The distribution of "big ticket" medical technologies in OECD countries. Organization for Economic Cooperation and Development

Diagnosis of retinal damage using Resnet rescaling and support vector machine (Resnet-RS-SVM): a case study from an Indian hospital

PURPOSE

This study aims to address the challenge of identifying retinal damage in medical applications through a computer-aided diagnosis (CAD) approach. Data was collected from four prominent eye hospitals in India for analysis and model development.

METHODS

Data was collected from Silchar Medical College and Hospital (SMCH), Aravind Eye Hospital (Tamil Nadu), LV Prasad Eye Hospital (Hyderabad), and Medanta (Gurugram). A modified version of the ResNet-101 architecture, named ResNet-RS, was utilized for retinal damage identification. In this modified architecture, the last layer's softmax function was replaced with a support vector machine (SVM). The resulting model, termed ResNet-RS-SVM, was trained and evaluated on each hospital's dataset individually and collectively.

RESULTS

The proposed ResNet-RS-SVM model achieved high accuracies across the datasets from the different hospitals: 99.17% for Aravind, 98.53% for LV Prasad, 98.33% for Medanta, and 100% for SMCH. When considering all hospitals collectively, the model attained an accuracy of 97.19%.

CONCLUSION

The findings demonstrate the effectiveness of the ResNet-RS-SVM model in accurately identifying retinal damage in diverse datasets collected from multiple eye hospitals in India. This approach presents a promising advancement in computer-aided diagnosis for improving the detection and management of retinal diseases.

Impact of Guidelines on the Diffusion of Medical Technology: A Case Study of Cardiac Resynchronization Therapy in the UK

INTRODUCTION

Research on clinical practice guidelines as a determinant of the diffusion of medical technology remains sparse. We aim to evaluate the impact of guidelines on the awareness of medical technology, as a proxy of its use, with the example of cardiac resynchronization therapy (CRT) in the United Kingdom (UK).

METHODS

We measured clinician awareness based on Google searches performed for CRT that corresponded with actual CRT implant numbers provided by the European Heart Rhythm Association (EHRA). We identified the guideline recommendations published by the National Institute of Health and Care Excellence (NICE) within the UK, the European Society of Cardiology (ESC) at the European level, and the American College of Cardiology Foundation/American Heart Association in the United States (US). We specified a dynamic moving average model, with Google searches as the dependent variable and guideline changes as the independent variables.

RESULTS

One guideline change published by NICE in 2007 and two changes released by the US guidelines in 2005 and 2012 were significantly correlated with the Google searches (p = 0.08, p = 0.02, and p = 0.02, respectively). Guideline changes by the ESC had no significant impact. Changes recommending CRT in place of a conventional pacemaker, in patients with atrial fibrillation, and restricting CRT due to contraindication, remained universally uninfluential.

CONCLUSION

The factors associated with a lack of awareness (as a proxy for technology diffusion) in our case study were: a lack of strong clinical evidence that resulted in the moderate strength of a recommendation, a lack of recognition of any externally published recommendation by NICE, and the frequent release of guidelines with minor changes targeting small patient groups. At least in our case, in the absence of NICE guidelines, the US guidelines received more attention than their non-UK European counterparts, even if the former were released after the latter.

The global diffusion of organ transplantation: trends, drivers and policy implications

Rising incomes, the spread of personal insurance, lifestyle factors adding to the burden of illness, ageing populations, globalization and skills transfer within the medical community have increased worldwide demand for organ transplantation. The Global Observatory on Donation and Transplantation, which was built in response to World Health Assembly resolution WHA57.18, has conducted ongoing documentation of global transplantation activities since 2007. In this paper, we use the Global Observatory’s data to describe the current distribution of – and trends in – transplantation activities and to evaluate the role of health systems factors and macroeconomics in the diffusion of transplantation technology. We then consider the implications of our results for health policies relating to organ donation and transplantation. Of the World Health Organization’s Member States, most now engage in organ transplantation and more than a third performed deceased donor transplantation in 2011. In general, the Member States that engage in organ transplantation have greater access to physician services and greater total health spending per capita than the Member States where organ transplantation is not performed. The provision of deceased donor transplantation was closely associated with high levels of gross national income per capita. There are several ways in which governments can support the ethical development of organ donation and transplantation programmes. Specifically, they can ensure that appropriate legislation, regulation and oversight are in place, and monitor donation and transplantation activities, practices and outcomes. Moreover, they can allocate resources towards the training of specialist physicians, surgeons and transplant coordinators, and implement a professional donor-procurement network.

Diffusion of innovations in health care: Does the structural context determine its direction?

Objectives: The aim of this study was to present and illustrate an instrument to measure the level of innovation at country level.

Methods: The data used are the Organisation for Economic Co-operation and Development (OECD) health data 2009, in particular the information on use of medical technology. Two composite scales expressing a relative level of adoption of innovations in health care are regressed, using multilevel regression analysis, on country characteristics. The country characteristics are selected as proxies on availability or scarcity of resources in a country. We expect that scarcity will promote adoption of innovations that enhance efficiency, and that availability of resources will promote advanced, expensive innovations.

Results: Two scales were constructed. One scale indicates the use of efficiency-enhancing innovations (day case treatment), and the other scale indicates availability of advanced technical innovations. The application of day case treatment is significantly associated with education level (+), the ratio of people aged 15–64 versus younger and older people (+) and the number of hospital beds (−). Availability of advanced medical devices are associated with the expenditure on health (+), demographic dependency (−), number of hospital beds (+), and the annual reduction of hospital beds (−).

Conclusions: Diffusion of innovations is influenced by characteristics of the country and of the healthcare system; fewer resources encourage diffusion of innovations that enhance efficiency and more resources encourage diffusion of complex, expensive devices. This indicates that decisions by healthcare professionals on which innovation to adopt is embedded in a context that is influenced and shaped by the availability of resources on macro level.

The influence of economic incentives and regulatory factors on the adoption of treatment technologies: a case study of technologies used to treat heart attacks

The Technological Change in Health Care Research Network collected unique patient-level data on three procedures for treatment of heart attack patients (catheterization, coronary artery bypass grafts and percutaneous transluminal coronary angioplasty) for 17 countries over a 15-year period to examine the impact of economic and institutional factors on technology adoption. Specific institutional factors are shown to be important to the uptake of these technologies. Health-care systems characterized as public contract systems and reimbursement systems have higher adoption rates than public-integrated health-care systems. Central control of funding of investments is negatively associated with adoption rates and the impact is of the same magnitude as the overall health-care system classification. GDP per capita also has a strong role in initial adoption. The impact of income and institutional characteristics on the utilization rates of the three procedures diminishes over time.

Patterns of care for COPD by Japanese physicians

OBJECTIVE

COPD treatment guidelines are available worldwide, yet it is not known how widely they are followed. This study evaluated the clinical care of COPD patients in Japan as compared to guideline recommendations.

METHODS

A sample of general and specialist physicians was selected from private outpatient clinics and public hospitals in Japan. Physicians were provided two clinical vignettes (COPD and asthma) and asked to make a diagnosis. They were next asked to define diagnostic tests and treatment recommendations specifically for a COPD patient. Responses were compared to recommendations from current COPD guidelines.

RESULTS

For the COPD unknown vignette, 6.2% of physicians diagnosed COPD while 54% diagnosed chronic bronchitis or emphysema. For COPD diagnosis, 81.9% of physicians recommended a CXR, 49.1% spirometry, and 17.7% a computed tomography scan. The most frequently recommended medication for a newly diagnosed COPD patient was theophylline (37.2%) followed by expectorants (32.1%) and inhaled anticholinergics (25.9%). Inhaled beta-agonists were recommended by fewer than 20% of all physicians.

CONCLUSION

Care for COPD patients by selected Japanese physicians diverges from published practice guidelines. COPD is an infrequently used diagnostic label; diagnostic evaluation is characterized by a high use of computed tomography scans, particularly by specialists; and bronchodilator use was low.

Socio-economic factors and health care system characteristics related to cancer survival in the elderly

The ELDCARE study aims to investigate, at the ecological level, the relationships between socio-economic variables and cancer survival in patients aged 65 years and over. Survival data for patients diagnosed during the period 1985-1989 and followed up to 1994 were provided by 43 European Cancer Registries in 16 countries participating in the EUROCARE 2 project. Relative survival was computed by Hakulinen's methods. Data on socio-economic factors were collected by national statistics offices for the years around 1991. Pearson's correlation was used to study the relationships between cancer survival and socio-economic factors. We selected four groups of variables. The first group included macro-economic variables (such as Gross Domestic Product, GDP; Total Health Expenditure, THE); the second, the main characteristics of national health care systems; the third, demographic factors; and the fourth, variables on labour market organisation. The countries with the largest proportions of elderly populations, in Northern and Western Europe, spent more on health than the less affluent countries of Eastern Europe. GDP was strongly related to THE but a very high variability in Computed Tomography Scanners (CTS) among countries with similar THE was observed. Indeed, those countries with THE around US 1500 dollars per capita had survival rates for breast cancer ranging from 67 to 82%. Cancer survival in elderly patients in Europe was most strongly related to GDP and THE, especially for good prognosis cancers. Survival was strongly correlated with health care technologies, particularly CTS, but not with health employment. Survival was positively correlated with proportion of married elderly people (and negatively with widowed elderly), suggesting a role played by social support in influencing the prognosis of elderly patients. These results highlight how health outcomes in the elderly are a complex phenomenon, not determined only by GDP and THE, but affected by social organisation and life habits as well as economic development conditions.

Determinants of the diffusion of computed tomography and magnetic resonance imaging

OBJECTIVES

The aim of this study is to explain factors influential to the diffusion of computed tomography (CTs) and magnetic resonance imaging (MRIs).

METHODS

Variables were identified from a review of the literature on the diffusion of health technologies. A formal process was applied to build a conceptual model of the mechanism that drives technology diffusion. Variables for the analysis were classified as predisposing, enabling, or reinforcing factors, in keeping with a model commonly used to explain the diffusion of health behaviors. Multiple regression analysis was conducted using year 2000 OECD data.

RESULTS

The results of this study showed that total health expenditure per capita (p < .01, both CTs and MRIs) and flexible payment methods to hospitals (p < .05, both CTs and MRIs) were significantly associated with the diffusion of CTs and MRIs (adjusted R2 = 0.477, 0.656, respectively).

CONCLUSIONS

This study presents a systematically developed model of the mechanism governing technology diffusion. Important findings from the study show that purchasing power, represented by total health expenditure per capita and economic incentives to hospitals in the form of flexible payment methods, were positively correlated with diffusion. Another important achievement of our model is that it accounts for all thirty OECD member countries without excluding any as outliers. This study shows that variation across countries in the diffusion of medical technology can be explained well by a logical model with multiple variables, the results of which hold profound implications for health policy regarding the adoption of innovations.

Determinants of computed tomography and magnetic resonance imaging utilization in Taiwan

OBJECTIVES

Magnetic resonance imaging (MRI) and computerized tomography (CT) scanners are high-tech equipment with the highest utilizations and expenditures in Taiwan. This study investigates the factors that affect MRI and CT utilization, such as whether supply-side factors have more impact than demand-side factors, and the effect of utilization control policies.

METHODS

This study used the nationwide CT and MRI claim data for the years 1998 to 2001 from the Bureau of National Health Insurance (BNHI) in Taiwan. Multiple regression analysis was the statistical method used to determine the relative factors that influence CT and MRI utilization.

RESULTS

CT: population ratio, hospital-based physician: population ratio, female ratio, pediatric (< or =14 years) : population ratio, and family income significantly influenced CT utilization. MRI : population ratio and hospital-based physician : population ratio, female ratio, and family income significantly influenced MRI utilization. However, the proportion of the aged (> or =65 years of age) did not significantly influence CT or MRI utilization after controlling for other factors. The rates of CT and MRI utilization for the outpatient and inpatient settings and the repeated uses of CT or MRI have decreased significantly after a utilization review was implemented by BNHI, which suggests that CT and MRI have been overused.

CONCLUSIONS

Increases in supply-side factors significantly increase CT/MRI utilization, and supply-side factors impact CT/MRI utilization more than demand-side factors. The results show that the utilization instant report policy effectively decreases repeated uses of CT/MRI.

The relationship between per capita income and diffusion of medical technologies

It is commonly known that per capita income is correlated with the level of health care spending and that technology is a major factor in explaining the increase in health care spending. This study examines differences in the rate of diffusion of medical technologies in Organization for Economic Cooperation and Development countries between 1975 and 1995. We find that the importance of income in explaining the long-term availability of a technology generally declines over time and becomes insignificant for some technologies. In other words, more affluent countries are earlier adopters of new technologies, but access to technology becomes less dependent on income over time. The evidence also suggests that the effects of reimbursement incentives are greater for purchases of diagnostic technologies than for lifesaving technologies and that reimbursement incentive effects are less significant for older technologies.

The role of media and communication in improving the use of drugs and other technologies

Policy makers, health care providers, and the general public need valid information about the benefits and harmful effects of drugs and technologies to be able to make rational choices in their acquisition, distribution, and use. Effective communication is important for quality choices of drugs and other technologies. In effective communication, the choice of messages and media must correspond to the culture and beliefs of the target groups to make them comprehend and adopt the conclusions. Messages must be presented on a regular basis. Most regulatory agencies do not have enough resources to mount effective communication programs. Private advertising agencies and other stakeholders have definite roles. Valid knowledge must be the basis of dialogues to reduce emotional disputes among various benefit groups in society.

In search of value: an international comparison of cost, access, and outcomes

The United States spent the most resources on health care of all the twenty-nine industrialized countries in 1996 by a wide margin. Managed care and other recent initiatives have been credited with slowing the rate of increase in the U.S. health care spending in recent years. Although the rate of increase slowed, it was still more rapid than the rate in most other industrialized countries between 1990 and 1996. Among the twenty-nine industrialized countries, the United states had the lowest percentage of its population eligible for publicly mandated insurance in 1995. Since 1960 Greece, Korea, and Mexico have surpassed the United States on this measure. AMong the twenty-nine industrialized countries, only the United States had less than half of its population eligible for publicly mandated health insurance in 1995. The United States appears to be comparable to the other G7 countries in terms of access to physicians, in-patient hospital services, and pharmaceuticals. However, on outcomes indicators such as life expectancy and infant mortality, the United States is frequently in the bottom quartile among the twenty-nine industrialized countries, and its relative ranking has been declining since 1960.

Economic incentives and the distribution of extracorporeal shock wave lithotripters and linear accelerators in Spain

We studied the role of economic incentives for private providers in explaining Spain's disproportionately large number of extracorporeal shock wave lithotripters (ESWLs) and low number of linear accelerators (linacs) per million population (pmp) in comparison to other countries of the Organization for Economic Cooperation and Development (OECD). We found that the reimbursement policy for 1990 allowed an average profit per private ESWL of $732,000, but no profit for linacs. Regional per-capita income was positively correlated with ESWLs pmp in Spain (R2 = 0.49; p = .001), but not with linacs. Sixty-nine percent of ESWLs were privately held versus only 16% of linacs. To avoid these types of distortions, financial incentives should be based on a reasonable relationship between cost and charges and should be associated with the appropriateness of medical care.

Clinical practice, ethics and economics: the physician at the crossroads

In recent years health services have faced the challenge of increasingly complex services and rising costs, thus the consideration of costs is a key factor in health policy decisions. The introduction of an economic perspective has sometimes been viewed as conflicting with the ethics of the health care system, especially at the physician-patient level. this article explores the important role of the physician from the ethical and economic perspective in the distribution and allocation of services. An understanding of economic and ethical principles reveals that these two perspectives are compatible with good clinical practice: more efficient health care implies better care for the individual patient and makes it possible to increase the resources available to improve care for the population as a whole. Thus, being efficient is an ethical objective. The selective elimination of ineffective services would free resources to care for those who need effective diagnostic or therapeutic procedures. This requires a better understanding of the determinants and outcomes of clinical practice, physician motivation, the appropriate design and application of incentives, and the best use of limited resources. The physician can play a key role in increasing the efficiency, equity, and quality of the health system without restricting the provision of effective services.

From universalism to selectivity: is 'appropriateness' the answer?

As health expenditures continue to consume increasingly large proportions of national budgets, ways must be found to assure that money spent on health is used for effective services. Only a small proportion of medical decisions are based on scientific evidence about their outcomes, thus it is not surprising that wide variations exist in clinical practice. In recent years, questions have been raised about how medical decisions are made and the proportion of medical procedures and services that are performed for appropriate reasons. One method that has been developed to quantify the amount of inappropriate use is the so-called 'RAND appropriateness method,' which is based on a structured review of the scientific literature and the collective judgement of an expert panel. Measured by this method, a number of procedures have been shown to have high rates of inappropriate or uncertain use. The challenge is to find ways to eliminate ineffective services and procedures to free resources for those that have been proven effective. Further research is needed to improve the method and to find acceptable ways its findings can be used to promote effective care.