bluuebunny/crossref_metadata_2025_split huggingface dataset:
Different Regional Organisational Models and the Quality of Health Care: The Case of Coronary Artery Bypass Graft Surgery
Authors: Nobilio Lucia , Ugolini Cristina 
Published: January 2017

Objectives: The Italian regions of Emilia-Romagna and Lombardy within the Italian National Health Service provide an opportunity to see if two different approaches to the organisation of care – one more hierarchical and planned, the other more competitive and market-like – influence its quality through examining the relationship between the number of coronary artery bypass grafts (CABGs) and the rate of in-hospital mortality using administrative data for the period 1996–1998. Methods: Descriptive statistics and logistic regression models were used. Results: The volume–outcome relation was statistically significant in both regions (odds ratio 0.71, P < 0.0001). Although CABG performance in Emilia-Romagna was slightly poorer than in Lombardy (OR 1.22, P < 0.05), the potential advantage in terms of the reduced risk of death for patients treated at high-volume versus low-volume hospitals was significantly greater. In Emilia-Romagna, the average performance advantage of high-volume units was more substantial in the case of private accredited hospitals than public hospitals (OR = 0.50, P < 0.0001 versus OR = 0.64, P < 0.0001). In Lombardy, the performance advantage of concentrating CABG procedures was greater in private research hospitals (OR = 0.67, P < 0.0001), whereas results were not statistically significant for the other types of hospital, indicating a good level of performance in both public and private hospitals even at low volumes. This also partially explained the lower mortality rate observed in that region. Conclusions: The degree of hierarchical regionalisation versus market-like arrangements characterising the two systems produced contrasting effects in terms of the quality of CABG surgery. Lombardy's more competitive environment appeared to achieve better performance in terms of a slightly lower probability of adverse outcomes, in a system with no formal assessment of population need and very high per capita revascularisation rates. To improve performance in the more hierarchical system adopted in Emilia-Romagna would require considerable effort to increase CABG surgery in low-volume cardiac units, and to sharpen performance incentives.
The ‘Number Needed to Treat’ and the ‘Adjusted NNT’ in Health Care Decision-Making
Authors: Dowie Jack 
Published: January 2017

Within ‘evidence-based medicine and health care’ the ‘number needed to treat’ (NNT) has been promoted as the most clinically useful measure of the effectiveness of interventions as established by research. Is the NNT, in either its simple or adjusted form, ‘easily understood’, ‘intuitively meaningful’, ‘clinically useful’ and likely to bring about the substantial improvements in patient care and public health envisaged by those who recommend its use? The key evidence against the NNT is the consistent format effect revealed in studies that present respondents with mathematically-equivalent statements regarding trial results. Problems of understanding aside, trying to overcome the limitations of the simple (major adverse event) NNT by adding an equivalent measure for harm (‘number needed to harm’ NNH) means the NNT loses its key claim to be a single yardstick. Integration of the NNT and NNH, and attempts to take into account the wider consequences of treatment options, can be attempted by either a ‘clinical judgement’ or an analytical route. The former means abandoning the explicit and rigorous transparency urged in evidence-based medicine. The attempt to produce an ‘adjusted’ NNT by an analytical approach has succeeded, but the procedure involves carrying out a prior decision analysis. The calculation of an adjusted NNT from that analysis is a redundant extra step, the only action necessary being comparison of the results for each option and determination of the optimal one. The adjusted NNT has no role in clinical decision-making, defined as requiring patient utilities, because the latter are measurable only on an interval scale and cannot be transformed into a ratio measure (which the adjusted NNT is implied to be). In any case, the NNT always represents the intrusion of population-based reasoning into clinical decision-making.
Establishing Patient Preferences for Blood Transfusion Support: An Application of Conjoint Analysis
Authors: van der Pol Marjon , Cairns John 
Published: January 2017

Objective: To develop a method of determining the relative importance of waiting time and location of care for patients with haematological disorders requiring red cell transfusion. Such information is particularly relevant when evaluating interventions that affect patient well-being (e.g. by changing waiting time and location) but do not affect health outcomes. Methods: Conjoint analysis is used to assess the relative importance of waiting time and location with respect to pre-transfusion testing and red cell transfusion. Compensation is also included as an attribute in order to estimate the monetary value of changes in waiting time and location. Results: Waiting time and location are important attributes in the provision of pre-transfusion testing and red cell transfusion. Compensation is not an important attribute. On average patients are willing to wait an additional 45 minutes in order to have pre-transfusion testing in their own home and an additional 35 minutes in order to receive red cell transfusions in their preferred location. Conclusion: The relative importance of waiting time and location of care was established. However, it was not possible to assign monetary values since compensation was not an important attribute for these respondents. The paper highlights the scope for using conjoint analysis to analyse the non-health benefits that may result from changes in the delivery of care.
Health Policy in Transition: Terminal Care and Site of Death in Japan
Authors: Babazono Akira , Weiner Janet , Hamada Hirohisa , Tsuda Toshihide , Mina Yoshio , Hillman Alan L. 
Published: January 2017

Objectives: In Japan, hospitals have replaced homes as the predominant site of death, especially for the elderly. Site of death is a reliable indicator of where older people receive care before they die. We conducted a population-based study to identify the factors that determine site of death in a typical rural area in Japan. Methods: Study subjects were residents of Kawakami town, aged 70 years or older, who died during 1981 and 1990. Death certificates provided information on age, gender, cause of death, duration of illness before death, family members, family occupation, and site of death. Results: Among 455 subjects, 52.7% died at home, while 47.3% died in hospital. Multiple logistic regression analyses indicated that subjects with cancer were 6.1 times more likely to die in hospitals than those with other diseases. Subjects who died in their seventies were 2.3 times more likely to die in hospital than older subjects. Members of non-farming families were 1.7 times more likely to die in hospital than members of farming families. Gender, duration of illness, and the presence of spouse or children in the household were not significantly related to site of death according to multivariate analyses, although trends did exist. Conclusion: This case study illustrates the importance of developing geriatric care systems in Japan, utilizing alternatives to hospitals, such as nursing homes and formal home care. This is particularly true for patients with cancer. As the older population rapidly increases in Japan, the need for alternatives in geriatric care grows more critical.
The SF-36 Physical and Mental Health Summary Measures: An Example of How to Interpret Scores
Authors: Jenkinson Crispin 
Published: January 2017

Objectives: To provide normative data, in the form of percentile scores from a community sample, for the Physical Component and Mental Health Component Summary scores derived from the SF-36, and to provide an example of how to interpret scores on these measures, comparing normative results with data from a clinical sample. Method: Normative data were gained from a postal survey using a questionnaire, containing the SF-36 and a number of other items concerned with lifestyles and illness. The questionnaire was sent to 13 042 randomly selected subjects between the ages of 18 and 64 years, drawn from Family Health Services Authority computerised registers for four English counties. The clinical sample comprised 84 patients aged 18–64 years diagnosed with obstructive sleep apnoea (OSA) who were asked to take part in the study. The Physical Component Summary (PCS) score and Mental Health Component Summary (MCS) score gained from the SF-36 health status measure were the outcome measures. Results: The community survey achieved a response rate of 72% (n = 9332). All 84 patients in the age range 18–64 years approached to take part in the OSA study agreed to do so; complete data were available for 60 patients. Results indicated that, prior to treatment, 75% of OSA patients' scores on the PCS/MCS were less than the standardised mean score of 50 and fell in the lowest 34% of scores in the general population. However, after treatment, over 50% of patients scored above the standardised mean score on both the PCS and MCS and more closely mirrored the distribution of the normative sample. Conclusion: The data provided here should enable a more meaningful presentation of data than is generally provided in research papers presenting SF-36 summary scores.
Advice Provided in British Community Pharmacies: What People Want and What They Get
Authors: Hassell Karen , Noyce Peter , Rogers Anne , Harris Jennifer , Wilkinson Jane 
Published: January 2017

Objectives: This study explored advice-giving behaviour in community pharmacies in order to understand the nature and process of pharmaceutical consultations and consumers' views of the advice-giving role. Method: An ethnographic research strategy was used, combining patient interviews with non-participant observation of interactions between consumers and pharmacy staff. One week was spent in each of 10 pharmacies. Results: The study demonstrated that the advice given in a community pharmacy is almost wholly focused on product recommendation and use. Advice-giving varies according to whether consultations concern prescription or non-prescription medicines. When the latter are involved, advice-giving is mostly consumer-led. Consumers' major ‘need’ for pharmacy services appears to be for information about the effectiveness of products they buy, whilst pharmacists and pharmacy assistants concentrate on providing advice on the safety of medicines. Conclusion: The notion of pharmacists as general health advisors does not appear to be shared by the public and may be at odds with how the public view and use pharmacies. Protocols to guide staff may be improved by including the consumer perspective. Most consumers have previous experience of their ailments and use pharmacies as one of several resources available to them to treat their minor illness, having made their own diagnosis and assessment before entering the pharmacy. The scope for giving new advice is therefore limited. The broader role of community pharmacies merits further attention.
What Determines Geographical Variation in Rates of Acceptance onto Renal Replacement Therapy in England?
Authors: Roderick Paul , Clements Steve , Stone Nicole , Martin David , Diamond Ian 
Published: January 2017

Objective: To determine the independent effects of need and supply factors on the known geographical variation in acceptance rates onto renal replacement therapy (RRT) in England. Methods: Data were obtained from all renal units in England on the characteristics of all cases aged 16 years and over, resident in England, who were accepted onto RRT in 1991 and 1992. Of these, 5715 (94.5%) had a valid postcode that could be matched to a census ward. Multilevel modelling using Poisson regression was used. The number of acceptances in each census ward within age bands 16–34, 35–64 and 65+ was the dependent variable. Independent effects modelled were: (1) individual factors (age, sex); (2) census ward need factors — ethnicity (expressed as the percentage of the ward population that was Asian or African-Caribbean), socio-economic deprivation — and supply factors — ‘access’ to the nearest renal unit using crowfly and road travel time and distance, and services available to each ward expressed as number of haemodialysis stations per 100 000 catchment population of the nearest renal unit; (3) district health authority level effects. Results: Age was a major determinant of acceptance, with a 7-fold higher rate in males aged over 64 years compared with younger men. Acceptance rates were lower in females, with a negative age-sex interaction in females aged over 64 years. The percentage of both Asian and African-Caribbean populations per ward was a highly significant positive determinant. Deprivation was also a significant determinant, best represented by a customised index. There was an inverse relation of acceptance with distance, especially road travel time. Other supply side variables had a significant effect though there was no independent district effect. There was some variation in the strength of these relationships by type of area (Greater London, urban and non-urban). Conclusions: Need and supply factors influence service use as expressed as acceptance onto RRT. Pressure to expand RRT services needs to be aimed at areas with large minority ethnic populations and those living far from existing units.
Geographic Variations in Hospital Discharge Rates and Discretionary Hospital Use
Authors: Porell Frank 
Published: January 2017

Objectives: While past research has shown that there is greater geographic variability in hospital discharge rates for medical conditions where there is less agreement about proper treatment, there is little empirical evidence to support the corollary that high hospital use in a community is primarily the result of a greater volume of such discretionary hospitalizations. This study assesses the contribution of discretionary hospitalizations to higher overall rates of hospital use in communities. Methods: Hospital discharge files and Medicare eligibility files were used to estimate adjusted rates of hospital discharge, days of care and adjusted mortality for a sample of 761 geographic communities in four states in the USA. Diagnostic information was used to classify hospitalizations into low, moderate and high discretion categories. Correlation and multiple regression analysis methods were used to test for systematic relationships between a community's overall rate of hospital use and discretion-level mix of hospitalizations. Results: Although about half of the variance in overall rates of hospital use among communities was found to be related to the discretion-level mix of hospital discharges, only a small portion of the explained variance could be attributed specifically to community differences in the prevalence of high discretion hospitalizations. Conclusions: High overall rates of hospital use in communities were not found to be largely the result of high discretion hospital use.
Corporation tax as a problem of MNC organisational circuits: The case for unitary taxation
Authors: Morgan Jamie 
Published: January 2017

Research Highlights and Abstract Contextualises and clarifies the case for unitary taxation In so doing sets out the structural and institutional constraints of the current system of taxation for multinational corporations (separate entity status and the arms length principle) Explores the limits and potentials of current policy initiatives that are shaping the ongoing response to issues of taxation for multinational corporations (from the Organisation for Economic Co-operation and Development (OECD), within the UK and the EC) The tax practices of multinational corporations have become a matter of significant public and political concern. The underlying issues are rooted in the capacity of multinational corporations (MNCs) to construct organisational circuits that shift where sales, revenue and profit are reported. This capacity in turn becomes a focus because of the way MNCs are treated as a series of separate entities, subject to the arm’s length principle. This has become a classic example of a system whose current form and consequences were not foreseen when the original principles were set out. The continued existence of that system owes more to specific interests and inertia than it does to the absence of a viable alternative. Unitary taxation based on formula apportionment clearly resolves the underlying issues and unitary taxation may well ultimately emerge as a new generalised basis for corporate taxation. However, for it to do so, the problems of the current system and the advantages of the alternative need to be more clearly understood within academia, business and on a societal basis. This paper is a contribution to such an understanding.
Laparoscopic Floppy Nissen Fundoplication for Gastro-Oesophageal Reflux Disease is Feasible as a Day-Case Procedure
Authors: Victorzon M. , Tolonen P. , Vuorialho T. 
Published: January 2017

Background/Aims: We launched aprospective study to assess the feasibility of day-case laparoscopic fundoplication for gastro-oesophageal reflux disease in March 2003. The specific aims were to assess safety, acceptability and patient satisfaction. Methods: The inclusion criteria were American Society of Anaesthesiologists grade I-II surgical risk, body mass index < 35, and adult company at home (less than 50 km travel) or at patient hotel (more than 50 km travel). Patients were informed about the surgical procedure, the expected postoperative course, and the possible postoperative problems and complications. Surgery was performed under general anaesthesia with proposal-infusion, fentanyl, rocuronium and sevoflurane with air + oxygen. All patients received parenteral propacetamol, NSAID, local anaesthetics and metoclopramide, as pre-emptive analgesia before awakening. A total 360° floppy Nissen fundoplication was performed in all patients. Results: Twenty-eight patients were included. There was one conversion to open surgery. All the other patients were discharged as planned and there were no readmissions. No intra- or postoperative complications occurred. Postoperative pain, nausea, fatigue and dysphagia were moderate. At interview the morning following the operation three patients reported they would rather have stayed over night at the hospital. However, all patients were ready for a similar procedure as day-case surgery again, if offered. At follow-up 26/28 (< 92.9%) patients were satisfied with the day-case treatment, one patient had no preference. All patients would recommend this operation as day-case surgery for a family member or friend. Conclusion: Laparoscopic day-case surgery for gastro-oesophageal reflux disease appears to be safe and well tolerated by the patients.
A Comparison of the Haemodynamic Effects of 4% Succinylated Gelatin, 6% Hydroxyethyl Starch (200/0.5) and 4% Human Albumin after Cardiac Surgery
Authors: Kuitunen A. , Suojaranta-Ylinen R. , Kukkonen S. , Niemi T. 
Published: January 2017

Background and Aims: The goal for volume replacement therapy is to maintain stable haemodynamics after cardiac surgery. We hypothesized that a short term infusion of hydroxyethyl starch results in better haemodynamic response than an infusion of lower molecular weight gelatin. Material and Methods: 45 patients received a predetermined fixed dose of 15 ml kg−1 of either 4% succinylated gelatin (GEL) or 6% hydroxyethyl starch (HES) or 4% human albumin (HA) after cardiac surgery. Results and Conclusions: Pulmonary capillary wedge pressure was more increased in GEL and HES groups [mean (SD) 153% (54) and 168% (57) of pre-infusion value] than in HA group [122% (23)] (P = 0.031) after completion of infusion, but no differences in cardiac index (CI) and stroke volume index (SVI) were observed. At 2 and 18 hours after end of study infusions SVI was more increased in HES [143% (38) and 148% (41) of pre-infusion values] and HA [143% (35) and 163% (42) of pre-infusion values] groups than in GEL [116% (23) and 125% (30)] group (P = 0.047 at 2 hours and P = 0.033 at 18 hours). In early postoperative phase after cardiac surgery, HES and HA infusions improve haemodynamics more and longer period than GEL infusion.
An Open Access Technique to Create Pneumoperitoneum in Laparoscopic Surgery
Authors: Moberg A.-C. , Petersson U. , Montgomery A. 
Published: January 2017

Background: An open access technique might reduce severe vascular and visceral injuries. An open access technique through the umbilical cicatrix tube has been developed as a routine method with the goal to be easy, safe and used by all surgeons in patients without a previous midline incision. Aim: To evaluate the open technique in a prospective study in 100 consecutive laparoscopic operations regarding time for entrance, surgeons experience and BMI of the patients. Methods: A midline incision from the linea alba up into the inverted umbilicus was performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow into the abdominal cavity followed by a blunt trocar insertion. Results: Time for access was median 93 seconds. Entrance time in patients with BMI > 30 (n = 18) was 100 sec and with BMI < 30 it was 90 sec (p = 0,71). The median time for consultants was 88 sec and for residents 120 sec (p = 0,003). No gas leakage was seen. Prolonged time for access was seen in three patients; two equipment failures and one obese patent. Conclusion: The open access technique is applicable in all patients without a former midline incision. It is fast, easy to learn with very few associated problems.
Anterior Mid-Tibial Stress Fractures. Results of Surgical Treatment
Authors: Liimatainen E. , Sarimo J. , Hulkko A. , Ranne J. , Heikkilä J. , Orava S. 
Published: January 2017

Background and Aims: An anterior mid-tibial stress fracture is an uncommon, but possibly career threatening condition for an athlete. We wanted to evaluate the results of the surgical treatment of this notorious stress fracture and compare two different surgical methods. Material and Methods: Forty-nine anterior mid-tibial stress fractures were treated surgically in 45 patients during the years 1985–2005. All the patients were athletes, mainly runners. The mean age of the patients was 26 years. Thirty-four of the fractures occurred in men and 15 in women. The first method of treatment (anteromedial and lateral drilling) was used in 20 operations and the second method (laminofixation) in 29 operations. Results: Good results were achieved with drilling in only 50% of the operations, where as with laminofixation good results were achieved in 93% of operations. This difference was statistically significant (p = .002). Healing of the stress fracture after laminofixation occurred in less than 6 months. The length of the plate used in the laminofixation had no effect on the end result. Conclusions: An anterior mid-tibial stress fracture may often lead to delayed union or non-union in vigorously training athletes. Surgical treatment with laminofixation proved to be superior to tibial fracture site drilling.