Influence of age and hospital volume on the results of carotid endarterectomy: a statewide analysis of 9918 cases

PURPOSE: This study evaluated the impact of patient age and hospital volume on the results of carotid endarterectomy (CEA) in contemporary practice. METHODS: The Maryland Health Services Cost Review Commission (MHSCRC) database was reviewed to identify all patients who underwent elective CEA as the primary procedure in all acute care hospitals in the state over the past 6 years. RESULTS: From January 1990 through December 1995, 9918 elective CEAs were performed in 48 hospitals at a total charge of $68.9 million. Postoperative death and neurologic complications occurred in 90 (0.9%) and 166 (1.7%) cases, including 0.8% and 1.7%, 0.9% and 1.6%, 0.9% and 1.8%, and 1.4% and 1.3% of patients < 65 years, 65 to 69 years, 70 to 79 years, and > or = 80 years old, respectively. The mean length of stay and hospital charges increased linearly with increasing age: 4.2 days/$6550, 4.4 days/$6834, 4.8 days/$7059, and 5.6 days (p < 0.0001 vs others)/$7756 (p < 0.005 vs 70 to 79 years and p < 0.0003 vs < 70 years old), respectively, for patients < 65, 65 to 69, 70 to 79, and > or = 80 years old. The mortality rate was 1.9% in low-volume hospitals, 1.1% in moderate-volume hospitals, and 0.8% in high-volume hospitals. The neurologic complication rate was significantly higher (6.1%; p < 0.0001) in low-volume when compared with moderate-volume (1.3%) and high-volume (1.8%) hospitals. CONCLUSIONS: CEA is a safe procedure in the majority of hospitals in contemporary practice, even among the very elderly, who may experience a longer length of stay and higher charges correlating with their documented greater medical complexity.     

Anger expression and incident hypertension

OBJECTIVE: To determine the incidence and prevalence of multiple sclerosis in the Lothian and Border Health Board Regions of south east Scotland. METHODS: Incidence study: all patients were identified in whom a diagnosis of Poser category probable or definite multiple sclerosis was made by a neurologist between 1992 and 1995. Prevalence study: all patients known to have multiple sclerosis who were alive and resident in the study area on 15 March 1995 were recorded. RESULTS: The crude annual incidence rates of probable or definite multiple sclerosis per 100000 population were the highest ever reported: 12.2 (95% confidence interval (95% CI) 10.8-13.7) in the Lothian Region and 10.1 (95% CI 6.6-13.6) in the Border Region. A total of 1613 patients with multiple sclerosis were resident in the study area, giving standardised prevalence rates per 100000 population of 203 (95% CI 192-214) in the Lothian Region and 219 (95% CI 191-251) in the Border Region. Prevalent cases were more likely than expected to have a Scottish surname (risk ratio 1.24, 95% CI 1.14-1.34). CONCLUSION: Orkney and Shetland were previously thought to have by far the highest prevalence of multiple sclerosis in the world: about double that found in England and Wales. However, the prevalence in south east Scotland is equally high, suggesting that the Scottish population as a whole has a genetic susceptibility to the disease, and undermining the hypothesis that patterns of infection specific to small sparsely populated island communities are important in the causation of multiple sclerosis.     

Effect of the Asymptomatic Carotid Atherosclerosis Study on carotid endarterectomy in Florida

BACKGROUND AND PURPOSE: The value of carotid endarterectomy (CEA) has been defined by several recent multicenter trials. The clinical effect of these trials remains undetermined since the Asymptomatic Carotid Atherosclerosis Study (ACAS) Clinical Advisory (dated September 28, 1994). METHODS: Patients undergoing CEA (ICD-9-CM 38.12) in nonfederal Florida hospitals were identified from the discharge database. Data were analyzed by federal fiscal year (FY, October 1 through September 30), comparing the years following the Advisory (FY95-FY96) to the preceding 3 years (FY92-FY94). RESULTS: There was a 68.3% increase in the number of CEAs during FY95-FY96 (mean FY92-FY94, 7,343; mean FY95-FY96, 12,356). This exceeded increases in total hospital discharges (4.5%), surgical discharges (2.2%), and the state's population (4.7%). The increase in CEAs spanned all patient demographic groups (gender, race, and age), although the magnitude was not consistent (range, 57.8% increase for 55 to 64 age group; 92.9% increase for > 84 age group). Concomitantly, there was a significant decrease in mortality (1.2% versus 0.8%), cardiac complication rate (ICD-9-CM 997.1, 4.1% versus 3.0%) and percentage of patients discharged > 7 days postoperatively (8.9% versus 4.9%). Mean length of stay declined 28% (5.8 versus 4.1 days), and mean adjusted charges declined 7% ($19,456 versus $18,055). Although the average case was less costly, the increased volume resulted in an estimated $56 million increase in annual hospital payments. CONCLUSIONS: The dramatic increase in the number of CEAs performed in the state of Florida after release of the ACAS Clinical Advisory suggests a causal relationship and mandates further cost-effectiveness analyses.     

Survey of changes in the provision of vascular surgical services in the Oxford Region over 5 years

AIM: This study aimed to examine changes in the provision of vascular services in the Oxford region over 5 years. METHODS: A questionnaire was sent to all general surgeons in the region asking of their involvement in vascular surgery. Data were obtained from the Department of Health concerning vascular procedures and inpatient codes for each district in the Oxford Region from 1990-1991 to 1994-1995. Office of Population Censuses and Surveys (OPCS) data for abdominal aortic aneurysm repair and femoral artery reconstruction were validated against data collected prospectively for West Berkshire. RESULTS: Eighteen of 45 surgeons who replied to the questionnaire carried out elective and emergency arterial work. All were members of the Vascular Surgical Society of Great Britain and Ireland (VSS). All but one took part in the general surgical rota. Eight surgeons carried out emergency arterial surgery only; only two of these were members of the VSS. Of 19 surgeons undertaking no arterial surgery, 15 operated on primary and 11 on recurrent varicose veins. The number of arterial reconstructions rose from 20.8 per 100000 population to 28 per 100000 throughout the study. The greatest increase occurred in districts where a new vascular consultant had been appointed. Similar results were obtained with endovascular procedures. The number of major amputations remained fairly constant at approximately 11 per 100000 population. The number of inpatient episodes for arterial disease also rose, from 35.7 to 47.6 per 100000. In validating OPCS codes against prospectively collected data, discrepancies for individual years were noted but the annual trend was reflected fairly accurately by the codes. CONCLUSION: There has been an increase in vascular activity in the region, but variations still exist between different districts.     

In-hospital mortality following carotid endarterectomy

OBJECTIVES: To determine population-based estimates of in-hospital mortality following carotid endarterectomy (CEA) and identify potential risk factors for in-hospital death. METHODS: Data from the Healthcare Cost and Utilization Project (HCUP-3) were analyzed for the year 1993. Nationally representative estimates of risk were calculated by age, sex, race, income, census region, hospital location (urban versus rural), teaching status of hospital, number of hospital beds, hospital ownership, third-party payer, principal procedure, and presence of surgical complications. Multivariate models were developed using stepwise logistic regression and a logit model fit by generalized estimating equations. RESULTS: There were 228 deaths among 18,510 CEAs performed in 17 states of the United States in 1993, yielding an estimated in-hospital mortality rate of 1.2%. Multivariate analysis showed that age, principal procedure, and presence of any surgical complication were significant predictors of in-hospital mortality. Mortality increased with increasing age (from 0.9% in those younger than 65 years to 1.7% in those age 75 and older) and was markedly higher with CEA performed as a secondary procedure (6.1% versus 0.9%) or with any surgical complication (5.9% versus 0.9%). CONCLUSIONS: Increasing age, CEA performed as a secondary procedure, and surgical complications are important predictors of in-hospital mortality following CEA.     

Carotid restenosis: operative and endovascular management

PURPOSE: Surgical management of carotid restenosis (CR) after carotid endarterectomy (CEA) has been associated with a higher perioperative complication rate than that of primary CEA. We recently used carotid angioplasty-stenting (CAS) as an alternative to operative management in patients who had undergone CEA within three years, and we retrospectively compared these results with those of operative management of CR and the overall results of CEA. METHODS: CEA was performed on 1065 adult patients (58% symptomatic, 42% asymptomatic), 62% of whom were men (n = 660) and 38% of whom were women (n = 405), from 1989 to 1997. Before our initiation of a program of CAS, 16 operative procedures (1.9% of CEAs) were performed for CR in 14 adult patients (7 women and 7 men). During the last 20 months, CAS was used in the management of 17 CRs (16 patients; 9 women and 7 men). RESULTS: The 30-day stroke morbidity-death rate for all CEAs (n = 1065) was 1.4%; 11 strokes (1. 0%) occurred (4 major strokes with disability and 7 strokes with minor or no disability), and 4 deaths (0.4%) occurred (2 deaths caused by myocardial infarction, 1 caused by intracranial hemorrhage, and 1 caused by stroke). Operative management of CR (n = 16) included patch angioplasty in 12 cases (autologous vein patches in 10 cases and synthetic patches in 2 cases), whereas interposition grafting was used in 4 cases (saphenous vein in 3 instances and synthetic [polytetrafluoroethylene] in one case). No strokes or deaths were observed. One recurrent laryngeal nerve palsy occurred (6.2%). Among the 16 patients undergoing 17 CAS procedures, the technical procedures were accomplished in all patients. No strokes or deaths occurred. No recurrent restenoses (50% or greater) have been identified within or adjacent to the CAS procedures. CONCLUSION: CR caused by myointimal hyperplasia can be managed by operative techniques or CAS with comparable periprocedural complications. Although long-term follow-up will be required to determine the incidence of recurrent restenosis, CAS may become the preferred procedure in these cases. A randomized clinical trial ultimately will be necessary to determine the role of CAS, as compared with that of operative management.     

Relationship between intraoperative color-flow duplex findings and early restenosis after carotid endarterectomy: a preliminary report

PURPOSE: This study was undertaken to examine the relationship between intraoperative color-flow duplex (CFD) findings and the development of restenosis in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-eight patients (43 male and 35 female; mean age, 65 years) underwent 86 CEAs (eight staged bilateral) and intraoperative CFD during a 31-month period. Three patients (three CEAs, 3%) underwent both CFD and a completion arteriographic scan. Patients were observed in a postoperative protocol using CFD surveillance. The follow-up interval ranged from 6 to 24 months (average, 12 months). RESULTS: After undergoing CEA, 10 patients (10 CEAs, 11%) had an abnormality detected by intraoperative CFD; one was confirmed with a completion arteriographic scan. These abnormalities consisted of elevated peak systolic velocities (PSV) with a mosaic color pattern suggesting turbulence seen in six CEAs, including one internal carotid artery (ICA) with abnormal hemodynamics and an unremarkable completion arteriogram. Intimal defects on B-mode were seen in another four CEAs. These carotid arteries were reexplored, defects (intimal flaps with platelet thrombus) were confirmed by direct examination, and all were repaired with or without a patch (six ICAs, three external carotid arteries, and one common carotid artery). No cerebrovascular events occurred in the perioperative period. No carotid restenosis (> or = 50% diameter reduction) was identified during follow-up of 43 patients (48 CEAs, 56%). Two patients had recurrent neurologic symptoms. CONCLUSION: Intraoperative CFD is an effective test for detecting flow abnormalities or intimal defects in patients undergoing CEA. Ensuring normal intraoperative hemodynamics after CEA may be a major factor associated with decreased incidence of perioperative cerebrovascular events and subsequent carotid artery restenosis.     

Rooming-in and cesarean section in maternity hospitals in the State of Rio de Janeiro, Brazil

OBJECTIVE: To disclose the existence of rooming-in (RI) in public and government contracted private hospitals that offer obstetric beds, in the State of Rio de Janeiro, Brazil, and to examine whether there is any association between RI and another quality care indicator which influences breastfeeding, namely the rate of cesarean section operations performed in these hospitals. METHODS: A survey was made of the existence of RI through a questionnaire sent to the Municipal Health Offices, the information collected being confirmed by telephone with each maternity hospital. The C-section rate data was obtained from the Rio de Janeiro State Health Office and divided into 2 groups: "below 40%" and "40% and above". The prevalence ratio was applied to the measurement of the association between the variables. RESULTS: A rooming-in rate of 65.2% was found for the State as a whole, with regional variations: a better situation in the capital (84.8%), an intermediate one in the interior (69.9%), and a worse one in the metropolitan belt (44.2%). The public maternity hospitals revealed a higher rate (89.7%) than that of the government contracted private hospitals (53.3%). A direct relation between the practice of RI and low C-section rates was found in the hospitals. However, this association did not present the same weight in all regions of the State. The lowest proportion of hospitals adopting RI was verified in the metropolitan belt, whereas the highest relative number of hospitals with high C-section rates was observed in the interior. CONCLUSION: It is concluded that to reverse the observed status, government authorities must fulfil their gerencial role within their own health system, as well as in the government contracted private hospitals.     

Uptake and intracellular activity of moxifloxacin in human neutrophils and tissue-cultured epithelial cells

BACKGROUND AND PURPOSE: In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency. METHODS: Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses >/=70%, uncertain for those with symptomatic stenoses <70% or asymptomatic stenoses >/=60%, and inappropriate for patients with asymptomatic carotid stenoses <60% or preoperative neurological or medical instability. RESULTS: Forty percent of patients were asymptomatic. Compared with our prior audit, the rate of appropriate CEAs improved from 33% previously to 49% of cases in the present study (P=0.0005), uncertain indications did not change significantly (49% versus 47%; P=0.61), and inappropriate indications dropped from 18% to 4% (P=0. 00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found. CONCLUSIONS: In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure.     

Role of kinases and G-proteins on arachidonate release induced by zymosan in mouse peritoneal macrophages

Each of the 15 Health Boards in Scotland maintains a computer file of its residents who are registered with a general practitioner; this is known as the Community Health Index or CHI. The CHI allows a variety of demographic data and indicators of health to be analysed on either a geographic or general practice base, or both simultaneously. The considerable potential of the CHI as a public health tool may be of interest to health authorities outside Scotland which are developing wider uses for their own family practitioner registers.     

Magnetic resonance imaging assessment of cerebral hemodynamics during spreading depression in rats

Cost-benefit and cost-effectiveness analyses (CEAs) are only now beginning to be used by business, government, and policymakers to evaluate various medical treatments. The evolution of why CEAs are being demanded is reviewed. To date, a formal CEA of obesity treatments has not been published. This article outlines how a CEA is performed, reviews data relevant to setting up a formal CEA of medical and surgical obesity treatments, and lists published reports that demonstrate the effectiveness of surgical obesity treatments. The general level of discrimination that society allows the obese to suffer also allows medical insurance companies, businesses, and government to not provide many obese Americans with obesity treatments that have established a level of effectiveness far surpassing many other forms of medical therapy. CEAs of obesity treatments, by themselves, cannot be expected to reverse this discrimination. This type of data, however, provides individual obese patients and their physicians with evidence to challenge policymakers' decisions, especially when cost-effective obesity treatments are excluded or placed at a lower priority than treatments with less proven effectiveness.     

National hospital discharge survey

OBJECTIVES: This report presents national estimates of the use of non-Federal short-stay hospitals in the United States during 1995. Estimates are provided by demographic characteristics of patients discharged, geographic region of hospitals, conditions diagnosed, and surgical and nonsurgical procedures performed. Measurements of hospital use include number and rate of discharges and days of care, and the average length of stay. METHODS: The estimates are based on data collected through the National Hospital Discharge Survey for 1995. In 1995 data were collected for approximately 263,000 discharges. Of the 508 eligible non-Federal short-stay hospitals, 466 (92 percent) responded to the survey. Diagnoses and procedures are presented according to their code numbers listed in the International Classification of Diseases, 9th Revision, Clinical Modification, or ICD-9-CM. RESULTS: In 1995 there were an estimated 30.7 million discharges from non-Federal short-stay hospitals. These patients used a total of 164.6 million days of care and had an average length of stay of 5.4 days. Other data summarized in this report include estimates for diagnoses, procedures, expected source of payment, hospital deaths, and newborn infants.     

Comparison of North American Symptomatic Carotid Endarterectomy Trial and population-based outcomes for carotid endarterectomy

PURPOSE: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) advocated the use of carotid endarterectomy (CEA) for transient ischemic attacks (TIAs), nondisabling strokes, and ipsilateral high-grade stenosis in highly selected patients. Whether similar results are achieved when CEA is applied to an entire geographically defined population is unknown but important if the NASCET recommendations are to be applied broadly to all community patients. METHODS: To determine the survival rate to ipsilateral stroke after CEA for all symptomatic patients in a defined population, we reviewed the medical records of all patients residing in Olmsted County, Minn. (approximately 100,000), who underwent a CEA for TIA or nondisabling stroke between 1970 and 1995. Their outcomes were compared with the NASCET results. RESULTS: In the community of Olmsted County, 297 patients (108 women and 189 men) underwent 322 CEAs during the study period. TIAs or nondisabling stroke was the indication in 254 patients (86%), whereas the remaining 14% had asymptomatic stenosis. After CEA for symptomatic lesions, survival rate free of ipsilateral stroke was 97% at 2 years, 93% at 5 years, and 92% at 10 years. These results are similar to the NASCET survival rates free of ipsilateral stroke at 2 years (91%). However, the 30-day postoperative stroke rate for patients older than 80 years was significantly higher than that for patients younger than 80 years. CONCLUSIONS: When the NASCET results are compared with a population-based experience in which all symptomatic patients undergoing CEA were analyzed, the early outcomes were similar. Our population-based data also document the remarkably durable long-term results of CEA in preventing stroke and present another benchmark for carotid stent angioplasty.     

Significant regional differences in the frequency of vascular surgery

The six health care regions of Sweden were compared with regard to the frequency of vascular surgery for three diagnoses: chronic lower extremity ischaemia, abdominal aorta aneurysm, and carotid stenosis. In 1995, the frequency of intervention for chronic lower extremity ischaemia varied from 26/100,000 of the population in northern Sweden to 68/100,000 in the southern region, the variation being greater for critical limb ischaemia than for intermittent claudication. In the country as a whole, the frequency of abdominal aorta aneurysm surgery increased five-fold from 1987-89 to 1993-95. During 1995, regional figures varied from 4.7 to 8.4 per 100,000 for elective procedures, and from 3.8 to 5.5 per 100,000 for emergency procedures. Overall surgical mortality varied regionally, and emergency surgery mortality differed between regional and county hospitals. Carotid surgery manifested the greatest regional difference in frequency, which was 7-fold greater in the southern than in the northern region, while its overall mean frequency was 6/100,000.     

Increased shelf-life of fosphenytoin: solubilization of a degradant, phenytoin, through complexation with (SBE)7m-beta-CD

BACKGROUND: Rates of in-hospital death after coronary artery bypass grafting (CABG) have been studied in many regions of Canada as possible indicators of hospital-specific quality of care. This nationwide study examined observed and risk-adjusted death rates for 23 Canadian hospitals performing CABG. METHODS: Hospital discharge data were obtained from the Canadian Institute for Health Information and were used to identify all CABG procedures performed in Canadian hospitals in fiscal years 1992/93 through 1995/96. Cases from Quebec hospitals were not studied because hospitals in that province do not report to the institute. Observed death rates were evaluated, and a logistic regression model was used to calculate a risk-adjusted death rate for each hospital for the 4-year period studied. Changes over time in hospital-specific death rates were also examined. RESULTS: A total of 50,357 CABG cases were studied, with an overall death rate of 3.6%. Interhospital comparisons showed that average severity of illness varied considerably across hospitals. Despite risk adjustment accounting for this variable severity, there was considerable variation in adjusted death rates across the 23 hospitals, from 1.95% to 5.76% (p < 0.001 for difference across hospitals). For some hospitals, death rates decreased between 1992/93 and 1995/96, whereas for others the rates were stable or increased. INTERPRETATION: Risk-adjusted rates of in-hospital death after CABG vary widely across Canadian hospitals. There may be differences in quality of care across hospitals, and focused quality-improvement initiatives may be necessary in some institutions.     

Time-dependent changes in CT-based dosimetry of I-125 prostate brachytherapy

OBJECTIVE: To determine if overnight hospital stay after carotid endarterectomy (CEA) is feasible and safe in the Australian setting. DESIGN: Case series with follow-up of 4-11 months (mean, 7 months). PATIENTS AND SETTING: All patients undergoing primary CEA performed by a vascular surgeon (BMB) between 30 May and 11 November 1996. Surgery was performed in one of four hospitals (a district general public hospital with about 400 beds and three private hospitals) in the Gosford area of New South Wales. INTERVENTIONS: CEA using regional anaesthesia and sedation, after diagnosis by duplex ultrasound scan, avoiding cerebral angiography and intensive care; planned discharge after overnight hospital stay; review at one month and duplex ultrasound scan at four months. OUTCOME MEASURES: Length of hospital stay and complications. RESULTS: 65 patients were admitted for CEA during the study period and 59 were scheduled for overnight stay (one had "re-do" surgery, two remained longer for reasons unrelated to carotid artery disease, and three had been scheduled before the change to overnight stay). 54 (92%) were discharged on the first postoperative day, and only three required readmission within 30 days (for urinary retention, angina and reperfusion syndrome). There were no deaths, no myocardial infarctions and no recognised instances of cerebral ischaemia during follow-up. CONCLUSION: CEA can be performed safely without cerebral angiography or intensive care, with over 90% expectation of a single night's stay in hospital.     

Development of early-summer meningoencephalitis (FSME) in the Thurgau region 1990-1995--a new endemic area?

Tick-borne encephalitis (TBE) is a viral infection transmitted by bites of infected ticks. The clinical course is mostly mild, but death occurs in 1-2% of TBE infections and nearly half of patients with meningitis/meningoencephalitis show residual disease, above all chronic headache. TBE-infected ticks occur only in endemic areas. A knowledge of the endemic areas is very important for immunoprophylaxis of TBE. In recent years between 26 and 97 cases of TBE have occurred in Switzerland. The largest endemic areas are in Canton Schaffhausen, the northern part of Canton Zurich and the north-west of Canton Thurgau. Another endemic area is known in the region of Thun in Canton Berne. Another possible endemic area is known in the Zurich Oberland around Elgg, only 7 km from Aadorf in Thurgau. Up to now, Diessenhofen in the north-west of Thurgau was the only known possible endemic area. In 1994 and 1995 we observed an accumulation of TBE infections in western Thurgau. The question was whether there are other endemic areas in Thurgau. In this retrospective analysis we studied the TBE cases in Thurgau between 1990 and 1995 with data derived from the cantonal health authorities reports. Clinical data were taken from case histories of the two cantonal hospitals in Frauenfeld and Münsterlingen, completed by data from family doctors and patients. Between 1990 and 1995 30 TBE infections (1990; 1, 1991: 4, 1992: 3, 1993: 1, 1994: 4 certain, 3 uncertain, 1995: 14) were observed. TBE infections appeared between May and October (maximum in May). 14 patients remembered a bite by a tick several weeks before onset of the illness. 7 bites occurred in the area of Frauenfeld/Aadorf. Only one bite occurred in Diessenhofen. 2 patients were infected in well-known endemic areas in Canton Zurich, a vicinal region in the west of Thurgau. In 1995 the incidence of TBE in Thurgau was 5.4/100000 population. In 9 of the 14 patients recalling a bite by a tick (64.4%), the bites occurred near their domicile. No bite was seen east of a line between Steckborn and Weinfelden. The incidence of TBE in Thurgau in 1995 was clearly higher than the average in Switzerland in recent years (0.46/100000), and higher than in the well-known endemic areas in the vicinity (Schaffhausen 3.95, Zurich 1.31). Based on our data, the region Frauenfeld/Aadorf must be declared a new endemic area for TBE. Probably the well-known endemic area in the Zurich Oberland in the vicinity of Elgg has spread eastward. Persons who are often in the forests of this region should be advised to be vaccinated.     

Recommendations of the Panel on Cost-effectiveness in Health and Medicine

OBJECTIVE: To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations. PARTICIPANTS: The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). EVIDENCE: The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users. CONSENSUS PROCESS: The panel developed recommendations through 2 1/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists. CONCLUSIONS: The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the ?rule of reason,? balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.     

Royal Society of Tropical Medicine and Hygiene Meeting at Manson House, London, 12 December 1996. HIV and pneumococcal infection in Africa. Microbiological aspects

The aim of this study was to ascertain the incidence of Type 1 diabetes mellitus in Navarre, an autonomous community in northern Spain. Subjects were patients who presented with diabetes between 1975 and 1991, age range 0-16 years, resident in Navarre at the onset of symptoms. Endocrinologists in outpatient centres and hospitals (both public and private) in Navarre were the primary source of data, while secondary sources were: independent general practitioners, health centre paediatricians and the Child-Youth Diabetics Parents' Association of Navarre. The degree of ascertainment was 97.8%. Average annual incidence of diabetes detected was 9.54/100000 (95% CI 8.2-11.1) in the 0-14 year-old group. The least incidence was observed in 1976 and highest in 1990. The incidence in males (9.71/100000) was higher than in females (7.83/100000). The highest incidence was observed in the 10-14 year-old group (13.70/100000) when analysed by groups. No seasonal variation in the onset of diabetes was observed. These results suggest a significant increase in the incidence of type 1 diabetes between 1975 and 1991.