Variation in Preferences for Long-Acting Injectable Pre-Exposure Prophylaxis Among US Men Who Have Sex with Men: A Latent Class Analysis

Cabotegravir long-acting injectable HIV pre-exposure prophylaxis (LA PrEP) is efficacious, with a good safety profile, and was approved by the US Food and Drug Administration in December 2021. Understanding variations in potential user preferences for LA PrEP may inform implementation and subsequently improve uptake and community-level effectiveness. HIV-negative, sexually active men who have sex with men (MSM) aged ≥15 years were recruited online for the 2019 American Men's Internet Survey, before LA PrEP approval. Respondents completed a discrete-choice experiment (DCE) with hypothetical LA PrEP attributes (out-of-pocket cost, perceived side effects, injection frequency, perceived stigma, service location). Latent class analysis segmented respondents into groups based on their preferences for the attributes presented, and relative importance of preference weights and willingness-to-pay were calculated. While the majority had never used daily oral PrEP, 73% of the 2489 respondents were very or somewhat likely to use LA PrEP. Three latent classes were identified from 2241 respondents in the DCE. The "side effects-averse" class was the largest group (64% of respondents) and placed 61% relative importance on side effects. The "ambivalent" class (20% of respondents) placed higher importance on stigma (17% of relative importance) than other classes. The "cost-conscious" class (16% of respondents) placed higher relative importance (62%) on cost compared with other attributes and classes. Perceived side effects were an important hypothetical barrier for LA PrEP uptake among a large proportion of potential MSM users. Minimizing out-of-pocket costs is likely to increase uptake and may be important to equitable access. Tailored communication strategies are recommended for the different groups of potential LA PrEP users.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

Evaluating a patient-centered discrete choice experiment to quantify individual treatment preferences of newly diagnosed older adults with acute myeloid leukemia: A mixed methods study

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Background: Numerous studies have demonstrated that physician perceptions of patient priorities and patients’ stated preferences differ substantially. Use of preference clarification using discrete choice experiments (DCEs) has been shown to improve preference-concordance for patients with solid tumors. Previously, we developed a DCE to describe preferences of survivors of acute myeloid leukemia (AML). We sought to evaluate this DCE among newly diagnosed patients with AML to inform shared decision-making. Methods: We used a sequential explanatory (quantitative to qualitative) mixed methods design to assess acceptability, feasibility, and content validity of the DCE to elicit individual preferences. Newly diagnosed older (≥ 60 years) adults with AML completed the DCE at the time of treatment decision. Patients and caregivers then completed semi-structured interviews to expand on quantitative findings. Based on initial results, healthy volunteers completed think-aloud sessions while completing the DCE and semi-structured interviews to further evaluate comprehensibility. Results: 47 participants were enrolled (18 patients [8 female, 10 male; aged 60-87], 16 caregivers, 15 healthy volunteers). Patients received best supportive care (n = 1), hypomethylating agents (n = 9), and high-intensity chemotherapy (n = 8). Feasibility/Acceptability: All patients completed the DCE (100% feasibility), and all reported that they answered according to their preferences (100% acceptability). Content Validity: 1) Relevance: 17/18 (94%) felt the DCE was relevant. 2) Comprehensiveness: In addition to the attributes in the DCE, provider recommendations and family considerations were noted to be critical in treatment decision-making. 3) Comprehensibility: Only 13/18 (72%) felt the DCE was easy to understand, and 14/18 (78%) felt it was easy to answer. Explanatory Interviews: Patients reported being in “shock,” “devastated” from receiving the diagnosis, feeling overwhelmed (“I was floored”) and not being able to reliably concentrate on the DCE due to these factors. Caregivers corroborated patients’ reports. Healthy volunteers also reported “information overload” and that the DCE was “technical” and the included outcome levels were “confusing.”. Conclusions: This DCE designed for older adults with AML was relevant, feasible, and acceptable. However, nearly 30% of patients reported difficulty understanding the DCE. Some reported not being able to attend to the complex tasks in the DCE, thereby compromising content validity of the measure. We suspect this was due to the distress caused by the diagnosis. This study demonstrates the challenge of developing valid preference elicitation instruments for newly diagnosed patients and highlights the need for extensive evaluation prior to clinical implementation.

Structural and Social Determinants of Health Factors Associated with County-Level Variation in Non-Adherence to Antihypertensive Medication Treatment

Background: Non-adherence to antihypertensive medication treatment (AHM) is a complex health behavior with determinants that extend beyond the individual patient. The structural and social determinants of health (SDH) that predispose populations to ill health and unhealthy behaviors could be potential barriers to long-term adherence to AHM. However, the role of SDH in AHM non-adherence has been understudied. Therefore, we aimed to define and identify the SDH factors associated with non-adherence to AHM and to quantify the variation in county-level non-adherence to AHM explained by these factors. Methods: Two cross-sectional datasets, the Centers for Disease Control and Prevention (CDC) Atlas of Heart Disease and Stroke (2014–2016 cycle) and the 2016 County Health Rankings (CHR), were linked to create an analytic dataset. Contextual SDH variables were extracted from the CDC-CHR linked dataset. County-level prevalence of AHM non-adherence, based on Medicare fee-for-service beneficiaries’ claims data, was extracted from the CDC Atlas dataset. The CDC measured AHM non-adherence as the proportion of days covered (PDC) with AHM during a 365 day period for Medicare Part D beneficiaries and aggregated these measures at the county level. We applied confirmatory factor analysis (CFA) to identify the constructs of social determinants of AHM non-adherence. AHM non-adherence variation and its social determinants were measured with structural equation models. Results: Among 3000 counties in the U.S., the weighted mean prevalence of AHM non-adherence (PDC < 80%) in 2015 was 25.0%, with a standard deviation (SD) of 18.8%. AHM non-adherence was directly associated with poverty/food insecurity (β = 0.31, P-value < 0.001) and weak social supports (β = 0.27, P-value < 0.001), but inversely with healthy built environment (β = −0.10, P-value = 0.02). These three constructs explained one-third (R² = 30.0%) of the variation in county-level AHM non-adherence. Conclusion: AHM non-adherence varies by geographical location, one-third of which is explained by contextual SDH factors including poverty/food insecurity, weak social supports and healthy built environments.

Priorities among HIV-positive individuals for tuberculosis preventive therapies

BACKGROUND: There has been slow uptake of isoniazid preventive therapy (IPT) among people living with HIV (PLWH).METHODS: We surveyed adults recently diagnosed with HIV in 14 South African primary health clinics. Based on the literature and qualitative interviews, sixteen potential barriers and facilitators related to preventive therapy among PLWH were selected. Best-worst scaling (BWS) was used to quantify the relative importance of the attributes. BWS scores were calculated based on the frequency of participants' selecting each attribute as the best or worst among six options (across multiple choice sets) and rescaled from 0 (always selected as worst) to 100 (always selected as best) and compared by currently receiving IPT or not.RESULTS: Among 342 patients surveyed, 33% (n = 114) were currently taking IPT. Having the same standard of life as someone without HIV was most highly prioritized (BWS score = 67.3, SE = 0.6), followed by trust in healthcare providers (score, 66.3 ± 0.6). Poor standard of care in public clinics (score, 30.6 ± 0.6) and side effects of medications (score, 33.7 ± 0.6) were least prioritized. BWS scores differed by IPT status for few attributes, but overall ranking was similar (spearman's rho = 0.9).CONCLUSION: Perceived benefits of preventive therapy were high among PLWH. IPT prescription by healthcare providers should be encouraged to enhance IPT uptake among PLWH.

Prioritizing outcome preferences in patients with ocular hypertension and open-angle glaucoma using best-worst scaling

Purpose

To quantify patients' preferences for glaucoma outcomes and use this information to prioritize outcomes that are important to patients.

Design

A cross-sectional study using best-worst scaling object case (BWS).

Participants

Two hundred seventy-four participants newly diagnosed with ocular hypertension or mild to moderate open angle glaucoma from three private practices and one academic medical center in the United States.

Methods

We designed a preference-elicitation survey based on findings from 25 semi-structured, qualitative interviews with patients with glaucoma (reported elsewhere). The survey asked participants to rate the importance of 13 glaucoma outcomes on a Likert scale as a warm-up exercise followed by completion of 13 BWS tasks. For each task, we presented participants a subset of four outcomes from the possible thirteen, and participants chose the most important and least important outcome. Outcomes included in the survey pertain to maintaining ability to perform vision-dependent activities of daily living (e.g., driving), maintaining visual function and perception (e.g., depth perception), minimizing need to take glaucoma drops, not experiencing ocular surface symptoms (e.g., red eyes, teary eyes), and having adequate control of intraocular pressure (IOP). We administered the survey online and analyzed response patterns using conditional logistic regression to determine the relative importance of different outcomes.

Main outcome

Ordinal ranking of glaucoma outcomes based on preference weights.

Results

Between September 1, 2017 and February 28, 2018, we invited 1035 patients to complete our survey, among whom 274 (26%) responded. Most participants were older than 65 years of age (146/274, 53%) and currently on IOP-lowering drops (179/274, 65%). Participants identified that outcomes with the largest relative importance weight were having "adequate IOP control" and ability to "drive a car during the day," and the outcomes with the smallest relative importance weights were "maintaining appearance of the eye" and "reducing the number of IOP-lowering drops".

Conclusions

Determining the relative importance of glaucoma outcomes to patients can help researchers design studies that may better inform clinical and regulatory decision-making. Although IOP is an outcome that researchers often measure in glaucoma clinical trials, patients also prioritized outcomes related to the ability to perform vision-dependent activities such as driving.

Predicting chance of liver transplantation for pediatric wait-list candidates

Information about wait-list time has been reported as one of the single most frequently asked questions by individuals awaiting a transplant but data regarding wait-list time have not been processed in a useful way for pediatric candidates. To predict chance of receiving a DDLT, we identified 6471 pediatric (<18 years), non status-1A, liver-only transplant candidates between 2006 and 2017 from the SRTR. Cox regression with shared frailty for DSA level effect was used to model the association of blood type, weight, allocation PELD and MELD, and DSA with chance of DDLT. Jackknife technique was used for validation. Median (interquartile range) wait-list time was 100 (34-309) days. Non-O Blood type, higher PELD/MELD score at listing, and DSA were associated with increased chance of DDLT, while age 1-5 years and 10-18 years was associated with lower chance of DDLT (P < 0.001 for all variables). Our model accurately predicted chance of transplant (C-statistic = 0.68) and was able to predict DDLT at specific follow-up times (eg, 3 months). This model can serve as the basis for an online tool that would provide useful information for pediatric wait-list candidates.

Barriers to access in pediatric living-donor liver transplantation

Children receiving a LDLT have superior post-transplant outcomes, but this procedure is only used for 10% of transplant recipients. Better understanding about barriers toward LDLT and the sociodemographic characteristics that influence these underlying mechanisms would help to inform strategies to increase its use. We conducted an online, anonymous survey of parents/caregivers for children awaiting, or have received, a liver transplant regarding their knowledge and attitudes about LDLT. The survey was completed by 217 respondents. While 97% of respondents understood an individual could donate a portion of their liver, only 72% knew the steps in evaluation, and 69% understood the donor surgery was covered by the recipient's insurance. Individuals with public insurance were less likely than those with private insurance to know the steps for LDLT evaluation (44% vs 82%; P < 0.001). Respondents with public insurance were less likely to know someone that had been a living donor (44% vs 56%; P = 0.005) as were individuals without a college degree (64% vs 85%; P = 0.007). Nearly all respondents generally trusted their healthcare team. Among respondents, 82% believed they were well-informed about LDLT but individuals with public insurance were significantly less likely to feel well-informed (67% vs 87%; P = 0.03) and to understand how donor surgery might impact donor work/time off (44% vs 81%; P = 0.001). Substantial gaps exist in parental understanding about LDLT, including its evaluation, potential benefits, and complications. Greater emphasis on addressing these barriers, especially to individuals with fewer resources, will be helpful to expand the use of LDLT.

Caregivers' Priorities and Observed Outcomes of Attention-Deficit Hyperactivity Disorder Medication for Their Children

OBJECTIVE

To document variability among caregivers' priorities when considering medication to treat their Children's attention-deficit hyperactivity disorder (ADHD) and explore associations between these priorities and medication-related improvements.

METHODS

Caregivers of children, ages 4 to 14 years, diagnosed with ADHD were recruited from outpatient clinics and support groups across Maryland. A survey gathered data on caregiver-reported concerns when considering ADHD medication, demographic characteristics, and observed and desired improvements in their child's ADHD. A validated Best-Worst Scaling instrument assessed priorities among 16 concerns when considering ADHD medication. Latent class analysis identified subgroups with similar ADHD medication concerns. Differences in self-reported medication-related improvements were examined across subgroups.

RESULTS

The 184 participants (mean = 42 yrs) were primarily the biological mother, 68% white and 25% black. Their children were mostly male (73%) and using medication (81%). Overall, the most important ADHD medication concerns were the child becoming a successful adult (p < 0.0001), school behavior improvements (p < 0.0001), and better grades (p < 0.0001). Others thinking badly of the child was a significantly less important concern (p < 0.0001). Three subgroups were identified: short-term outcomes-oriented group (39%), long-term outcomes-oriented group (37%), and side effects/safety-oriented group (27%). Relative to the other 2 groups, a smaller proportion of the side effects/safety-oriented group desired these improvements (p < 0.2618).

CONCLUSION

Most caregivers prioritize short- and long-term outcomes when considering ADHD medication. However, those most concerned with long- or short-term outcomes tended to desire additional improvements in their child's ADHD.

Is immunotherapy toxicity associated with improved overall survival among older adults with advanced cancer?

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Background: There is growing evidence that checkpoint inhibitor immunotherapy (IO) toxicity is associated with improved treatment response. There is a paucity of evidence examining the relationship between toxicity and overall survival (OS) in older adults. Methods: We performed a single institution retrospective cohort study of adults who received IO for advanced cancer from 2011-2017. Baseline clinical characteristics were abstracted from the electronic health record. Immune-related toxicities were graded by physicians based on Common Terminology for Adverse Events criteria, v4.0. Bivariate analysis with chi-squared statistics was used to describe baseline characteristics of patients ≥70 years (y) vs. <70y. Survival outcomes were estimated by the Kaplan-Meier method (time zero = start of first-line IO) and compared using the log-rank test. The association of age and ≥ grade 3 toxicity with OS was tested with a Cox proportional hazards model. Results: Among 676 patients treated with IO, 238 (35.4%) were ≥70y. There was no difference in baseline characteristics of each age group except cancer type (P<0.01). The incidence of ≥ grade 3 toxicity did not differ by age (<70y: 14.5% vs. ≥70y: 13.5%, P=0.71). Median OS was significantly longer for adults <70y (16.4 vs. 13.2 months, P<0.01) or those with ≥ grade 3 toxicity (18.3 vs. 14.7 months, P<0.01). When stratified by age and toxicity, patients <70y with ≥ grade 3 toxicity had longer OS vs. those without ≥ grade 3 toxicity (P<0.01). However, there was no OS difference among adults ≥70y with vs. without ≥ grade 3 toxicity (P=0.78). Adjusted hazard ratios with an interaction term are below. Conclusions: Though the incidence of ≥ grade 3 toxicity did not significantly differ by age, there was no significant OS advantage for older adults with ≥ grade 3 toxicity as compared to younger adults. Caution should be used in considering a toxicity-survival relationship in older adults.[Table: see text]

Demographic, health, and attitudinal factors predictive of cancer screening decisions in older adults

Many older adults receive routine cancer screening even when it is no longer recommended. We sought to identify demographic, health-related, and attitudinal factors that are most predictive of continued breast, colorectal, and prostate cancer screening decisions in older adults under various scenarios. A sample of adults age 65+ (n = 1272) were recruited from a nationally representative panel in November 2016, of which 881 (69.3%) completed our survey. Participants were presented vignettes in which we experimentally varied a hypothetical patient's life expectancy, age, quality of life, and physician screening recommendation. The dependent variable was the choice to continue cancer screening in the vignette. Classification and regression tree (CART) analysis was used to identify characteristics most predictive of screening decisions; both the participants' characteristics and the hypothetical patient's characteristics in the vignettes were included in the analysis. CART analysis uses recursive partitioning to create a classification tree in which variables predictive of the outcome are included as hierarchical tree nodes. We used automated ten-fold cross-validation to select the tree with lowest misclassification and highest predictive accuracy. Participants' attitude towards cancer screening was most predictive of choosing screening. Among those who agreed with the statement "I plan to get screened for cancer for as long as I live" (n = 300, 31.9%), 73.2% chose screening and 57.2% would still choose screening if hypothetical patient had 1-year life expectancy. For this subset of older adults with enthusiasm towards screening even when presented with scenario involving limited life expectancy, efforts are needed to improve informed decision-making about screening.

Utilizing advance care planning videos to empower perioperative cancer patients and families: Results from a randomized controlled trial

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Background: The feasibility and impact of integrating advance care planning (ACP) in surgical oncologic populations is unknown. We hypothesized that an ACP video could be integrated into surgical oncologic care and that patients who preoperatively viewed the video would engage in more ACP and patient-centered communication with their surgeon. Methods: Randomized controlled, phase II trial with two study arms: intervention ACP video and control (no ACP) video; and four data collection periods: enrollment, presurgical consent, postoperative one week, and postoperative one month. Participants included patients undergoing major cancer surgery recruited from nine surgical oncology clinics at a single, academic, inner city, tertiary care hospital. Main Outcomes and Measures: Primary Outcome - Content of ACP and patient-centeredness during the presurgical consent visit as measured through the Roter Interaction Analysis System (RIAS). Secondary patient outcomes – mood; goals of care; and video helpfulness. Results: Ninety-two patients (target enrollment of ninety) were enrolled over 15 months. The ACP video was successfully integrated into the intervention arm and no study-related harms were noted. Patient-centeredness was unchanged between the study arms (IRR=1.06, CI [0.87,1.3], p=0.545) and there was a trend of increased ACP content in the intervention arm (23% intervention vs. 10% control, p=0.182). There were no differences in secondary outcomes other than patients found the intervention video more “helpful” (p=0.007). There was a statistically significant increase in mood symptoms in both groups one week post-operative as compared to enrollment (p=0.01). Patients in both groups most frequently noted cure-related goals of care. Conclusions: The ACP video was integrated successfully into surgical care, well-tolerated, and thought helpful by patients, but did not significantly change the nature or ACP content in patient-surgeon pre-operative conversation. Future studies could increase the “dose” of ACP through modifying video content and/or how or who presents that content prior to surgery. Clinical trial information: NCT02489799.

Caregiver Treatment Preferences for Children with a New Versus Existing Attention-Deficit/Hyperactivity Disorder Diagnosis

OBJECTIVES

Parental experiences with managing their child's attention-deficit/hyperactivity disorder (ADHD) can influence priorities for treatment. This study aimed to identify the ADHD management options caregivers most prefer and to determine if preferences differ by time since initial ADHD diagnosis.

METHODS

Primary caregivers (n = 184) of a child aged 4-14 years old in care for ADHD were recruited from January 2013 through March 2015 from community-based pediatric and mental health clinics and family support organizations across the state of Maryland. Participants completed a survey that included child/family demographics, child clinical treatment, and a Best-Worst Scaling (BWS) experiment to elicit ADHD management preferences. The BWS comprised 18 ADHD management profiles showing seven treatment attributes, where the best and worst attribute levels were selected from each profile. A conditional logit model using effect-coded variables was used to estimate preference weights stratified by time since ADHD diagnosis.

RESULTS

Participants were primarily the mother (84%) and had a college or postgraduate education (76%) with 75% of the children on stimulant medications. One-on-one caregiver behavior training, medication use seven days a week, therapy in a clinic, and an individualized education program were most preferred for managing ADHD. Aside from caregiver training and monthly out-of-pocket costs, caregivers of children diagnosed with ADHD for less than two years prioritized medication use lower than other care management attributes and caregivers of children diagnosed with ADHD for two or more years preferred school accommodations, medication, and provider specialty.

CONCLUSIONS

Preferences for ADHD treatment differ based on the duration of the child's ADHD. Acknowledging that preferences change over the course of care could facilitate patient/family-centered care planning across a range of resources and a multidisciplinary team of professionals.

The future of breast cancer research and practice in Asia, Latin America, and the Middle East/North Africa: a qualitative horizon scanning analysis

Abstract #5095

Objective: To conduct a horizon-scanning analysis to identify future needs, challenges and trends relating to breast cancer research and practices globally with special emphasis on emerging and understudied regions.&#x2028; Methods: Following the design and pilot of the survey instrument, data was derived from key informant interviews with 221 thought leaders in breast cancer in Asia (n=97), Latin America (n=46), Middle East/North Africa (n=39) and Australia and Canada (n=39). Thought leaders were identified using a combination of purposive and snowballing sampling and included oncologists, surgeons, other breast cancer specialists, advocacy leaders and policy makers. Transcripts and field notes were then coded and compared, and a taxonomy of 20 issues was developed. The propensity of these themes were then analyzed and compared across the four regions.&#x2028; Results: In Asia the most prevalent issues were i) building capacity for clinical research, ii) more nurses for patient care/education, iii) keeping up to date with new information and iv) increased targeted/personalized treatment. In Latin America key themes were the need to i) increase targeted/personalized treatment, ii) address disparities among the underserved, iii) high cost to third party payers, iv) increase capacity for clinical research and v) control out of pocket costs for patients. In the Middle East/North Africa key themes were the need for i) building capacity for clinical research, ii) more nurses for patient care/education, iii) increased public education on screening and iv) increased capacity for early detection. In Australia and Canada issues were i) keeping up to date with new information, ii) weighing the cost effectiveness of new treatments, iii) the need for increased data sharing and iv) improving communication between stakeholders.&#x2028; Discussion: While a number of respondents expressed observations relating to country specific etiology of disease (such as women presenting at younger ages and with more aggressive tumors) the lack of national registries and local clinical/genetic research make it hard to confirm these anecdotes scientifically. Finally, increased focus on the development of effective advocacy and policy leadership are needed in these regions to draw attention and resources towards issues of community empowerment, survivorship and quality of life which were neglected by all but a handful of respondents.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5095.

Increasing the efficiency and flexibility of capital funding for public and private hospitals

This paper outlines the recent history of capital funding in the health sector in Australia. It focuses on the trends in capital expenditures and the roles of the public and private sectors. The demand for future capital funding will depend upon a number of factors, including the state of the current capital stock and uncertain future impacts of technology and changes in patient demands. Because of these uncertainties, capital funding for the future must be flexible to meet any changes in operations and demand. The paper highlights the possible use of joint ventures between various public and private organisations, based on the principles of competition and cooperation.

Developing better casemix education for rural New South Wales

Casemix is now an important mechanism for the planning, evaluation and funding of health services in Australia. In New South Wales (NSW) it was believed that while staff from most hospitals in metropolitan Sydney had become both literate and vocal about casemix, staff from rural areas were less familiar and much less likely to participate in casemix initiatives. In conjunction with the NSW Casemix Clinical Committee (NCCC), NSW Health considered a special program of casemix education for rural NSW. Before an education program was attempted, NSW Health inquired into the specific needs for casemix education in rural NSW. Qualitative and quantitative methods of analysis were used. Results of the quantitative analysis indicate that the understanding of casemix classifications is highest among managers. Of concern were the relatively low proportion of Allied Health staff who had more than a vague understanding of the Sub- and Non-Acute Patient (SNAP) classification; the lack of any knowledge of the Mental Health Costing And Service Classification (MH-CASC) by nursing staff; and the lack of any knowledge of the emergency department classification: Urgency, Disposition and Age-related Groups (UDAG), either by clinical or nursing staff. The results of the qualitative analysis show that casemix education for rural areas needs to differ from metropolitan education programs. The analysis also highlights the perception of casemix in rural areas and the special circumstances in rural hospitals that place limits on the ability to use casemix more fully.

Understanding heroin as a "rational addiction"

This paper makes some interpretations on the Becker and Murphy model of rational addiction so as to consider policy issues beyond the discussion of the effects of price on heroin consumption. Through the model of the rational heroin user, this paper argues that heroin use is a symptom of other factors. The focus of the analysis is placed on the negative life events that underpin heroin consumption. Thus, policy makers who want to stop heroin use may find it more effective to first stop the underlying problems that are the cause of the catalytic consumption of heroin use. It may prove better to promote other religious, family and educational activities than to actively discourage heroin use.

The importance of age and other variables in predicting paediatric patient flows in New South Wales

This research focuses upon the relationship between a child's age and the likelihood that the child was treated at a Specialist Children's Hospital rather than at a local hospital. While it is generally regarded that younger patients are more resource intensive, a study was required to determine whether the Specialist Children's Hospitals attracted younger patients. The analysis is based on 42,363 children treated in Greater Metropolitan Sydney in 1996/97, and on separations classified (role delineated) as non-tertiary DRGs (defined as Level 4 activity). However, this activity is of varying degrees of severity. A number of variables were used to explain why a child was treated at either a local hospital or at a specialist children's hospital. This study clearly demonstrates that Specialist Children's Hospitals do attract younger and more severe patients.

Casemix funding for a specialist paediatrics hospital: a hedonic regression approach

This paper inquires into the effects that Diagnosis Related Groups (DRGs) have had on the ability to explain patient-level costs in a specialist paediatrics hospital. Two hedonic models are estimated using 1996/97 New Children's Hospital (NCH) patient level cost data, one with and one without a casemix index (CMI). The results show that the inclusion of a casemix index as an explanatory variable leads to a better accounting of cost. The full hedonic model is then used to simulate a funding model for the 1997/98 NCH cost data. These costs are highly correlated with the actual costs reported for that year. In addition, univariate regression indicates that there has been inflation in costs in the order of 4.8% between the two years. In conclusion, hedonic analysis can provide valuable evidence for the design of funding models that account for casemix.

Radiolabeling, stability, and body distribution in rats, of low molecular weight polylactide homopolymer and polylactide-polyethyleneglycol copolymer

In order to study its fate in vivo, a low molecular-weight polylactide homopolymer was derivatized with a p-methoxyphenyl moiety, so as to make it susceptible to radiolabeling with 125I. A low molecular weight polylactide-polyethyleneglycol copolymer capped with ap-methoxyphenyl residue was also synthesized. The derivatized polymers were successfully [125I]iodinated in organic medium. The radiolabeled products were freed from [125I]iodide by dialysis and shown to be stable for 24 h on incubation at 37 degrees C in buffered saline or in blood. On longer incubation at 37 degrees C in buffered saline the radiolabeled polylactide released [125I]iodide and [125I]iodinated 3-(p-methoxyphenyl)propionic acid. The radiolabeled copolymer was more stable on incubation at 37 degrees C in buffered saline, but some [125I]iodide was released. The tissue distribution of radioactivity was determined 5 min, 1, 5 and 24 h after injecting male rats with 125I-labeled homopolymer or copolymer. Intravenous, intraperitoneal and subcutaneous injection routes were employed. Further rats were injected with [125I]iodide, to aid interpretation of the data. After administration of labeled homopolymer, a high concentration of radioactivity was found in the liver tissue. The levels slowly decreased over 24 h, and the polymer was successively found in the small and large intestine and the faeces. This is probably indicative of excretion via the bile. Concurrently radioactivity was excreted in the urine. After administration of labeled copolymer, a high concentration of radioactivity was found in the liver and the residual soft tissue, the latter fraction containing two-thirds of the radioactivity one hour after injection. The precise tissue location that this result indicates was not identified. After 1 h radioactivity was excreted in the faeces, again probably via the bile, and in the urine. Tissue distributions after intraperitoneal or subcutaneous injections were concordant with the above results and interpretations, with the additional factor of slow clearance from the injection site.

Echinococcus granulosus equinus: variation in the germinal layer of murine hydatids and evidence of autophagy

The germinal layer of sterile 9-month-old murine peritoneal cysts of Echinococcus granulosus equinus shows interrelated variation in depth, tissue integrity, metabolic reserves and the number of autophagic lamellar bodies present. These features are similar in large and medium-sized cysts from the same host, whether occurring singly or within cyst masses. Deep germinal layers (greater than 16 micron) are lipid- and glycogen-rich and possess numerous autophagic vacuoles with 6 nm period lamellar stacks asymmetrically disposed peripherally; shallow layers (less than 12 micron), with indications of degeneration, have depleted metabolic reserves and fewer lamellar bodies. These bodies are formed by smooth endoplasmic reticulum encirclement of small glycogen masses followed by further sequestration, and eventually definition of glycogen particles may be lost. Autophagy of mitochondria and cytoplasmic vesicles also occurs. The presence of lysosomal enzymes within the layer suggests autolysosomal compartmentalization of excess substrate and effete material. Mucopolysaccharide bodies, containing material similar to that exocytosed to form the laminated layer matrix, occur and are formed from fusion and autophagy of Golgi-derived vesicles. These bodies may also develop peripheral 6 nm period lamellar stacks, but of limited depth. Mucopolysaccharide bodies are the dominant feature of the germinal layer of very small cyst-mass cysts in which laminated layer production is considered to be arrested. They thus represent a repository for the unreleased mucopolysaccharide material.

Echinococcus granulosus equinus: an ultrastructural study of the laminated layer, including changes on incubating cysts in various media

The microfibrillate component of the laminated layer of Echinococcus granulosus equinus contains, except for the zone adjacent to the germinal layer, aggregates of electron-dense bodies displaying a sub-structure of electron-lucent spheres. The tegumentary syncytial cytoplasm contains randomly distributed electron-dense granules, many occurring near the apical plasmalemma, although exocytosis was rarely seen. Granules, similar in size and sub-structure to the bodies of the aggregates, also occur in the internuncial connexions and tegumentary cytons, suggesting that they may be produced in the cytons and released into the laminated layer via the internuncial connexions and tegumentary cytoplasm. Cysts incubated for 0.5-2.5 h in serum- and non-serum-containing media showed differences from non-incubated cysts. The distal half of the syncytium contained a progressive increase in the number of granules (distal: proximal 1.9:1 at 2.5 h; cf. 1:1 in non-incubated cysts), and exocytosis of granules into the laminated layer adjacent to the cyst had occurred. This cannot be attributed wholly to serum proteins. Cysts incubated for 21 h appeared 'normal', suggesting re-establishment of an equilibrium. Since the matrix of the laminated layer is considered homologous to the glycocalyx of other cestodes, the possible protective role played by the granules/bodies, characteristic of Echinococcus spp., is discussed.

Echinococcus granulosus equinus: an ultrastructural study of murine tissue response to hydatid cysts

Peritoneal hydatids of Echinococcus granulosus equinus of 9 months standing in BALB/c mice occurred as free cysts or cysts within cyst masses. Both showed wide variation in size and in host tissue response, and all had a well-developed laminated layer separating the host tissue response from the germinal layer. In the smallest cyst-mass cysts the host tissue response was present as remnants of the initial cellular attack involving eosinophils. Slightly larger cyst-mass cysts possessed a primary macrophage invasion which phagocytosed the remnants of the initial attack and also, though to little effect, the laminated layer material. In the largest cyst-mass cysts a second macrophage invasion, of monocyte origin, had commenced and transformation stages of these cells to macrophages were observed. No fibroblasts surrounded individual cyst-mass cysts but they were present around the cyst mass, encapsulating it and possibly preventing further host cell invasion. Thus, the host tissue response around individual cyst-mass cysts remained 'preserved' at an early stage such as existed at the time of encapsulation. Small free cysts showed a primary macrophage invasion and transformation stages of cells of a secondary infiltration of peritoneal origin. Peripheral to the macrophages were fibroblasts demonstrating limited fibrinogenesis, and each cyst was surrounded by a layer of mesothelial cells. Large free cysts, also delimited by a mesothelial layer, possessed peripheral connective tissue, a deep fibrous layer and a monolayer of very compressed macrophages lying adjacent to the laminated layer. It is emphasized that an understanding of the host tissue response in cysts of different sizes and from different locations is an essential pre-requisite for the design of experimental studies.

The uptake of liposome-entrapped 125I-labelled poly(vinylpyrrolidone) by rat jejunum in vitro

The uptake of free and liposome-entrapped 125I-labelled poly(vinylpyrrolidone) was measured in an intestinal sac preparation from adult rats. At an equal concentration of 125I-labelled poly(vinylpyrrolidone), the rate of uptake of the liposome-entrapped material was four times that of the free macromolecule.