Bridging the gap: Exploring the barriers to using economic evidence in healthcare decision making and strategies for improving uptake

Evidence from economic evaluations is often not used to inform healthcare policy despite being well regarded by policy makers and physicians. This article employs the accessibility and acceptability framework to review the barriers to using evidence from economic evaluation in healthcare policy and the strategies used to overcome these barriers. Economic evaluations are often inaccessible to policymakers due to the absence of relevant economic evaluations, the time and cost required to conduct and interpret economic evaluations, and lack of expertise to evaluate quality and interpret results. Consistently reported factors that limit the translation of findings from economic evaluations into healthcare policy include poor quality of research informing economic evaluations, assumptions used in economic modelling, conflicts of interest, difficulties in transferring resources between sectors, negative attitudes to healthcare rationing, and the absence of equity considerations. Strategies to overcome these barriers have been suggested in the literature, including training, structured abstract databases, rapid evaluation, reporting checklists for journals, and considering factors other than cost effectiveness in economic evaluations, such as equity or budget impact. The factors that prevent or encourage decision makers to use evidence from economic evaluations have been identified, but the relative importance of these factors to decision makers is uncertain.

Quality of life and caregiver outcomes following decompressive hemicraniectomy for severe stroke: A narrative literature review

AIMS The aim of this narrative review of the literature was to examine the current state of knowledge regarding the impact of aggressive surgical interventions for severe stroke on patient and caregiver quality of life and caregiver outcomes. BACKGROUND Decompressive hemicraniectomy (DHC) is a surgical therapeutic option for treatment of massive middle cerebral artery infarction (MCA), lobar intracerebral hemorrhage (ICH), and severe aneurysmal subarachnoid hemorrhage (aSAH). Decompressive hemicraniectomy has been shown to be effective in reducing mortality in these three life-threatening conditions. Significant functional impairment is an experience common to many severe stroke survivors worldwide and close relatives experience decision-making difficulty when confronted with making life or death choices related to surgical intervention for severe stroke. DATA SOURCES Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PsychInfo. REVIEW METHODS A narrative review methodology was utilized in this review of the literature related to long-term outcomes following decompressive hemicraniectomy for stroke. The key words decompressive hemicraniectomy, severe stroke, middle cerebral artery stroke, subarachnoid hemorrhage, lobar ICH, intracerebral hemorrhage, quality of life, and caregivers, literature review were combined to search the databases. RESULTS Good functional outcomes following DHC for life-threatening stroke have been shown to be associated with younger age and few co-morbid conditions. It was also apparent that quality of life was reduced for many stroke survivors, although not assessed routinely in studies. Caregiver burden has not been systematically studied in this population. CONCLUSION Most patients and caregivers in the studies reviewed agreed with the original decision to undergo DHC and would make the same decision again. However, little is known about quality of life for both patients and caregivers and caregiver burden over the long-term post-surgery. Further research is needed to generate information and interventions for the management of ongoing patient and carer recovery following DHC for severe stroke.

Editorial: Structure of the case report

The CJNN is one of only two international nursing journals with a focus on neuroscience nursing. We at CJNN (the editorial staff and CANN board of directors) have had to make the difficult decision to reduce publication frequency from quarterly (four times per year) down to three editions per year. The reason behind this decision relates to the current lack of submitted articles for peer review and potential publication in the journal; it is difficult to put out a quality edition with only one or two new manuscripts. We would like to encourage Canadian neuroscience nurses to share their insights and expertise with colleagues by writing about challenges and achievements in patient care, experiences encountered on a daily basis, or about unique/interesting cases that may inform others in their practice.

Kuluttajamuotti : Kuluttajuuden tuottamisesta mainonnan instituutioissa

Advertising and marketing institutions produce categorisations of different groups of population. These categorisations serve as tools for addressing the potential consumers. This research is about how and what kind of categorisations of consumerhood are produced and how they are used as governing patterns within the institutions of advertising. My goal is to shed light on methods, cultural patterns and discourses for making people become consumers, objects for marketing measures. The data consists of 23 qualitative thematic interviews with Finnish advertising professionals. Moreover, examples are drawn from professional magazines and brochures of media agencies and marketing research organisations. First, I present some of the the official consumer categories in the consumer monitors produced by research organisations. Then, I analyse the unofficial consumer categories which are produced by advertising professionals in the interviews. The methodological framework is based on discourse theory and especially on Michel Foucault s ideas on power, governmentality, and discourses. Discursive categorisation of the population is one of the means of governmentality used in marketing and advertising. Knowledge of the consumer research is used as a tool for governing the potential consumers. Even though the real consumers always have a possibility to behave against the marketer s wishes. The marketers can not make people buy certain products or services, but they aim at influencing people in a way that they want to buy the products and start to govern themselves. As result, I present six unofficial discursive consumer categories, which are used by the advertising professionals. The consumerhood may be represented as rational, self-fulfilling, indifferent, whimsical, manipulated or sovereign. However, The discursive consumer categorisations are overlapping and controversial. The interviewed advertising professionals construct their own particular position in relation to the consumers which are viewed as others . On the other, the interviewees may talk about themselves as consumers. Finally, I maintain that the consumers and target groups of advertising are viewed as commodities in advertising institutions. The end product of the product development is not only the product but the aim is to produce the consumer of the product. The research of the ways advertising professionals aim to govern the consumers gives knowledge on the networks of power in which people act within consumer culture.

Consent Practices and Biomedical Knowledge Production in Tissue Economies

The use of human tissue sample collections has become an important tool in biomedical research. The collection, use and distribution of human tissue samples, which include blood and diagnostic tissue samples, from which DNA can be extracted and analyzed has also become a major bio-political preoccupation, not only in national contexts, but also at the transnational level. The foundation of medical research rests on the relationship between the doctor and the research subject. This relationship is a social one, in that it is based on informed consent, privacy and autonomy, where research subjects are made aware of what they are getting involved in and are then able to make an informed decision as to whether or not to participate. Within the post-genomic era, however, our understanding of what constitutes informed consent, privacy and autonomy is changing in relation to the needs of researchers, but also as a reflection of policy aspirations. This reflects a change in the power relations between the rights of the individual in relation to the interests of science and society. Using the notions of tissue economies and biovalue (Waldby, 2002) this research explores the changing relationship between sources and users of samples in biomedical research by examining the contexts under which human tissue samples and the information that is extracted from them are acquired, circulated and exchanged in Finland. The research examines how individual rights, particularly informed consent, are being configured in relation to the production of scientific knowledge in tissue economies in Finland from the 1990s to the present. The research examines the production of biovalue through the organization of scientific knowledge production by examining the policy context of knowledge production as well as three case studies (Tampere Research Tissue Bank, Hereditary Non-polyposis Colorectal Cancer and the Finnish Genome Information Center) in which tissues are acquired, circulated and exchanged in Finland. The research shows how interpretations of informed consent have become divergent and the elements and processes that have contributed to these differences. This inquiry shows how the relationship between the interests of individuals is re-configured in relation to the interests of science and society. It indicates how the boundary between interpretations of informed consent, on the one hand, and social and scientific interests, on the other, are being re-drawn and that this process is underscored, in part, by the economic, commercial and preventive potential that research using tissue samples are believed to produce. This can be said to fundamentally challenge the western notion that the rights of the individual are absolute and inalienable within biomedical legislation.

Regional IAM: analysis of risk-adjusted costs and benefits of climate policies

23 p.

An ecological characterization of the marine resources of Vieques, Puerto Rico. Part I: Historical data synthesis

From the 1940s until 2003, portions of the island of Vieques, a municipality within the Commonwealth of Puerto Rico, were used by the US Navy as a base and training facility, resulting in development and zoning history that differ in comparison to other Caribbean islands. The majority of former Navy lands are now under the jurisdiction of the Department of the Interior’s Fish and Wildlife Service as a National Wildlife Refuge, while a smaller percentage of land was transferred to the Vieques municipality and the Puerto Rico Conservation Trust. An analysis of the distribution and status of the marine resources is timely in light of the recent land transfer, increases in development and tourism, and potential changes in marine zoning around the island. To meet this need, NOAA’s Biogeography Branch, in cooperation with the Office of Response and Restoration and other local and regional partners, conducted Part I of an ecological characterization to integrate historical data and research into a synthesis report. The overall objective of this report is to provide resource managers and residents a comprehensive characterization of the marine resources of Vieques to support research, monitoring, and management. For example, knowledge of the spatial distribution of physical features, habitats, and biological communities is necessary to make an informed decision of the establishment and placement of a marine protected area (MPA). The report is divided into chapters based on the physical environment (e.g., climate, geology, bathymetry), habitat types (e.g., reefs and hardbottom, seagrasses, mangroves) and major faunal groups (e.g. fish, turtles, birds). Each section includes five subsections: an overview, description of the relevant literature, methods of analysis, information on the distribution, status and trends of the particular resource, and a discussion of ecological linkages with other components of the Vieques marine ecosystem and surrounding environment. The physical environment of Vieques is similar to other islands within the Greater Antilles chain, with some distinctions. The warm, tropical climate of Vieques, mediated by the northeasterly trade winds, is characterized by a dry season (December-April) and a rainy season (May-November), the latter of which is characterized by the occasional passage of tropical cyclones. Compared to mainland Puerto Rico, Vieques is characterized by lower elevation, less annual precipitation, and higher average temperatures. The amount of annual precipitation also varies spatially within Vieques, with the western portion of the island receiving higher amounts of rainfall than further east. While the North Equatorial Current dominates the circulation pattern in the Greater Antilles region, small scale current patterns specific to Vieques are not as well characterized. These physical processes are important factors mitigating the distribution and composition of marine benthic habitats around Vieques. In general, the topography of Vieques is characterized by rolling hills. Mt. Pirata, the tallest point at 301 m, is located near the southwest coast. In the absence of island wide sedimentation measurements, information on land cover, slope, precipitation, and soil type were used to estimate relative erosion potential and sediment delivery for each watershed. While slope and precipitation amount are the primary driving factors controlling runoff, land use practices such as urban development, military activity, road construction, and agriculture can increase the delivery of pollution and sediments to coastal waters. Due to the recent land transfer, increased development and tourism is expected, which may result in changes in the input of sediments to the coastal environment.

The protective role of religious coping in adolescents' responses to poverty and sexual decision-making in rural Kenya.

In this study, we explored how adolescents in rural Kenya apply religious coping in sexual decision-making in the context of high rates of poverty and Human Immunodeficiency Virus (HIV). Semi-structured interviews were conducted with 34 adolescents. One-third (13) reported religious coping related to economic stress, HIV, or sexual decision-making; the majority (29) reported religious coping with these or other stressors. Adolescents reported praying for God to partner with them to engage in positive behaviors, praying for strength to resist unwanted behaviors, and passive strategies characterized by waiting for God to provide resources or protection from HIV. Adolescents in Sub-Saharan Africa may benefit from HIV prevention interventions that integrate and build upon their use of religious coping.

Guidelines on artificial nutrition versus hydration in terminal cancer patients

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step I: define the eight key elements necessary to reach a decision: Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e. improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Thalidomide for managing cancer cachexia [review paper]

Cancer cachexia is a multidimensional syndrome characterised by wasting, loss of weight, loss of appetite, metabolic alterations, fatigue and reduced performance status. A significant number of patients with advanced cancer develop cachexia before death. There is no identified optimum treatment for cancer cachexia. While the exact mechanism of the action of thalidomide is unclear, it is known to have immunomodulatory and anti-inflammatory properties, which are thought to help reduce the weight loss associated with cachexia. Preliminary studies of thalidomide have demonstrated encouraging results. This review aimed to (1) evaluate the effectiveness of thalidomide, and (2) identify and assess adverse effects from thalidomide for cancer cachexia. Electronic searches were undertaken in CENTRAL, MEDLINE, EMBASE, Web of Science and CINAHL (from inception to April 2011). Reference lists from reviewed articles, trial registers, relevant conference documents and thalidomide manufacturers identified additional literature. This review included randomised controlled trials (RCTs) and non-RCTs. Participants were adults diagnosed with advanced or incurable cancer and weight loss or a clinical diagnosis of cachexia who were administered thalidomide. All titles and abstracts retrieved by electronic searching were downloaded to a reference management database. Duplicates were removed and the remaining citations were read by two review authors and checked for eligibility. Studies that were deemed ineligible for inclusion had clear reasons for exclusion documented. Data were extracted independently by two review authors for all eligible studies. While a meta-analysis was planned for this review, this was not possible due to the small number of studies included and high heterogeneity among them. Thus a narrative synthesis of the findings is presented. The literature search revealed a dearth of large, well conducted trials in this area. This has hindered the review authors' ability to make an informed decision about thalidomide for the management of cancer cachexia. At present, there is insufficient evidence to refute or support the use of thalidomide for the management of cachexia in advanced cancer patients. The review authors cannot confirm or refute previous literature on the use of thalidomide for patients with advanced cancer who have cachexia and there is inadequate evidence to recommend it for clinical practice. Additional, well conducted, large RCTs are needed to test thalidomide both singularly and in combination with other treatment modalities to ascertain its true benefit, if any, for this population. Furthermore, one study (out of the three reviewed) highlighted that thalidomide was poorly tolerated and its use needs to be explored further in light of the frailty of this population

Morphological and ecological studies on the phylum Cycliophora

Cycliophora é um filo animal descrito recentemente que acomoda, apenas, duas espécies: Symbion pandora Funch e Kristensen, 1995 e S. americanus Obst, Funch e Kristensen, 2006. Este filo é caracterizado por um ciclo de vida assaz complexo, cuja posição filogenética tem sido debatida desde a sua descoberta. Esta dissertação visa aprofundar o conhecimento geral existente acerca destes enigmáticos e pouco explorados metazoários. Assim, vários aspectos da morfologia e ecologia de ciclióforos foram estudados através de observações in vivo, técnicas de microscopia e reconstrução tridimensional. A mioanatomia de várias fases do ciclo de vida é descrita para S. pandora e S. americanus. Os nossos resultados revelam uma similaridade contundente entre a musculatura das duas espécies. A mioanatomia geral de Symbion é, ainda, comparada à de outros metazoários. A expressão de algumas substâncias imunorreactivas, como são exemplo a serotonina e as sinapsinas, é investigada em várias formas do ciclo de vida. Quando comparados com outros representantes de Spiralia, conclui-se que a neuroanatomia geral dos ciclióforos se assemelha mais às formas larvares do que aos adultos. Apesar de possuírem um plano corporal sofisticado, com extensas áreas ciliadas e uma mioanatomia complexa, descobrimos que o macho de ambas as espécies Symbion é composto por apenas algumas dezenas de células. Baseando-nos nestas observações, inferimos que a complexidade dos metazoários não se relaciona com o tamanho corporal nem com o número de células de um organismo. Estudos sobre a ultra-estrutura da fêmea revelaram, entre outras estruturas, um putativo poro genital, extensões citoplasmáticas do oócito e glândulas posteriores. Morfologia e implicações funcionais destas estruturas são aqui discutidas. A anatomia do protonefrídeo da larva cordóide é descrita. A arquitectura deste órgão diverge daquela presente noutros representantes de Nephrozoa, particularmente ao nível da área de filtração da célula terminal. As nossas observações são discutidas em termos filogenéticos. A maturação sexual em ciclióforos é investigada. Os nossos resultados sugerem que a transição de reprodução assexual a sexual se relacione com a idade da forma séssil, a “feeding stage”. A presença da larva Prometeus assente no tronco desta também poderá influenciar o processo, embora mais estudos sejam desejáveis para o comprovar. Os nossos resultados são discutidos integrativa e comparativamente com o conhecimento prévio sobre Cycliophora. A cumulação deste conhecimento será essencial para a compreensão da evolução e filogenia deste enigmático filo.

Quantity-setting competition with differentiated goods under uncertain demand

We consider a quantity-setting duopoly model, and we study the decision to move first or second, by assuming that the firms produce differentiated goods and that there is some demand uncertainty. The competitive phase consists of two periods, and in either period, the firms can make a production decision that is irreversible. As far as the firms are allowed to choose (non-cooperatively) the period they make the decision, we study the circumstances that favour sequential rather than simultaneous decisions.

Does it pay to be socially responsible? Evidence from spanish retail banking sector

This paper presents a theoretical and empirical analysis of strategic competition in retail banking when some of the financial firms are non-profit organisations that invest in social activities. Banking literature about competition is fairly large, but the strategic interaction between profit maximizing and non profit maximizers has not been extensively analysed except for Purroy and Salas (1999). In this paper, a completely different approach is taken. An adaptation of Hotelling’s two stage model of spatial competition is developed to take into account consumer perceptions respect to the two different types of financial institutions. The empirical analysis confirms that consumers take into account other features different from the price, such as social contribution or closer service to make a deposit or mortgage decision. These conclusions are of interest in the debate about a firm’s social or ethical activities. It is shown that if consumers value social activities, firms can improv

Dynamic correlations across REIT sub-sectors

The issue of whether Real Estate Investment Trusts should pursue a focused or diversified investment strategy remains an ongoing debate within both the academic and industry communities. This paper considers the relationship between REITs focused on different property sectors in a GARCH-DCC framework. The daily conditional correlations reveal that since 1990 there has been a marked upward trend in the coefficients between US REIT sub-sectors. The findings imply that REITs are behaving in a far more homogeneous manner than in the past. Furthermore, the argument that REITs should be focused in order that investors can make the diversification decision is reduced.

Dynamic correlations between REIT sub-sectors and the implications for diversification

The issue of whether Real Estate Investment Trusts (REITs) should pursue a focused or diversified investment strategy remains an ongoing debate within both the academic and industry communities. This article considers the relationship between REITs focused on different property sectors in a Generalized Autoregressive Conditional Heteroscedasticity-Dynamic Control Correlation (GARCH-DCC) framework. The daily conditional correlations reveal that since 1990 there has been a marked upward trend in the coefficients between US REIT sub-sectors. The findings imply that REITs are behaving in a far more homogeneous manner than in the past. Furthermore, the argument that REITs should be focused in order that investors can make the diversification decision is reduced.