Integrating cost-effectiveness evidence into clincal practice guidelines in Australia for acute myocardial infarction

 A teaching hospital is working with the Victorian State Government and universities, integrating cost-effectiveness evidence into clinical practice guidelines (CPGs), protocols and pathways for respiratory and cardiology interventions. Acute myocardial infarction (AMI) findings are reported. Results will stimulate cost-effective practice and inform medical associations, federal and state governments and international organisations developing CPGs. Published CPGs by the American College of Cardiology/American Heart Foundation for AMI in 1999 are reviewed by a large interdis- ciplinary hospital-based committee given cost-effectiveness evidence. Levels of evi- dence criteria rating on methodological rigor for effectiveness and costs are applied. National Health and Medical Research Council (NHMRC) grades of recommendation criteria for combinations of relative effectiveness versus relative costs and cut-off points are used. Extrapolating results between countries was addressed by applying the OECD's health purchasing power parity series. Recommendations for revisions to United States guidelines and for local application are formulated. United States Guide- lines require updating: Regarding angioplasty, percutaneous transluminal coronary angioplasty (PTCA) is cost-effective for men aged 60 years relative to recombinant tissue plasminogen activator (tPA),with additional cost per life year saved of 274 ecu. PTCA with discharge after 3 days is cost-effective in low-risk AMI. Regarding GP llb/Illa drugs, Abciximab during intervention incurred equal mean hospital costs for placebabciximab bolus, and abciximab bolus+ infusion with incremental 6-month cost for the latter treatment costing US$ 293 per patient. Agent recouped almost all initial therapy costs with significant benefits. Incre- mental cost of abciximab per event prevent- ed is US$ 3,258.Tirofiban was compared to placebo after high-risk angioplasty for AMI or unstable angina.Tirofiban decreased the rate of hospital deaths, myocardial infarc- tion, revascularisation at 2 days by 36% relative to placebo (8% vs. 12%) without increased cost. Clinical benefits were similar at 30 days.Tirofiban+heparin+aspirin was compared to heparin+aspirin.Tirofiban arm resulted in net savings of 33,418 ecu per 100 patients for the first 7 days of treatment. Regarding thrombolytics,tPA is more cost- effective than streptokinase. Incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasmi- nogen are 31%,45%, 97% higher in Germa- ny, Italy and the United States than in the United Kingdom. Regarding anticoagulants, enoxaparin is a promising alternative to unfractionated heparin for hospitalised patients with non-Q-wave myocardiai infarc- tion or unstable angina, saving C$ 1,485 per patient over 12 months with 10% reduction in 1 year risk of death, myocardial infarction or recurrent angina. Regarding anti- arrhymics, the cost-effectiveness of no amiodarone, amiodarone for patients with depressed heart rate variability (DHRV),and amiodarone for patients with DHRV plus positive programmed ventricular stimula- tion (PPVS) for high-risk post-AMI was investigated. Amiodarone for DHRV+PPVS patients was dominated by a blend of the two alternatives. Compared to no amioda- rone, the incremental cost-effectiveness of amiodarone for DHRV patients was US$ 39,422 per quality adjusted life year gained. Amiodarone for DHRV is the most appropriate. Other CPG updates concern serum markers, for example, cardiac troponin I assay (c-Tnl), cost advantages of ad hoc angioplasty and secondary prevention through antioxidants and pravastatin. Australian costs are reported later in the paper.

The relationship betwen NaCl concentration and taste perception of saltiness in bread

Background – Sodium (Na+ ) is present in food in the form of sodium chloride (NaCl). There is strong evidence that high dietary Na+ intakes increase the risk of developing various adverse health conditions. Many international organisations encourage Na+ reduction in both the diet and the food supply. One of the major dietary sources of NaCl is bread, where NaCl has the essential function of imparting flavour. At present, no literature has been published examining taste interactions that may play a role in limiting the maximum saltiness perception in bread.
Objective – To determine the extent the physical structure of bread inhibits salty taste perception. Additionally, to determine whether common commercial bread additives suppress saltiness of bread.
Design – Subjects (n=14, 12 females) tasted and rated samples with varying NaCl concentrations in water (0 – 1724 mg NaCl/100 g) and bread (125 – 1550 mg NaCl/100 g) using the general Labelled Magnitude Scale. Psychophysical curves plotting NaCl concentration against NaCl intensity were constructed for water and bread. Breads of fixed NaCl concentration (1125 mg NaCl/100 g) and various common additives (sucrose, soya flour, canola oil, gluten) were also rated to assess perceived saltiness.
Outcomes – There was a significant difference between Na+ psychophysical curves in water and bread (P<0.05) with the bread matrix suppressing maximum possible saltiness by 25% to 70%. Suppression of saltiness was observed after the addition of sucrose (55% decrease) or soya flour (60% decrease) during bread production compared to prototypical bread (both P<0.05).
Conclusions – The physical structure of bread and some common additives have a major influence on perceptual saltiness of bread. The removal of additives that suppress saltiness combined with strategies to modify the texture of bread could lead to significant reduction in dietary Na+, whilst maintaining optimal salty taste.

Healthy markets - healthy people/ : reforming health care in Cambodia

Health care reform has been described as a global epidemic. This thesis deals with nature and experience of health care reform in developing countries. Increasing privatisation, economic transition, and structural adjustment have provided the context for health system changes. Different approaches to reform have been developed by international organisations such as the World Bank, WHO and UNICEF. What has driven national health care reforms? Are such policies really appropriate to developing countries? Has a consensus now emerged in relation to international health policy? Has a new health care ‘model’ appeared? The study of health care reform in Cambodia is a timely opportunity to investigate the implementation of health care reform under extreme conditions. These conditions include a legacy of genocide, long-term conflict, political isolation, and economic transition. This case study uses both qualitative and quantitative methods and multiple sources of data to analyse the reform program. The study reinforces the conclusion that, under conditions of extreme poverty, market based reforms are likely to have limited positive impact. Rather, understanding the cultural conditions that determine demand, delivering health care of a satisfactory quality, providing appropriate incentives for health practitioners, and supporting services with adequate public funding are the prerequisites for improved service delivery and utilisation. Cambodia's strategy of integrated district health service development and universal population coverage may provide an instructive example of reform. Emerging policy issues identified by this case study include the fundamental role of equity in service provision, the influence of the social determinants of health and illness and interest in the appropriate use of evidence in international health policy-making.

Global education policy directives : impact on teachers from the north and south

Education policies from international organisations such as the World Bank and OECD are restructuring education to promote a utilitarian vision of education. By examining the experiences and opinions of teachers from countries representing north-south global regions, it is possible to identify the social and political implications of education reform as it impacts on teachers as not only practitioners, but also as social and political agents. As global communities are more inexorably linked through global, macro policies, an outcome of this trend is a growing political and social divide between the global north and south. The paper aims to identify and discuss the significant concerns of teachers from the global north and south in relation to education reform.

Changing the future of obesity : science, policy, and action

The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. An emerging science that uses quantitative models has provided key insights into the dynamics of this epidemic, and enabled researchers to combine evidence and to calculate the effect of behaviours, interventions, and policies at several levels—from individual to population. Forecasts suggest that high rates of obesity will affect future population health and economics. Energy gap models have quantified the association of changes in energy intake and expenditure with weight change, and have documented the effect of higher intake on obesity prevalence. Empirical evidence that shows interventions are effective is limited but expanding. We identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. We call for a sustained worldwide effort to monitor, prevent, and control obesity.

Are CGE Models still useful in economic policy making?

This paper develops background considerations to help better framing the results of a CGE exercise. Three main criticisms are usually addressed to CGE efforts. First, they are too aggregate, their conclusions failing to shed light on relevant sectors or issues. Second, they imply huge data requirements. Timeliness is frequently jeopardised by out-dated sources, benchmarks referring to realities gone by. Finally, results are meaningless, as they answer wrong or ill-posed questions. Modelling demands end up by creating a rather artificial context, where the original questions lose content. In spite of a positive outlook on the first two, crucial questions lie in the third point. After elaborating such questions, and trying to answer some, the text argues that CGE models can come closer to reality. If their use is still scarce to give way to a fruitful symbiosis between negotiations and simulation results, they remain the only available technique providing a global, inter-related way of capturing economy-wide effects of several different policies. International organisations can play a major role supporting and encouraging improvements. They are also uniquely positioned to enhance information and data sharing, as well as putting people from various origins together, to share their experiences. A serious and complex homework is however required, to correct, at least, the most dangerous present shortcomings of the technique.

From capital surges to drought: seeking stability for emerging economies

Includes bibliography

Population ageing, intergenerational transfers and social protection in Latin America and the Caribbean

Includes bibliography

Dissemination of Caribbean census microdata to researchers: Including an experiment in the anonymization of microdata for Grenada and Trinidad and Tobago

Caribbean census microdata are not easily accessible to researchers. Although there are well-established and commonly used procedures technical, administrative and legal which are used to disseminate anonymized census microdata to researchers, they have not been widely used in the Caribbean. The small size of Caribbean countries makes anonymization relatively more difficult and standard methods are not always directly applicable. This study reviews commonly used methods of disseminating census microdata and considers their applicability to the Caribbean. It demonstrates the application of statistical disclosure control methods using the census datasets of Grenada and Trinidad and Tobago and considers various possible designs of microdata release file in terms of disclosure risk and utility to researchers. It then considers how various forms of microdata dissemination: public use files, licensed use files, remote data access and secure data laboratories could be used to disseminate census microdata. It concludes that there is scope for a substantial expansion of access to Caribbean census microdata and that through collaboration with international organisations and data archives, this can be achieved with relatively little burden on statistical offices.

Democracy Reconsidered : Britain, France, Sweden, and the EU

The purpose of this thesis is to investigate whether some positions in democratic theory should be adjusted or abandoned in view of internationalisation; and if adjusted, how. More specifically it pursues three different aims: to evaluate various attempts to explain levels of democracy as consequences of internationalisation; to investigate whether the taking into account of internationalisation reveals any reason to reconsider what democracy is or means; and to suggest normative interpretations that cohere with the adjustments of conceptual and explanatory democratic theory made in the course of meeting the other two aims. When empirical methods are used, the scope of the study is restricted to West European parliamentary democracies and their international affairs. More particularly, the focus is on the making of budget policy in Britain, France, and Sweden after the Second World War, and recent budget policy in the European Union. The aspects of democracy empirically analysed are political autonomy, participation, and deliberation. The material considered includes parliamentary debates, official statistics, economic forecasts, elections manifestos, shadow budgets, general election turnouts, regulations of budget decision-making, and staff numbers in government and parliament budgetary divisions. The study reaches the following conclusions among others. (i) The fact that internationalisation increases the divergence between those who make and those who are affected by decisions is not by itself a democratic problem that calls for political reform. (ii) That international organisations may have authorities delegated to them from democratic states is not sufficient to justify them democratically. Democratisation still needs to be undertaken. (iii) The fear that internationalisation dissolves a social trust necessary for political deliberation within nations seems to be unwarranted. If anything, views argued by others in domestic budgetary debate are taken increasingly serious during internationalisation. (iv) The major difficulty with deliberation seems to be its inability to transcend national boundaries. International deliberation at state level has not evolved in response to internationalisation and it is undeveloped in international institutions. (v) Democratic political autonomy diminishes during internationalisation with regard to income redistribution and policy areas taken over by international organisations, but it seems to increase in public spending. (vi) In the area of budget policy-making there are no signs that governments gain power at the expense of parliaments during internationalisation. (vii) To identify crucial democratic issues in a time of internationalisation and to make room for theoretical virtues like general applicability and normative fruitfulness, democracy may be defined as a kind of politics where as many as possible decide as much as possible.

Il contributo dell’Unione europea all’affermazione dello stato di diritto nella comunità internazionale

This thesis is aimed at analysing EU external relations from the perspective of the promotion of the rule of law in order to evaluate the effectiveness and consistency of its action within the international community. The research starts with an examination of the notion of the rule of law from a theoretical point of view. The first chapter initially describes the historical-political evolution of the establishment of the notion of the rule of law. Some of the most significant national experiences (France, the UK, Germany and Austria) are discussed. Then, the focus is put on the need to propose interpretations which explain the grounds of the rule of law, by highlighting the different formal and substantive interpretations. This philosophical-historical analysis is complemented by a reconstruction of how the notion of the rule of law was developed by the international community, with a view to searching a common notion at the international level by comparing theory and practice within the main international organisations such as the UN, OECD and the Council of Europe. Specific mention is made of the EU experience, whose configuration as a Community based on the rule of law is often debated, starting from the case law of the European Court of Justice. The second chapter deals with the conditionality policy and focuses on the development and scope of democratic conditionality according to the dominant approach of the doctrine. First, the birth of conditionality is analysed from an economic point of view, especially within international financial organisations and the different types of conditionality recreated in the scientific sector. Then an analysis is provided about the birth of democratic conditionality in the EC – in relation to its external relations – firstly as a mere political exercise to be then turned into a standardised system of clauses. Specific reference is made to the main scope of conditionality, that is to say enlargement policy and the development of the Copenhagen criteria. The third chapter provides further details about the legal questions connected to the use of democratic clauses: on the one hand, the power of the EC to include human rights clauses in international agreements, on the other, the variety and overlapping in the use of the legal basis. The chapter ends with an analysis of the measures of suspension of agreements with third countries in those rare but significant cases in which the suspension clause, included in the Lomè Convention first and in the Cotonou Agreement then, is applied. The last chapter is devoted to the analysis of democratic clauses in unilateral acts adopted by the European Union which affect third countries. The examination of this practice and the comparison with the approach analysed in the previous chapter entails a major theoretical question. It is the clear-cut distinction between conditionality and international sanction. This distinction is to be taken into account when considering the premises and consequences, in terms of legal relations, which are generated when democratic clauses are not complied with. The chapter ends with a brief analysis of what, according to the reconstruction suggested, can be rightly labelled as real democratic conditionality, that is to say the system of incentives, positive measures developed within the community GSP. The dissertation ends with a few general considerations about the difficulties experienced by the EU in promoting the rule of law. The contradictory aspects of the EU external actions are manifold, as well as its difficulties in choosing the most appropriate measures to be taken which, however, reflect all the repercussions and tension resulting from the balance of power within the international community. The thesis argues that it is difficult to grant full credibility to an entity like the EU which, although it proclaims itself as the guardian and promoter of the rule of law, in practice, is too often biased in managing its relations with third countries. However, she adds, we must acknowledge that the EU is committed and constantly strives towards identifying new spaces and strategies of action.

La dimensione esterna della politica migratoria dell'UE

Conformemente ai trattati, l'UE sviluppa una politica comune in materia di asilo, immigrazione e controllo delle frontiere esterne, fondata sulla solidarietà e sul rispetto dei diritti fondamentali e, a tal fine, avvia relazioni strategiche con i Paesi terzi e le Organizzazioni internazionali. Un fenomeno “senza frontiere”, quale quello migratorio, esige del resto un'azione coerente e coordinata sia sul piano interno sia su quello esterno. La messa in atto di quest'ultima, tuttavia, si scontra con difficoltà di rilievo. Innanzitutto, l'UE e i suoi Stati membri devono creare i presupposti per l'avvio della collaborazione internazionale, vale a dire stimolare la fiducia reciproca con i Paesi terzi, rafforzando la propria credibilità internazionale. A tal fine, le istituzioni, gli organi e gli organismi dell'UE e gli Stati membri devono impegnarsi a fornire un modello coerente di promozione dei valori fondanti, quali la solidarietà e il rispetto dei diritti fondamentali, nonché a coordinare le proprie iniziative, per individuare, insieme ai Paesi terzi e alle Organizzazioni internazionali, una strategia d'azione comune. In secondo luogo, l'UE e gli Stati membri devono adottare soluzioni volte a promuovere l'efficacia della collaborazione internazionale e, più precisamente, assicurare che la competenza esterna sia esercitata dal livello di governo in grado di apportare il valore aggiunto e utilizzare la forma collaborativa di volta in volta più adeguata alla realizzazione degli obiettivi previsti. In definitiva, l'azione esterna dell'UE in materia di politica migratoria necessita di una strategia coerente e flessibile. Se oggi la coerenza è garantita dalla giustiziabilità dei principi di solidarietà, di rispetto dei diritti fondamentali e, giustappunto, di coerenza, la flessibilità si traduce nel criterio del valore aggiunto che, letto in combinato disposto con il principio di leale cooperazione, si pone al centro del nuovo modello partenariale proposto dall'approccio globale, potenzialmente idoneo a garantire la gestione efficace del fenomeno migratorio.

Essays on the Empirical Analysis of Economic and Political Development in Sub-Saharan Africa

In Sub-Saharan Africa, non-democratic events, like civil wars and coup d'etat, destroy economic development. This study investigates both domestic and spatial effects on the likelihood of civil wars and coup d'etat. To civil wars, an increase of income growth is one of common research conclusions to stop wars. This study adds a concern on ethnic fractionalization. IV-2SLS is applied to overcome causality problem. The findings document that income growth is significant to reduce number and degree of violence in high ethnic fractionalized countries, otherwise they are trade-off. Income growth reduces amount of wars, but increases its violent level, in the countries with few large ethnic groups. Promoting growth should consider ethnic composition. This study also investigates the clustering and contagion of civil wars using spatial panel data models. Onset, incidence and end of civil conflicts spread across the network of neighboring countries while peace, the end of conflicts, diffuse only with the nearest neighbor. There is an evidence of indirect links from neighboring income growth, without too much inequality, to reduce the likelihood of civil wars. To coup d'etat, this study revisits its diffusion for both all types of coups and only successful ones. The results find an existence of both domestic and spatial determinants in different periods. Domestic income growth plays major role to reduce the likelihood of coup before cold war ends, while spatial effects do negative afterward. Results on probability to succeed coup are similar. After cold war ends, international organisations seriously promote democracy with pressure against coup d'etat, and it seems to be effective. In sum, this study indicates the role of domestic ethnic fractionalization and the spread of neighboring effects to the likelihood of non-democratic events in a country. Policy implementation should concern these factors.