Individual Healthcare Systems Research Articles

Evaluation of an emergency room in operation during the COVID-19 pandemic: diagnoses and recommendations concerning environmental factors

To optimize the emergency room environment, this article puts forward comprehensive diagnoses and recommendations to minimize healthcare-associated infections. Emergency rooms are usually the initial point of entry into the healthcare system for individuals with different illnesses and needs. These environments frequently operate at maximum capacity, which result in challenges related to spatial organization. Therefore, a Post-Occupancy Evaluation was conducted within such an environment during the COVID-19 pandemic, utilizing a combination of qualitative and quantitative data collection methods. The following methodologies were employed to achieve the research objectives and scope: semi-structured interviews with staff members and a specialized architect; walkthrough accompanied by key individuals; behavior observation for flow mapping and quantification; visual records and physical surveys; measurements of environmental conditions; and computational fluid dynamics simulations. The obtained results show the significance of maintaining and monitoring environmental conditions in specific environments; ensuring the appropriate allocation of hospital sectors; leveraging technology to reduce the exchange of paper among professionals; employing video calls to receive patients with flu symptoms; and implementing segregated patient-staff flow. Conclusively, these diagnoses and recommendations hold the potential to not only enhance the built environment of the case study but also to benefit other facilities with similar typologies.

Costs of fall injuries in the STRIDE study: an economic evaluation of healthcare system heterogeneity and heterogeneity of treatment effect

ObjectivesThe Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) Study cluster-randomized 86 primary care practices in 10 healthcare systems to a patient-centered multifactorial fall injury prevention intervention or enhanced usual care, enrolling 5451 participants. We estimated total healthcare costs from participant-reported fall injuries receiving medical attention (FIMA) that were averted by the STRIDE intervention and tested for healthcare-system-level heterogeneity and heterogeneity of treatment effect (HTE).MethodsParticipants were community-dwelling adults age ≥ 70 at increased fall injury risk. We estimated practice-level total costs per person-year of follow-up (PYF), assigning unit costs to FIMA with and without an overnight hospital stay. Using independent variables for treatment arm, healthcare system, and their interaction, we fit a generalized linear model with log link, log follow-up time offset, and Tweedie error distribution.ResultsUnadjusted total costs per PYF were $2,034 (intervention) and $2,289 (control). The adjusted (intervention minus control) cost difference per PYF was -$167 (95% confidence interval (CI), -$491, $216). Cost heterogeneity by healthcare system was present (p = 0.035), as well as HTE (p = 0.090). Adjusted total costs per PYF in control practices varied from $1,529 to $3,684 for individual healthcare systems; one system with mean intervention minus control costs of -$2092 (95% CI, -$3,686 to -$944) per PYF accounted for HTE, but not healthcare system cost heterogeneity.ConclusionsWe observed substantial heterogeneity of healthcare system costs in the STRIDE study, with small reductions in healthcare costs for FIMA in the STRIDE intervention accounted for by a single healthcare system.Trial registrationClinicaltrials.gov (NCT02475850).

Improving Hospital Incident Command Organizational Structures

Introduction:The current Incident Command System (ICS) was developed to manage wildland fires, then was adopted by general firefighting. It has since been adapted to multiple other sectors and widely used. The Hospital Emergency Incident Command (HICS) was introduced in 1991. An ICS currently is required to be used for hospital incident management in the US.The overarching structure of traditional HICS consists of Command Staff (Incident Commander, Public Information Officer, Safety Officer, Liaison Officer and Medical/Technical Specialist) and General Staff. The General Staff has Sections consisting of Operations, Planning, Logistics and Finance/Administration. Multiple and flexible subgroups carry out the processes in these areas.This HICS structure does not adapt easily to hospital daily functions and alternatives have been proposed. This includes structuring around essential functions and mixed models. Over time hospital systems have become larger, and incidents more complex and sustained. New more expansive and flexible ICS structures are needed for complex responses.Method:We reviewed both the published and grey literature for examples of different incident management structures and evidence of their effectiveness.Results:There is very little scientific literature on this topic. Several different descriptive reports exist. Multiple examples of hospital incident command organization structures from the hospital level progressing to hospital (and healthcare) system level and then multistate regional models will be reviewed. This includes the standard HICS model, emergency support function models and modifications following advanced ICS principles such as area command.Conclusion:Different ICS models exist that may offer individual healthcare systems improved ways to manage disasters.

An evidence-based practice guideline of the National Society of Genetic Counselors for telehealth genetic counseling.

There are currently no practice guidelines available for genetic counseling using telehealth modalities. This evidence-based practice guideline was developed in response to increasing use of alternative service delivery models for genetic counseling, specifically telephone and video-based genetic counseling (telehealth genetic counseling or THGC). A recent systematic evidence review (SER) compared outcomes of THGC with in-person genetic counseling and found that for the majority of studied outcomes, THGC was a non-inferior and comparable service delivery model. The SER results were used to develop this guideline. The current and anticipated future use of THGC, including the influence of the COVID-19 pandemic, provides the context for this guideline. Recommendation: The Telehealth Practice Guideline author workgroup conditionally recommends telehealth genetic counseling, either via telephone or video, as a delivery method for genetic counseling. Depending on factors unique to individual healthcare systems and provider and patient populations, THGC may be the only service delivery model available or may be utilized in addition to other service delivery models including in-person genetic counseling. The evidence shows large desirable effects, minor undesirable effects, and increased equity for patients when THGC is available. THGC may reduce or remove existing barriers to patient access to genetic counseling, such as medical conditions and/or disabilities that may affect a patient's ability to travel, inflexible work or school schedules, and lack of reliable transportation, finances, or dependent care. THGC is likely acceptable to key groups impacted by its use and is feasible to implement. Certain patient populations may require additional resources or encounter more barriers in using telemedicine services in general. For these populations, THGC can still be a valuable option if solutions are available.

Quality Standard Position Statements for Health System Policy Changes in Diagnosis and Management of COPD: A Global Perspective.

IntroductionDespite being a leading cause of death worldwide, chronic obstructive pulmonary disease (COPD) is underdiagnosed and underprioritized within healthcare systems. Existing healthcare policies should be revisited to include COPD prevention and management as a global priority. Here, we propose and describe health system quality standard position statements that should be implemented as a consistent standard of care for patients with COPD.MethodsA multidisciplinary group of clinicians with expertise in COPD management together with patient advocates from eight countries participated in a quality standards review meeting convened in April 2021. The principal objective was to achieve consensus on global health system priorities to ensure consistent standards of care for COPD. These quality standard position statements were either evidence-based or reflected the combined views of the panel.ResultsOn the basis of discussions, the experts adopted five quality standard position statements, including the rationale for their inclusion, supporting clinical evidence, and essential criteria for quality metrics. These quality standard position statements emphasize the core elements of COPD care, including (1) diagnosis, (2) adequate patient and caregiver education, (3) access to medical and nonmedical treatments aligned with the latest evidence-based recommendations and appropriate management by a respiratory specialist when required, (4) appropriate management of acute COPD exacerbations, and (5) regular patient and caregiver follow-up for care plan reviews.ConclusionsThese practical quality standards may be applicable to and implemented at both local and national levels. While universally applicable to the core elements of appropriate COPD care, they can be adapted to consider differences in healthcare resources and priorities, organizational structure, and care delivery capabilities of individual healthcare systems. We encourage the adoption of these global quality standards by policymakers and healthcare practitioners alike to inform national and regional health system policy revisions to improve the quality and consistency of COPD care worldwide.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-022-02137-x.

Controlled Substance Waste: Concerns, Controversies, Solutions.

Hospitals, clinics, and organizations using controlled substances must have policies and procedures in place for disposing of these substances and to avoid potential drug diversion as well as environmental pollution. Challenging, particularly to hospitals, is the ability to dispose of the waste of any number of hundreds of products every day, some of which require specific handling and protocols for safety. Incineration might be appropriate but many hospitals and certainly smaller clinics lack the appropriate facilities. Clinics and facilities that use controlled substances must maintain adequate and detailed records, but individual healthcare systems impose their own specific requirements. Some, for example, require drug disposal to be witnessed. However, recordkeeping systems must be robust and frequently audited to prevent diversion. Most healthcare systems want to dispose of controlled substances in an environmentally responsible way but in addition to federal laws in the United States, most states have their own environmental agencies and may have local regulations. Navigating this system can be complex, and since all regulations are subject to change, it requires vigilance and expertise.

Global Survey of Demand-Side Factors and Incentives that Influence Advanced Trauma Life Support (ATLS) Promulgation.

We aimed to identify and describe demand-side factors that have been used to support ATLS global promulgation, as well as current gaps in demand-side incentives. We performed a cross-sectional survey about demand-side factors that influence the uptake and promulgation of ATLS and other trauma-related CME courses. The survey was sent to each of the four global ATLS region chiefs and 80 ATLS country directors. Responses were described and qualitative data were analyzed using a content analysis framework. Representatives from 30 countries and each region chief responded to the survey (40% response rate). Twenty of 30 country directors (66%) reported that there were some form of ATLS verification requirements. ATLS completion, not current verification, was often the benchmark. Individual healthcare systems were the most common agency to require ATLS verification (37% of countries) followed by medical/surgical accreditation boards (33%), governments (23%), training programs (27%), and professional societies (17%). Multiple credentialing frameworks were reported including making ATLS verification a requirement for: emergency unit or trauma center designation (40%), contract renewal or promotion (37%); professional licensing (37%); training program graduation (37%); and increases in remuneration (3%). Unique demand-side incentives were reported including expansion of ATLS to non-physician cadre credentialing and use of subsidies. ATLS region chiefs and country directors reported a variety of demand-side incentives that may facilitate the promulgation of ATLS. Actionable steps include: (i) shift incentivization from ATLS course completion to maintenance of verification; (ii) develop an incentive toolkit of best practices to support implementation; and (iii) engage leadership stakeholders to use demand-side incentives to improve the training and capabilities of the providers they oversee to care for the injured.

Predicting pharmacotherapeutic outcomes for type 2 diabetes: An evaluation of three approaches to leveraging electronic health record data from multiple sources

Electronic health record (EHR) data are increasingly used to develop prediction models to support clinical care, including the care of patients with common chronic conditions. A key challenge for individual healthcare systems in developing such models is that they may not be able to achieve the desired degree of robustness using only their own data. A potential solution—combining data from multiple sources—faces barriers such as the need for data normalization and concerns about sharing patient information across institutions. To address these challenges, we evaluated three alternative approaches to using EHR data from multiple healthcare systems in predicting the outcome of pharmacotherapy for type 2 diabetes mellitus(T2DM). Two of the three approaches, named Selecting Better (SB) and Weighted Average(WA), allowed the data to remain within institutional boundaries by using pre-built prediction models; the third, named Combining Data (CD), aggregated raw patient data into a single dataset. The prediction performance and prediction coverage of the resulting models were compared to single-institution models to help judge the relative value of adding external data and to determine the best method to generate optimal models for clinical decision support. The results showed that models using WA and CD achieved higher prediction performance than single-institution models for common treatment patterns. CD outperformed the other two approaches in prediction coverage, which we defined as the number of treatment patterns predicted with an Area Under Curve of 0.70 or more. We concluded that 1) WA is an effective option for improving prediction performance for common treatment patterns when data cannot be shared across institutional boundaries and 2) CD is the most effective approach when such sharing is possible, especially for increasing the range of treatment patterns that can be predicted to support clinical decision making.

‘Other patients become a secondary priority:’ perceptions of Estonian frontline healthcare professionals on the influence of COVID-19 on health (in)equality and ethical decision-making

ABSTRACT Background The COVID-19 pandemic has posed many challenges to societies, individual healthcare systems and global public health. Manifestations of increasing health inequalities, social stigmatization and challenging ethical decision-making have been previously noticed. The aim of this article is to analyse the perceptions of frontline healthcare professionals regarding the potential impact of COVID-19 on the provision of healthcare services and the ethical challenges it may entail. Method This research is a part of a larger research project which was conducted among frontline healthcare professionals in Estonia and used both quantitative and qualitative methods of data collection. In this article, answers to specific open-ended questions from the questionnaire (n = 116) and in-depth interviews (n = 8) were analysed. For data analysis, inductive content analysis was used. The research was granted ethical approval. Results Findings show that through changes in regular and routinized practices in the provision of emergency medicine services, COVID-19 influences an increase of health inequality and social stigmatization. Other factors as well, such as lack of information about the disease, lack of resources, and fear of the disease, might reinforce these social phenomena. Additionally, from patient-centred and legal perspectives, issues of personal data management and privacy are highlighted. Conclusions In addition to medical issues arising from COVID-19, countries worldwide should pay attention to the social and legal side effects of the illness to minimize health inequality and social stigmatization, as well as to moral, ethical and legal shortcomings in responses to the pandemic.

Integrated Healthcare and the Dilemma of Public Health Emergencies

Traditional healthcare services have demonstrated structural shortcomings in the delivery of patient care and enforced numerous elements of integration in the delivery of healthcare services. Integrated healthcare aims at providing all healthcare that makes humans healthy. However, with mainly chronically ill people and seniors, typically suffering from numerous comorbidities and diseases, being recruited for care, there is a need for a change in the healthcare service structure beyond direct-patient care to be compatible in peacetime and during public health emergencies. This article’s objective is to discuss the opportunities and obstacles for increasing the effectiveness of healthcare through improved integration. A rapid evidence review approach was used by performing a systematic followed by a non-systematic literature review and content analysis. The results confirmed that integrated healthcare systems play an increasingly important role in healthcare system reforms undertaken in European Union countries. The essence of these changes is the transition from the episodic treatment of acute diseases to the provision of coordinated medical services, focused on chronic cases, prevention, and ensuring patient continuity. However, integrated healthcare, at a level not yet fully defined, will be necessary if we are to both define and attain the integrated practice of both global health and global public health emergencies. This paper attains the necessary global challenges to integrate healthcare effectively at every level of society. There is a need for more knowledge to effectively develop, support, and disseminate initiatives related to coordinated healthcare in the individual healthcare systems.

Stakeholder opinion of care pathways to increase physical activity in individuals with knee osteoarthritis in Saudi Arabia

Purpose: In our prior research in Saudi Arabia, we have found that individuals with Knee Osteoarthritis (OA) and healthy controls were physically inactive with high body composition. This finding was not expected since there are recommendations on physical activity levels for adults. However, the utilisation of such recommendation and organisation of care by the healthcare providers in this setting, as well as the attitude and awareness of members of society to physical activity has not been addressed yet. Therefore, this study aimed to explore: 1. Stakeholder perspectives on the opportunities and barriers to physical activity in Saudi Arabia for individuals with knee osteoarthritis.2. Stakeholder perspectives on healthcare delivery for individuals with knee osteoarthritis in Saudi Arabia. Methods: A qualitative design using semi-structured telephone interviews. Recruitment of a purposive sample was carried out by social media posts and advertisements at local hospitals in the three main regions in Saudi Arabia (Western, Central and Eastern). The interview schedule was guided by the literature around knee OA management and healthcare system in Saudi Arabia, physical activity studies and the findings of a prior study. Interviews were digital audio recorded and were transcribed verbatim and translated from Arabic to English. Data were analysed using thematic analysis. After familiarisation with data, two researchers coded 40% of the interviews independently and agreed on the coding in discussion with a 3rd reviewer. All of the manuscripts were coded by the lead researcher. Codes were grouped into categories and themes inductively by the lead applicant and discussed and agreed upon with the rest of the team. Data were managed using NVIVO software. Ethical approval was obtained from the School of Healthcare Sciences at Cardiff University. Results: 26 interviews were carried out with stakeholders; 6 physiotherapists, five physicians, eight people with knee OA, five healthy members of the society without knee pain, one personal trainer and one teacher. Data analysis revealed four themes, which are displayed in Figure 1. Theme 1) Organisation of care for individuals with knee OA. This theme detailes the perspective of people with knee OA and stakeholders on the journey within the healthcare system in Saudi Arabia for the management of knee OA, from the time of the first contact with a healthcare professional to discharge. Key findings from this theme are an uncoordinated multidisciplinary team or organised system for the management of knee OA. The journey pathways and treatments choices were mainly dependant on the available resources, the choices of the individual with knee OA and the decisions of their physician. Theme 2) Physiotherapy service and International guidelines practice for knee OA. This theme focuses on the different issues related to the physiotherapy service such as the number and organisation of clinics, treatments protocols and adherence to treatment guidelines for knee osteoarthritis. Key findings are lack of physiotherapy clinics, delayed referrals, limited autonomy and limited use of treatment guidelines by physiotherapists. Theme 3) The Culture of Physical Inactivity. This explores the stakeholder perception of physical activity while identifying barriers to physical activity and suggestions to increase it. Key findings were several barriers that led to the state physical inactivity, especially with females. Theme 4) Stakeholders views of the healthcare system for individuals with knee OA. This theme describes the experience of individuals with knee OA with the healthcare service. The key findings were the limitations in healthcare service that led to the individuals with knee OA reporting a negative experience such as the delayed care and the repetition of care by physicians. Moreover, it revealed an issue of lack of awareness of the role physiotherapy in knee OA management. Conclusions: The findings provide insight into the healthcare provision from the perspective of stakeholders and individuals with knee OA. There was a consensus amongst all stakeholders that there was poor engagement with physical activity as part of the care for people with knee OA. Limitations and challenges were identified that could be addressed to improve the service and organisation of care. A coordinated approach to care amongst members of the multi-disciplinary team is required, with all members recognising the role that the different professions have to play. Better links with facilities within the community that can support the individuals to become more physically active and the need to promote physical activity in children's education are recommended.

Big Data - How to Realize the Promise.

The increasing volume and complexity of data now being captured across multiple settings and devices offers the opportunity to deliver a better characterization of diseases, treatments, and the performance of medicinal products in individual healthcare systems. Such data sources, commonly labeled as big data, are generally large, accumulating rapidly, and incorporate multiple data types and forms. Determining the acceptability of these data to support regulatory decisions demands an understanding of data provenance and quality in addition to confirming the validity of new approaches and methods for processing and analyzing these data. The Heads of Agencies and the European Medicines Agency Joint Big Data Taskforce was established to consider these issues from the regulatory perspective. This review reflects the thinking from its first phase and describes the big data landscape from a regulatory perspective and the challenges to be addressed in order that regulators can know when and how to have confidence in the evidence generated from big datasets.

Does task delegation to non-physician health professionals improve quality of diabetes care? Results of a scoping review.

ObjectiveAs a result of unhealthy lifestyles, reduced numbers of healthcare providers are having to deal with an increasing number of diabetes patients. In light of this shortage of physicians and nursing staff, new concepts of care are needed. The aim of this scoping review is to review the literature and examine the effects of task delegation to non-physician health professionals, with a further emphasis on inter-professional care.Research design and methodsSystematic searches were performed using the PubMed, Embase and Google Scholar databases to retrieve papers published between January 1994 and December 2017. Randomised/non-randomised controlled trials and studies with a before/after design that described the delegation of tasks from physicians to non-physicians in diabetes care were included in the search. This review is a subgroup analysis that further assesses all the studies conducted using a team-based approach.ResultsA total of 45 studies with 12,092 patients met the inclusion criteria. Most of the interventions were performed in an outpatient setting with type-2 diabetes mellitus patients. The non-physician healthcare professionals involved in the team were nurses, pharmacists, community health workers and dietitians. Most studies showed significant improvements in glycaemic control and high patient satisfaction, while there were no indications that the task delegation affected quality of life scores.ConclusionsThe findings of the review suggest that task delegation can provide equivalent glycaemic control and potentially lead to an improvement in the quality of care. However, this review revealed a lack of clinical endpoints, as well as an inconsistency between the biochemical outcome parameters and the patient-centred outcome parameters. Given the vast differences between the individual healthcare systems used around the world, further high-quality research with an emphasis on long-term outcome effects and the expertise of non-physicians is needed.

Primary care providers' attitudes towards individuals with intellectual disability: Associations with experience and demographics.

Primary care providers are the main point of contact with the healthcare system for individuals with intellectual disability, and they may have pre-existing attitudes towards this group that impacts care. We examined whether participants' gender, age, professional status and experience with individuals with intellectual disability were associated with attitudes by surveying 95 family physicians, family medicine trainees and advanced practice nursing students across a Canadian province. Younger participants were more likely to feel that those with intellectual disability are similar to themselves and that individuals with intellectual disability should be empowered to take control of their lives. Older participants were more likely to believe that individuals with intellectual disability are vulnerable. These findings suggest there may be a generational difference in attitudes, and educational interventions may be needed to ameliorate attitudes among older primary care providers to reduce the impact of pre-existing attitudes on the provision of care.

Health supports needed for homeless persons transitioning from hospitals.

Being homeless has a negative effect on health and the health needs of individuals experiencing homelessness are complex and challenging to address. As a result of limited access to and use of primary healthcare, the main point of entry into the healthcare system for individuals experiencing homelessness is often hospitals and emergency departments. Persons experiencing homelessness are commonly discharged from hospital settings to locations that do not support recovery or access to follow-up care (e.g. shelters or the street). This can be costly to both the healthcare system and to individuals' health and quality of life. We conducted a scoping review of the literature published between 2007 and 2017 to identify the types of health supports needed for persons experiencing homelessness who are discharged from the hospital. Thirteen literature sources met inclusion criteria and thematic data analyses by two researchers resulted in the identification of six themes related to the types of health supports needed for persons experiencing homelessness who are transitioning (i.e. being discharged) from the hospital. Using a community consultation approach, the scoping review themes were validated with 23 health and shelter service providers and included in our integrated findings. Themes included: (a) a respectful and understanding approach to care, (b) housing assessments, (c) communication/coordination/navigation, (d) supports for after-care, (e) complex medical care and medication management, and (f) basic needs and transportation. These themes were found to resonate with participants of the community consultation workshop. Recommendations for trauma-informed care and patient- or client-centred care approaches are discussed.

How are the principles of integration currently taught to Scottish medical students? Sharing ideas and building connections in undergraduate education

An introduction: (comprising background and problem statement) In April 2016, legislation came into force in Scotland implementing Health and Social Care integration. This project looks at teaching and promoting integrated care to medical students who will be involved in its future delivery. Description of policy context and objective: To explore how integration is currently taught to medical students with an aim to highlight and share innovation, and explore relevant incorporation into the undergraduate curriculum. Targeted population: This project looks at the medical undergraduate population in Scotland. Highlights: (innovation, Impact and outcomes) Staff involved in curriculum design from all five Scottish Medical Schools were interviewed, exploring healthcare system structure, health and social care integration, person-centred care and inter-professional teaching. Overall they demonstrated, to differing extents, these principles with specific teaching on professionalism, teamwork, communication, self-reflection etc. One university has introduced managing uncertainty at an early stage, another has introduced a module which focuses on the operation of a ward. Medical students work closely with nurses and allied health professionals (as well as families), giving insight into the healthcare system and holistic care. Some had strong inter-professional teaching with one university using clinical scenario/simulation teaching and group reflection with good feedback. Positive role-modelling of community facing specialities, joint teaching from doctors and other healthcare professionals, clinical skills taught by nurses etc. is displaying professional behaviour required for working within integrated services. These projects have received positive feedback from students, staff and patients involved. It has also encouraged use of new technology to encourage engagement of students. Comments on transferability: Each university’s curriculum is different and changes recommended need to be general to allow appropriate and relevant adaptation. A focus on the themes of integration – including empowering patients, families and communities; social determinants, managing risk, health inequalities, complexity, multi-morbidity – rather than detailed teaching on specifics of the Scottish healthcare system will make the teaching more relevant and transferrable to international students, those who move after graduation etc. Conclusions: (comprising key findings, discussion and lessons learned) There is already a lot of teaching on integration principles. There is understandable caution regarding adding material to an already full curriculum but the importance of integration is acknowledged with a willingness to explore this. One of the strongest themes was that the specifics of individual healthcare systems might not be relevant to all medical students. What is valued though, is creating doctors of the future who have a wide range of skills to adapt to an evolving healthcare landscape with a knowledge of the principles of integration. These findings are being fed back to the Deans of the Scottish universities to share ideas and to develop teaching further – creating links and continuity across medical schools. From this project there is now discussion developing with third sector organisations and the government to explore and develop ideas. Further learning/research: - Integration teaching in postgraduate medical education? - Integration teaching for nursing/allied health professional undergraduates? - Could these be connected?

OP141 Patient Relevant Outcome Measures As Predictors Of Healthcare Use In Multiple Sclerosis

INTRODUCTION:Multiple-sclerosis (MS) is a highly disabling chronic disorder affecting young adults with long term economic consequences on society that escalate as MS disability increases (1,2). In the long-term, progression of MS results in increased level of disability and most patients will eventually experience some degree of functional impairment of the nervous system that impacts on mobility as well as sensory and coordination issues, bladder and sexual functioning, and mood and cognitionon (2). This is usually accompanied by a deterioration of their quality of life. Patient relevant outcome measures (PROMS) are largely used to measure individual disability, and quality of life in MS (2). International evidence from the International Multiple Sclerosis Study (IMPrESS) (2) was used to quantify the relationship between healthcare resources utilisation and disability, quality of life in individuals with MS.METHODS:Multivariable logistic regression was performed in order to identify patient-related variables reporting disability (Barthel) and utility (EQ-5D) that predict use of healthcare services (visits to GP, specialists, nurses, hospitalisation and treatment) and work limitation within the participants of the IMPrESS.RESULTS:Reponses were collected from 1,152 individuals across 21 countries of which 74.3 percent (856) were useful for analysis. Preliminary findings indicated that for the pooled data sets both EQ-5D and Barthel scores were predictors of healthcare resource use, across different categories (p<.05), except for nurse visits (Barthel only; p<.09). Overall the association between PROM data and use of healthcare resources appeared to be stronger with EQ-5D compared to Barthel. EQ-5D appeared to also predict the impact of MS on loss of productivity (in terms of work limitation; p<.05).CONCLUSIONS:PROMs can be used to predict the economic consequences of MS on healthcare providers and society, but more research is needed to confirm the robustness of the evidence and its validity across individual healthcare system settings.

Treatment Costs of Bladder Pain Syndrome/Interstitial Cystitis in Austria: A Pharmacoeconomic Approach Following Current Guidelines

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease with a significant impact on quality of life. A broad range of therapies are used to treat this condition, and patients are often excluded from receiving more expensive and more effective therapies because of cost issues. The objective of this study was to assess the mid- and long-term costs (over 1, 5 and 10years) of various therapies for BPS/IC. Costs in an open-access health system (Austria) for three BPS/IC-specific therapies (intravesical hyaluronan, pentosanpolysulfate and amitriptyline), taken from the American Urological Association guidelines, were evaluated and compared with those of non-specific symptomatic therapies. Response rates for the different therapies were taken from peer-reviewed publications and used to define the need for therapy maintenance with regard to symptom improvement. Despite the highest initial costs, the reduced need for further therapy in patients with long-term symptom remission after hyaluronan therapy resulted in the lowest total treatment costs at all three timepoints. Hyaluronan was cost saving against all alternatives in standard assumptions and in all sensitivity analyses. As a limitation, treatment costs in this study are specific for Austria. However, the template used for calculation of treatment costs can be transferred to all countries by inserting local prices. Disease-specific therapies with high remission rates result in significantly lower long-term costs in BPS/IC. Non-specific symptomatic therapies are most expensive. Long-term cost effectiveness is crucial in the treatment of chronic diseases to limit expenses in individual healthcare systems.

Intravenous to Oral Conversion of Antihypertensives: A Toolkit for Guideline Development

To provide a toolkit of information for hospitals to use in developing intravenous to oral conversion protocols for antihypertensives. Articles describing intravenous to oral conversion protocols for any therapeutic category were identified in an English-language MEDLINE search (1990-April 2010) using a wide variety of MeSH terms. References from selected articles were reviewed for additional material. Experimental and observational English-language studies and review articles that focused on oral transition of intravenous drugs were selected. Most of the literature on conversion from intravenous to oral formulations involves antimicrobials. There is considerable evidence documenting reduced costs and improved patient flow through the health-care system following implementing these protocols with drugs like antimicrobials, histamine-2 receptor antagonists, and proton pump inhibitors. Although antihypertensives have not been studied, principles and implementation strategies used for other drug classes can be applied to antihypertensives. Guidance is provided on framing the problem, issues surrounding oral absorption principles, information pertaining to oral conversion in specific disease states, and implementation and documentation strategies. Detailed tables of oral and intravenous antihypertensives are provided. We recommend that hospitals consider developing protocols on conversion of intravenous to oral antihypertensives in an attempt to reduce unnecessarily prolonged intravenous therapy. Information contained in this article can be used as a toolkit to select information specific to the characteristics of individual health-care systems.

The Use of QALYs in Clinical and Patient Decision-Making: Issues and Prospects

The Use of QALYs in Clinical and Patient Decision-Making: Issues and Prospects