Routine Measurement of Health-Related Quality of Life in Assessing Cost-Effectiveness in Secondary Health Care

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.

Quality Assessment of a Forest Inventory Based on Airborne Laser Scanning

In this study, a quality assessment method based on sampling of primary laser inventory units (microsegments) was analysed. The accuracy of a laser inventory carried out in Kuhmo was analysed as a case study. Field sample plots were measured on the sampled microsegments in the Kuhmo inventory area. Two main questions were considered. Did the ALS based inventory meet the accuracy requirements set for the provider and how should a reliable, cost-efficient and independent quality assessment be undertaken. The agreement between control measurement and ALS based inventory was analysed in four ways: 1) The root mean squared errors (RMSEs) and bias were calculated. 2) Scatter plots with 95% confidence intervals were plotted and the placing of identity lines was checked. 3) Bland-Altman plots were drawn so that the mean difference of attributes between the control method and ALS-method was calculated and plotted against average value of attributes. 4) The tolerance limits were defined and combined with Bland-Altman plots. The RMSE values were compared to a reference study from which the accuracy requirements had been set to the service provider. The accuracy requirements in Kuhmo were achieved, however comparison of RMSE values proved to be difficult. Field control measurements are costly and time-consuming, but they are considered to be robust. However, control measurements might include errors, which are difficult to take into account. Using the Bland-Altman plots none of the compared methods are considered to be completely exact, so this offers a fair way to interpret results of assessment. The tolerance limits to be set on order combined with Bland-Altman plots were suggested to be taken in practise. In addition, bias should be calculated for total area. Some other approaches for quality control were briefly examined. No method was found to fulfil all the required demands of statistical reliability, cost-efficiency, time efficiency, simplicity and speed of implementation. Some benefits and shortcomings of the studied methods were discussed.

Offloading content routing cost from routers

The publish/subscribe paradigm has lately received much attention. In publish/subscribe systems, a specialized event-based middleware delivers notifications of events created by producers (publishers) to consumers (subscribers) interested in that particular event. It is considered a good approach for implementing Internet-wide distributed systems as it provides full decoupling of the communicating parties in time, space and synchronization. One flavor of the paradigm is content-based publish/subscribe which allows the subscribers to express their interests very accurately. In order to implement a content-based publish/subscribe middleware in way suitable for Internet scale, its underlying architecture must be organized as a peer-to-peer network of content-based routers that take care of forwarding the event notifications to all interested subscribers. A communication infrastructure that provides such service is called a content-based network. A content-based network is an application-level overlay network. Unfortunately, the expressiveness of the content-based interaction scheme comes with a price - compiling and maintaining the content-based forwarding and routing tables is very expensive when the amount of nodes in the network is large. The routing tables are usually partially-ordered set (poset) -based data structures. In this work, we present an algorithm that aims to improve scalability in content-based networks by reducing the workload of content-based routers by offloading some of their content routing cost to clients. We also provide experimental results of the performance of the algorithm. Additionally, we give an introduction to the publish/subscribe paradigm and content-based networking and discuss alternative ways of improving scalability in content-based networks. ACM Computing Classification System (CCS): C.2.4 [Computer-Communication Networks]: Distributed Systems - Distributed applications

Barrett's Esophagus and Associated Adenocarcinoma : studies on pathogenesis, clinical staging and cost-utility of cancer treatment

Esophageal and gastroesophageal junction (GEJ) adenocarcinoma is rapidly increasing disease with a pathophysiology connected to oxidative stress. Exact pre-treatment clinical staging is essential for optimal care of this lethal malignancy. The cost-effectiviness of treatment is increasingly important. We measured oxidative metabolism in the distal and proximal esophagus by myeloperoxidase activity (MPA), glutathione content (GSH), and superoxide dismutase (SOD) in 20 patients operated on with Nissen fundoplication and 9 controls during a 4-year follow-up. Further, we assessed the oxidative damage of DNA by 8-hydroxydeoxyguanosine (8-OHdG) in esophageal samples of subjects (13 Barrett s metaplasia, 6 Barrett s esophagus with high-grade dysplasia, 18 adenocarcinoma of the distal esophagus/GEJ, and 14 normal controls). We estimated the accuracy (42 patients) and preoperative prognostic value (55 patients) of PET compared with computed tomography (CT) and endoscopic ultrasound (EUS) in patients with adenocarcinoma of the esophagus/GEJ. Finally, we clarified the specialty-related costs and the utility of either radical (30 patients) or palliative (23 patients) treatment of esophageal/GEJ carcinoma by the 15 D health-related quality-of-life (HRQoL) questionnaire and the survival rate. The cost-utility of radical treatment of esophageal/GEJ carcinoma was investigated using a decision tree analysis model comparing radical, palliative, and hypothetical new treatment. We found elevated oxidative stress ( measured by MPA) and decreased antioxidant defense (measured by GSH) after antireflux surgery. This indicates that antireflux surgery is not a perfect solution for oxidative stress of the esophageal mucosa. Elevated oxidative stress in turn may partly explain why adenocarcinoma of the distal esophagus is found even after successful fundoplication. In GERD patients, proximal esophageal mucosal anti-oxidative defense seems to be defective before and even years after successful antireflux surgery. In addition, antireflux surgery apparently does not change the level of oxidative stress in the proximal esophagus, suggesting that defective mucosal anti-oxidative capacity plays a role in development of oxidative damage to the esophageal mucosa in GERD. In the malignant transformation of Barrett s esophagus an important component appears to be oxidative stress. DNA damage may be mediated by 8-OHdG, which we found to be increased in Barrett s epithelium and in high-grade dysplasia as well as in adenocarcinoma of the esophagus/GEJ compared with controls. The entire esophagus of Barrett s patients suffers from increased oxidative stress ( measured by 8-OhdG). PET is a useful tool in the staging and prognostication of adenocarcinoma of the esophagus/GEJ detecting organ metastases better than CT, although its accuracy in staging of paratumoral and distant lymph nodes is limited. Radical surgery for esophageal/GEJ carcinoma provides the greatest benefit in terms of survival, and its cost-utility appears to be the best of currently available treatments.

Current Care Guidelines for Cardiopulmonary Resuscitation : Implementation, skills and attitudes

Background: The national resuscitation guidelines were published in Finland in 2002 and are based on international guidelines published in 2000. The main goal of the national guidelines, available on the Internet free of charge, is early defibrillation by nurses in an institutional setting. Aim: To study possible changes in cardiopulmonary resuscitation (CPR) practices, especially concerning early defibrillation, nurses and students attitudes of guideline implementation and nurses and students ability to implement the guideline recommendations in clinical practices after publication of the Current Care (CC) guidelines for CPR 2002. Material and methods: CPR practices in Finnish health centres; especially concerning rapid defibrillation programmes, as well as the implementation of CC guidelines for CPR was studied in a mail survey to chief physicians of every health centre in Finland (Study I). The CPR skills using an automated external defibrillator (AED) were compared in a study including Objective stuctured clinical examination (OSCE) of resuscitation skills of nurses and nursing students in Finnish and Swedish hospital and institution (Studies II, III). Attitudes towards CPR-D and CPR guidelines among medical and nursing students and secondary hospital nurses were studied in surveys (Studies IV, V). The nurses receiving different CPR training were compared in a randomized trial including OSCE of CPR skills of nurses in Finnish Hospital (Study VI). Results: Two years after the publication, 40.7% of Finnish health centres used national resuscitation guidelines. The proportion of health centres having at least one AED (66%) and principle of nurse-performed defibrillation without the presence of a physician (42%) had increased. The CPR-D training was estimated to be insufficient regarding basic life support and advanced life support in the majority of health centres (Study I). CPR-D skills of nurses and nursing students in two specific Swedish and Finnish hospitals and institutions (Study II and III) were generally inadequate. The nurses performed better than the students and the Swedish nurses surpassed the Finnish ones. Geriatric nurses receiving traditional CPR-D training performed better than those receiving an Internet-based course but both groups failed to defibrillate within 60 s. Thus, the performance was not satisfactory even two weeks after traditional training (Study VI). Unlike the medical students, the nursing students did not feel competent to perform procedures recommended in the cardiopulmonary resuscitation guidelines including the defibrillation. However, the majority of nursing students felt confident about their ability to perform basic life support. The perceived ability to defibrillate correlated significantly with a positive attitude towards nurse-performed defibrillation and negatively with fear of damaging the patient s heart by defibrillation (Study IV). After the educational intervention, the nurses found their level of CPR-D capability more sufficient than before and felt more confident about their ability to perform defibrillation themselves. A negative attitude toward defibrillation correlated with perceived negative organisational attitudes toward cardiopulmonary resuscitation guidelines. After CPR-D education in the hospital, the majority (64%) of nurses hesitated to perform defibrillation because of anxiety and 27 % hesitated because of fear of injuring the patient. Also a negative personal attitude towards guidelines increased markedly after education (Study V). Conclusions: Although a significant change had occurred in resuscitation practices in primary health care after publication of national cardiopulmonary resuscitation guidelines the participants CPR-D skills were not adequate according to the CPR guidelines. The current way of teaching is unlikely to result in participants being able to perform adequate and rapid CPR-D. More information and more frequent training are needed to diminish anxiety concerning defibrillation. Negative beliefs and attitudes toward defibrillation affect the nursing students and nurses attitudes toward cardiopulmonary resuscitation guidelines. CPR-D education increased the participants self-confidence concerning CPR-D skills but it did not reduce their anxiety. AEDs have replaced the manual defibrillators in most institutions, but in spite of the modern devices the anxiety still exists. Basic education does not provide nursing students with adequate CPR-D skills. Thus, frequent training in the workplace has vital importance. This multi-professional program supported by the administration might provide better CPR-D skills. Distance learning alone cannot substitute for traditional small-group learning, tutored hands-on training is needed to learn practical CPR-D skills. Standardized testing would probably help controlling the quality of learning. Training of group-working skills might improve CPR performance.

Koulun kestävän kehityksen työn merkitys kiinteistön jätehuollossa Case: Helsingin peruskoulujen jätekustannukset ja -määrät

Koulujen kestävän kehityksen työllä tarkoitetaan ekologiseen, taloudelliseen, sosiaaliseen ja kulttuuriseen kestävyyteen pohjautuvaa ympäristökasvatusta. Helsingissä peruskoulujen kestävän kehityksen työvälineet (ympäristökartoitukset ja – ohjelmat) ovat perustuneet koulujen ympäristöasioiden suunnitteluun, opetussuunnitelmien toteutumiseen ja ylläpitotoimintoihin, kuten jätehuoltoon. Opetusvirasto käytti vuosina 2005 ja 2009 ympäristötoiminnan arvioinnissa ympäristötasokuvauksia 1-3, joista arvosana 3 kuvaa ympäristöasioissa edistyneintä koulua. Tutkielman tavoitteena on tutkia ympäristötoiminnan tasojen perusteella ryhmiteltyjen peruskoulujen välisiä eroja jätekustannuksissa ja – määrissä (euroa/henkilö ja kg/henkilö) ja löytää mahdollisesti eroihin vaikuttavia tekijöitä. Tutkielman toimeksiantajana on 4V-Välitä, vaikuta, viihdy, voi hyvin – hanke, jonka yhtenä toiminnan osa-alueena on koulujen kestävän kehityksen työ. Tuloksista tullaan johtamaan tietoa Opetusviraston sekä muiden tahojen, kuten HSY:n ja Palmian ympäristötyöhön sekä Kiinteistöviraston Tilakeskuksen hallinnassa olevien koulukiinteistöjen jätehuollon kehittämiseen. Tutkimusaineistoina käytettiin Helsingin peruskoulujen vuoden 2009 jätekustannuksia ja tutkielman yhteydessä kerätyn jäteseurannan tuloksia vuodelta 2010. Jätekustannus- ja jätemääräaineistot yhdistettiin vuoden 2009 ympäristötoiminnan tasoluokitusten perusteella otokseksi (n=64). Lopullinen jätekustannus- ja jätemääräanalyysi tehtiin 29 koulun otoksella, josta oli rajattu pois kiinteistöt, joilla on koulun toiminnan lisäksi muita käyttötarkoituksia. Analyysiin sisällytettiin myös tarkempi tarkastelu koulujen seka- ja biojätejakeiden kustannuksista ja määristä. Tutkimuksen johtopäätöksenä todettiin, että eri ympäristötasoisten peruskoulujen välillä on huomattavia euro- ja kilomääräisiä eroja henkilöä kohden lasketuissa jätekustannuksissa ja –määrissä. Kokonaisjätemäärässä ei ole tapahtunut merkittävää muutosta tarkasteluvuosien välillä, mutta lajittelu näyttäisi kuitenkin tehostuneen. Tulosten perusteella ympäristöasioissa edistyneiden tason 3 koulujen keskimääräiset sekajätemäärät ja -kustannukset olivat pienimmät tasojen 1 ja 2 kouluihin verrattuna. Biojätemäärät ja –kustannukset olivat suurimmat tason 2 kouluissa. Jätekustannuksiin ja – määriin näyttäisivät vaikuttavan jäteastioiden määrien, kokojen ja tyhjennysrytmien optimointi sekä jäteastioiden täyttöasteet. Peruskoulujen tulisi keskittyä kestävän kehityksen työn avulla jätteiden synnyn ehkäisyyn ja vähentämiseen, jotta jätekustannuksetkin vähentyisivät jätehuollon kehittämistoimenpiteiden seurauksena.

The Problem of Implementation and its Relation to the Philosophy of Cognitive Science

According to certain arguments, computation is observer-relative either in the sense that many physical systems implement many computations (Hilary Putnam), or in the sense that almost all physical systems implement all computations (John Searle). If sound, these arguments have a potentially devastating consequence for the computational theory of mind: if arbitrary physical systems can be seen to implement arbitrary computations, the notion of computation seems to lose all explanatory power as far as brains and minds are concerned. David Chalmers and B. Jack Copeland have attempted to counter these relativist arguments by placing certain constraints on the definition of implementation. In this thesis, I examine their proposals and find both wanting in some respects. During the course of this examination, I give a formal definition of the class of combinatorial-state automata , upon which Chalmers s account of implementation is based. I show that this definition implies two theorems (one an observation due to Curtis Brown) concerning the computational power of combinatorial-state automata, theorems which speak against founding the theory of implementation upon this formalism. Toward the end of the thesis, I sketch a definition of the implementation of Turing machines in dynamical systems, and offer this as an alternative to Chalmers s and Copeland s accounts of implementation. I demonstrate that the definition does not imply Searle s claim for the universal implementation of computations. However, the definition may support claims that are weaker than Searle s, yet still troubling to the computationalist. There remains a kernel of relativity in implementation at any rate, since the interpretation of physical systems seems itself to be an observer-relative matter, to some degree at least. This observation helps clarify the role the notion of computation can play in cognitive science. Specifically, I will argue that the notion should be conceived as an instrumental rather than as a fundamental or foundational one.