract: Recently, health systems internationally have begun to use cost-effectiveness research as formal inputs into decisions about which interventions and programmes should be funded from collective resources. This process has raised some important methodological questions for this area of research. This paper considers one set of issues related to the synthesis of effectiveness evidence for use in decision-analytic cost-effectiveness (CE) models, namely the need for the synthesis of all sources of available evidence, although these may not 'fit neatly' into a CE model. Commonly encountered problems include the absence of head-to-head trial evidence comparing all options under comparison, the presence of multiple endpoints from trials and different follow-up periods. Full evidence synthesis for CE analysis also needs to consider treatment effects between patient subpopulations and the use of nonrandomised evidence. Bayesian statistical methods represent a valuable set of analytical tools to utilise indirect evidence and can make a powerful contribution to the decision-analytic approach to CE analysis. This paper provides a worked example and a general overview of these methods with particular emphasis on their use in economic evaluation.

Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy.

Abstract: Aims To determine the prevalence and clinical predictors of subclinical atherosclerosis and myocardial ischaemia in uncomplicated type 2 diabetes and assess their relationship to short-term outcome. Methods and results Established risk factors and coronary artery calcium (CAC) scores were prospectively measured in 510 asymptomatic type 2 diabetic subjects (mean age 53+ 8 years, 61% males) without prior cardiovascular disease. Myocardial perfusion scintigraphy (MPS) was performed in all subjects with CAC . 100 Agatston units (AU) (n ¼ 127), and a random sample of the remaining patients with CAC � 100 AU (n ¼ 53). Significant CAC (.10 AU) was found in 46.3%. Twenty events occurred (two coronary deaths, nine non-fatal myocardial infarctions, three acute coronary syndromes, three nonhaemorrhagic strokes, and three late revascularisations) during a median follow-up of 2.2 years (25th–75th percentile ¼ 1.9–2.5 years). The age, systolic blood pressure, the duration of diabetes, United Kingdom Prospective Diabetes Study risk score, CAC score, and extent of myocardial perfusion abnormality were significant predictors of time to cardiovascular events in a univariable Cox proportional hazard model. No cardiac events or perfusion abnormalities occurred in subjects with CAC � 10 AU up until 2 years of follow-up. CAC and MPS findings were synergistic for the prediction of short-term cardiovascular events. Conclusion Subclinical atherosclerosis, measured by CAC imaging, is superior to the established cardiovascular risk factors for predicting silent myocardial ischaemia and short-term outcome. Further studies evaluating the impact of CAC imaging on clinical outcomes and its cost effectiveness are warranted.

Bias in published cost effectiveness studies: systematic review

Abstract: Objective To investigate if published studies tend to report favourable cost effectiveness ratios (below $20 000, $50 000, and $100 000 per quality adjusted life year (QALY) gained) and evaluate study characteristics associated with this phenomenon. Design Systematic review. Studies reviewed 494 English language studies measuring health effects in QALYs published up to December 2001 identified using Medline, HealthSTAR, CancerLit, Current Content, and EconLit databases. Main outcome measures Incremental cost effectiveness ratios measured in dollars set to the year of publication. Results Approximately half the reported incremental cost effectiveness ratios (712 of 1433) were below $20 000/QALY. Studies funded by industry were more likely to report cost effectiveness ratios below $20 000/QALY (adjusted odds ratio 2.1, 95% confidence interval 1.3 to 3.3), $50 000/QALY (3.2, 1.8 to 5.7), and $100 000/QALY (3.3, 1.6 to 6.8). Studies of higher methodological quality (adjusted odds ratio 0.58, 0.37 to 0.91) and those conducted in Europe (0.59, 0.33 to 1.1) and the United States (0.44, 0.26 to 0.76) rather than elsewhere were less likely to report ratios below $20 000/QALY. Conclusion Most published analyses report favourable incremental cost effectiveness ratios. Studies funded by industry were more likely to report ratios below the three thresholds. Studies of higher methodological quality and those conducted in Europe and the US rather than elsewhere were less likely to report ratios below $20 000/QALY.

The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial

Abstract: Background: Vacuum-assisted closure therapy is a relatively new concept described in the literature that increases wound-healing capacity. The authors aimed to investigate the effect of vacuum-assisted closure therapy on wound healing, granulation tissue formation, bacterial clearance, pain, time involvement of the staff, and total costs in all types of wounds in comparison with modern wound dressings. Methods: Sixty-five patients with a chronic or acute wound were randomized to initial treatment with vacuum-assisted closure or modern dressings. The authors' primary endpoint was a granulated wound or a wound ready for skin grafting or healing by secondary intention. Results: The time to the primary endpoint with vacuum-assisted closure therapy was not significantly shorter, except for patients with cardiovascular disease and/or diabetics. Vacuum-assisted closure therapy did not result in significantly faster granulation or wound surface reduction or better bacterial clearance, but patient comfort was an important advantage. Time involvement and costs of nursing staff were significantly lower for the vacuum-assisted closure therapy, but overall costs were similar for both groups. Conclusions: With vacuum-assisted closure therapy, wound healing is at least as fast as with modern wound dressings. Especially cardiovascular and diabetic patients benefit from this therapy. The total costs of vacuum-assisted closure are comparable to those of modern wound dressings, but the advantage is its comfort for patients and nursing staff.

Screening HIV-infected individuals for anal cancer precursor lesions: a systematic review.

Abstract: Individuals with human immunodeficiency virus (HIV) infection are at increased risk for human papillomavirus-related squamous cell cancer of the anus. Screening HIV-infected patients for squamous cell cancer of the anus and human papillomavirus-related anal dysplasia may prevent excess morbidity and mortality. We have conducted a systematic review of the indirect evidence in the literature regarding the utility of anal Papanicolau (Pap) smear screening of HIV-infected individuals in the highly active antiretroviral therapy era. Although there are no published studies evaluating the efficacy of anal Pap smear screening for preventing squamous cell cancer of the anus or anal intraepithelial neoplasia, we reviewed data regarding the burden of disease, anal Pap smear sensitivity and specificity, the prevalence of anal dysplasia, and 1 cost effectiveness study. The available evidence demonstrates that HIV-infected individuals have an increased risk for squamous cell cancer of the anus and anal intraepithelial neoplasia. This review identifies important areas for further study before routine anal Pap smear screening can be recommended.

Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness.

Abstract: Adenocarcinoma of the pancreas accounts for approximately 40,000 deaths each year in the United States as well as in Europe1,2 Although surgery still offers the only option for cure, many patients develop early recurrence within 6–12 months of surgery The dismal prognosis is related to the aggressive biology of this tumor entity and the presence of undetected extrapancreatic tumor spread at the time of surgery Accurate staging, particularly identification of distant metastases, appears of paramount importance to properly select patients who are the most likely to benefit from surgery Current standard staging includes contrast-enhanced helical computed tomography (ceCT) of the abdomen and chest x-ray to detect infiltration of adjacent structures such as the superior mesenteric artery (SMA) and distant metastases2 Endoscopic ultrasonography (EUS) is increasingly used to detect vascular encasement and to obtain histologic confirmation of cancer by ultrasound-guided fine-needle aspiration cytology (FNA), if necessary3 In most current practice, exploratory laparotomy is performed for definitive surgical treatment, if the tumor is judged to be resectable by these means Despite extensive preoperative staging, previously undetected metastases are found during laparotomy or laparoscopy in up to 30% of patients with pancreatic cancer4–6 Positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) is a noninvasive imaging technique that can be used to scan the entire body in one session PET has been shown to be the most accurate examination for the detection of local recurrences and distant metastases in patients with colorectal cancer, with a significant impact on disease management7–11 In patients with suspected pancreatic cancer, PET also has a high sensitivity for liver metastases and may even differentiate between malignant and benign lesions7,9,12–14 However, the precise anatomic delineation of PET-positive findings is hampered by the limited anatomic information of PET images15,16 To overcome this limitation, simultaneous examination by PET and computed tomography (CT) has been developed with the aim to coregister functional (PET) and anatomic information (CT) by the same scanner (PET/CT)16 This combined diagnostic test should provide better detection rates with additional information of unclear lesions that may be missed on either ceCT or PET These theoretical advantages have recently been confirmed for colorectal and lung cancer, where PET/CT was significantly more accurate in predicting the tumor stage than PET or CT alone17–19 The aim of this study was to evaluate the impact of PET/CT on the management of patients with suspected pancreatic cancer, who underwent a standardized conventional diagnostic work-up

Building Collegial Information Networks: A Theory of Advice Network Generation

Abstract: The theory of network generation I present predicts actor selection and retention in forming an advice network. The research question explored is whom do people contact when needing advice? The theory posits that the advice seeker, when possessing rich information on potential alters, decides whom to contact by trading off expected knowledge value versus the cost of obtaining it. In the contact information poor case, alter selection antecedents are the potential contact's accessibility and perceived willingness to share advice.

Viability and effectiveness of large-scale HIV treatment initiatives in sub-Saharan Africa: experience from western Kenya.

Abstract: Objectives: To determine the clinical and immunological outcomes of a cohort of HIV infected patients receiving antiretroviral therapy. Design: Retrospective study of prospectively collected data from consecutively enrolled adult HIV-infected patients in eight HIV clinics in western Kenya. Methods: CD4 cell counts weight mortality loss to follow-up and adherence to antiretroviral therapy were collected for the 2059 HIV-positive non-pregnant adult patients treated with antiretroviral drugs between November 2001 and February 2005. Median duration of follow-up after initiation of antiretroviral therapy was 40 weeks (95% confidence interval 38-43); 111 patients (5.4%) were documented as deceased and 505 (24.5%) were lost to follow-up. Among 1766 (86%) evaluated for adherence to their antiretroviral regimen 78% reported perfect adherence at every visit. Although patients with and without perfect adherence gained weight patients with less than perfect adherence gained 1.04 kg less weight than those reporting perfect adherence (P = 0.059). CD4 cell counts increased by a mean of 109 cells/ml during the first 6 weeks of therapy and increased more slowly thereafter resulting in overall CD4 cell count increases of 160 225 and 297 cells/ml at 12 24 and 36 months respectively. At 1 year a mean increase of 170 cells/ml was seen among patients reporting perfect adherence compared with 123 cells/ml among those reporting some missed doses (P < 0.001). Antiretroviral treatment of adult Kenyans in this cohort resulted in significant and persistent clinical and immunological benefit. These findings document the viability and effectiveness of large-scale HIV treatment initiatives in resource-limited settings. (authors)

Use of quality-adjusted life years for the estimation of effectiveness of health care: A systematic literature review.

Abstract: Objectives The objectives of this study were to identify, in a systematic literature review, published studies having used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL) and to determine which HRQoL instruments have been used to calculate QALYs. Furthermore, the aims were to characterize studies with regard to medical specialty, intervention studied, results obtained, quality, country of origin, QALY gain observed, and interpretation of results regarding cost-effectiveness. Methods Systematic searches of the literature were made using the MEDLINE, Embase, CINAHL, SCI, and Cochrane Library electronic databases. Initial screening of identified articles was based on abstracts read independently by two of the authors; full-text articles were again evaluated by two authors, who made the final decision on which articles should be included. Results The search identified 3,882 articles; 624 were obtained for closer review. Of the reviewed full-text articles, seventy reported QALYs based on actual before-after measurements using a valid HRQoL instrument. The most frequently used instrument was EuroQol HRQoL instrument (EQ-5D, 47.5 percent). Other instruments used were Health Utilities Index (HUI, 8.8 percent), the Rosser-Kind Index (6.3 percent), Quality of Well-Being (QWB, 6.3 percent), Short Form-6D (SF-6D, 5.0 percent), and 15D (2.5 percent). The rest (23.8 percent) used a direct valuation method: Time Trade-Off (10.0 percent), Standard Gamble (5.0 percent), visual analogue scale (5.0 percent), or rating scale (3.8 percent). The most frequently studied medical specialties were orthopedics (15.5 percent), pulmonary diseases (12.7 percent), and cardiology (9.9 percent). Ninety percent of the studies came from four countries: United Kingdom, United States, Canada, the Netherlands. Approximately half of the papers were methodologically high quality randomized trials. Forty-nine percent of the studied interventions were viewed by the authors of the original studies as being cost-effective; only 13 percent of interventions were deemed not to be cost-effective. Conclusions Although QALYs gained are considered an important measure of effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited.

Water supply, sanitation, and hygiene promotion.

Abstract: This chapter focuses on three related interventions - water supply excreta disposal and hygiene promotion - and considers the costs and benefits of each in turn. Water supply and sanitation can be provided at various levels of service and these have implications for benefits. Water supply and sanitation offer many benefits in addition to improved health and these are considered in detail because they have important implications for the share of the cost which is attributable to the health sector. From the point of view of their impact on burden of disease the main health benefit of water supply sanitation and hygiene is a reduction in diarrheal disease though the impacts on other diseases are substantial. In the concluding section the percentage reductions arrived at in the preceding discussion are used together with data on existing levels of coverage to derive estimates of the potential impact of water supply and excreta disposal on the Burden of Disease globally and by region. (excerpt)

Long-Term Outcome After Stroke Evaluating Health-Related Quality of Life Using Utility Measurements

Abstract: Background and Purpose— As stroke mortality rates decline, individuals are increasingly likely to live with their residual impairments and disabilities. Therefore, the quality of poststroke life is...

Cost-effectiveness of second-generation antipsychotics and perphenazine in a randomized trial of treatment for chronic schizophrenia

Abstract: Background: Second-generation antipsychotics have largely replaced firstgeneration antipsychotics for the treatment of schizophrenia, but a large-scale cost/effectiveness analysis has not been attempted. Method: Patients with schizophrenia (N=1,493) were assigned to treatment with a first-generati on antipsychotic (perphenazine) or one of four secondgeneration drugs (olanzapine, quetiapine, risperidone, or ziprasidone) and followed for up to 18 months. Patients with tardive dyskinesia were prohibited from assignment to perphenazine. Patients could be reassigned at any time to another second-generation drug, including clozapine, but not to perphenazine. The cost analysis included medications plus health services use. Qualityadjusted life year (QALY) ratings were assessed on the basis of Positive and Negative Syndrome Scale (PANSS) subscale scores and side effects. An intention-totreat analysis included all available observations, classified by initial drug assignment, and costs of reassignment of most patients to another second-generation drug. The analysis was repeated considering only treatment on initially assigned medications. Results: Although QALY ratings, PANSS scores, and other quality of life measures indicated modest improvement over 18 months, there were no significant differences between perphenazine and any second-generation medication. Average total monthly health care costs were $300–$600 (20%–30%) lower for perphenazine than for second-generation antipsychotics because of lower drug cost. Differences in costs remained when maximally discounted drug prices were used for all patients and when only observations during treatment with the first medication were included. Conclusions: Treatment with perphenazine was less costly than treatment with second-generation antipsychotics with no significant differences in measures of effectiveness. However, the trial was limited by a high dropout rate, and longer-term neurological and metabolic side effects require further study.