Comparative cost-effectiveness analyses of cardiovascular magnetic resonance and coronary angiography combined with fractional flow reserve for the diagnosis of coronary artery disease.

BACKGROUND: According to recent guidelines, patients with coronary artery disease (CAD) should undergo revascularization if significant myocardial ischemia is present. Both, cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) allow for a reliable ischemia assessment and in combination with anatomical information provided by invasive coronary angiography (CXA), such a work-up sets the basis for a decision to revascularize or not. The cost-effectiveness ratio of these two strategies is compared. METHODS: Strategy 1) CMR to assess ischemia followed by CXA in ischemia-positive patients (CMR + CXA), Strategy 2) CXA followed by FFR in angiographically positive stenoses (CXA + FFR). The costs, evaluated from the third party payer perspective in Switzerland, Germany, the United Kingdom (UK), and the United States (US), included public prices of the different outpatient procedures and costs induced by procedural complications and by diagnostic errors. The effectiveness criterion was the correct identification of hemodynamically significant coronary lesion(s) (= significant CAD) complemented by full anatomical information. Test performances were derived from the published literature. Cost-effectiveness ratios for both strategies were compared for hypothetical cohorts with different pretest likelihood of significant CAD. RESULTS: CMR + CXA and CXA + FFR were equally cost-effective at a pretest likelihood of CAD of 62% in Switzerland, 65% in Germany, 83% in the UK, and 82% in the US with costs of CHF 5'794, euro 1'517, £ 2'680, and $ 2'179 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR. CONCLUSIONS: The CMR + CXA strategy is more cost-effective than CXA + FFR below a CAD prevalence of 62%, 65%, 83%, and 82% for the Swiss, the German, the UK, and the US health care systems, respectively. These findings may help to optimize resource utilization in the diagnosis of CAD.

Less frequent dosing of erythropoiesis stimulating agents in patients undergoing dialysis: a European multicentre cost study.

OBJECTIVE: To calculate the variable costs involved with the process of delivering erythropoiesis stimulating agents (ESA) in European dialysis practices. METHODS: A conceptual model was developed to classify the processes and sub-processes followed in the pharmacy (ordering from supplier, receiving/storing/delivering ESA to the dialysis unit), dialysis unit (dose determination, ordering, receipt, registration, storage, administration, registration) and waste disposal unit. Time and material costs were recorded. Labour costs were derived from actual local wages while material costs came from the facilities' accounting records. Activities associated with ESA administration were listed and each activity evaluated to determine if dosing frequency affected the amount of resources required. RESULTS: A total of 21 centres in 8 European countries supplied data for 142 patients (mean) per hospital (range 42-648). Patients received various ESA regimens (thrice-weekly, twice-weekly, once-weekly, once every 2 weeks and once-monthly). Administering ESA every 2 weeks, the mean costs per patient per year for each process and the estimates of the percentage reduction in costs obtainable, respectively, were: pharmacy labour (10.1 euro, 39%); dialysis unit labour (66.0 euro, 65%); dialysis unit materials (4.11 euro, 61%) and waste unit materials (0.43 euro, 49%). LIMITATION: Impact on financial costs was not measured. CONCLUSION: ESA administration has quantifiable labour and material costs which are affected by dosing frequency.

Pilot HIA of European Employment Strategy in Ireland

This pilot Health Impact Assessment (HIA) exercise was conducted as part of the ‘Policy Health Impact Assessment for the European Union’, commissioned by the European Commission ’s Directorate Generale Health and Consumer Protection (DG Sanco). The project is coordinated by Liverpool University and the research partners are from Ireland, Germany and the Netherlands. The aim of the European project is to develop a HIA methodology for assessing the health impacts of EU policies and activities. The purpose of the pilot HIA in Ireland was to test the methodology produced in the first phase of the project in 2002. The policy chosen for assessment was the European Employment Strategy. The Irish pilot used a range of methods suggested in the draft methodology but concentrated particularly on the participatory aspects of HIA. A key stakeholder group with knowledge of employment (including decision makers in labour market policy) was established to provide expert advice and support. Other methods used included policy analysis, information gathering from key informants, community profiling (including demographic and labour force data), data analysis, literature review, the production of a report and the development of recommendations.

Ambulatory healthcare information system: a conceptual framework

Despite the tremendous amount of data collected in the field of ambulatory care, political authorities still lack synthetic indicators to provide them with a global view of health services utilization and costs related to various types of diseases. Moreover, public health indicators fail to provide useful information for physicians' accountability purposes. The approach is based on the Swiss context, which is characterized by the greatest frequency of medical visits in Europe, the highest rate of growth for care expenditure, poor public information but a lot of structured data (new fee system introduced in 2004). The proposed conceptual framework is universal and based on descriptors of six entities: general population, people with poor health, patients, services, resources and effects. We show that most conceptual shortcomings can be overcome and that the proposed indicators can be achieved without threatening privacy protection, using modern cryptographic techniques. Twelve indicators are suggested for the surveillance of the ambulatory care system, almost all based on routinely available data: morbidity, accessibility, relevancy, adequacy, productivity, efficacy (from the points of view of the population, people with poor health, and patients), effectiveness, efficiency, health services coverage and financing. The additional costs of this surveillance system should not exceed Euro 2 million per year (Euro 0.3 per capita).

Influenza Pandemic Preparedness in Ireland Joint Assessment Report 2007

Influenza Pandemic Preparedness in Ireland Joint Assessment Report 2007 Evaluating the readiness of the European Union and its Member States for influenza are integral components of the overall process of improving overall pandemic preparedness in Europe. A starting point for improving pandemic preparedness was a workshop on preparedness planning organized jointly by the European Commission (EC) and WHO EURO in Luxembourg, March 2005. Click here to download PDF 471kb

Mapping HIV-related behavioural surveillance among injecting drug users in Europe, 2008.

The systematic collection of behavioural information is an important component of second-generation HIV surveillance. The extent of behavioural surveillance among injecting drug users (IDUs) in Europe was examined using data collected through a questionnaire sent to all 31 countries of the European Union and European Free Trade Association as part of a European-wide behavioural surveillance mapping study on HIV and other sexually transmitted infections. The questionnaire was returned by 28 countries during August to September 2008: 16 reported behavioural surveillance studies (two provided no further details). A total of 12 countries used repeated surveys for behavioural surveillance and five used their Treatment Demand Indicator system (three used both approaches). The data collected focused on drug use, injecting practices, testing for HIV and hepatitis C virus and access to healthcare. Eight countries had set national indicators: three indicators were each reported by five countries: the sharing any injecting equipment, uptake of HIV testing and uptake of hepatitis C virus testing. The recall periods used varied. Seven countries reported conducting one-off behavioural surveys (in one country without a repeated survey, these resulted an informal surveillance structure). All countries used convenience sampling, with service-based recruitment being the most common approach. Four countries had used respondent-driven sampling. Three fifths of the countries responding (18/28) reported behavioural surveillance activities among IDUs; however, harmonisation of behavioural surveillance indicators is needed.

Comparison of HIV-infected patients' characteristics, healthcare resources use and cost between native and migrant patients

OBJECTIVES: To assess whether patients' characteristics and healthcare resources consumption and costs were different between native and migrant populations in Switzerland. METHODS: All adult patients followed-up in the Swiss HIV-cohort study in our institution during 2000-2003 were considered. Patients' characteristics were retrieved from the cohort database. Hospital and outpatient resource use were extracted from individual charts and valued with 2002 tariffs. RESULTS: The 66 migrants were younger (29 +/- 8 years versus 37 +/- 11, p < 0.001), less often of male gender (38 % versus 70 %, p < 0.001), predominantly infected via heterosexual contact (87 % versus 52 %, p < 0.01), with lower mean CD4 level at enrollment (326 +/- 235 versus 437 +/- 305, p = 0.002) than their 200 native counterparts. Migrants had fewer hospitalizations, more frequent outpatient visits, laboratory tests, and lower total cost of care per year of follow-up (<euro> 2'215 +/- 4'206 versus 4'155 +/- 12'304, p = 0.037). Resource use and costs were significantly higher in people with < 200 CD4 cell counts in both groups. CONCLUSIONS: Migrant population had more advanced disease, more outpatient visits but less hospitalizations, resulting in lower costs of care when compared with native population.

Trends in drug consumption and risk of transmission of HIV and hepatitis C virus among injecting drug users in Switzerland, 1993-2006

As a part of the HIV behavioural surveillance system in Switzerland, repeated cross-sectional surveys were conducted in 1993, 1994, 1996, 2000 and 2006 among attenders of all low threshold facilities (LTFs) with needle exchange programmes and/or supervised drug consumption rooms for injection or inhalation in Switzerland. Data were collected in each LTF over five consecutive days, using a questionnaire that was partly completed by an interviewer and partly self administered. The questionnaire was structured around three topics: socio-demographic characteristics, drug consumption, health and risk/preventive behaviour. Analysis was restricted to attenders who had injected drugs during their lifetime (IDUs). Between 1993 and 2006, the median age of IDUs rose by 10 years. IDUs are severely marginalised and their social situation has improved little. The borrowing of used injection equipment (syringe or needle already used by other person) in the last six months decreased (16.5% in 1993, 8.9% in 2006) but stayed stable at around 10% over the past three surveys. Other risk behaviour, such as sharing spoons, cotton or water, was reported more frequently, although also showed a decreasing trend. The reported prevalence of HIV remained fairly stable at around 10% between 1993 and 2006; reported levels of hepatitis C virus (HCV) prevalence were high (56.4% in 2006). In conclusion, the overall decrease in the practice of injection has reduced the potential for transmission of infections. However as HCV prevalence is high this is of particular concern, as the current behaviour of IDUs indicates a potential for further spreading of the infection. Another noteworthy trend is the significant decrease in condom use in the case of paid sex.

1.5 m for Finglas Addiction Support Team (FAST)

Noel Ahern T.D., Minister of State at the Department of Community, Rural and Gaeltacht Affairs with responsibility for the National Drugs Strategy, has announced funding of &euro;1.5m under the Premises Initiative Fund to Finglas Addiction Support Team (FAST). FAST is a community-based initiative funded by the Department of Community, Rural & Gaeltacht Affairs under the National Drugs Strategy through Finglas/Cabra Local Drugs Task Force.This resource was contributed by The National Documentation Centre on Drug Use.

A future full of hope: Crosscare annual report 2003.

Crosscare (formerly known as the Catholic Social Service Conference CSSC) have been responding to the needs of people on the margins of society since 1941. Currently they employ close to 170 staff with an annual expenditure running towards &euro;11 million. Their range of programmes is diverse and they reach into areas of high need.This resource was contributed by The National Documentation Centre on Drug Use.

2006 Drugs estimate refuels debate on governance, Issue 17, Spring 2006

In November 2005 &euro;34.027 million was voted for the Drugs Initiative, which funds the local and regional drugs task forces, and the Young People’s Facilities and Services Fund (YPFSF), in 2006 – an 8 per cent increase on the allocation for 2005 and ‘well in excess of inflation’ according to the government. The community sector strongly criticised this estimate, calling for an additional &euro;8 million to &euro;15 million, to fund the projects identified following the creation of the Emerging Needs Fund in January 2005. In February 2006, the government revised its drugs estimate upwards by a further &euro;8.979 million. As well as criticising the 2006 drugs estimate, the community sector raised a series of concerns with regard to governance – the rules, processes and behaviour that affect the way in which powers are exercised4 – or, in short, decision-making with regard to drugs policy in Ireland.This resource was contributed by The National Documentation Centre on Drug Use.

Travellers and substance use in Ireland: Recommendations for drug and alcohol policy

The Traveller community was traditionally protected from drug use by distinct traditional anti-drug norms and potent family networks within their â&euro;˜separatenessâ&euro;™ from the â&euro;˜settledâ&euro;™ community. Estimations of Traveller substance use remain clouded due to lack of ethnic monitoring in drug reporting systems, and poor service utilization by Travellers. This article draws on a Traveller and substance use regional needs analysis in Ireland, comprising 12 Traveller focus groups and 45 interviews with key stakeholders. Drug activity in terms of both drug dealing and drug use among Travellers is increasing in recent years [Van Hout, M.C. (2009a). Substance misuse in the traveller community: A regional needs assessment. Western Regional Drug Task Force. Series 2. ISBN 978-0-9561479-2-9].   Traditional resiliency factors are dissipating in strength due to increased Traveller housing within marginalized areas experiencing drug activity and increased levels of young Travellers encountering youth drug use within school settings, by way of their attempts â&euro;˜to fit inâ&euro;™ and integrate with their â&euro;˜settled peersâ&euro;™ [Van Hout, M.C. (2009b). Irish travellers and drug use â&euro;“ An exploratory study. Ethnicity and Inequalities in Health and Social Care, 2(1), 42â&euro;“49]. Fragmentation of Traveller culture is occurring as Travellers strive to retain their identity within the assimilation process into modern sedentarist Irish society. Treatment and outreach policies need to protect Traveller identity by reducing discriminatory experiences, promoting cultural acceptance with service staff and addressing literacy, implementing peer led approaches and offering flexible therapy modalities.This resource was contributed by The National Documentation Centre on Drug Use.

Effective services for substance misuse & homelessness in Scotland: The recommendations of the Advisory Group on Homelessness and Substance Misuse

The Group makes 12 recommendations for actions covering the two key themes of strategic and organisational responses, and service design and delivery. It calls for: * A joint strategic response at national level to be developed * A joint strategic response at a local level to be developed (responsibility sitting with Alcohol and Drug Partnerships (ADPs) * Recognition of the importance of investing to save over the long term * A joint operational response at local level to be developed * More flexible approaches in rural and island areas * Service development and commissioning to be based on evidence of good practice * An individualâ&euro;™s priorities to be the starting point for the design and delivery of services and support * Ongoing evaluation of services in this field to be managed through the ADP planning and monitoring processes * Targeted service user participation and involvement to be supported * Training across homelessness, housing, alcohol and drug fields to be supported in statutory and commissioned services * The stigmatisation of these populations to be addressed at a local and national level.This resource was contributed by The National Documentation Centre on Drug Use.

Differentiated normalization and drug transitions among rural youth in Ireland.

Prevalence surveys in Ireland indicate an increased trend of youth drug use with rural areas reporting comparable drug availability and prevalence of use in urban settings (Currie, C., Nic Gabhainn, S., Godeau, E., Roberts, C., Smith, R., & Currie, D. (Eds.). (2008). Inequalities in young people's health: HBSC international report from the 2005/2006 survey. Copenhagen: WHO Regional Office for Europe). Few studies have explored the contexts and meaning of drug use on rural youth transitions in terms of increased drug prevalence, recent influx of rural drug activity, normative tolerance of recreational drug consumption and fragmentation of traditional rural communities. Qualitative interviews were conducted with 220 young people (15â&euro;“17 years), and 78 service providers in a rural area of Ireland, in order to yield contextualized narratives of their experiences of drug use and achieve a wider exploration of processes, drug transitions and realities of rural youth. The thematic analysis of the research described varied pathways, attitudes and typologies of rural youth drug use, ranging from abstinent, recreational and moderated to maturing out. The research suggests support for a â&euro;˜differentiatedâ&euro;™ normalization theory (Shildrick, T. (2002). Young people, illicit drug use and the question of normalisation theory. Journal of Youth Studies, 5, 35â&euro;“48) in terms of consumerist and normative rural youth drug use transitions in their negotiation of risk within integrating rural and urban dichotomies. In conclusion, it is recommended that drug education programmes need to situate localized rural drug taking behaviours within a wider understanding of rural community life.This resource was contributed by The National Documentation Centre on Drug Use.

Psychosis with coexisting substance misuse: assessment and management in adults and young people.

This guideline offers best practice advice on the assessment and management of people with psychosis and coexisting substance misuse. Psychosis is a condition that affects a personâ&euro;™s mental state, including their thoughts, mood and behaviour. The symptoms of psychosis are:â&euro;¢ hallucinations â&euro;“ hearing voices and sometimes seeing things that are not really thereâ&euro;¢ delusions â&euro;“ having fixed beliefs that are false but which the person believes in completely. Substance misuse is a broad term encompassing, in this guideline, the harmful use of any psychotropic substance, including alcohol and either legal or illicit drugs. Use of such substances is harmful when it has a negative effect on a personâ&euro;™s life, including their physical and mental health, relationships, work, education and finances or leads to offending behaviour.This resource was contributed by The National Documentation Centre on Drug Use.