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

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

Autism; it's for life, not just the weekend

An article about holidaying with a child with autism on a popular Australian website has sparked exasperation among many parents and advocates. Ian Rogerson, Nicole Rogerson and Michael Whelan respond. Against a backdrop of a middle-class vacation at a beach house, disability arrives and Lives are Changed when a kid "steals" a sausage roll. No. This is not the premise for a rejected David Williamson screenplay. It's the work of a writer who felt her weekend away with a family whose number happened to include an autistic kid deserved some attention. As parents of children on the autism spectrum we too think the piece published on a major Australian website yesterday deserves some attention. Just, perhaps, not in the way its author had hoped.

Life events and social support among patients with major depressive disorder

The study is part of a research project of 269 psychiatric patients with major depression, Vantaa Depression Study, in the Department of Mental Health and Alcohol Research of the National Public Health Institute and the Department of Psychiatry of the Peijas Medical Care District. The aim was to study at the onset of MDE psychosocial differences in subgroups of patients and clustering of events into time before depression and its prodromal phase, to study whether more severe life events and less social support predict poorer outcome in all patients, but most among those currently in partial remission, whether social support declines as a consequence of time spent in MDE, is sensitive to improvement, and whether social support is influenced by neuroticism and extraversion. After screening, a semistructured interview (SCAN, version 2.0) was used for the presence of DSM-IV MDE, and other psychiatric diagnoses. Life events and social support were studied with semistructured methods (IRLE, Paykel 1983; IMSR, Brugha et al. 1987), perceived social support and neuroticism/extraversion with questionnaires (PSSS-R, Blumenthal et al. 1987; EPI, Eysenck and Eysenck 1964) at baseline, 6 and 18 months. At the onset of depression life events were common. No major differences between subgroups of patients were found; the younger had more events, whereas those with comorbid alcoholism and personality disorders perceived less support. Although events were distributed evenly between the time before depression, the prodromal phase and the index MDE, two thirds of the patients attributed their depression to some life event. Adversities and poor perceived support influenced the outcome of all psychiatric patients, most in the subgroup of full remission. In the partial remission group, the impact of severe events and in the MDE, perceived support was important. Low objective and subjective support were predicted by longer time spent in MDE. Along with improvement subjective support improved. Neuroticism and extraversion were associated with the size of social network and perceived support and predicted change of perceived support. In conclusion, adversities were common in all phases of depression. They may thus have many roles; before depression they may precipitate it, in the prodromal phase worsen symptoms, and during the MDE, the outcome of depression. Patients often attributed their depression to a life event. Psychosocial subgroup differences were quite small. Perceived support predicted the outcome of depression, and time spent in MDE objective and subjective support. Neuroticism and extraversion may modify the level and change particularly in perceived support, thereby indirectly effecting vulnerability to depression.

Elisabet Eliasberg writing in her first American home after fleeing Hitler's Austria; 73 Payson Avenue, New York City Portraits Women

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The other country: A father's journey with autism

The memoir The Other Country and the essay Inspiration is Power examine i) contemporary experiences of autism and ii) the representation of autism disorder in scientific and autobiographical writing. The Other Country is a memoir of four years in the life of its author Michael Whelan, and his family, in the care of his son, Charlie. In February 1998, Charlie was diagnosed with autism, and in that moment Michael and his family's lives changed. The memoir describes in four parts a four-year journey through a father?s experiences: - Part 1, Welcome to Holland, the family's feelings of fear, grief and dislocation following diagnosis; - Part 2, Look at Me, the chaotic process of research and treatment, and intense early intervention programs; - Part 3, The Enchanted Cottage, the slow process of recovery that the family went through, and; - Part 4, The Long Way Home, the transformation of Charlie, Michael and his family and notions of home and normalcy. The title, The Other Country, in this context refers to the largely invisible parallel society inhabited by anyone who lives outside the mainstream. The accompanying critical essay, Inspiration is Power, examines the influence of the discourses of biomedical science and parental pathology on the representation and understanding of autism. Specifically, among autism narratives, the medical voice has an overwhelming authority and power in characterizing autistic disorder and experience for the lay reader. This discourse contests the moral authority of parental autobiographical writing, which, by contrast, characterizes autism as a personalized invading other and thief of their child. Through a critique of specific aspects of identity, narrative, evidence and authority, the essay suggests a register of rhetorical moves that may be employed to influence, and consequently empower, the reader of autism narratives.

Writing fashion’s future: the gods and monsters of the Anthropocene

This paper identifies two narratives of the Anthropocene and explores how they play out in the realm of future-looking fashion production. Each narrative draws on mythic comparisons to gods and monsters to express humanity’s dilemmas, albeit from different perspectives. The first is a Malthusian narrative of collapse and scarcity, brought about by the monstrous, unstoppable nature of human technology set loose on the natural world. In this vein, philosopher Slavoj Zizek (2010) draws on Biblical analogies, likening ecological crisis to one of the four horsemen of the apocalypse. To find a myth to suit the present times, novelist A.S Byatt (2011) proposes Ragnarök, a Norse myth in which the gods destroy themselves. In contrast, the second narrative is one of technological cornucopia. Stewart Brand (2009, 27), self-described ‘eco-pragmatist’ writes, ‘we are as gods and we have to get good at it’. In his view, human technologies offer the only hope to mitigating the problems caused by human technology – Brand suggests harnessing nuclear power, bioengineering of crops and the geoengineering of the planet as the way forward. Similarly, the French philosopher Bruno Latour (2012, 274), exhorts us to “love our monsters”, likening our technologies to Doctor Frankenstein’s monster – set loose upon the world, and then reviled by his creator. For both Brand and Latour, human technology may be monstrous, but it must also be turned toward solutions. Within this schema, hopeful visions of the future of fashion are similarly divided. In the techno-enabled cornucopian future, the fashion industry embraces wearable technology, speed and efficiency. Technologies such as waterless dyeing, 3D printing and self-cleaning garments shift fashion into a new era of cleaner production. Meanwhile, in the narrative of scarcity, a more cautious approach sees fashion return to a new localism and valuing of the hand-made in a time of shrinking resources. Through discussion of future-looking fashion designers, brands, and activists, this paper explores how they may align along a spectrum to one of these two grand narratives of the future. The paper will discuss how these narratives may unconsciously shape the perspective of both producers and users around the fashion of today and the fashion of tomorrow. This paper poses the question: what stories can be written for fashion’s future in the Anthropocene, and are they fated, or can they be re-written?

Jewish war veterans entering synagogue for service to honor the war dead; Munich Jewish Life

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Life history and host range of Alagoasa extrema (Coleoptera: Chrysomelidae: Alticinae), a potential biological control agent of Lantana spp. (Verbenaceae) in Australia

The life history and host range of the lantana beetle, Alagoasa extrema, a potential biocontrol agent for Lantana spp. were investigated in a quarantine unit at the Alan Fletcher Research Station, Brisbane, Australia. Adults feed on leaves and females lay batches of about 17 eggs on the soil surface around the stems of plants. The eggs take 16 days to hatch and newly emerged larvae move up the stem to feed on young leaves. Larvae feed for about 23 days and there are three instars. There is a prepupal non-feeding stage that lasts about 12 days and the pupal stage, which occurs in a cocoon in the soil, lasts 16 days. Teneral adults remain in the cocoon for 3 days to harden prior to emergence. Males live for about 151 days while females live for about 127 days. The pre-oviposition period is 19 days. In no-choice larval feeding trials, nine plant species, representing three families, supported development to adult. Three species, Aloysia triphylla, Citharexylum spinosum and Pandorea pandorana were able to support at least two successive generations. These results confirm those reported in South Africa and suggest that A. extrema is not sufficiently specific for release in Australia. Furthermore, it is not recommended for release in any other country which is considering biological control of lantana.

A multi-faceted approach for quantifying the estuarine-nearshore transition in the life cycle of the bull shark, Carcharhinus leucas.

Understanding the ontogenetic habitat linkages of sharks is important for conservation and managing human interactions. We used acoustic telemetry, catch data, elemental and stable isotope signatures and dietary analyses to investigate ontogenetic habitat use in south-east Queensland, Australia, by the bull shark Carcharhinus leucas, a IUCN 'near-threatened' species that is implicated in many shark attacks on humans in urban estuaries. Sequential analyses for delta(15)N and delta(13)C of vertebrae from five adult C. leucas and laser ablation inductively coupled plasma mass spectrometry (LA-ICPMS) for elemental composition from 23 C. leucas, including a pregnant female, were also used to trace ontogenetic habitat dependence. Acoustic telemetry indicated large juvenile and subadult C. leucas remained in estuarine habitats. delta(15)N values across shark vertebrae showed an ontogenetic shift in diet with total length (TL), confirmed by stomach contents. LA-ICPMS data reflected the ontogenetic movements of C. leucas from natal habitats. Differences among adults were gender related. Shifts in habitat use by subadults were correlated with a sigmoidal delta(13)C relationship with TL. C. leucas have a multipartite, stage-specific dependency in their transition between habitats along the freshwater-estuarine-marine continuum, making them particularly susceptible to the habitat alteration that is occurring globally.

Sustainable life cycles of natural-precursor-derived nanocarbons

Sustainable societal and economic development relies on novel nanotechnologies that offer maximum efficiency at minimal environmental cost. Yet, it is very challenging to apply green chemistry approaches across the entire life cycle of nanotech products, from design and nanomaterial synthesis to utilization and disposal. Recently, novel, efficient methods based on nonequilibrium reactive plasma chemistries that minimize the process steps and dramatically reduce the use of expensive and hazardous reagents have been applied to low-cost natural and waste sources to produce value-added nanomaterials with a wide range of applications. This review discusses the distinctive effects of nonequilibrium reactive chemistries and how these effects can aid and advance the integration of sustainable chemistry into each stage of nanotech product life. Examples of the use of enabling plasma-based technologies in sustainable production and degradation of nanotech products are discussed—from selection of precursors derived from natural resources and their conversion into functional building units, to methods for green synthesis of useful naturally degradable carbon-based nanomaterials, to device operation and eventual disintegration into naturally degradable yet potentially reusable byproducts.

Albert Einstein writing; California Portraits; Men

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Albert Einstein writing at desk Portraits; Men

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A new magnesium-air cell for long-life applications

A novel type of magnesium-air primary cell has been evolved which employs non-polluting and abundantly available materials. The cell is based on the scheme Mg/Mg(NO3)2, NaNO2, H20/Q(C). The magnesium anode utilization is about 90% at a current density of 20 mAcm -2. The anode has been shown to exhibit a low open-circuit corrosion, a relatively uniform pattern of corrosion and a low negative difference effect in the electrolyte developed above as compared to the conventional halide or perchlorate electrolytes. In the usual air-depolarized mode of operation, the cell has been found to be capable of continuous discharge over several months at a constant cell voltage of about 1 V and a current density of 1 mAcm -2 at the cathode. The long service-life capability arises from the formation of a protective film on the porous carbon cathode and fast sedimentation of the anodic product (magnesium hydroxide) in the electrolyte. The cell has a shelf-life in the activated state of about a year due to the low open-circuit corrosion of the anode. These favourable features suggest the practical feasibility of developing economical, long-life, non-reserve magnesium-air ceils for diverse applications using magnesium anodes with a high surface area and porous carbon-air electrodes.

Spatial variation in life history reveals insight into connectivity and geographic population structure of a tropical estuarine teleost: king threadfin, Polydactylus macrochir

Understanding the life history of exploited fish species is not only critical in developing stock assessments and productivity models, but has a dual function in the delineation of connectivity and geographical population structure. In this study, patterns in growth and length and age at sex change of Polydactylus macrochir, an ecologically and economically important protandrous estuarine teleost, were examined to provide preliminary information on the species' connectivity and geographic structure across northern Australia. Considerable variation in life history parameters was observed among the 18 locations sampled. Both unconstrained and constrained (t(0) = 0) estimates of von Bertalanffy growth function parameters differed significantly among all neighbouring locations with the exception of two locations in Queensland's east coast and two in Queensland's Gulf of Carpentaria waters, respectively. Comparisons of back-calculated length-at-age 2 provided additional evidence for growth differences among some locations, but were not significantly different among locations in the south-eastern Gulf of Carpentaria or on Queensland's east coast. The length and age at sex change differed markedly among locations, with fish from the east coast of Australia changing sex from males to females at significantly greater lengths and ages than elsewhere. Sex change occurred earliest at locations within Queensland's Gulf of Carpentaria, where a large proportion of small, young females were recorded. The observed differences suggest that P. macrochir likely form a number of geographically and/or reproductively distinct groups in Australian waters and suggest that future studies examining connectivity and geographic population structure of estuarine fishes will likely benefit from the inclusion of comparisons of life history parameters. (C) 2012 Elsevier B.V. All rights reserved.