Case Identification Rate Research Articles

Optimizing national border reopening policies in the COVID-19 pandemic: A modeling study.

After emergence of the COVID-19 pandemic and subsequent restrictions, countries worldwide have sought to reopen as quickly as possible. However, reopening involves the risk of epidemic rebound. In this study, we investigated the effective policy combination to ensure safe reopen. On the basis of the classical SEIR epidemic model, we constructed a COVID-19 system dynamics model, incorporating vaccination, border screening, and fever clinic unit monitoring policies. The case of China was used to validate the model and then to test policy combinations for safe reopening. Vaccination was found to be crucial for safe reopening. When the vaccination rate reached 60%, the daily number of newly confirmed COVID-19 cases began to drop significantly and stabilized around 1,400 [1/1,000,000]. The border screening policy alone only delayed epidemic spread for 8 days but did not reduce the number of infections. Fever clinic unit monitoring alone could reduce the peak of new confirmed cases by 44% when the case identification rate rose from 20 to 80%. When combining polices, once the vaccination rate reached 70%, daily new confirmed cases stabilized at 90 [0.64/1,000,000] with an 80% case identification rate at fever clinic units and border screening. For new variants, newly confirmed cases did not stabilize until the vaccination rate reached 90%. High vaccination rate is the base for reopening. Vaccination passport is less effective compared with a strong primary care monitoring system for early detection and isolation of the infected cases.

Linear pathway analysis of European botulism poisoning response guidelines

Abstract Background Botulism is a rare illness caused by Clostridium botulinum toxin with a naïve case fatality ratio of 40-50%. There is no coordinated collective worldwide reporting on cases and comparatively few recommendations on case management. This study examined 14 European botulism treatment guidelines. Methods A ten-language search was conducted to examine European botulism guidelines. The guidelines were classified by differential diagnosis advice; expert advice access; mention of causalities; contract tracing; biological sampling method; and treatment access rapidity. The guidelines were linearly represented on a probability pathway. Quantified probabilities were entered into the algorithm. Probabilities for algorithmic delay or deviance were estimated or mathematically modeled against Hamiltonian, Ford- Fulkerson and Kruskal pathways. Case recognition was deemed proportional to the availability of information at point of care and produced a hazard function related to a Bayes’ probability model. Results Two guidelines did not display all diagnostic information in one place, and six European nations had incomplete descriptions of the chain of causality linking botulism cases: factorially reducing the Borel algorithmic likelihood of diagnosis through contact tracing and decreasing the affectable survival chance. Another limitation was specialist advice and treatment availability in a 48-hour window. Survival probability models to the quoted naïve minimum constraint of a 60% survival factor were depicted, with pharmacokinetic tendential to an exponential decay model. This highlighted the importance of well-constructed case management and logistical stockpiling methods. Conclusions In botulism poisoning the 48-hour window is cited as crucial to patient survival chances, to this extent, the availability of clear diagnostic criteria including causation considerations, expert advice access and logistically considered therapeutic stockpiles could improve survival probability. Key messages • An international standard for botulism guidance may further improve botulism case identification and survival rates. • National botulism guidelines with direct contact method to an expert and with strategic positioning of therapeutic stockpiles may reduce time to treatment and improve survival chances.

Hindsight is 2020 vision: a characterisation of the global response to the COVID-19 pandemic

BackgroundThe global impact of COVID-19 and the country-specific responses to the pandemic provide an unparalleled opportunity to learn about different patterns of the outbreak and interventions. We model the global pattern of reported COVID-19 cases during the primary response period, with the aim of learning from the past to prepare for the future.MethodsUsing Bayesian methods, we analyse the response to the COVID-19 outbreak for 158 countries for the period 22 January to 9 June 2020. This encompasses the period in which many countries imposed a variety of response measures and initial relaxation strategies. Instead of modelling specific intervention types and timings for each country explicitly, we adopt a stochastic epidemiological model including a feedback mechanism on virus transmission to capture complex nonlinear dynamics arising from continuous changes in community behaviour in response to rising case numbers. We analyse the overall effect of interventions and community responses across diverse regions. This approach mitigates explicit consideration of issues such as period of infectivity and public adherence to government restrictions.ResultsCountries with the largest cumulative case tallies are characterised by a delayed response, whereas countries that avoid substantial community transmission during the period of study responded quickly. Countries that recovered rapidly also have a higher case identification rate and small numbers of undocumented community transmission at the early stages of the outbreak. We also demonstrate that uncertainty in numbers of undocumented infections dramatically impacts the risk of multiple waves. Our approach is also effective at pre-empting potential flare-ups.ConclusionsWe demonstrate the utility of modelling to interpret community behaviour in the early epidemic stages. Two lessons learnt that are important for the future are: i) countries that imposed strict containment measures early in the epidemic fared better with respect to numbers of reported cases; and ii) broader testing is required early in the epidemic to understand the magnitude of undocumented infections and recover rapidly. We conclude that clear patterns of containment are essential prior to relaxation of restrictions and show that modelling can provide insights to this end.

Sustaining the National Spinal Cord Injury Registry of Iran (NSCIR-IR) in a Regional Center: Challenges and Solutions

The National Traumatic Spinal Cord Injury Registry in Iran (NSCIR-IR), was implemented initially in three hospitals as a pilot phase from 11 Oct 2015 to 19 Jun 2016 and has been active in eight centers from 19 Jun 2016. Poursina Hospital, a trauma care referral center in Rasht, Guilan Province of Iran is one of the registry sites, and has been involved in registering eligible patients since 1 Jan 2016. This study aimed to identify the challenges and solutions for sustaining the NSCIR-IR in a regional center. This was a mixed-methods study. For the quantitative analysis, a retrospective observational design was used to measure case capture or case identification rate, mapping cases in the registry against those eligible for registry inclusion amongst the register of hospital admissions. For the qualitative component, data was collected using focus group discussions and semi-structured interviews, followed by thematic analysis. From 19 Jun 2016 to 24 Jan 2018, the proportion of case capture (case identification rate) was 17%. The median time between case identification and data entry to the system was 30.5 d (range: 2 to 193 d). Thematic analysis identified a lack of trained human resources as the most important cause of low case identification rate and delay in data completion. Recruitment and education to increase trained human resources are needed to improve case capture, the timeliness of data input and registry sustainability in a regional participating site.

Addressing Discrepancies Between ADHD Prevalence and Case Identification Estimates Among U.S. Children Utilizing NSCH 2007-2012

Objective: Among U.S. children, ADHD epidemiological estimates (3%-5%) vary significantly from case identification rates (over 11%), leading to confusion about true incidence and prevalence. We investigated the extent to which this discrepancy could be resolved by definitional issues through reexamining the most cited U.S. survey of case identification, the National Survey of Children’s Health (NSCH). Method: Using NSCH 2007/2008 and 2011/2012, we stratified identification of ADHD by current status, severity, psychiatric comorbidity, and ADHD medication usage. Using those criteria, definitional strength was coded into “Definite,” “Probable,” “Doubtful,” and “No.” Results: “Definite” ADHD in caseness in 2007/2008 was 4.04%, increasing to 5.49% in 2011/2012, roughly corresponding to epidemiological estimates. “Definite” ADHD was the primary contributor to an overall increase in caseness over that period. Conclusion: This analysis strengthens understanding of discrepancies in estimated ADHD rates. When low confidence identification is considered false positives, ADHD case identification rates match epidemiological estimates more closely.

Mental health training for primary health care workers and implication for success of integration of mental health into primary care: evaluation of effect on knowledge, attitude and practices (KAP)

BackgroundMental disorders are always remained a neglected public health problems in low and middle-income countries (LMICs), most people with mental disorders never receive effective care and there is a large treatment gap. In order to solve the problem integration of mental health into primary health care is recommended and in Ethiopia implementation of the scale of mental health services at primary health care level was started in 2014. For the success of the integration of mental health into primary health care, primary care health professionals are the key personnel who are responsible for the management of mental, neurologic and substance use disorders. However, proper training and education of primary care health professionals is mandatory for an optimal performance and success of integration. This interventional study was conducted to assess the effectiveness of mental health training course for scale up of mental health services at primary health care level in Ethiopia.MethodsThis quasi-experimental pre- and post-study design was conducted in Ethiopia from October to December 2016 using quantitative data collection methods. A total of 94 primary health care professionals were included in the study. The intervention was conducted by psychiatry professionals using standardized World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP) guide prepared for scaling up of mental health care through integration into primary health care (PHC) and general medical services. Pre- and post intervention assessment was done for knowledge, attitude and practice (KAP); and statistically analyzed. A paired sample t test with p values was performed to test the differences between the pre- and post-test. In additions mean and standard deviation of the responses were calculated. Overall the response rate was 100% at the end of the intervention.ResultsThe study resulted in a significant improvement in knowledge, attitude and practice (KAP) of PHC workers about all the four mental, neurologic and substance use disorders during the post intervention survey (p < 0.05). Post intervention the knowledge of health professionals increased by 53.19% for psychosis, 42.56% for depression, 19.25% for epilepsy and 54.22% for alcohol use disorders. Similarly, post intervention attitude increased by 55.32% for psychosis, 40.42% for depression, 36.17% for epilepsy and 43.6% for alcohol use disorders. In addition, post intervention case identification rate increased by 62.78% for psychosis, 55.46% for depression, 21.35% for epilepsy and 41.49% for alcohol use disorders with significant p value (p < 0.05).ConclusionsThe study results suggest that mental health training could be an effective intervention for improving knowledge, attitudes, and practices among primary health care professionals regarding mental, neurologic and substance use disorders. Training is a prerequisite and vital to enhance the knowledge, attitude, and practice of primary care professionals which plays a significant role for the easy success of integrated care and treatment of mental, neurologic and substance use disorders into the existing general health care services.

Physician staffed helicopter emergency medical service case identification - a before and after study in children.

BackgroundSeverely injured children may have better outcomes when transported directly to a Paediatric Trauma Centre (PTC). A case identification system using the crew of a physician staffed helicopter emergency medical service (P-HEMS) that identified severely injured children for P-HEMS dispatch was previously associated with high rates of direct transfer. It was theorised that discontinuation of this system may have resulted in deterioration of system performance.MethodsSevere paediatric trauma cases were identified from a state based trauma registry over two time periods. In Period A the P-HEMS case identification system operated in parallel with a paramedic dispatcher (Rapid Launch Trauma Co-ordinator-RLTC) operating from a central control room (n = 71). In Period B the paramedic dispatcher operated in isolation (n = 126). Case identification and direct transfer rates were compared as was time to arrival at the PTC.ResultsAfter cessation of the P-HEMS system the rate of case identification fell from 62 to 31 % (P < 0.001), identification of fatal cases fell from 100 to 47 % (P < 0.001), the rate of direct transfer to a PTC fell from 66 to 53 % (P = 0.076) and the time to arrival in a PTC increased from a median 69 (interquartile range 52 – 104) mins to 97 (interquartile range 56 – 305) mins (P = 0.003). When analysing the rate of direct transfer to a PTC as a function of team composition, after adjusting for age and injury severity scores, there was no change in the rate between the physician and paramedic groups across the two time periods (relative risk 0.92, 95 % CI: 0.44 to 1.41).DiscussionThe parallel identification system improves case identification rates and decreases time to arrival at the PTC, whilst requiring RLTC authorisation preserves the safety and efficiency benefits of centralised dispatch. The model could be extended to adult patients with similar benefits.ConclusionsA case identification system relying solely on RLTC paramedics resulted in a significantly lower case identification rate and increased prehospital time with a non-significant fall in direct transfer rate to the PTC. The elimination of the P-HEMS input from the tasking system resulted in worse performance indicators and has the potential for poorer outcomes.

94-OR

Objectives Circulating placental growth factor (PlGF) is a potential biomarker for preeclampsia. Prior studies show its limited precision in predicting or diagnosing preeclampsia, underscoring a common problem in biomarker data analyses in general – that large studies are needed to overcome clinical heterogeneity and to provide sufficient statistical power. Attaining such sample sizes often requires aggregation of cohorts. Different studies may use disparate platforms for laboratory analyses, complicating data merging. Here, we assessed whether PlGF concentrations could be merged across studies using inter-platform standardization. Methods Of 16516 pregnancies from 23 cohorts, 12,804 had at least one PlGF concentration (gestational age >20 weeks), analyzed using one of four platforms: R&D Systems, Alere-Triage, Roche-Elecsys or Abbott-Architect. Two merging algorithms, using Z -Score or Multiple of Median (MOM) transformations, were applied. A single Best Reference Curve (BRC), based on merged non-case PlGF concentrations, was constructed. Case-identification performance of the BRC for PlGF was compared to platform-specific curves. Results PlGF concentrations from different analytical platforms were merged ( Z -scores marginally better than MOMs) and, overall, BRC case-identification rates out-performed platform-specific curves. Conclusions Laboratory measurements from different platforms can be standardised and merged to give reference curves from aggregated PlGF datasets. This method allows for analysis of PlGF as a diagnostic marker for preeclampsia and is generalisable to other medical questions, thereby extending the scope of individual studies to answer a variety of important medical questions. Disclosures O. Burke: None. S. Benton: None. P. Szafranski: None. P. von Dadelszen: None. C. Buhimschi: None. I. Cetin: None. L. Chapell: None. F. Figueras: None. A. Galindo: None. I. Herraiz: None. C. Holzman: None. C. Hubel: None. U. Knudsen: None. C. Kronborg: None. H. Laivuori: None. T. McElrath: None. M. Moertl: None. J. Meyers: None. R.B. Ness: None. L. Oliviera: None. G. Olson: None. L. Poston: None. C. Ris-Stalphers: None. J.M. Roberts: None. E. Schistermann: None. E. Steegers: None. H. Stepan: None. O. Lapaire: None. D. Schlembach: None. S. Timmermans: None. V. Tsatsaris: None. J.A. van der Post: None. S. Verlohren: Consultant, Research Support Recipient, Commercial Interest: Roche Diagnostics, ThermoFisher, Novartis. P.M. Villa: None. D. Williams: None. H. Zeisler: None. C. Zhang: None. C.W. Redman: None. A. Staff: None.

Comparison of trends in sepsis incidence and coding using administrative claims versus objective clinical data.

National reports of a dramatic rise in sepsis incidence are largely based on analyses of administrative databases. It is unclear if these estimates are biased by changes in coding practices over time. We calculated linear trends in the annual incidence of septicemia, sepsis, and severe sepsis at 2 academic hospitals from 2003 to 2012 using 5 different claims methods and compared case identification rates to selected objective clinical markers, including positive blood cultures, vasopressors, and/or lactic acid levels. The annual incidence of hospitalizations with sepsis claims increased over the decade, ranging from a 54% increase for the method combining septicemia, bacteremia, and fungemia codes (P < .001 for linear trend) to a 706% increase for explicit severe sepsis/septic shock codes (P = .001). In contrast, the incidence of hospitalizations with positive blood cultures decreased by 17% (P = .006), and hospitalizations with positive blood cultures with concurrent vasopressors and/or lactic acidosis remained stable (P = .098). The sensitivity of sepsis claims for capturing hospitalizations with positive blood cultures with concurrent vasopressors and/or lactic acidosis increased (P < .001 for all methods), whereas the proportion of septicemia hospitalizations with positive blood cultures decreased from 50% to 30% (P < .001). The incidence of hospitalizations with sepsis codes rose dramatically while hospitalizations with corresponding objective clinical markers remained stable or decreased. Coding for sepsis has become more inclusive, and septicemia diagnoses are increasingly being applied to patients without positive blood cultures. These changes likely explain some of the apparent rise in sepsis incidence and underscore the need for more reliable surveillance methods.

Der Childhood Trauma Screener (CTS) - Entwicklung und Validierung von Schwellenwerten zur Klassifikation

Childhood abuse and neglect are associated with worse physical and mental health outcomes. There is some evidence, that the CTS is a brief and valid screening tool. To support the application of the CTS for categorical diagnostics cut-offs will be identified and validated. Based on two large-scale population studies suitable cut-off-scores for the different dimensions of childhood abuse and neglect were identified due to comparable case identification rates in the CTS compared with the Childhood Trauma Questionnaire. The cut-off-scores were validated with respect to depression as an external criterion. Suitable cut-off-scores were identified for all subscales in both samples. The cases and non-cases according to the cut-off-scores differed significantly regarding the severity of depressive symptoms and the prevalence of depression. Good to very good sensitivity and specificity of the CTS-items and the related subscales of the CTQ are shown, except for the dimension "physical neglect". With the help of the cut-off-scores it is possible to use the CTS for categorical diagnostics, especially in large-scale studies with two-step diagnostic approaches.

Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew – case identification rates and effect on the Sydney paediatric trauma system

BackgroundSevere paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC.MethodsPaediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS) > 15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available.ResultsNinety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p = 0.011), and shorter times to PTC (67 vs 261mins, p = 0.015) and length of intensive care unit stays (2 vs 0 days, p = 0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P < 0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P < 0.01).ConclusionsPhysician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival.

Electronic medical records for genetic research: results of the eMERGE consortium.

Clinical data in electronic medical records (EMRs) are a potential source of longitudinal clinical data for research. The Electronic Medical Records and Genomics Network (eMERGE) investigates whether data captured through routine clinical care using EMRs can identify disease phenotypes with sufficient positive and negative predictive values for use in genome-wide association studies (GWAS). Using data from five different sets of EMRs, we have identified five disease phenotypes with positive predictive values of 73 to 98% and negative predictive values of 98 to 100%. Most EMRs captured key information (diagnoses, medications, laboratory tests) used to define phenotypes in a structured format. We identified natural language processing as an important tool to improve case identification rates. Efforts and incentives to increase the implementation of interoperable EMRs will markedly improve the availability of clinical data for genomics research.

Identification of Cases by Non-Microscopic Rapid Diagnostic Test in Suspected Malaria Infection in Community Setting

Background: Malaria presents a diagnostic challenge in most tropical countries. Malaria is diagnosed pre-dominantly by using clinical criteria, with microscopy as gold standard for detecting parasitemia. Recently, rapid diagnostic tests (RDTs) have been developed for situations in which reliable microscopy may not be available. Objective: To identify the cases of malaria by non-microscopic Care Start malaria Pf/Pv combo RDT in suspected malaria infection in community setting. Subjects and Methods: This descriptive observa-tional study was conducted from October to December 2010 in Ehsas Field Hospital, Kot Addu, District Muzaffargarh. Data was collected from Medical and Paediatric outpatient departments of field hospital. Patients of age 5 - 75 years were included in the study. Malaria was clinically suspected in patients with recent fever, chills and/or anemia and was confirmed by Care Start malaria Pf/Pv combo RDT as per the manufacturer's instruction. Data was analyzed by SPSS 17. This study was not sponsored by manufac-turer. Results: Among patients of age 5 - 75 years, 2196 patients were clinically suspected and 1767 cases were confirmed for malaria infection by RDT common age group suspected was 16 - 25 yaers 556 (25%). Case identification rate of RDT was 80%. Conclusion: Non-microscopic Care Start malaria Pf/Pv combo RDT has reliable diagnostic accuracy to identify confirmed cases of malaria infection and may be preferred during malaria epidemics in community setting. Key words: Community setting, Diagnostic accuracy, Histidine rich protein, Lactate dehydrogenase, Malaria infection, Rapid diagnostic test.

Prévalence des troubles psychiatriques en médecine générale selon le patient health questionnaire : adéquation avec la détection par le médecin et le traitement prescrit

Psychiatric disorders, mainly depression and anxiety, are frequently encountered in primary care and are a major cause of distress and disability. Nearly half of cases go unnoticed and among those that are recognised, many do not receive adequate treatment. In France, there is limited research concerning the prevalence, detection and management of these conditions in primary care. To estimate the prevalence of psychiatric disorders, overall and for the main psychiatric diagnostic categories, encountered in primary care; to describe general practitioners' (GPs') case identification rate; to examine psychotropic medication prescription according to diagnosis, in a regionally representative sample of GP attenders. GP practicing standard general practice in an urban area of the city of Montpellier and a nearby semi-rural region were recruited to participate. The response rate was 32.8% (n=41). Five additional GP almost exclusively offering homeopathy and acupuncture were recruited nonrandomly for convenience purposes. In each GP surgery, consecutive patients entering the waiting room were invited by a research assistant to participate until 25 patients per GP were recruited. Each participant completed self-report questionnaires in the waiting time, including the patient health questionnaire (PHQ), which yields provisional DSM-IV diagnoses. The GP completed a brief questionnaire during the consultation, giving his/her rating of the severity of any psychiatric disorder present and action taken. The patient response rate was 89.8%. In all, 14.9% of patients reached DSM-IV criteria for major depression or anxiety disorder on the PHQ (9.1% for major depression, 7.5% for panic disorder; 6% for other anxiety disorders). For the subthreshold categories, 7.4% met criteria for other depressive disorders, 11.8% for somatoform disorders and 10.9% for probable alcohol abuse or dependence. 66.3% of patients with DSM-IV diagnoses of major depression or anxiety disorder were identified by the GP as having a psychiatric disorder. The identification rate was 51% for all depressive disorders, anxiety and somatoform disorders. Of patients receiving a prescription for anxiolytic or antidepressant medication on the survey day, 80% were classified as cases of psychiatric disorder by the GP. Only 48.8% met criteria for major depression or anxiety disorder on the PHQ. This study highlights the frequency of psychiatric disorders in a regional study of French general practice. Overall, prevalence rates were similar to those found elsewhere, except for probable alcohol abuse and dependence, which was considerably higher than in the USA PHQ validation study. As in other countries, GP identified roughly half of psychiatric cases. Furthermore, half of patients treated by anxiolytic or antidepressant medication did not meet the diagnostic criteria on the survey day for which these medications have mainly shown their efficacy. This confirms the French paradox of one of the highest psychotropic medication consumption rates in Europe despite many cases of depression remaining untreated. The PHQ could be a rapid and acceptable diagnostic aid tool for French general practice but first needs to be validated against the diagnosis of mental health professionals in this setting.

Childhood lead poisoning in Massachusetts communities: its association with sociodemographic and housing characteristics.

The purpose of the study was to examine the relationship between communities' sociodemographic and housing characteristics and incidence of lead poisoning. This was a population-based correlational study of 238,275 Massachusetts children from birth through 4 years of age who were screened for lead poisoning in 1991-1992. A logistic regression model was developed with the community as the unit of analysis, the case identification rate for lead poisoning (newly identified children with venous blood lead > or = 25 micrograms/dL per 1000 children) as the dependent variable, and US census variables as independent variables. A significant independent relationship with the community case identification rate of lead poisoning was found for seven variables: median per capita income, percentage of housing built before 1950, percentage of the population who were Black, percentage of children screened, and a "poverty index." Rates of iron deficiency and percentage of Hispanics were not associated with the case identification rate of lead poisoning. Massachusetts communities' incidence of lead poisoning is correlated with sociodemographic and housing characteristics. In states similar to Massachusetts and without screening data, this model may help target screening programs.

Identification of alcohol‐related problems in a general hospital setting: a cost‐effectiveness evaluation

Alcohol is a major cause of morbidity and mortality. The prevention of alcohol problems would result in significant savings to the NHS and society. Screening is an important step in preventing problems. This study examines the costs of screening patients for alcohol problems. Over a 21-month period doctors, nurses and a specialist worker screened medical and orthopaedic admissions to the York District Hospital. A cost-effectiveness analysis of screening data was carried out. Costs were measured by time taken to screen and the relative costs of employing different occupational groups. Effects included the screening rates of each occupational group and those identified as at risk. Results suggested a greater positive case identification rate could be achieved by employing a specialist worker, but at greater cost. The cost-effectiveness evaluation helps clarify the resource consequences of a screening programme and can be a useful aid in the decision-making process.