Broader Societal Perspective Research Articles

Innovative practice: exploring acculturation theory to advance rehabilitation from pediatric to adult “cultures” of care

Introduction: This perspective paper explores the application of acculturation and the inherent concepts and ideas associated with this theory in rehabilitation to provide a framework for interpreting patient circumstances, responses and behaviours as they move from one culture to the next. Traditionally acculturation theory has been use to examine changes in culture in an ethnic or country sense, however, this paper is among the first to apply acculturation theory to the rehabilitation service cultures from pediatric to adult care for youth with chronic health conditions. Purpose: The objectives of this paper are threefold: (1) to critically appraise key literature in the development of acculturation theory, (2) to discuss how acculturation theory can be applied in rehabilitation practice through a clinical vignette, and finally (3) to discuss how acculturation theory can advance rehabilitation by enhancing client-centered practice. Implications for rehabilitation: Acculturation theory can provide insight into how patients are experiencing a change in health care “cultures”, in the context of their overarching life circumstances. This, coming from a broader societal perspective can in turn inform an optimal approach to client-centered practice, and the application of rehabilitation-specific team inputs. This theoretical framework can heighten practitioners’ awareness of patients’ unique worldviews related to their expectations for care and treatment thus reducing fear of diversity to establish positive partnerships between patients and clinicians. Conclusions: An understanding of patients’ acculturation processes will add new insight into how we can best deliver services and supports to optimise health, opportunities and experiences for youth with chronic conditions.Implications for RehabilitationThe integration of acculturation theory and inherent concepts can provide a reassuring framework upon which to rely in interpreting patient circumstances, responses and behaviours when moving from one culture to the next.Cultural intelligence will reduce fear of diversity and establish positive partnerships between patients and clinicians.Acculturation can become a natural worldview for health systems practitioners when integrated into clinical practice frameworks.

The financial and economic feasibility of rural household biodigesters for poor communities in South Africa

Given the persistence of systemic poverty in, most notably, the rural parts of South Africa, the question is whether the use of biodigesters as a source of energy offers potential solutions to some of the difficulties and development needs faced by people in these areas. At the core, this translates into whether this technology would be financially and economically feasible for installation and use by rural households. Here we conduct both a financial and an economic cost-benefit analysis in one such community based on survey data from 120 households. Analysis of these data and supporting literature reveals that a biodigester is not a financially feasible investment for a rural household. Substantial economic benefits are, however, found to make a biodigester a worthwhile investment from a broader societal perspective. This is a compelling argument for further study and the consideration of government support in the light of broader economy-wide benefits.

Cost Analysis of Early Psychosocial Intervention in Alzheimer's Disease

Background/Aim: To investigate the impact of early psychosocial intervention aimed at patients with Alzheimer's disease (AD) and their caregivers on resource use and costs from a societal perspective. Methods: Dyads of patients and their primary caregiver were randomised to intervention (n = 163) or control (n = 167) and followed for 3 years. Health care use was extracted from national registers, and the Resource Utilisation in Dementia questionnaire was used to measure informal care and productivity loss. Multiple imputation was used to replace missing data, and non-parametric bootstrapping was used to estimate standard errors. Results: Overall, there were no statistically significant differences because of large variation in the observations. The average additional cost of psychosocial intervention provision was estimated at EUR 3,401 per patient. This cost masked a reduced use of formal health care and an increased use of informal care. Conclusions: Early psychosocial intervention in AD could be cost-saving from a health care perspective, whereas the opposite seems to be true from a broader societal perspective.

Unfolding Education for Sustainable Development as Didactic Thinking and Practice

This article’s primary objective is to unfold how teachers translate education for sustainable development (ESD) in a school context. The article argues that exploring tensions, ruptures and openings apparent in this meeting is crucial for the development of existing teaching practices in relation to ESD. The article draws on doctoral research involving interviews with researchers and teachers who have collaborated in ESD research and development projects at primary and secondary schools in two different countries, Denmark and Ireland. It is the teachers’ perspectives on the projects which form the analytical foundation; thus, it is the practices as seen from the ‘inside’. Furthermore, ESD practices are considered in a broader societal perspective, pointing to the critical power of the practice lens.

The cost-effectiveness of mandatory 20 mph zones for the prevention of injuries

Traffic calming and speed limits are major public health strategies for further reducing road injuries, especially for vulnerable pedestrians such as children and the elderly. We conducted a cost-benefit analysis (CBA-favoured by transport economists) alongside a cost-utility analysis (CUA-favoured by health economists) of mandatory 20 mph zones, providing a unique opportunity to compare assumptions and results. A CUA from the public sector perspective and a CBA from a broader societal perspective. One-way, threshold and probabilistic sensitivity analyses were undertaken. In low casualty areas the intervention was not cost-effective regardless of approach (CUA: cost per QALY = £429 800; CBA: net present value = -£25 500). In high casualty areas, the intervention was cost-effective from the CBA (a saving of £90 600), but not from the CUA [cost per quality-adjusted life year (QALY) = £86 500; assuming National Institute for Health and Clinical Excellence's benchmark for approving health technologies]. Mandatory 20 mph zones may be cost-effective in high casualty areas when a CBA from a societal perspective is considered. Although CBA may appear, in principle, more appropriate, the quality, age or absence of reliable data for many parameters means that there is a great deal of uncertainty and the results should be interpreted with caution.

A New Reimbursement System for Innovative Pharmaceuticals Combining Value-Based and Free Market Pricing

Sweden has experienced a national value-based pricing (VBP) system for innovative outpatient drugs operated by the Pharmaceutical Benefits Board - LFN (now called the Dental and Pharmaceutical Benefits agency - TLV) since 2002. VBP has the character of a monopoly system, leading to reimbursement decisions where usage of new medicines is limited to subgroups and not the population for which the drug is approved. VBP relies on a broad societal perspective, encouraging innovations by signaling to firms that value-adding treatments are demanded. However, the VBP system is operated without a drug budget responsibility. The budget responsibility lies at the regional level, not operating VBP, thus an intrinsic conflict is built into the system. The aim of this article is to suggest a modification to the current reimbursement system in Sweden where payment for pharmaceuticals is split between the regional and national levels. The system is expected to make new innovative pharmaceuticals accessible to a larger number of patients and provide more consumer surplus without reducing the producer surplus. In short, the county councils pay the marginal cost of production while the state pays for the innovation.

Social and Economic Benefits of Early Optimised Treatment for Parkinson’s Disease Patients - Improved Quality of Life and Greater Productivity

From a broad societal perspective, the economic burden of Parkinson’s disease ranges from direct medication expenses to costs associated with home help and lost production. The last two generally arise in the more advanced stages of the disease. Savings are nevertheless possible and the two main ways of attaining this are by slowing down disease progression and reducing the time patients spend in off-periods. Earlier onset of optimised treatment, both in the initial and later disease stages, has the potential to achieve both. We highlight examples of advanced therapies that alleviate severe motor symptoms and thereby prolong the time patients can remain in their own homes and at their places of work. Health economic calculations for two forms of advanced therapy, continuous dopaminergic stimulation via pumps and deep brain stimulation, are also shown.

P1-10-06: Economic Analysis of Chemotherapy Costs for Adjuvant Therapy in Breast Cancer in France.

Abstract Background: Total costs of adjuvant chemotherapy can be estimated using different perspectives. To date, only few studies are available in France and only few of these studies have incorporated all the relevant cost items. Indeed the total cost of adjuvant chemotherapy for breast cancer should include not only the drug costs and their administration but also supportive care, transportation and part of the work absenteeism, because all these costs are borne by the French social security. The study objective was to estimate the total costs of adjuvant chemotherapy in France using two different perspectives: the French social security and society. Methods: We conducted a retrospective study to calculate the total cost of first line adjuvant chemotherapy for breast cancer in France. We developed an electronic CRF to collect clinical data, chemotherapy drug details, side effects and personal data such as the type of transportation from home to hospital for chemotherapy treatments and duration of work absenteeism. We added the cost of medical consultations, radiology and biology. We also calculated the exact cost of paramedical time and material. All data were collected after patient's acceptance from clinical records and by phone. Medical resource data were collected from patients’ files for which data were recorded in February 2010 in Tenon hospital (Paris). Unit costs were collected from the French medical insurance database, and other public sources such as national statistics and the technical agency for hospitalization information. Results: We collected data from 30 patients who had adjuvant chemotherapy for breast cancer. Median age was 57.7 years and 37.9% of patients had a regular work. Using the social security perspective, the mean cost (+/− SD) for pre chemotherapy exams and management (biology, oncologist consultation, implantable port system) was €320 +/−€32. For each chemotherapy cycle, the costs of chemotherapy drugs, preventive medications and chemotherapy administration were €1267 +/− €1424. The cost of chemotherapy adverse events was €405 +/− €829 and €39 +/− €28 for usual monitoring of chemotherapy (biology tests and medical consultations). Transportation costs were estimated at €11 +/− €12 and sick leave payments at €445 +/− €521. The mean total cost per cycle was €1806 +/− €1226 per chemotherapy cycle and €12724 +/− €8426 for the whole adjuvant chemotherapy regimen. Using a broader societal perspective, the total cost of chemotherapy was €14668 +/− €9707 per patient, as it included the full cost of lost productivity due to work absenteeism. Conclusion: We reported the first cost analysis of adjuvant chemotherapy for breast cancer in France using two different perspectives (the French social security and the society). Using the social security perspective, chemotherapy drugs and their administration accounted for 70% of the total cost of chemotherapy against 60% when using the societal perspective. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-10-06.

Consequences of Receipt of a Psychiatric Diagnosis for Completion of College

Consequences of Receipt of a Psychiatric Diagnosis for Completion of College

Ten arguments for a societal perspective in the economic evaluation of medical innovations

Springer-Verlag 2009 Health technology assessment (HTA) is increasingly used to assist decisions about reimbursement and funding of new medical technologies, particularly drugs. This means that the economic evaluation that is part of an HTA will form the core element of an assessment used for guiding decisions on resource allocation. While HTA in general has a societal policy perspective, many HTA and reimbursement agencies advising payers take a narrow budget perspective on the impact on resource use when performing economic evaluations. Examples of such agencies are the National Institute for Health and Clinical Excellence (NICE) in England and Wales, the Canadian Agency for Drugs and Technologies in Health (CADTH) in Canada, the Pharmaceutical Management Agency (Pharmac) in New Zealand, and the reimbursement agency NIHISB in Belgium. A number of initiatives for introducing or promoting the use of use HTA for health care policy making (IQWIG, EUnetHTA) seem uncertain about where to stand on the perspective of economic evaluation. There is also an important discussion about the consequences for pharmaceutical innovation of using cost-effectiveness studies to determine which technologies should qualify for reimbursement [1]. Ignoring important costs and benefits in an economic evaluation will lead to an inefficient allocation of resources, in the short term as well as from a long-term perspective. Cost-effective drugs will not be reimbursed and incentives for innovation will be adversely affected. The role of HTA in establishing a transparent and efficient global market for medical innovations may therefore be questioned. This paper provide ten arguments for taking a broad societal perspective on value, specifically to include all relevant costs, in HTA studies aimed at informing decisions about resource allocation. The purpose is to advocate that a broad perspective on value is necessary in order for the study to provide the correct incentives for decision makers to take into account, for both static and dynamic

Why New Tobacco “Harm-Reduction” Products should be Regulated

“Snus” consist of loose ground tobacco in a very small tea bag–like pouch, placed behind the upper gum for up to 30 minutes. With a different curing process and in the absence of combustion, several carcinogens are reduced, if not eliminated. Epidemiological studies in Sweden, where snus were developed and adopted by approximately 20% of males, have found few, if any, increases in oral/head cancers or cardiovascular risks. Although snus are considerably safer than cigarettes from the perspective of an individual smoker, from a broader societal perspective, at least three problems suggest the need for regulatory oversight: (1) Snus could serve as a “gateway” product for adolescents; (2) snus could serve as a temporary bridge/replacement product for smokers in situations in which cigarettes cannot be used, thus dampening their motivation to quit smoking; and (3) studies have found potentially heightened risks of pancreatic cancer, premature birth, dental disease, and oral lesions among users.

A review of the theories of corporate social responsibility: Its evolutionary path and the road ahead

This study aims to trace the conceptual evolutionary path of theories on corporate social responsibility (CSR) and to reflect on the implications of the development. The retrospection has revealed that the trend has been a progressive rationalization of the concept with a particular focus on tighter coupling with organizations’ financial goals. Rationalization involves two broad shifts in the conceptualization of CSR. First, in terms of the level of analysis, researchers have moved from the discussion of the macro‐social effects of CSR to organizational‐level analysis of CSR's effect on profit. Next, in terms of theoretical orientation, researchers have moved from explicitly normative and ethics‐oriented arguments to implicitly normative and performance‐oriented managerial studies. Based on the retrospection, the limitations of the current state of CSR research that places excessive emphasis on the business case for CSR are outlined, and it is suggested that future research needs to refocus on basic research in order to develop conceptual tools and theoretical mechanisms that explain changing organizational behavior from a broader societal perspective.

Cost Effectiveness of Long-Term Treatment with Eszopiclone for Primary Insomnia in Adults

Although the clinical benefits of pharmacological treatments for insomnia have been studied, no systematic assessment of their economic value has been reported. This analysis assessed, from a broad payer and societal perspective, the cost effectiveness of long-term treatment with eszopiclone (LUNESTA, Sepracor Inc., [Marlborough, MA, USA]) for chronic primary insomnia in adults in the US. A decision analytical model was developed based on the reanalysis of a 6-month placebo-controlled trial, which demonstrated that eszopiclone 3mg significantly improved sleep and daytime function measures versus placebo in adults with primary insomnia. Patients were classified as either having remitted or not remitted from insomnia based upon a composite index of eight sleep and daytime function measures collected during the trial. These data were supplemented with quality-of-life and healthcare and lost productivity cost data from the published literature and medical and absenteeism claims databases. Compared with non-remitted patients, patients classified as remitted had lower monthly healthcare and productivity costs (in 2006 dollars) [a reduction of $US242 and $US182, respectively] and higher quality-adjusted life-year (QALY) weight (a net gain of 0.0810 on a scale ranging from 0 to 1). During the study, eszopiclone-treated patients were about 2.5 times more likely to have remitted than placebo-treated patients. Six months of eszopiclone treatment reduced direct (healthcare) and indirect (productivity) costs by an estimated $US245.13 and $US184.19 per patient, respectively. Eszopiclone use was associated with a cost of $US497.15 per patient over 6 months (including drug cost, dispensing fee, physician visit and time loss to receive care). Thus, after considering the above savings and the costs associated with eszopiclone treatment over 6 months, cost increased by $US252.02 (excluding productivity gains) and $US67.83 (including productivity gains) per person. However, eszopiclone treatment was also associated with a net QALY gain of 0.006831 per patient over the same period. Consequently, the incremental cost per QALY gained associated with eszopiclone was approximately $US9930 (including productivity gains [i.e. $US67.83 / 0.006831]) and $US36 894 (excluding productivity gains [i.e. $US252.02 / 0.006831]). Sensitivity analyses using a variety of scenarios suggested that eszopiclone is generally cost effective. This analysis suggested that long-term eszopiclone treatment was cost effective over the 6-month study period, particularly when the impact on productivity costs is considered. Given the increasing interest in new pharmacological interventions to manage insomnia, payers and clinicians alike should carefully consider the balance of health and economic benefits that these interventions offer. Accordingly, additional research in this area is warranted.

Wave energy potential in the Baltic Sea and the Danish part of the North Sea, with reflections on the Skagerrak

Wave power, along with renewable energy-generating sources like tides and streams, is underestimated considering its advantageous physical properties and predictability. This paper examines possible examples of wave power installations in the Baltic Sea and the Danish part of the North Sea. Hindcasting data is used allowing estimations of wave energy generated and results show promising areas in the North Sea, but also several parts of the Baltic Sea are of interest. The study is based upon linear generator technique, placed on the seabed using point-absorbers arranged in arrays of up to several thousand units. The study aims at showing the physical possibilities of wave energy, including economical feasibility and environmental advantages of wave energy even in moderate wave climates. With discussion from two examples in the Baltic Sea, one in the Danish North Sea and a new pilot study site in the Swedish part of Skagerrak, this study show feasible illustrations of wave energy takeouts. Project examples vary in size due to distance to grid, grid voltage, and may thus be economically feasible. Examples also show considerations in societal and nature conservation matters, including aspects such as industrial and military interests, archaeological or marine reserves and local geology. The authors conclude that wave energy electric conversion is an option that needs more attention and which has several advantages compared to conventional renewable sources. Sound engineering, in combination with producer, consumer and broad societal perspective is advised for a sustainable development of wave energy conversion.

Cost-analysis of different management policies for patients with mild hepatitis A virus infection in Kazakhstan

ObjectiveFor patients with mild hepatitis A virus (HAV) infection, this study compared estimates of total costs associated with managing cases under a policy of mandatory hospitalization in the Republic of Kazakhstan and estimates of total costs associated with managing cases in outpatient settings. Costs were estimated both from the perspective of the Ministry of Health and from a broader societal perspective.MethodsData were collected by using a standardized structured questionnaire. For cases of mild HAV infection, medical records were obtained from 200 patients managed by hospitalization and from 251 patients managed in an outpatient setting. Personal interviews were also conducted to collect information on productivity losses and out-of-pocket expenses.ResultsNationally, we estimated about 21,600 cases of mild HAV infection annually. The mean annual treatment costs in hospital for mild HAV infection was estimated at US$3.39 million (2001 US$) (95% confidence interval [CI] = [US$3.26 million – US$3.52 million]). The total annual mild HAV infection cost to the society, including direct medical and nonmedical costs and productivity losses due to 721,440 lost work days, was estimated at US$6.26 million (95% CI [US$6.05 million – US$6.47 million]). In sensitivity analyses, the total annual cost of mild HAV infection ranged from US$4.37 million to US$24.66 million. The survey results showed that a relatively minor change in the current policy of mandatory hospitalization could result in an estimated total annual savings of US$4.62 million (2001 US$) in Kazakhstan.ConclusionAdoption of an outpatient management policy for cases of mild HAV infection would generate substantial cost savings to the Ministry of Health and society.

A Randomised Trial of the Cost Effectiveness of Buprenorphine as an Alternative to Methadone Maintenance Treatment for Heroin Dependence in a Primary Care Setting

Buprenorphine offers an alternative to methadone in the treatment of heroin dependence, and has the advantage of allowing alternate-day dosing. This study is the first to examine the cost effectiveness of buprenorphine as maintenance treatment for heroin dependence in a primary care setting using economic and clinical data collected within a randomised trial. The study was a randomised, open-label, 12-month trial of 139 heroin-dependent patients in a community setting receiving individualised treatment regimens of buprenorphine or methadone. Those who were currently on a methadone program (n = 57; continuing therapy subgroup) were analysed separately from new treatment recipients (n = 82; initial therapy subgroup). The study took a broad societal perspective and included health, crime and personal costs. Data on resource use and outcomes were a combination of clinical records and self report at interview. The main outcomes were incremental cost per additional day free of heroin use and per QALY. An analysis of uncertainty calculated the likelihood of net benefits for a range of acceptable money values of outcomes. All costs were in 1999 Australian dollars (DollarA). The estimated mean number of heroin-free days did not differ significantly between those randomised to methadone (225 [95% CI 91, 266]), or buprenorphine (222 [95% CI 194, 250]) over the year of the trial. Buprenorphine was associated with an average 0.03 greater QALYs over 52 weeks (not significant). The total cost was DollarA 17,736 (95% CI -DollarA 2981, DollarA 38,364) with methadone and DollarA 11,916 (95% CI DollarA 7697, DollarA 16,135) with buprenorphine; costs excluding crime were DollarA 4513 (95% CI DollarA 3495, DollarA 5531) and DollarA 5651 (95% CI DollarA 4202, DollarA 7100). With additional heroin-free days as the outcome, and crime costs included buprenorphine has a lower cost but less heroin-free days. If crime costs are excluded buprenorphine has a higher cost and worse outcome than methadone. With additional QALYs as the outcome, the cost effectiveness of buprenorphine is DollarA 39,404 if crime is excluded, but buprenorphine is dominant if crime is included. The trial found no significant differences in costs or outcomes between methadone and buprenorphine maintenance in this particular setting. Although some of the results suggest that methadone may have a cost advantage, it is difficult to infer from the trial data that offering buprenorphine as an alternative would have a significant effect on total costs or outcomes. The point estimates of costs and outcomes suggest that buprenorphine may have an advantage in those initiating therapy. The confidence intervals were wide, however, and the likelihood of net benefits from substituting one treatment for another was close to 50%.

An Economic Evaluation of Rizatriptan in the Treatment of Migraine

Migraine is a common, chronic, neurovascular disorder, generally characterised by attacks of severe headache and autonomic nervous system dysfunction. Triptans are selective serotonin 5-HT(1B/1D) receptor agonists that represent effective therapeutic options for moderate-to-severe migraine attacks but with higher acquisition costs relative to usual care therapies. The objective of this study was to examine the cost effectiveness of rizatriptan treatment compared with 'Usual Care' or other triptans available in Canada for patients with moderate-to-severe migraine for whom other therapies (e.g. NSAIDs, simple analgesics) are insufficient or contraindicated. A decision-analysis model was created to estimate migraine treatment costs over a 24-hour period in patients with a diagnosis of moderate-to-severe migraine as defined by the International Headache Society criteria. Costs and clinical outcomes were observed over a 24-hour period from therapy initiation. Efficacy measures consisted of 'pain-free response at 2 hours' and 'sustained pain free for 2-24 hours'. Oral rizatriptan 10 mg was compared with other oral triptans (i.e. sumatriptan 50 or 100 mg), naratriptan 2.5 mg and zolmitriptan 2.5 mg, based on a meta-analysis and compared with 'Usual Care' based on a naturalistic study of people who experience migraine and who were similar to the target population. 'Usual Care' was defined as an aggregate of medications prescribed for the Canadian population for the indication of migraine, weighted by the relative frequency of use of prescriptions over a 1-year period. Analyses were conducted from the Ontario (Canada) Ministry of Health and Long-Term Care (MOH<C) perspective and the broader societal perspective. Results are presented as the cost per migraine attack aborted (i.e. pain free at 2 hours), as well as the cost per QALY. Several one-way sensitivity analyses were conducted to test the robustness of the model. All costs are expressed in 2002 $Can. Cost estimates are similar to previously published Canadian studies. Rizatriptan compared with 'Usual Care' produced an incremental cost per attack aborted of $Can49.82 and a cost per QALY gained of $Can31 845 from the MOH<C perspective. When a societal perspective was considered (which included time loss from paid and unpaid work activities), rizatriptan dominates 'Usual Care': that is, it is cost saving and more effective. All other triptans are also dominated by rizatriptan as they offer higher costs and lower efficacy. This study shows that rizatriptan treatment for patients who experience moderate-to-severe migraines may represent a cost-effective strategy for improving care of migraine patients in Canada.

Socio-Technical Networks: How a Technology Studies Approach May Help to Solve Problems Related to Technical Change

This paper is motivated by a desire to deal with the problematic aspects of technical development. To achieve this, we need a new approach to the analysis of socio-technical change. In this paper we develop such an approach, called the `Socio-Technical Networks' (STN) approach. The basic concepts of this approach, and its application, are illustrated in a case study of the development of the European Fighter Aircraft. In the final section, some suggestions are made as to how the STN approach can help to induce technological change in a direction that is considered desirable from a broader societal perspective, and how the approach should be further elaborated.

Health Policy In Two Nations: What A British Analyst Might Say

Health Policy In Two Nations: What A British Analyst Might Say

LET US FIRST DO NO HARM

This article offers the hypothesis that an increasing effort to help families and marriages may inadvertently contribute to their dysfunction. By examining the institutions of family and marriage in the broader societal perspective as well as the theories we use to assign the labels “functional” or “dysfunctional” to families and marriages, we may render a more useful service to the health of these systems. In our enthusiasm to do good, let us first do no harm.