Evidence Base to Inform the Operational Arrangements for the Proposed Prescribing and Supply of Specialist Medicines

Executive Summary

Spirituality and religious practices among outpatients with schizophrenia and their clinicians

OBJECTIVES: Religious issues may be neglected by clinicians who are treating psychotic patients, even when religion constitutes an important means of coping. This study examined the spirituality and religious practices of outpatients with schizophrenia compared with their clinicians. Clinicians' knowledge of patients' religious involvement and spirituality was investigated. METHODS: The study sample included 100 patients of public psychiatric outpatient facilities in Geneva, Switzerland, with a diagnosis of nonaffective psychosis. Audiotaped interviews were conducted with use of a semistructured interview about spirituality and religious coping. The patients' clinicians (N=34) were asked about their own beliefs and religious activities as well as their patients' religious and clinical characteristics. RESULTS: Sixteen patients (16 percent) had positive psychotic symptoms reflecting aspects of their religious beliefs. A majority of the patients reported that religion was an important aspect of their lives, but only 36 percent of them had raised this issue with their clinicians. Fewer clinicians were religiously involved, and, in half the cases, their perceptions of patients' religious involvement were inaccurate. A few patients considered religious practice to be incompatible with treatment, and clinicians were seldom aware of such a conflict. CONCLUSIONS: Religion is an important issue for patients with schizophrenia, and it is often not related to the content of their delusions. Clinicians were commonly not aware of their patients' religious involvement, even if they reported feeling comfortable with such an issue.

Do resources, justice administration practices and federalism have an impact on registered and sentenced crime prevalence ?

This contribution, based on a statistical approach, undertakes to link data on resources (personnel and financial means) and the working of the administration of penal justice (prosecution, sentencing) taking into account the nationality of those prosecuted. In order to be able to distinguish prosecution and sentencing practices of judicial authorities and possible processes of discrimination, diverse sources have been used such as data from court administrations, public finances and police forces, collected by the Swiss Federal Statistical Office and the Swiss Federal administration of finances. The authors discuss discrimination in prosecution and sentencing between Swiss residents and foreigners taking into account localization and resources regarding personnel and public finances.

Treatment with tumor necrosis factor inhibitors in axial spondyloarthritis: comparison between private rheumatology practices and academic centers in a large observational cohort.

OBJECTIVE: To evaluate the initiation of and response to tumor necrosis factor (TNF) inhibitors for axial spondyloarthritis (axSpA) in private rheumatology practices versus academic centers. METHODS: We compared newly initiated TNF inhibition for axSpA in 363 patients enrolled in private practices with 100 patients recruited in 6 university hospitals within the Swiss Clinical Quality Management (SCQM) cohort. RESULTS: All patients had been treated with ≥ 1 nonsteroidal antiinflammatory drug and > 70% of patients had a baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 4 before anti-TNF agent initiation. The proportion of patients with nonradiographic axSpA (nr-axSpA) treated with TNF inhibitors was higher in hospitals versus private practices (30.4% vs 18.7%, p = 0.02). The burden of disease as assessed by patient-reported outcomes at baseline was slightly higher in the hospital setting. Mean levels (± SD) of the Ankylosing Spondylitis Disease Activity Score were, however, virtually identical in private practices and academic centers (3.4 ± 1.0 vs 3.4 ± 0.9, p = 0.68). An Assessment of SpondyloArthritis international Society (ASAS40) response at 1 year was reached for ankylosing spondylitis in 51.7% in private practices and 52.9% in university hospitals (p = 1.0) and for nr-axSpA in 27.5% versus 25.0%, respectively (p = 1.0). CONCLUSION: With the exception of a lower proportion of patients with nr-axSpA newly treated with anti-TNF agents in private practices in comparison to academic centers, adherence to ASAS treatment recommendations for TNF inhibition was equally high, and similar response rates to TNF blockers were achieved in both clinical settings.

Family doctors' consultations with people suffering from chronic pain without objective findings: Which protective practices might they develop in these challenging medical encounters?

Introduction: Consultations with patients suffering from chronic pain without objective findings represent a challenge fo r family doctors (FDs). A mutual lack of understanding may arise, which threatens the doctor-patient relationship and may lead to dissatisfaction of both patient and doctor and to a breakdown of the therapeutic alliance. Objectives: This study aims to investigate FDs' potential protective practices to preserve the doctor-patient relationship during this type of consultation. Method: In the first step of this qualitative research, I carried out a range of 10 se- mi-structured interviews with FDs to explore their reported practices and repre- sentations during consultations with people suffering from chronic pain without objective findings. The interviews' transcripts were integrally analysed with computer-assisted thematic content analysis (QSR NVivo ® ) to highlight the main themes related to the topic in the participants' talk. Results: At this point of the research, two types of FDs' protective practices can be identified: first the use of complementary sources of knowledge in addition to the medical model to provide explanations to patients, second the collaboration with multidisciplinary teams or support gr oups that allow them to share profes- sional expertise and emotional experiences. Conclusion: The findings could be useful to develop ways to improve the follow- up of patients suffering from chronic pain without objective findings and conse- quently the FDs' work satisfaction.

Causes of health expenditure growth : the predominance of changes in medical practices over population ageing

On the basis of French individual data, this paper compares the effects of demographic change, changes in morbidity and changes in practices on the growth in health expenditures that occurred between 1992 and 2000. Micro simulations show that the rise in expenditures due to ageing is relatively small and that the impact of changes in practices is times larger. Furthermore, changes in morbidity induce savings which more than offset the increase in spending due to population ageing. [Authors]

Insecticide treated mosquito nets for malaria control in India-experience from a tribal area on operational feasibility and uptake

The study assessed the operational feasibility and acceptability of insecticide-treated mosquito nets (ITNs) in one Primary Health Centre (PHC) in a falciparum malaria endemic district in the state of Orissa, India, where 74% of the people are tribes and DDT indoor residual spraying had been withdrawn and ITNs introduced by the National Vector Borne Disease Control Programme. To a population of 63,920, 24,442 ITNs were distributed free of charge through 101 treatment centers during July-August 2002. Interview of 1,130, 1,012 and 126 respondents showed that the net use rates were 80%, 74% and 55% in the cold, rainy and summer seasons, respectively. Since using ITNs, 74.5-76.6% of the respondents observed reduction of mosquito bites and 7.2-32.1% reduction of malaria incidence; 37% expressed willingness to buy ITNs if the cost was lower and they were affordable. Up to ten months post-treatment, almost 100% mortality of vector mosquitoes was recorded on unwashed and washed nets (once or twice). Health workers re-treated the nets at the treatment centers eight months after distribution on a cost-recovery basis. The coverage reported by the PHC was only 4.2%, mainly because of unwillingness of the people to pay for re-treatment and to go to the treatment centers from their villages. When the re-treatment was continued at the villages involving personnel from several departments, the coverage improved to about 90%.Interview of 126 respondents showed that among those who got their nets re-treated, 81.4% paid cash for the re-treatment and the remainder were reluctant to pay. Majority of those who paid said that they did so due to the fear that if they did not do so they would lose benefits from other government welfare schemes. The 2nd re-treatment was therefore carried out free of charge nine months after the 1st re-treatment and thus achieved coverage of 70.4%. The study showed community acceptance to use ITNs as they perceived the benefit. Distribution and re-treatment of nets was thus possible through the PHC system, if done free of charge and when personnel from different departments, especially those at village level, were involved.

OER in Portugal as agent of curriculum innovation and technological change. Inducing practices of "new" teaching standards

This research project aimed the following goal: promote the creation, use and disclosure of OER in a Group of Schools, involving schools and teachers from different learning levels, expecting to test and validate the use of OER, in a learning-teaching model towards curricular innovation. Defining as a starting point different subjects and teachers from distinct academic areas, we have implemented a set of activities leading to the creation of OER supported, when possible, in FLOSS tools. We adopted an action research methodology with a dual purpose: to act within a community of teachers and students, while increasing at the same time their knowledge, as well as the researcher's. The activity was developed cooperatively in order to process a certain reality of the teaching-learning process, through practical/reflective action towards it and inducing its implementation by others in the Portuguese School System, based on the production and sharing OER.

Pédiatrie. 4. Dépistage de la dénutrition chez les enfants: nouvelles pratiques alimentaires à l'Hôpital de l'Enfance de Lausanne [Pediatrics. Screening for nutritional deficiencies in hospitalized children: new practices at the Hôpital de I'Enfance in Lausanne].

Screening for undernutrition among hospitalized children requires a systematic assessment of dietary intake. The development of a new tool for quick and playful assessment of dietary intake, called "Fleur" ("Flower"), at the Hôpital de l'Enfance in Lausanne allows to identify children at risk of undernutrition and to adapt their nutrition to their specific needs.

Why Public Health Agencies Cannot Depend on Good Laboratory Practices as a Criterion for Selecting Data: The Case of Bisphenol A

In their safety evaluations of bisphenol A (BPA), the U.S. Food and Drug Administration (FDA) and a counterpart in Europe, the European Food Safety Authority (EFSA), have given special prominence to two industry-funded studies that adhered to standards defined by Good Laboratory Practices (GLP). These same agencies have given much less weight in risk assessments to a large number of independently replicated non-GLP studies conducted with government funding by the leading experts in various fields of science from around the world. OBJECTIVES: We reviewed differences between industry-funded GLP studies of BPA conducted by commercial laboratories for regulatory purposes and non-GLP studies conducted in academic and government laboratories to identify hazards and molecular mechanisms mediating adverse effects. We examined the methods and results in the GLP studies that were pivotal in the draft decision of the U.S. FDA declaring BPA safe in relation to findings from studies that were competitive for U.S. National Institutes of Health (NIH) funding, peer-reviewed for publication in leading journals, subject to independent replication, but rejected by the U.S. FDA for regulatory purposes. DISCUSSION: Although the U.S. FDA and EFSA have deemed two industry-funded GLP studies of BPA to be superior to hundreds of studies funded by the U.S. NIH and NIH counterparts in other countries, the GLP studies on which the agencies based their decisions have serious conceptual and methodologic flaws. In addition, the U.S. FDA and EFSA have mistakenly assumed that GLP yields valid and reliable scientific findings (i.e., "good science"). Their rationale for favoring GLP studies over hundreds of publically funded studies ignores the central factor in determining the reliability and validity of scientific findings, namely, independent replication, and use of the most appropriate and sensitive state-of-the-art assays, neither of which is an expectation of industry-funded GLP research. CONCLUSIONS: Public health decisions should be based on studies using appropriate protocols with appropriate controls and the most sensitive assays, not GLP. Relevant NIH-funded research using state-of-the-art techniques should play a prominent role in safety evaluations of chemicals.

Factors influencing interprofessional practices of physiotherapists working in private settings with people with low back pain: a qualitative study

Purpose: Collaboration and interprofessional practices are highly valued in health systems everywhere, partly based on the rationale that they improve outcomes of care for people with complex health problems, such as low back pain. Research in the area of low back pain also supports the involvement of different health professionals in the interventions for people who present this condition. The aim of this studywas to identify factors influencing the interprofessional practices of physiotherapists working in private settings with people with low back pain. Relevance: Physiotherapists, like other health professionals, are encouraged to engage in interprofessional practices in their dailywork. However, to date, very little is known of their interprofessional practices, especially in private settings. Understanding physiotherapists' interprofessional practices and their influencing factors will notably advance knowledge relating to the organisation of physiotherapy services for people with low back pain. Participants: Participants in this study were 13 physiotherapists including 10 women and 3 men, having between 3 and 22 years of professional experience, and working in one of 10 regions of the Province of Quebec (Canada). In order to obtain maximal variation in the perspectives, participants were selected using a recruitment matrix including three criteria: duration of professional experience, work location, and physical proximity with other professionals. Methods: Thiswas a descriptive qualitative study using faceto- face semi-structured interviews as the main method of data collection. An interview guide was developed based on an evidence-derived frame of reference. Each interview lasted between 55 and 95 minutes and was transcribed verbatim. Analysis: Qualitative analyses took the form of content analysis, encompassing data coding and general thematic regrouping. NVivo version 8 was used to assist data organisation and analysis. Results: Multiple factors influencing the interprofessional practices of physiotherapists were identified. The main factors include the consulting person's health condition, the extent of knowledge on health professionals' roles and fields of practice, the proximity and availability of professional resources, as well as daily work schedules. Conclusions: Our findings highlight the influence of multiple factors on physiotherapists' interprofessional practices, including professional practice and organisational issues. However, further research on the interprofessional practices of physiotherapists is still required. Research priorities targeting the views of other health professionals, as well as those of services users, would enhance our comprehension of interprofessional practices of physiotherapists. Implications: This study provides new insights that improve our understanding of the interprofessional practices of physiotherapists working in private settings with people with low back pain, more specifically on the factors influencing these practices. Based on our findings, implementing changes such as improving current and future health professionals' knowledge of the fields and roles of other health professionals through training may contribute to positively influencing interprofessional practices. Keywords: Interprofessional practices; Private practice; Low back pain Funding acknowledgements: This research was supported in part by a B.E. Schnurr Memorial Fund Research Grant administered by the Physiotherapy Foundation of Canada, as well as from a clinical research partnership in physiotherapy between the Quebec Rehabilitation Research Network (REPAR) and the Ordre professionnel de la physiothérapie du Québec (OPPQ). KP received doctoral-level scholarships from the Canadian Institutes of Health Research (CIHR) and the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST). CE Dionne is a FRSQ senior Research Scholar. Ethics approval: This project was approved by the ethics research committee of the Institut de réadaptation en déficience physique de Québec.

Improving anemia management with less frequently dosed erythropoiesis stimulating agents

Introduction and Aims: The process of delivering erythropoiesis stimulating agents (ESAs) to hemodialysis patients (HD) is complex. Many European countries are requiring centers to document this process. To date, there has not been any comprehensive description of the operational aspects of ESA delivery in Europe. The objective of the Mercurius study was to describe the entire process of ESA delivery in dialysis centers. In addition, we explored the benefits of less frequent dosing. Methods: A conceptual model was developed to classify the sub-processes in the pharmacy, dialysis unit, waste unit, and back office. Within each dialysis unit activities associated with dose determination, ordering procedures, receipt and storage of ESAs, and ESA administration were measured. Within the pharmacy, ordering from supplier, receiving and storing, and delivering ESA to the dialysis unit were measured. The amount of time and materials associated with waste disposal and back office activities were also observed. We also evaluated the impact of less frequent dosing on the resources required to perform anemia management for HD patients. Structured interviews with staff were used to develop a comprehensive list of processes, sub-processes, and activities that are routinely followed to order, register, administer, and dispose of waste associated with ESAs. Each activity was evaluated to determine if less frequent dosing influenced the amount of resources required. A model was developed to estimate the change in resources consumed using less frequent dosing regimens. Results: Eight centers from 5 European countries (Belgium, France, Italy, Sweden, and Switzerland) participated in the study. The number of HD patients in each center ranged from 42 to 707 (mean=175). Across all of the centers, patients received a variety of dosing regimens (eg, TIW, BIW, QW and Q2W). The mean (±SD) time spent for the pharmacy to order an ESA from the supplier was 6.1 (±8.7) minutes; time spent in the dialysis unit and pharmacy for receiving and storing ESPs was 5.3 (±5.3) and 10.0 (±10.9) minutes, respectively; and time spent administering each injection was 6.4 (±6.5) minutes. Switching from current dosing practices to Q2W could decrease the mean number of syringes used from 12,420 to 5,085 per year. We estimate a reduction in the number of disinfective tissues and liquids of 58% and 71%, respectively by switching from current practice to dosing ESAs Q2W. Conclusions: There was significant variation in the time that it takes to perform routine ESA activities. We estimate that a reduction in resources required to manage anemia can be obtained by reducing the frequency of administration from the current mix of ESAs. These resources could be redeployed for patient care.

Espacio y tiempo en el imaginario digital. La construcción técnico estética de la espacio-temporalidad contemporánea.

Partiendo de la idea ampliamente aceptada de que las TIC (Tecnologías de Información y Comunicación) han tenido una profunda influencia en los modos en que la sociedad contemporánea experimenta y concibe las nociones de espacio y tiempo, y sustentándose en el contexto de la importancia adquirida por dichas nociones en la comprensión de los procesos sociales en general y estéticos en particular, esta investigación ha tenido por objetivo analizar la espacio-temporalidad en el contexto específico de la era digital. Poniendo en relación la fenomenología de los dispositivos tecnológicos con las nuevas estrategias de representación y puesta en imagen del espacio y el tiempo, nuestro propósito ha sido mostrar no sólo cómo a través de las prácticas artísticas digitales puede identificarse y analizarse el imaginario espacio-temporal de la era digital, sino también cómo éstas –basadas en una larga trayectoria estética de intersecciones entre arte y tecnología- han revestido al espacio y al tiempo de nuevas fenomenologías posibles, dando lugar a nuevas formas de percibirlos y cumpliendo, por tanto, un papel activo en la configuración de dicho imaginario y sus sucesivas transformaciones. La perspectiva teórica adoptada para esta investigación parte de las teorías postmodernas del espacio y el tiempo –considerando autores como Harvey o Jameson-, recurriendo a la sociología del Imaginario Social desarrollada por Castoriadis, Castro-Nogueira o J. L. Pintos para comprender cómo el espacio y el tiempo adquieren significaciones particulares. Combinando estas bases teóricas con los estudios visuales y los trabajos de teóricos de los medios como McLuhan, De Kerckhove o Lev Manovich, se establecerían las posibles relaciones entre las tecnologías, las representaciones sociales del espacio y el tiempo – analizadas a partir de metáforas como “compresión espacio-temporal”, “espacio de los flujos” o “tiempo atemporal” y sus relaciones con el Ciberespacio- y la fenomenología espacio-temporal de las prácticas artísticas y sus estrategias de representación visual –tomando como objeto de estudio tipologías artísticas que van desde el Hipercine a la Realidad Virtual y Aumentada, los Medios Locativos o la Telepresencia. La conclusión que hemos podido extraer de este estudio es que si bien distintos tipos de tecnologías afectan operacional y perceptivamente a la construcción social de la espacio-temporalidad, los modos en que estas tecnologías han estetizado la propia realidad y los modos en que condicionan la construcción estética de las nociones de espacio y tiempo, tanto a partir de la propia fenomenología del dispositivo como de la experimentación creativa con el mismo, ejercen una profunda influencia sobre el imaginario social y espacio-temporal propios de la era digital.