The standard problem

OBJECTIVE

This article proposes a framework to support the scientific research of standards so that they can be better measured, evaluated, and designed.

METHODS

Beginning with the notion of common models, the framework describes the general standard problem-the seeming impossibility of creating a singular, persistent, and definitive standard which is not subject to change over time in an open system.

RESULTS

The standard problem arises from uncertainty driven by variations in operating context, standard quality, differences in implementation, and drift over time. As a result, fitting work using conformance services is needed to repair these gaps between a standard and what is required for real-world use. To guide standards design and repair, a framework for measuring performance in context is suggested, based on signal detection theory and technomarkers. Based on the type of common model in operation, different conformance strategies are identified: (1) Universal conformance (all agents access the same standard); (2) Mediated conformance (an interoperability layer supports heterogeneous agents); and (3) Localized conformance (autonomous adaptive agents manage their own needs). Conformance methods include incremental design, modular design, adaptors, and creating interactive and adaptive agents.

DISCUSSION

Machine learning should have a major role in adaptive fitting. Research to guide the choice and design of conformance services may focus on the stability and homogeneity of shared tasks, and whether common models are shared ahead of time or adjusted at task time.

CONCLUSION

This analysis conceptually decouples interoperability and standardization. While standards facilitate interoperability, interoperability is achievable without standardization.

The Evolving Nature of Health Technology Assessment: A Critical Appraisal of NICE's New Methods Manual

OBJECTIVES

The National Institute for Health and Care Excellence (NICE) recently completed a review of its methods for health technology assessment, involving a 2-stage public consultation. We appraise proposed methodological changes and analyze key decisions.

METHODS

We categorize all changes proposed in the first consultation as "critical," "moderate" or "limited" updates, considering the importance of the topic and the degree of change or the level of reinforcement. Proposals were followed through the review process, for their inclusion, exclusion, or amendment in the second consultation and the new manual.

RESULTS

The end-of-life value modifier was replaced with a new "disease severity" modifier and other potential modifiers were rejected. The usefulness of a comprehensive evidence base was emphasized, clarifying when nonrandomized studies can be used, with further guidance on "real-world" evidence developed separately. A greater degree of uncertainty was accepted in circumstances when evidence generation raised challenges, in particular for children, rare diseases, and innovative technologies. For some topics, such as health inequality, discounting, unrelated healthcare costs, and value of information, significant changes were possibly warranted, but NICE decided not to make any revisions at present.

CONCLUSION

Most of the changes to NICE's health technology assessment methods are appropriate and modest in impact. Nevertheless, some decisions were not well justified and further research is needed on several topics, including investigation of societal preferences. Ultimately, NICE's role of protecting National Health Services resources for valuable interventions that can contribute toward improving overall population health must be safeguarded, without accepting weaker evidence.

"Functioning better is doing better": older adults' priorities for the evaluation of assistive technology

Despite the benefits of assistive technology (AT), barriers to technology adoption still exist and are uniquely affecting older populations. Improving technology adoption can be achieved by involving end-users in the development and evaluation process. However, existing AT evaluation tools rarely take into account older adults' experiences. The goal of this study was to fill this gap by determining which AT evaluation criteria are important for older adults. We conducted 4 nominal group meetings with 21 participants aged 50+ in Vancouver, Canada. In the meetings, participants generated AT evaluation criteria and organized them in the order of importance. The content from the meetings was analyzed using qualitative content analysis. Final rankings were collated to reveal which criteria were the most important across the groups. We found that promotion of independence, affordability, ease of use and ethics are the most important AT evaluation criteria for older adults. Some aspects of ATs that older adults value, such as reliability, are not featured in AT evaluation tools. This study provides insight into older adults' priorities for AT evaluation criteria, and concerns that older adults have about AT use. The findings are supplemented with a comprehensive analysis of the group discussions that contextualizes the criteria.

Evaluating Low-Carbon Transportation Technologies When Demand Responds to Price

The carbon intensity (CI) of travel is commonly used to evaluate transportation technologies. However, when travel demand is sensitive to price, CI alone does not fully capture the emissions impact of a technology. Here, we develop a metric to account for both CI and the demand response to price (DR) in technology evaluation, for use by distributed decision-makers in industry and government, who are becoming increasingly involved in climate change mitigation as the costs of lower-carbon technologies fall. We apply this adjusted carbon intensity (ACI) to evaluate ethanol-fueled, hybrid, and battery electric vehicles individually and against policy targets. We find that all of these technologies can be used to help meet a 2030 greenhouse gas emissions reduction target of up to 40% below 2005 levels and that decarbonized battery electric vehicles can meet a 2050 target of 80%, even when evaluated using the ACI instead of CI. Using the CI alone could lead to a substantial overshoot of emissions targets especially in markets with significant DR, including in rapidly growing economies with latent travel demand. The ACI can be used to adjust decarbonization transition plans to mitigate this risk. For example, in examining several transportation technologies, we find that accelerating low-carbon technology transitions by roughly 5-10 years would mitigate the risk associated with DR estimates. One particularly robust strategy is to remove carbon from fuels through faster decarbonization of electricity and vehicle electrification.

Capturing nurses' perception of communicative technologies in nursing facilities: Survey instrument development

BACKGROUND

Despite the common perception of the call light system as crucial for patient safety, there are usability gaps between what features staff in nursing facilities need to address an alarm quickly and how the call system is designed. A survey instrument was developed to investigate nursing home staff experiences in using call light technology.

METHODS

A survey instrument was developed and distributed to staff in two nursing facilities in Up-State, New York (N = 278). The strength and direction of relationships between pairs of variables were measured using Pearson correlation and analysis of variance to investigate the perceived effect of staff's perception of the call light system on the work system's elements, process and staff outcomes.

RESULTS

The study found correlations between the job-level workload and the noise in the unit (r = 0.272, p = .000), between job-level workload and the ease of locating call lights (r = 0.154, p = .023), and between job stress and burnout (r = 0.176, p = .009). Only 64% of nursing home staff believed that the call light system reflected urgent needs, with younger staff relating to this group. The staff gave the work environment a high score, which corresponds to excessive noises caused by the call light alarm, according to 74% of the staff. These associations stem from gaps caused by a lack of user feedback in the design and acquisition process, leading to usability issues that reduce performance and satisfaction over time.

CONCLUSION

The study found that the type of call light system used is associated with usability challenges that often impeded the performance of the nursing home staff's response to residents. These insights can improve the selection of a new call light system that avoids usability issues and challenges identified by end-users.

A Hybrid Fuzzy Decision Model for Evaluating MEMS and IC Integration Technologies

Integrated devices incorporating MEMS (microelectromechanical systems) with IC (integrated circuit) components have been becoming increasingly important in the era of IoT (Internet of Things). In this study, a hybrid fuzzy MCDM (multi-criteria decision making) model was proposed to effectively evaluate alternative technologies that incorporate MEMS with IC components. This model, composed of the fuzzy AHP (analytic hierarchy process) and fuzzy VIKOR (VIseKriterijumska Optimizacija I Kompromisno Resenje) methods, solves the decision problem of how best to rank MEMS and IC integration technologies in a fuzzy environment. The six important criteria and the major five alternative technologies associated with our research themes were explored through literature review and expert investigations. The priority weights of criteria were derived using fuzzy AHP. After that, fuzzy VIKOR was deployed to rank alternatives. The empirical results show that development schedule and manufacturing capability are the two most important criteria and 3D (three-dimensional) SiP (system-in-package) and monolithic SoC (system-on-chip) are the top two favored technologies. The proposed fuzzy decision model could serve as a reference for the future strategic evaluation and selection of MEMS and IC integration technologies.

[Evaluation and Screening of Dioxin Control Technology in Waste Incineration Flue Gas]

To determine the best control technology for dioxin in waste incineration flue gas, a three-level comprehensive evaluation index system with environment, economy, and technology as the first-level indexes was constructed. The fuzzy comprehensive evaluation method and the analytic hierarchy process (AHP) were used to evaluate ten dioxin pollution control technologies or technology groups including "double bag activated carbon adsorption technology," "sulfur and sulfide inhibition technology," and "sulfur and sulfide inhibition technology+activated carbon fixed bed reactor technology". The "sulfur and sulfur compound inhibition technology+activated carbon fixed bed technology" scored the highest, and thus is currently the best control technology for dioxin pollution in waste incineration exhaust gas. This technology is suitable for small rural waste incinerators to ensure that dioxin emissions meet the standards. Depending on the local economic development level, enterprise scale, furnace profile, and technological process, waste incineration enterprises in various regions of China can adopt this index evaluation system and method to evaluate the dioxin control technologies and select the best one suitable for the enterprise so that dioxin emissions in the waste incineration flue gas can be effectively controlled.

Evaluation environment for digital and analog pathology: a platform for validation studies

We present a platform for designing and executing studies that compare pathologists interpreting histopathology of whole slide images (WSIs) on a computer display to pathologists interpreting glass slides on an optical microscope. eeDAP is an evaluation environment for digital and analog pathology. The key element in eeDAP is the registration of the WSI to the glass slide. Registration is accomplished through computer control of the microscope stage and a camera mounted on the microscope that acquires real-time images of the microscope field of view (FOV). Registration allows for the evaluation of the same regions of interest (ROIs) in both domains. This can reduce or eliminate disagreements that arise from pathologists interpreting different areas and focuses on the comparison of image quality. We reduced the pathologist interpretation area from an entire glass slide (10 to [Formula: see text]) to small ROIs ([Formula: see text]). We also made possible the evaluation of individual cells. We summarize eeDAP's software and hardware and provide calculations and corresponding images of the microscope FOV and the ROIs extracted from the WSIs. The eeDAP software can be downloaded from the Google code website (project: eeDAP) as a MATLAB source or as a precompiled stand-alone license-free application.

Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes

BACKGROUND

Homecare is an important and effective way of managing chronic illnesses using skilled nursing care in the home. Unlike hospitals and ambulatory settings, clinicians visit patients at home at different times, independent of each other. Twenty-nine percent of 10,000 homecare agencies in the United States have adopted point-of-care EHRs. Yet, relatively little is known about the growing use of homecare EHRs.

OBJECTIVE

Researchers compared workflow, financial billing, and patient outcomes before and after implementation to evaluate the impact of a homecare point-of-care EHR.

METHODS

The design was a pre/post observational study embedded in a mixed methods study. The setting was a Philadelphia-based homecare agency with 137 clinicians. Data sources included: (1) clinician EHR documentation completion; (2) EHR usage data; (3) Medicare billing data; (4) an EHR Nurse Satisfaction survey; (5) clinician observations; (6) clinician interviews; and (7) patient outcomes.

RESULTS

Clinicians were satisfied with documentation timeliness and team communication. Following EHR implementation, 90% of notes were completed within the 1-day compliance interval (n = 56,702) compared with 30% of notes completed within the 7-day compliance interval in the pre-implementation period (n = 14,563; OR 19, p <. 001). Productivity in the number of clinical notes documented post-implementation increased almost 10-fold compared to pre-implementation. Days to Medicare claims fell from 100 days pre-implementation to 30 days post-implementation, while the census rose. EHR implementation impact on patient outcomes was limited to some behavioral outcomes.

DISCUSSION

Findings from this homecare EHR study indicated clinician EHR use enabled a sustained increase in productivity of note completion, as well as timeliness of documentation and billing for reimbursement with limited impact on improving patient outcomes. As EHR adoption increases to better meet the needs of the growing population of older people with chronic health conditions, these results can inform homecare EHR development and implementation.

Breaking the addiction to technology adoption

A major driver of cost growth in health care is the rapid increase in the utilisation of existing technology and not simply the adoption of new technology. Health economists and their health technology assessment colleagues have become obsessed by technology adoption questions and have largely ignored 'technology management' questions. Technology management would include the life-cycle assessment of technologies in use, to assess their real-world performance; and monitoring of technology indication creep. A rebalancing of focus might serve to encourage a more self-critical and learning culture amongst those involved in technology evaluation analysis. Further, health economists and health technology assessment analysts could make a more significant contribution to system efficiency through rebalancing their efforts away from technology adoption questions towards technology management issues.

Challenges and facilitators to adoption of a point-of-care electronic health record in home care

Electronic health records (EHRs), intended to improve the clinical process, are understudied in home care. The researchers assessed clinician satisfaction, informed by workflow and patient outcomes, to identify EHR adoption challenges. The mixed methods study setting was a Philadelphia agency with 137 clinicians. Adoption challenges included: (a) hardware problems coupled with lack of field support; (b) inadequate training; and (c) mismatch of EHR usability/functionality and workflow resulting in decreased efficiency. Adoption facilitators were support for team communication and improved clinical data timeliness. Opportunities for improved adoption included sharing with front-line clinicians EHR data related to patient care and health outcomes.

Bone graft substitutes for the treatment of traumatic fractures of the extremities

HEALTH POLITICAL AND SCIENTIFIC BACKGROUND: Bone graft substitutes are increasingly being used as supplements to standard care or as alternative to bone grafts in the treatment of traumatic fractures.

RESEARCH QUESTIONS

The efficacy and cost-effectiveness of bone graft substitutes for the treatment of traumatic fractures as well as the ethical, social and legal implications of their use are the main research questions addressed.

METHODS

A systematic literature search was conducted in electronic medical databases (MEDLINE, EMBASE etc.) in December 2009. Randomised controlled trials (RCT), where applicable also containing relevant health economic evaluations and publications addressing the ethical, social and legal aspects of using bone graft substitutes for fracture treatment were included in the analysis. After assessment of study quality the information synthesis of the medical data was performed using metaanalysis, the synthesis of the health economic data was performed descriptively.

RESULTS

14 RCT were included in the medical analysis, and two in the heath economic evaluation. No relevant publications on the ethical, social and legal implications of the bone graft substitute use were found. In the RCT on fracture treatment with bone morphogenetic protein-2 (BMP-2) versus standard care without bone grafting (RCT with an elevated high risk of bias) there was a significant difference in favour of BMP-2 for several outcome measures. The RCT of calcium phosphate (CaP) cement and bone marrow-based composite materials versus autogenous bone grafts (RCT with a high risk of bias) revealed significant differences in favour of bone graft substitutes for some outcome measures. Regarding the other bone graft substitutes, almost all comparisons demonstrated no significant difference. The use of BMP-2 in addition to standard care without bone grafting led in the study to increased treatment costs considering all patients with traumatic open fractures. However, cost savings through the additional use of BMP-2 were calculated in a patient subgroup with high-grade open fractures (Gustilo-Anderson grade IIIB). Cost-effectiveness for BMP-2 versus standard care with autologous bone grafts as well as for other bone graft substitutes in fracture treatment has not been determined yet.

DISCUSSION

Although there were some significant differences in favour of BMP-2, due to the overall poor quality of the studies the evidence can only be interpreted as suggestive for efficacy. In the case of CaP cements and bone marrow-based bone substitute materials, the evidence is only weakly suggestive for efficacy. From an overall economic perspective, the transferability of the results of the health economic evaluations to the current situation in Germany is limited.

CONCLUSIONS

The current evidence is insufficient to evaluate entirely the use of different bone graft substitutes for fracture treatment. From a medical point of view, BMP-2 is a viable alternative for treatment of open fractures of the tibia, especially in cases where bone grafting is not possible. Autologous bone grafting is preferable comparing to the use of OP-1. Possible advantages of CaP cements and composites containing bone marrow over autogenous bone grafting should be taken into account in clinical decision making. The use of the hydroxyapatite material and allograft bone chips compared to autologous bone grafts cannot be recommended. From a health economic perspective, the use of BMP-2 in addition to standard care without bone grafting is recommended as cost-saving in patients with high-grade open fractures (Gustilo-Anderson grade IIIB). Based on the current evidence no further recommendations can be made regarding the use of bone graft substitutes for the treatment of fractures. To avoid legal implications, use of bone graft substitutes outside their approved indications should be avoided.

The effectiveness of interventions in workplace health promotion as to maintain the working capacity of health care personal

Background

The increasing proportion of elderly people with respective care requirements and within the total population stands against aging personnel and staff reduction in the field of health care where employees are exposed to high load factors. Health promotion interventions may be a possibility to improve work situations and behavior.

Methods

A systematic literature search is conducted in 32 databases limited to English and German publications since 1990. Moreover, internet-searches are performed and the reference lists of identified articles are scanned. The selection of literature was done by two reviewers independently according to inclusion and exclusion criteria. Data extraction and tables of evidence are verified by a second expert just like the assessment of risk of bias by means of the Cochrane Collaboration’s tool.

Results

We identified eleven intervention studies and two systematic reviews. There were three randomized controlled trials (RCT) and one controlled trial without randomization (CCT) on the improvement of physical health, four RCT and two CCT on the improvement of psychological health and one RCT on both. Study duration ranged from four weeks to two years and the number of participants included from 20 to 345, with a median of 56. Interventions and populations were predominantly heterogeneous. In three studies intervention for the improvement of physical health resulted in less complaints and increased strength and flexibility with statistically significant differences between groups. Regarding psychological health interventions lead to significantly decreased intake of analgesics, better stress management, coping with workload, communication skills and advanced training.

Discussion

Taking into consideration the small to very small sample sizes, other methodological flaws like a high potential of bias and poor quality of reporting the validity of the results has to be considered as limited. Due to the heterogeneity of health interventions, study populations with differing job specializations and different lengths of study durations and follow-up periods, the comparison of results would not make sense.

Conclusions

Further research is necessary with larger sample sizes, with a sufficient study duration and follow-up, with a lower risk of bias, by considering of relevant quality criteria and with better reporting in publications.

Individual health services

BACKGROUND

The German statutory health insurance (GKV) reimburses all health care services that are deemed sufficient, appropriate, and efficient. According to the German Medical Association (BÄK), individual health services (IGeL) are services that are not under liability of the GKV, medically necessary or recommendable or at least justifiable. They have to be explicitly requested by the patient and have to be paid out of pocket.

RESEARCH QUESTIONS

The following questions regarding IGeL in the outpatient health care of GKV insurants are addressed in the present report: What is the empirical evidence regarding offers, utilization, practice, acceptance, and the relation between physician and patient, as well as the economic relevance of IGeL?What ethical, social, and legal aspects are related to IGeL? FOR TWO OF THE MOST COMMON IGEL, THE SCREENING FOR GLAUCOMA AND THE SCREENING FOR OVARIAN AND ENDOMETRIAL CANCER BY VAGINAL ULTRASOUND (VUS), THE FOLLOWING QUESTIONS ARE ADDRESSED: What is the evidence for the clinical effectiveness?Are there sub-populations for whom screening might be beneficial?

METHODS

The evaluation is divided into two parts. For the first part a systematic literature review of primary studies and publications concerning ethical, social and legal aspects is performed. In the second part, rapid assessments of the clinical effectiveness for the two examples, glaucoma and VUS screening, are prepared. Therefore, in a first step, HTA-reports and systematic reviews are searched, followed by a search for original studies published after the end of the research period of the most recent HTA-report included.

RESULTS

29 studies were included for the first question. Between 19 and 53% of GKV members receive IGeL offers, of which three-quarters are realised. 16 to 19% of the insurants ask actively for IGeL. Intraocular tension measurement is the most common single IGeL service, accounting for up to 40% of the offers. It is followed by ultrasound assessments with up to 25% of the offers. Cancer screening and blood or laboratory services are also frequent and represent a major proportion of the demand. The ethical, social, and legal aspects discussed in the context of IGeL concern eight subject areas: autonomous patient decisions versus obtrusion,commercialization of medicine, duty of patient information, benefit, evidence, and (quality) control, role and relation of physicians and patients,relation to the GKV, social inequality,formally correct performance. For glaucoma screening, no randomized controlled trial (RCT) is identified that shows a patient relevant benefit. For VUS three RCT are included. However, they do not yet present mortality data concerning screened and non-screened persons. VUS screening shows a high degree of over-diagnosis in turn leading to invasive interventions. To diagnose one invasive carcinoma, 30 to 35 surgical procedures are necessary.

CONCLUSION

IGeL are a relevant factor in the German statutory health care system. To provide more transparency, the requests for evidence-based and independent patient information should be considered. Whether official positive and negative-lists could be an appropriate instrument to give guidance to patients and physicians, should be examined. Generally, IGeL must be seen in the broader context of the discussions about the future design and development of the German health care system.

Prevention of alcohol misuse among children, youths and young adults

BACKGROUND

Despite many activities to prevent risky alcohol consumption among adolescents and young adults there is an increase of alcohol intoxications in the group of ten to twenty year old juveniles.

OBJECTIVES

This report gives an overview about the recent literature as well as the German federal prevention system regarding activities concerning behavioral and policy prevention of risky alcohol consumption among children, adolescents and young adults. Furthermore, effective components of prevention activities are identified and the efficiency and efficacy of ongoing prevention programs is evaluated.

METHODS

A systematic literature review is done in 34 databases using Bool'sche combinations of the key words alcohol, prevention, treatment, children, adolescents and young adults.

RESULTS

401 studies were found and 59 studies were selected for the health technology assessment (HTA). Most of the studies are done in USA, nine in Germany. A family strengthening program, personalized computer based intervention at schools, colleges and universities, brief motivational interventions and policy elements like increase of prices and taxes proved effective.

DISCUSSION

Among the 59 studies there are three meta-analyses, 15 reviews, 17 randomized controlled trials (RCT) and 18 cohort studies. Despite the overall high quality of the study design, many of them have methodological weaknesses (missing randomization, missing or too short follow-ups, not clearly defined measurement parameters). The transferability of US-results to the German context is problematic. Only a few prevention activities reach a sustainable reduction of frequency and/or amount of alcohol consumption.

CONCLUSION

The HTA-report shows the need to develop specific and target group focused prevention activities for the German situation. Essential for that is the definition of target goals (reduction of consumption, change of behaviour) as well as the definition and empirical validation of risky alcohol consumption. The efficacy of prevention activities should be proven before they are launched. At present activities for the reduction or prevention of risky alcohol consumption are not sufficiently evaluated in Germany concerning their sustainable efficacy.

Over-, under- and misuse of pain treatment in Germany

BACKGROUND

The HTA-report (Health Technology Assessment) deals with over- and undertreatment of pain therapy. Especially in Germany chronic pain is a common reason for the loss of working hours and early retirement. In addition to a reduction in quality of life for the affected persons, chronic pain is therefore also an enormous economic burden for society.

OBJECTIVES

Which diseases are in particular relevant regarding pain therapy?What is the social-medical care situation regarding pain facilities in Germany?What is the social-medical care situation in pain therapy when comparing on international level?Which effects, costs or cost-effects can be seen on the micro-, meso- and macro level with regard to pain therapy?Among which social-medical services in pain therapy is there is an over- or undertreatment with regard to the micro-, meso- and macro level?Which medical and organisational aspects that have an effect on the costs and/or cost-effectiveness have to be particularly taken into account with regard to pain treatment/chronic pain?What is the influence of the individual patient's needs (micro level) in different situations of pain (e. g. palliative situation) on the meso- and macro level?Which social-medical and ethical aspects for an adequate treatment of chronic pain on each level have to be specially taken into account?Is the consideration of these aspects appropriate to avoid over- or undertreatment?Are juridical questions included in every day care of chronic pain patients, mainly in palliative care?On which level can appropriate interventions prevent over- or undertreatment?

METHODS

A systematic literature research is done in 35 databases. In the HTA, reviews, epidemiological and clinical studies and economic evaluations are included which report about pain therapy and in particular palliative care in the years 2005 till 2010.

RESULTS

47 studies meet the inclusion criteria. An undertreatment of acupuncture, over- and misuse with regard to opiate prescription and an overuse regarding unspecific chest pain and chronic low back pain (LBP) can be observed. The results show the benefit and the cost-effectiveness of interdisciplinary as well as multi-professional approaches, multimodal pain therapy and cross-sectoral integrated medical care. Only rough values can be determined about the care situation regarding the supply of pain therapeutic and palliative medical facilities as the data are completely insufficient.

DISCUSSION

Due to the broad research question the HTA-report contains inevitably different outcomes and study designs which partially differ qualitatively very strong from each other. In the field of palliative care hospices for in-patients and palliative wards as well as hospices for out-patients are becoming more and more important. Palliative care is a basic right of all terminally ill persons.

CONCLUSION

Despite the relatively high number of studies in Germany the HTA-report shows a massive lack in health care research. Based on the studies a further expansion of out-patient pain and palliative care is recommended. Further training for all involved professional groups must be improved. An independent empirical analysis is necessary to determine over or undertreatment in pain care.

Effectiveness of programmes as part of primary prevention demonstrated on the example of cardiovascular diseases and the metabolic syndrome

Background

The HTA-report (HTA = Health Technology Assessment) deals with the primary prevention of cardiovascular diseases and diabetes mellitus type 2. In 2009 approximately 356,000 people died in Germany due to cardiovascular diseases. According to estimations about 6.3 million people are suffering from diabetes mellitus type 2. The interventions that are subsidized by the public health insurance are mainly focused on sufficient physical activities, healthy nutrition, stress management and the reduction of the consumption of addictive drugs and luxury food.

Objectives

Which lifestyle-related measures and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are effective? To what extent will the health status be improved by these offers? To what extent will existing health resources and skills be strengthened by these offers? Are there any differences regarding the effectiveness among the interventions with respect to different settings or subgroups?

Which lifestyle-related interventions and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are sustainable and cost-effective? Which outcome parameters are in the view of the contributors decisive for the evaluation of the effectiveness? In the view of the contributor are there different values between the outcome parameters? In the view of the payers and other actors are there different values between the outcome parameters?

Which ethical and juridical factors have to be considered? Which social and/or socio-economic parameters influence the use of the services and effectiveness?

Methods

A systematic literature research is done in 35 databases. For the period 2005 to 2010, reviews, epidemiological and clinical studies as well as economical evaluations which deal with primary prevention programmes regarding cardiovascular diseases or the metabolic syndrome are included.

Results

44 publications meet the inclusion criteria. These studies confirm the effectiveness of the primary prevention programmes. Physical activity programs seem to have a stronger effect than nutrition programmes. Psychological programmes prove as well effectiveness, if they include cognitive behaviour therapy. The identified economical studies indicate that programmes for cardiovascular prevention can be conducted cost-effectively. Interventions that focus on the general population turn out to be particularly cost-effective and sustainable.

Discussion

There is a wide range of primary preventive effective lifestyle-related interventions with high evidence. The outcomes and results are consistent with the recommendations of the two identified evidence-based guidelines regarding the recommendations on lifestyle and healthy nutrition. Furthermore, the cost-effectiveness of primary prevention services is proven. With regard to the economical studies it is however worth noting that this result is based on very few publications. The transferability has to be critically assessed as the studies mainly originate from the American health system.

Conclusion

On the whole a comprehensive setting approach with educative, somatic, psychosocial and activity therapeutic components is recommended. The sustainability of a prevention intervention must be ensured from programme to programme. Long-term studies are necessary to make valid statements regarding the sustainable effectiveness: There is an essential deficit in the current practiced evaluation of the use of primary prevention services provided by the health insurance – mainly regarding the comprehensive setting approach – regarding the evidence-based evaluation of the prescribed preventive interventions. With regard to the ethical, social and economical evaluation the research situation is deficient. The situation has to be particularly analyzed for the socially deprived and one has to respond to their specific needs for prevention.

Informative value of Patient Reported Outcomes (PRO) in Health Technology Assessment (HTA)

Background

“Patient-Reported Outcome” (PRO) is used as an umbrella term for different concepts for measuring subjectively perceived health status e. g. as treatment effects. Their common characteristic is, that the appraisal of the health status is reported by the patient himself. In order to describe the informative value of PRO in Health Technology Assessment (HTA) first an overview of concepts, classifications and methods of measurement is given. The overview is complemented by an empirical analysis of clinical trials and HTA-reports on rheumatoid arthritis and breast cancer in order to report on type, frequency and consequences of PRO used in these documents.

Methods

For both issues systematic reviews of the literature have been performed. The search for methodological literature covers the publication period from 1990 to 2009, the search for clinical trials of rheumatoid arthritis and breast cancer covers the period 2005 to 2009. Both searches were performed in the medical databases of the German Institute of Medical Documentation and Information (DIMDI). The search for HTA-reports and methodological papers of HTA-agencies was performed in the CRD-Databases (CRD = Centre for Reviews and Dissemination) and by handsearching the websites of INAHTA member agencies (INAHTA = International Network of Agencies for Health Technology Assessment). For all issues specific inclusion and exclusion criteria were defined. The methodological quality of randomized controlled trials (RCT) was assessed by a modified version of the Cochrane Risk of Bias Tool. For the methodological part information extraction from the literature is structured by the report’s chapters, for the empirical part data extraction sheets were constructed. All information is summarized in a qualitative manner.

Results

Concerning the methodological issues the literature search retrieved 158 documents (87 documents related to definition or classification, 125 documents related to operationalisation of PRO). For the empirical analyses 225 RCT (rheumatoid arthritis: 77; breast cancer: 148) and 40 HTA-reports and method papers were found.

The analysis of the methodological literature confirms the role of PRO as an umbrella term for a variety of different concepts. The newest classification system facilitates the description of PRO measures by construct, target population and the method of measurement. Steps of operationalisation involve defining a conceptual framework, instrument development, exploration of measurement properties or, possibly, the modification of existing instruments.

Seven out of 59 RCT analysing the effects of antibody therapy for rheumatoid arthritis define PRO as the primary endpoint, 38 trials utilize composite measures (ACR, DAS) and ten trials report clinical or radiological parameters as the primary endpoint. Six out of 123 chemotherapy trials for breast cancer define PRO as the primary endpoint, while 98 trials report clinical endpoints (survival, tumour response, progression) in their primary analyses. Discrepancies in the number of trials result from inaccurate specifications of endpoints in the publications. This distribution is reflected in the HTA-reports: while almost all reports on rheumatoid arthritis refer to PRO, this is only the case in about half of the reports on breast cancer.

Conclusions

As definition and classification of PRO are concerned, coherent concepts are found in the literature. Their operationalisation and implementation must be guided by scientific principles. The type and frequency of PRO used in clinical trials largely depend on the disease analysed. The HTA-community seems to pursue the utilization of PRO proactively – in case of missing data the need for further research is stated.

Advice for Decision Makers Based on an Electronic Health Record Evaluation at a Program for All-inclusive Care for Elders Site

OBJECTIVE

Provide evidence-based advise to "Program of All-inclusive Care for the Elderly" (PACE) decision makers considering implementing an electronic health record (EHR) system, drawing on the results of a mixed methods study to examine: (1) the diffusion of an EHR among clinicians documenting direct patient care in a PACE day care site, (2) the impact of the use of the EHR on the satisfaction levels of clinicians, and (3) the impact of the use of the EHR on patient functional outcomes.

METHODS

Embedded mixed methods design with a post-test design quantitative experiment and concurrent qualitative component. Quantitative methods included: (1) the EHR audit log used to determine the frequency and timing during the week of clinicians' usage of the system; (2) a 22-item clinician satisfaction survey; and (3) a 16-item patient functional outcome questionnaire related to locomotion, mobility, personal hygiene, dressing, feeding as well the use of adaptive devices. Qualitative methods included observations and open-ended, semi-structured follow-up interviews. Qualitative data was merged with the quantitative data by comparing the findings along themes. The setting was a PACE utilizing an EHR in Philadelphia: PACE manages the care of nursing-home eligible members to enable them to avoid nursing home admission and reside in their homes. Participants were 39 clinicians on the multi-disciplinary teams caring for the elders and 338 PACE members.

RESULTS

Clinicians did not use the system as intended, which may help to explain why the benefits related to clinical processes and patient outcomes as expected for an EHR were not reflected in the results. Clinicians were satisfied with the EHR, although there was a non-significant decline between 11 and 17 months post implementation of the EHR. There was no significant difference in patient functional outcome the two time periods. However, the sample size of 48 was too small to allow any conclusive statements to be made. Interpretation of findings underscores the importance of the interaction of workflow and EHR functionality and usability to impact clinician satisfaction, efficiency, and clinician use of the EHR.

CONCLUSION

This research provides insights into EHR use in the care of the older people in community-based health care settings. This study assessed the adoption of an EHR outside the acute hospital setting and in the community setting to provide evidence-based recommendations to PACE decision makers considering implementing an EHR.