Reduction In Overall Use Research Articles

19 Quality Improvement bundled approach reduces the use of inotropes in extremely premature babies

Abstract Background Consensus on definition and management of hypotension in preterm neonates is lacking. Owing to this, there are wide variations in the reported incidence of hypotension in premature infants, especially during first week of life. Inotropes can often cause vasoconstriction, which may alter brain perfusion especially in the absence of established cerebral autoregulation. Use of these drugs is associated with multiple short- and long-term morbidities. Objectives To evaluate the effect of quality improvement (QI) bundle on rate of inotrope use and associated morbidities. Design/Methods Inborn preterm neonates born at <29weeks gestational age (GA) and admitted to level III NICU were included. Neonates with major congenital malformations, congenital heart diseases, antenatal diagnosed genetic defects, and neonates admitted after 72 hours of age were excluded from the study. We implemented a QI bundle (Figure 1) focussing on first 72hours from birth which included delayed cord clamping, avoidance of routine echocardiography, addition of clinical criteria to define hypotension, factoring iatrogenic causes of hypotension (ruling out lung hyperinflation), and standardization of respiratory management. Rate of use of inotropes in the first 72hours of life along with acute brain injury and mortality before and after implementation of the QI bundle were compared. The balancing measure was the rate of ischemic lesions in the form of cPVL. Cranial ultrasound was performed to screen for brain injury. Study was approved by the local research ethics board (REB14-1466). Results We included 671 neonates (301 before and 364 after the implementation of the bundle) among which 6 neonates were excluded based on the criteria. QI bundle implementation was associated with significant reduction in overall use of inotropes (24% vs 7%, p<0.001), dopamine (18% vs 5%, p<0.001), and dobutamine (17% vs 4%, p<0.001). Rate of acute brain injury decreased significantly: Acute brain injury of any grade (34% vs 20%, p<0.001) and severe brain injury (15% vs 6%, p<0.001). There was no difference in incidence of cPVL (1% vs 1.4%, p=0.66). Associations remained significant after adjusting for confounding factors. The QI bundle implementation was associated with a significant reduction in the use of inotropes when analyzed based on the 6 monthly time intervals (p = 0.006) (Figure 2) Conclusion Our QI bundled approach resulted in reduction in inotrope use and associated brain morbidities in premature babies. Follow-up studies evaluating the impact of this initiative on long-term outcomes in survivors are required to complement findings of improved short-term outcomes seen in this study.

Environmental and human health at risk - Scenarios to achieve the Farm to Fork 50% pesticide reduction goals.

The recently released Farm to Fork Strategy of the European Union sets, for the first time, pesticide reduction goals at the EU level: 50% reduction in overall use and risk of chemical pesticides and a 50% use reduction of more hazardous pesticides. However, there is little guidance provided as to how to achieve these targets. In this study, we compiled the characteristics of all 230 EU-approved, synthetic, open-field use active substances (AS) used as herbicides, fungicides and insecticides, and explored the potential of seven Farm to Fork-inspired pesticide use reduction scenarios to achieve the 50% reduction goals. The pesticide reduction scenarios were based on recommended AS application rates, pesticide type, soil persistence, presence on the candidate for substitution list, and hazard to humans and ecosystems. All 230 AS have been found to cause negative effects on humans or ecosystems depending on exposure levels. This is found despite the incomplete hazard profiles of several AS. 'No data available' situations are often observed for the same endpoints and specific organisms. The results of the scenarios indicate that only severe pesticide use restrictions, such as allowing only low-hazard substances, will result in the targeted 50% use and risk reductions. Over half of the 230 AS considered are top use or top hazard substances, however, the reduction actions depend on the still to be defined EC priority areas and action plans, also for other recent and related strategies. Broader scenario implications (on productivity, biodiversity or economy) and the response of farmers to the pesticide use restrictions should be explored in those plans to define effective actions. Our results emphasize the need for a re-evaluation of the approved AS and of their representative uses, and the call for open access to AS, crop and region-specific use data to refine scenarios and assess effective reductions.

Hemodynamic Quality Improvement Bundle to Reduce the Use of Inotropes in Extreme Preterm Neonates.

We evaluated the effect of the quality improvement (QI) bundle on the rate of inotrope use and associated morbidities. We included inborn preterm neonates born at <29 weeks admitted to level III NICU. We implemented a QI bundle focusing on the first 72 h from birth which included delayed cord clamping, avoidance of routine echocardiography, the addition of clinical criteria to the definition of hypotension, factoring iatrogenic causes of hypotension, and standardization of respiratory management. The rate of inotropes use was compared before and after implementing the care bundle. Incidence of cystic periventricular leukomalacia (cPVL) was used as a balancing measure. QI bundle implementation was associated with significant reduction in overall use of inotropes (24 vs 7%, p<0.001), dopamine (18 vs 5%, p<0.001), and dobutamine (17 vs 4%, p<0.001). Rate of acute brain injury decreased significantly: acute brain injury of any grade (34 vs 20%, p<0.001) and severe brain injury (15 vs 6%, p<0.001). There was no difference in the incidence of cPVL (0.8 vs 1.4%, p=0.66). Associations remained significant after adjusting for confounding factors. A quality improvement bundled approach resulted in a reduction in inotropes use and associated brain morbidities in premature babies.

Intensive Care Antifungal Stewardship Programme Based on T2Candida PCR and Candida Mannan Antigen: A Prospective Study.

Non-culture-based biomarkers may improve diagnosis and antifungal treatment (AFT) of invasive candidiasis (IC). We evaluated an antifungal stewardship programme (AFSP) in a prospective intensive care unit (ICU) study, which included T2Candida and Candida mannan antigen (MAg) screening of patients with sepsis and a high risk of IC. Patients with non-neutropenic sepsis and a high risk of IC from two large tertiary ICUs were prospectively included, during a one-year period. IC was classified as proven, likely, possible or unlikely. The AFSP, diagnostic values of T2Candida and MAg, and the consumption of antifungals were evaluated. An amount of 219 patients with 504 T2Candida/MAg samples were included. IC was classified as proven in 29 (13.2%), likely in 7 (3.2%) and possible in 10 (5.5%) patients. Sensitivity/specificity/PPV/NPV values, comparing proven/likely versus unlikely IC, were 47%/100%/94%/90% for BC alone, 50%/97%/75%/90% for T2Candida alone, and 39%/96%/67%/88% for MAg alone. For the combination of T2Candida/MAg taken ≤3 days after AFT initiation, sensitivity/specificity/PPV/NPV was 70%/90%/63%/93%. T2Candida/MAg contributed to early (<3 days) AFT initiation in 13%, early AFT discontinuation in 25% and abstaining from AFT in 24% of patients. No reduction in overall use of AFT during the study period compared with the previous year was observed. An AFSP based on T2Candida and MAg screening contributed to a reduction of unnecessary treatment, but not overall AFT use. The diagnostic performance of T2Candida was lower than previously reported, but increased if T2Candida was combined with MAg.

‘No one’s going to buy steroids for a home workout’: the impact of the national lockdown on hardcore gym users, anabolic steroid consumption and the image and performance enhancing drugs market

2020 has proven to be an unprecedented year for all of us, as the ‘new normal’ of lockdown, the challenges of home schooling and the realities of living through a global pandemic have raised fundamental questions about the structure of our society and made us evaluate how we live. But how has the COVID-19 pandemic, and the subsequent restrictions upon public life, affected those of the population whose lives are contoured around the gym and bodywork? Utilising data precured through semi-structured interviews with image and performance enhancing drug-using bodybuilders as part of the author’s PhD research, this article sets out to provide a glimpse into the realities of life in the hardcore fitness community in 2020. First, the impact of lockdown on the men’s training will be explored, and their flouting of the restrictions will be described. Following this, the sample’s IPED consumption during this period will be examined, noting an overall reduction in use and a homogenisation of their favoured substances. Finally, the impacts of the COVID-19 pandemic on the IPED market itself will be explored, wherein the sample’s accounts of panic-buying, supply chain issues and declining demand will be presented. Ultimately, whilst not entirely generalisable given the modest sample size, it is hoped that this article will serve to paint a picture of life under lockdown for the most committed gym users in the population, and follow the community’s challenges during the ‘longest year’.

Migraine Characteristics, Comorbidities, Healthcare Resource Utilization, and Associated Costs of Early Users of Erenumab in the USA: A Retrospective Cohort Study Using Administrative Claims Data.

IntroductionErenumab is indicated for migraine preventive treatment in adults. The objective of this study was to provide descriptive information on real-world use of erenumab including patient profile and treatment patterns.MethodsWe completed a retrospective review of US data (through May 2019) from the IBM MarketScan® Early View Databases, identifying adult patients newly treated with erenumab with a migraine claim in the year prior to first erenumab claim (index) and at least 1 year of continuous pre-index medical and pharmacy insurance coverage, to assess pre- and post-erenumab migraine characteristics, comorbidities, healthcare resource utilization, and associated costs. All data were summarized using descriptive statistics.ResultsA total of 9753 patients met inclusion criteria. The average (SD) age was 46 (12) years, 85% of patients were female, and 64% had at least one claim for chronic migraine; 70% of erenumab users had an initial dose of 70 mg; 77% of patients in the 6-month follow-up sample (n = 4437) remained on their initial erenumab dose. Persistence at 6-month follow-up was 47.3% with a mean (95% CI) proportion of days covered of 0.68 (0.67, 0.68). In the post-erenumab period, claims for comorbidities of non-migraine headaches and anxiety were reduced and there was a shift to decreased use of acute and preventive medications. Reductions in overall use and associated cost of healthcare resources such as inpatient hospitalization and outpatient office visits were minimal, with slightly more pronounced reductions in the subgroup of patients that were persistent to erenumab.ConclusionsWe observed reductions in claims for important migraine characteristics, comorbidities, and a shift to decreased use of acute and preventive migraine medications—observations indicative of the real-world effectiveness of erenumab. Further examination is required as persistence to erenumab, which may be influenced by dose titration, appears to be an important factor in changes to healthcare resource utilization and costs.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-021-00319-z.

Antibiotics for gastroenteritis in general practice and out-of-hour services in Norway 2006-15.

BackgroundWhen patients with gastroenteritis (GE) seek health care, they are generally managed in primary care. Little is known about the use of antibiotic treatment in these cases.ObjectiveThe aim of this study was to investigate time trends and patient characteristics associated with antibiotic treatment for GE in Norwegian primary care in a 10-year period.MethodsWe linked data from two nationwide registries, reimbursement claims data from Norwegian primary care (the KUHR database) and The Norwegian Prescription Database, for the period 2006–15. GE consultations were extracted, and courses of systemic antibiotics dispensed within 1 day were included for further analyses.ResultsAntibiotic treatment was linked to 1.8% (n = 23 663) of the 1 279 867 consultations for GE in Norwegian primary care in the period 2006–15. The proportion of GE consultations with antibiotic treatment increased from 1.4% in 2006 to 2.2% in 2012 and then decreased to 1.8% in 2015. Fluoroquinolones (28.9%) and metronidazole (26.8%) were most frequently used. Whereas the number of fluoroquinolones courses decreased after 2012, the number of metronidazole courses continued to increase until year 2015. The antibiotic treatment proportion of GE consultations was lowest in young children and increased with increasing age.ConclusionAntibiotic treatment is infrequently used in GE consultations in Norwegian primary care. Although there was an overall increase in use during the study period, we observed a reduction in overall use after year 2012. Young children were treated with antibiotics in GE consultations less frequent than older patients.

1798. Phenotypic and Genotypic Impact of Antibiotic Stewardship Intervention on Daptomycin-Nonsusceptible Enterococcus faecium (DNSE) Clinical Isolates

BackgroundSince its introduction in 2009, use of daptomycin for treatment of enterococcal infections has resulted in the emergence of DNSE. Between 2009 and 2013, daptomycin nonsusceptibility among E. faecium was closely associated with emergence of a unique and dominant clone ST736 in our institution. In 2014, we instituted targeted measures to optimize the use of daptomycin. In this study, we describe the significant phenotypic and genotypic impact of reduced daptomycin use on clinical enterococcal isolates.MethodsEnterococcal clinical isolates were recovered from January 2014 through December 2017. Daptomycin susceptibility was determined by MicroScan WalkAway™ System and confirmed by E-test. Selected DNSE and vancomycin-resistant E. faecium (VREfm) clinical isolates were analyzed by next-generation sequencing (NGS) using the Illumina systems to provide multilocus sequencing type (MLST). Daptomycin utilization data were extracted from pharmacy records.ResultsTargeted antibiotic stewardship initiatives consisted of preapproval, daily review for optimization of dose and duration, rapid de-escalation, consideration for appropriate alternative antibiotics for select disease syndromes and stopping of inappropriate daptomycin therapy. Over 4 years, this lead to a 39% reduction in overall use of daptomycin. Besides direct cost saving, this reduced use was associated with significant reduction in daptomycin nonsusceptibility from 12% to 4%, lowering of MIC90 from 8 to 4 μg/mL, and a clonal shift from dominant ST736 to ST117.Daptomycin Usage Days of Therapy /1,000 Days (Monthly Average)Phenotypic ChangesGenotypic ChangesMIC50 (μg/mL)MIC90 (μg/mL)% DNSEDominant Genotype Among VREfm20147424812 ST736 (38%)ST18 (21%)ST412 (12%)ST117 (11%)2015633461020165764472017455444ST736 (5%)ST18 (4%)ST412 (11%)ST117 (41%)ConclusionA targeted antibiotic stewardship initiative to address rising rate of daptomycin nonsusceptibility among E. faecium, resulted in significant phenotypic and genotypic changes among clinical isolates. This study also shows successful integration of NGS in a clinical microbiology lab to validate phenotypic changes of daptomycin nonsusceptibility and to help design future infection control and antibiotic stewardship endeavors.Disclosures A. Dhand, Merck: Speaker’s Bureau, Speaker honorarium. Astellas: Scientific Advisor, Consulting fee.

Assessing Responsiveness of Health Systems to Drug Safety Warnings

In 2011-2012 the U.S. Food and Drug Administration (FDA) issued safety announcements cautioning providers against prescribing high doses of citalopram given concerns for QT prolongation. The authors evaluated Veterans Affairs (VA) national trends in citalopram use and dose compared with alternative antidepressants after the FDA warnings. Time series analyses estimated the effect of the FDA warnings on citalopram and other antidepressant across three periods: before the first FDA warning in August 2011, after the 2011 FDA warning until the second warning in March 2012, and after the 2012 FDA warning. In a National VA health system, adult VA outpatients prescribed citalopram or alternative antidepressants from February 2010 to September 2013 were studied. Outpatient use of high-dose citalopram (>40 or >20 mg daily in adults aged > 60 years) including the proportion of patients prescribed citalopram and difference between study periods. Between the first and second FDA warnings, among patients aged 18-60, high-dose citalopram use decreased by 2.0% per month (p < 0.001) and by 1.9% per month (p < 0.001) for older adults. After the second FDA warning in 2012, 30.7% of older patients remained on doses higher than the newly recommended dose of 20 mg. Reductions in overall use of citalopram were accompanied by significant increases in prescriptions of alternative antidepressants, with sertraline most widely prescribed. Although trends in high-dose citalopram use declined after the 2011-2012 FDA warnings, roughly one-third of older adults still remained on higher than recommended doses. Concomitant increases in sertraline and other antidepressant prescriptions suggest potential substitution of these medications for citalopram.

Abstract P5-15-07: Knowledge of oncotype Dx recurrence score increases confidence and concordance in adjuvant decisions of U.K. oncologists

Abstract Introduction The addition of Oncotype Dx Recurrence Score (RS) to the assessment of patients with ER positive, HER2 negative, node negative breast cancer has led to a reduction in the use of adjuvant chemotherapy. However, crude measurement of this reduction masks a more complex scenario. Prior to the introduction of routine Oncotype DX testing by NHS England, we wished to explore in more detail the potential impact of the knowledge of the RS on the therapeutic discussion. This study analyses the impact of RS on the adjuvant therapy recommendations within a UK Cancer Centre. In particular, it examines how the degree of certainty the oncologist has about the best option changes with knowledge of RS and how this influences concordance of decision making between oncologists. Methods A panel of five breast oncologists reviewed 50 consecutive cases, collected from November 2012 until November 2014, across two hospitals. Oncologists allocated each case to one of four treatment categories: chemotherapy recommended (CRec), chemotherapy discussed with a bias towards recommended (CDis), chemotherapy discussed with a bias toward endocrine therapy alone (EDis) or endocrine therapy only advised (ERec). The cases were analysed blindly and in random order without and with RS . The degree to which knowledge of RS altered treatment recommendation was analyzed. Other outcomes included the proportion of patients who were scored ERec compared with any other outcome, the trend towards definitive recommendations, the impact of RS on concordant decision making and the degree to which outcome was stratified by RS result. Chi squared and Spearman's coefficient statistical tests were used in analysis. Results Knowledge of the RS altered the recommended treatment category in 66.7% of cases (p&amp;lt;0.001). Alterations in treatment recommendations in response to Oncotype Recurrence Score in addition to pathological parameters CRec (n)CDis (n)EDis (n)ERec (n)Without RS2% (1)40% (20)52% (26)6% (3)With RS12% (6)16% (8)26% (13)46% (23) Overall, RS correlated significantly with treatment recommendation. Oncologists were confident to recommend endocrine therapy alone in 46% of patients when RS was known compared with only 6% of patients without RS. Complete concordance between oncologists increased with the knowledge of RS from 14% to 64%. Conclusion Discussion of adjuvant chemotherapy with patients who have ER positive, HER2 negative, node negative breast cancer can be complex and, at times, confusing for the patient, leading to increased distress. This study shows that, in addition to the previously recognised reduction in overall use of chemotherapy, the knowledge of the RS increased the proportion of patients for whom the oncologist felt confident in making a firm treatment recommendation. An added benefit was to increase concordance between different oncologists compared to that achieved when relying on standard pathological features. Citation Format: Kiernan T, Olsson-Brown AC, Innes H, Holcombe C, Thorp N, O'Hagan J, Wong H, Palmieri C, O'Reilly S. Knowledge of oncotype Dx recurrence score increases confidence and concordance in adjuvant decisions of U.K. oncologists. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-15-07.

Trends in the aetiology of urogenital fistula: a case of 'retrogressive evolution'?

It has long been held as conventional wisdom that urogenital fistulae in low-income and middle-income countries are almost exclusively of obstetric aetiology, related to prolonged neglected obstructed labour, whereas those seen in high-income countries are largely iatrogenic in nature. There is, however, a growing perception amongst those working in the field that an increasing proportion of urogenital fistulae in low-income and middle-income countries may be iatrogenic, resulting from caesarean section. Recent studies suggest that adverse patterns of care may also be emerging in high-income countries; an increase in the risk of both vesicovaginal and ureterovaginal fistulae following hysterectomy has been reported, concurrently with the reduction in overall use of the procedure. These apparent secular trends are discussed in the context of evolution of practice, teaching and training in obstetrics and gynaecology.

Trust, reciprocity and collective action to fight antibiotic resistance. An experimental approach

Antibiotic resistance is a collective action dilemma. Individuals may request antibiotics, but an overall reduction in use is necessary to limit resistance. A reoccurring theoretical claim is that social capital increase cooperation in social dilemmas. The aim of this paper is to investigate the link between generalized trust and reciprocity and the willingness to postpone antibiotic treatment in order to limit overuse in a scenario-based study. A between-subject scenario experimental approach with hypothetical scenarios was utilized. Participants were asked to imagine that they were seeing a doctor for a respiratory infection. The doctor prescribes antibiotics, but advise postponing therapy to see if the disease resolves by itself, for the sake of limiting overuse. Respondents were asked to answer how long they could accept postponing antibiotic treatment, from 0 to 7 days. The number of days that most people would be able to accept postponing treatment was considered the between-subject factor. In total, the study sample included 981 respondents with a mean age of 51 years. A majority of respondents were men (65.7%). The mean number of days that the respondents stated they were willing to postpone antibiotic treatment was positively associated with the number of days the respondents were told that most people were willing to postpone antibiotic treatment, p < 0.001. There was a positive association between number of days they were willing to postpone antibiotic treatment and generalized trust, p = 0.001. In conclusion, the results showed that the proclaimed public willingness to postpone therapy influenced a respondent's willingness to postpone antibiotic therapy in different scenarios. Also, generalized trust was positively associated with the willingness to postpone therapy.

Improving appropriateness of acid-suppressive medication use via computerized clinical decision support.

As part of the Choosing Wisely Campaign, the Society of Hospital Medicine identified reducing inappropriate use of acid-suppressive medication for stress ulcer prophylaxis as 1 of 5 key opportunities to improve the value of care for hospitalized patients. We designed a computerized clinical decision support intervention to reduce use of acid-suppressive medication for stress ulcer prophylaxis in hospitalized patients outside of the intensive care unit at an academic medical center. Using quasiexperimental interrupted time series analysis, we found that the decision support intervention resulted in a significant reduction in use of acid-suppressive medication with stress ulcer prophylaxis selected as the only indication, a nonsignificant reduction in overall use, and no change in use on discharge. We found low rates of use of acid-suppressive medication for the purpose of stress ulcer prophylaxis even before the intervention, and continuing preadmission medication was the most commonly selected indication throughout the study. Our results suggest that attention should be focused on both the inpatient and outpatient settings when designing future initiatives to improve the appropriateness of acid-suppressive medication use.

Spore Dispersal byDothistroma septosporumin Northwest British Columbia

We studied spore dispersal by Dothistroma septosporum, causal agent of a serious outbreak of red band needle blight in lodgepole pine plantations in northwest British Columbia. Spore abundance was assessed at different distances and heights from inoculum sources and microclimatic factors were recorded during two consecutive years. Conidia were observed on spore traps from June to September during periods of rainfall. It was rare to detect spores more than 2 m away from inoculum sources. The timing and number of conidia dispersed were strongly tied to the climatic variables, particularly rainfall and leaf wetness. Should the trend toward increased spring and summer precipitation in the study area continue, the results suggest that disease spread and intensification will also increase. Increasing the planting distances between lodgepole pine trees through mixed species plantations and overall reduction in use of lodgepole pine for regeneration in wet areas are the best strategies to reduce the spread of the disease and enhance future productivity of plantations in the study area.

Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: systematic review and meta-analysis of randomised controlled trials

Objective To assess the effects of the neuraminidase inhibitors oseltamivir and zanamivir in treatment of children with seasonal influenza and prevention of transmission to children in households.Design Systematic review and...

Controlling Use of Antimicrobials in a Community Teaching Hospital

To test the hypothesis that antibiotic use could be controlled or improved in a community teaching hospital, with improvement defined as reductions in overall use, overall cost, and antimicrobial resistance. Interventional study with historical comparison. A not-for-profit, 900-bed community general hospital with residents in medicine, surgery, obstetrics-gynecology, and psychiatry. Physicians who requested any of the targeted antibiotics. Three categories of inpatient antibiotic orders were monitored beginning in April 2001: conversion from intravenous to oral administration for selected highly bioavailable antimicrobials, cessation of perioperative prophylaxis within 24 hours for patients undergoing clean and clean-contaminated surgery, and consultation with an infectious diseases physician before continuing administration of selected drugs beyond 48 hours. Data were analyzed after the first 33 months. Patient outcomes were reviewed during the hospital stay and at readmission if it occurred within 30 days after discharge. From April 2001 through December 2003, a total of 1426 requests for antimicrobial therapy met criteria for intervention. Overall physician compliance with the program was 76%, ranging from 57% for perioperative prophylaxis to 92% for intravenous to oral conversion. Antimicrobial costs per patient-day decreased by 31%, from 13.67 US dollars in 2000 (before program implementation) to 9.41 US dollars in 2003. Total savings in acquisition costs were 1,841,203 US dollars for the 3-year period. Resistance to numerous drugs among Klebsiella pneumoniae isolates was also significantly reduced. A program to improve the use of antibiotics in a community hospital was successful in reducing overall use, overall cost, and antimicrobial resistance.

Acupuncture for Substance Abuse Treatment in the Dowtown Eastside of Vancouver

In British Columbia, Canada, the City of Vancouver's notorious Downtown Eastside (DES) represents the poorest urban population in Canada. A prevalence rate of 30% for HIV and 90% for hepatitis C makes this a priority area for public-health interventions aimed at reducing the use of injected drugs. This study examined the utility of acupuncture treatment in reducing substance use in the marginalized, transient population. Acupuncture was offered on a voluntary, drop-in basis 5 days per week at two community agencies. During a 3-month period, the program generated 2,755 client visits. A reduction in overall use of substances (P=.01) was reported by subjects in addition to a decrease in intensity of withdrawal symptoms including "shakes," stomach cramps, hallucinations, "muddle-headedness," insomnia, muscle aches, nausea, sweating, heart palpitations, and feeling suicidal, P<.05. Acupuncture offered in the context of a community-based harm reduction model holds promise as an adjunct therapy for reduction of substance use.

Entering the policy debate: An economic evaluation of groundwater policy in flux

This is an age of transition in groundwater policy. The ownership and control of aquifers, changing groundwater quality, and the impact of groundwater on the environment command the attention of policy makers around the globe. Substantial pressure exists for change in the laws and regulations governing groundwater, which are critical to the management of this critical resource. The objective of this paper is to contribute to the practical policy debate from an economic perspective. This study begins by outlining the basic stages of change in groundwater policy and their economic relevance. A set of physical, economic, and institutional indicators are suggested that may help to understand various country issues. The indicators are used to describe some actual experiences in groundwater policy in the United States and Spain that are examined for insights into common policy questions. This study suggests that the public authority to initiate groundwater policy innovations often results from the physical ties between surface and groundwater. In contexts rich with spatial and temporal externalities the situation is more complex, but this increases the social benefits that result from successful reform. A credible threat of losing rights is often necessary to create enough incentives to firm existing rights. Reductions in overall use are better achieved through purchasing and retiring rights, rather than through compensation for nonuse. Finally, the policy issues important to groundwater are often more fundamental than pricing alone. These insights may help policy makers adapt to emerging groundwater management problems.

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy.

To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients. Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs). We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years. The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.

Introducing a community health center at Mosgiel, New Zealand: effects on use of the hospital accident and emergency (A & E) department.

The effects of introducing a community health center on utilization of the accident and emergency (A & E) department of a New Zealand hospital are examined. Use by the recipient community during the 3 years before the health center existed was compared with use over the succeeding 3 years and with that by a nearby city served by traditional forms of primary care. Results from the study did not support the postulated reduction in overall use by the health center population, nor did they confirm a reduction in use during the hours that the health center was open or by those subgroups thought likely to find the new facility a preferred alternative. Furthermore, there appeared to be no change in the behavior of A & E staff toward using the health center as a potential alternative to follow-up care at the hospital.