Economic evaluation of cancer treatments: methodological and practical issues

Economic evaluation is a comparative analysis of alternatives in terms of both their costs and consequences. Therefore, the basic task of economic evaluation is to identify, measure, value and compare the costs and effects of the alternatives being considered. In this paper, the methodology of economic evaluation in general and in cancer in particular is reviewed and practical issues are illuminated. In the treatment of cancer patients not only survival and disease-free survival are important outcome parameters, but also quality of years alive. Hence, specific attention is given to the measurement and valuation of quality of life. Economic evaluation is intended to support health policy at different levels of decision making. In cancer treatment, health policy concerns both preventive, curative and palliative strategies, and decisions are often made at the micro and macro level. Economic evaluation can provide essential information on the costs and benefits of each option, and consequently on the optimal policy mix, and thus support decisions on the adoption and utilization of new treatments. Such information may assist policy makers in formulating regulatory policies and legislation, industry in developing products, health professionals in treating and serving patients, and consumers in making personal health decisions.     

Economic evaluation of 2 treatments for pediatric femoral shaft fractures

The purpose of this study was to assess the relative health system costs of early hip spica cast immobilization and external fixation for pediatric femoral shaft fractures. A cost analysis was performed from the viewpoint of the study hospital and physicians using protocols based on current practice. Cost estimates were based on patient and financial information from April 1, 1993, to January 31, 1994, including the fully allocated inpatient and outpatient costs. A sensitivity analysis was conducted to analyze the effect of complications on costs. Total estimated costs (in 1994 Canadian dollars, $1.00 = $0.75 US) of uncomplicated external fixation and hip spica treatments were $7626.30 and $5970.11, respectively. Fifty percent of this difference was attributable to longer inpatient stays for the external fixation treatment. The remaining difference was because of the cost of the fixator, additional operating room staff time costs, and additional professional and technical fees. Total expected costs of treatment complicated by loss of reduction, pin tract infection, and return to the operating room were $7716.01 and $6128.44 for the external fixation and hip spica treatment options, respectively. For the range of complication probabilities considered, expected total costs were always greater with the external fixation option than with the hip spica treatment.     

Conceptualizing and defining psychosomatic disorders.

The concept of psychosomatic illnesses as physical problems resulting from emotional stress is questioned as one that may have outlived its usefulness. A broader definition involving all behavioral concomitants of illness is suggested. The new conception encompasses (a) organic problems created by difficulties in learning and development rather than affect, (b) organic problems created by deviation in personality and character rather than affect, (c) psychological disturbance created indirectly by physical illness, and (d) psychological disturbance created directly by physical illness. Several illustrations of the newly defined types of psychosomatic disorders are given. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pelvic and perineal sequelae of delivery

Vaginal delivery especially with dystocia, may result in relaxation or disruption of fascial and ligamentous supports of pelvic organs. The relationship between first childbirth and obstetric trauma is strong but additional pregnancies and deliveries are aggravating factors as well as ageing and hormonal effects of the menopause. These anatomic changes are contributing to the development of stress urinary incontinence, anal incontinence and genital prolapse. Preventing obstetric trauma needs changes in current obstetric practice: reduction in the episiotomy rate, use of vacuum extractor in preference to forceps. General practitioners can help at the time of postnatal control by making a full clinical evaluation of pelvic floor damage, referring women for further investigation and asking them about postnatal sexual difficulties. Postpartum perineal physiotherapy is indicated for women at risk: pelvic floor congenital weakness instrumental delivery, postpartum urinary and/or anal incontinence.     

Cardiovascular sequelae and risks of obesity

Obesity is a well documented separate risk factor for metabolic and vascular diseases which may reduce life expectancy for overweight people. This is expected to create soon a major health economic problem in more or less all western countries because the numbers of morbidly obese people increase steadily. It is a type of visceral android fat deposition which bears a high risk to develop vascular remodelling processes causing coronary and cerebral artery disease with all its consequences. The various biochemical processes which may contribute to cause these vascular lesions in obesity are discussed by the author and the various resulting clinical findings are described. Further the chance is emphasized to reduce by weight reduction the risks of obesity since regression of vascular changes may result by an even moderate loss of weight.     

Pre-eclampsia and its psychosocial sequelae

In the present work some psychosomatic conditions in the setting of preeclampsia are described. The important psychosocial consequences for women suffering from this disease and the drawback for their partners will be elucidated. Preeclampsia as a disease including hypertension, proteinuria and generalized edema is often associted with generalized seizures occuring most commonly at the end of the second trimenon of pregnancy. The disease bears a heavy risk for the mothers as well as for her unborn child. Until now the exact pathophysiological basis of the disease has not been entirely elucidated. For the pregnant woman and her psychosocial surrounding the outbreak of the disease is in most cases unexpected. During development of the disease she has to face a role change from a so far normal pregnancy to a high-risk situation. This may change also the attitude to the unborn child by herself and her partner. The preterm delivery induced therapeutically, together with the succeeding problems for the newborn complete the high psychosocial stress related to the entire situation. Therefore it is useful and important to offer psychosocial support to the mother as well as to her parter during the illness and the time after delivery.     

Aesthetic sequelae of septoplasty

BACKGROUND: Low bone mineral content (BMC) has been reported in patients with inflammatory bowel disease. The aim of the present study was to measure BMC in patients with Crohn's disease. METHODS: BMC was monitored for a mean period of 5.5 years in 108 patients. The patients were divided into two groups: group A, patients with the colon preserved; group B, patients with a resected colon. The mean length of the resected small intestine was 90 cm. RESULTS: The BMC of the lumbar spine expressed as Z-score ((actual value-mean)/s) was significantly reduced: mean Z-score for group A, -0.51, P < 0.05; group B, -0.80, P < 0.001. The BMC of the femoral neck was significantly reduced: mean Z-score for group A, -1.24, P < 0.001; group B, -1.23, P < 0.001. A Z-score below -2.0 of spine or femoral neck BMC was found in 10% and 23% of the patients, respectively. The BMC of the femoral neck decreased significantly in both groups during the study period (group A, -2.2%, P < 0.001; group B, -1.21%, P < 0.05). The BMC of the lumbar spine did not change. There was an inverse correlation between the initial Z-score and the rate of change in BMC (P < 0.05). We found no correlation between Z-score or change in BMC and period of prednisolone treatment. Moreover, there was no correlation between the length of the resected small intestine and BMC or annual percentage change in BMC. CONCLUSION: At inclusion the BMC of the spine and femoral neck was low in patients with Crohn's disease. During the study significant bone loss was only demonstrated in the femoral neck. BMC or rate of change in BMC was not related to treatment with steroids or length of the resected small intestine.     

Quality assurance in inpatient psychosomatic treatment and rehabilitation

In addition to the requirements of quality management imposed by legislative and in consideration of research projects on the evaluation of psychotherapy the German pension funds introduced a systematic program for quality control in 1994. By the end of this year all the German rehabilitation centers will regularly have to provide information concerning the structure and concepts of the hospital and details of the rehabilitation programs. All therapeutic interventions are listed for every patient. In a subsample of patients detailed information regarding diagnosis and outcome (goal attainment) is required in addition to the final report. A subsample of the final reports is peer-reviewed. Patient's satisfaction and estimation of outcome variables are regularly assessed 3 months after discharge. Within and between institutions quality circles meet regularly. Advantages and limits of these programs are discussed and additional approaches towards total quality management in Bad Kreuznach are described.     

Planning and implementation of research projects in psychosomatic medicine

Based on experiences of the author in planning and realization of scientific studies the different phases and steps of research process are discussed. Especially in the phases of reflecting and planning of a study, a lot of essential preliminary tasks are quite often missed. Failures in these initial phases of a scientific study lead to difficulties in collecting and evaluating of data. Important steps in the different phases of a project are reported in an overview. Finally some typical failures and faults in psychosomatic research made by physicians and social scientists are mentioned.     

A report card for occupational injuries and illnesses

We present a case of cutaneous nerve hypertrophy possibly secondary to scratching or other trauma. The patient was symptomatic and sought surgical treatment, despite no clinical lesion being evident. This type of change has not been previously reported in this clinical setting. There was no clinical evidence of multiple endocrine neoplasia-type 2b (MEN-2b). Awareness of this entity may avoid unnecessary surgery.     

Management of failed and infected axillofemoral grafts

PURPOSE: The purpose of this study was to review the treatment of patients with failed or infected axillofemoral bypass grafts and to determine the efficacy of remedial procedures in maintaining graft patency and limb preservation. METHODS: Thirty-four patients with 37 failed or infected axillofemoral grafts were retrospectively reviewed. In nine cases there was no attempt at revascularization, and in the remaining 28 cases, a total of 52 remedial procedures was performed. Nine were performed in patients with graft infection and 43 in patients with graft thrombosis. In patients with axillofemoral graft failure, 21 thrombectomies, 13 graft revisions, and 9 secondary reconstructions were performed. Eighty-eight percent of patients were monitored at least 2 years or until graft failure. RESULTS: Eight of nine patients receiving no remedial procedure required major amputation. The limb salvage rate was 64% +/- 11% at 30 months in the 25 patients undergoing remedial procedures. Twenty-eight percent of failed axillofemoral grafts remained patent at 2 years after initial failure with single or multiple thrombectomies or revisions. Life-table primary patency after secondary reconstructions (81% +/- 10.9% at 24 months) was significantly better than after thrombectomy alone (10% +/- 4.2% at 24 months) or graft revision (16% +/- 10.6% at 24 months) by log-rank test (p < 0.001 and p < 0.005, respectively). Patients undergoing reconstruction with descending thoracic aorta to femoral artery bypass had an 89% +/- 11% patency rate at 24 months. Graft infection resulted in a perioperative mortality rate of 22% and amputation in 57% of survivors. CONCLUSION: Axillofemoral graft failure most often results in limb loss without remedial procedures. Thrombectomy and revision procedures had poor long-term patency rates and salvaged only a minority of grafts despite multiple procedures. Reconstruction by use of an alternate source of inflow such as the descending thoracic aorta resulted in better long-term patency rates in patients well enough to tolerate a major reoperative procedure.     

The contribution of epidemiology to psychosomatic medicine

The G1 glycoprotein of California encephalitis (CE) virus plays a critical role in the infection of mosquito and mammalian cells. We found that CE virus enters baby hamster kidney (BHK-21) and Aedes albopictus (C6/36) cells by the endocytic pathway. Ammonium chloride, a lysosomotropic amine that prevents release of virus from endosomes, inhibited infection of both cell types when added within 10 min after viral adsorption. In addition, infected cells formed polykaryons when the extracellular pH was lowered to 6.3; optimal fusion occurred at pH 5.8 and 6.0 (C6/36 and BHK-21 cells, respectively). Two neutralizing G1 MAba, 6D5.5 and 7D4.5, inhibited low pH-induced syncytia formation without affecting viral attachment, suggesting a role for G1 in viral entry. Since viral fusion proteins have been demonstrated to undergo conformational changes at low pH, acid-induced changes in G1 and G2 were assessed. While both G1 and G2 demonstrated low pH-induced alterations in detergent binding, only G1 displayed an altered protease cleavage pattern at the fusion pH. These results indicate that the G1 protein of CE virus undergoes conformational changes necessary for low pH-mediated entry into both mosquito and mammalian cells.     

Common sense representations of common illnesses.

Data from 320 undergraduates provide evidence that common sense representations of common illnesses involve 5 components: (1) a label, (2) consequences, (3) a time line, (4) a cause, and (5) a cure. The content of schemas for a person's most recent illness is shown to have small but significant effects on changes in health locus of control beliefs but not on preventive health behaviors. It is suggested that if people consistently employ the same schemas for every disease they experience, then cumulatively schematic processing could have large effects on health beliefs and health behaviors. It is also suggested that if the same illness schemas are employed when major diseases are encountered, then schemas based on the experience of minor illnesses could have dramatic and more immediate effects on morbidity and mortality. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emotional sequelae of stroke.

This study is the first to use reporting sources close to the S to examine mood and personality changes in patients with left- (LH) and right-hemisphere (RH) stroke lesions. Ss (29 with RH lesions, 27 with LH lesions, and 14 with bilateral lesions) together with their significant others, were assessed approximately 2 wks poststroke. Depression was one of the major types of emotional change regardless of lesion site. Other emotional concomitants included increased indifference, inappropriate behavior, and pragnosia (defective social communication style). A significant 3-way interaction indicated that, during the acute stroke phase, the syndrome of depression and other mood and personality changes in LH patients significantly differentiated them from their RH counterparts. Specific patterns of changes from premorbid to poststroke status are discussed in terms of their theoretical, clinical, and research implications. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term behavioral sequelae of prematurity

Between the end of 1989 and June 1992, 380,152 Russian Jews left the former Soviet Union for Israel, swelling Israel's Jewish population by nearly 10%. Absorbing great waves of immigrants was not new to Israel. Since its establishment in 1948 and the enactment of its Law of Return, large population groups from dozens of different ethnic and cultural backgrounds had immigrated into the country. In 1992 Israel's Jewish population totaled 4,242,500. Of that number, 360,949 had been born in Asian countries, 458,009 in Africa, 1,252,131 in Europe, and 184,317 in America and Oceana.