The Value of Preventative Dental Care: A Discrete-Choice Experiment

Scale and polish (SP) and oral hygiene advice (OHA) are commonly provided in primary care dental practice to help prevent periodontal disease. These services are widely consumed by service users, incurring substantial cost, without any clear evidence of clinical benefit. This article aims to elicit general population preferences and willingness to pay (WTP) for preventative dental care services and outcomes. An online discrete-choice experiment (DCE) was completed by a nationally representative sample of the UK general population. Respondents each answered 10 choice tasks that varied in terms of service attributes (SP, OHA, and provider of care), outcomes (bleeding gums and aesthetics), and cost. Choice tasks were selected using a pivoted segmented experimental design to improve task realism. An error components panel logit model was used to analyze the data. Marginal WTP (mWTP) for each attribute and level was calculated. In total, 667 respondents completed the DCE. Respondents valued more frequent SP, care provided by a dentist, and personalized OHA. Respondents were willing to pay for dental packages that generated less frequent ("never" or "hardly ever") bleeding on brushing and teeth that look and feel at least "moderately clean." Respondents were willing to pay more (+£145/y) for improvements in an aesthetic outcome from "very unclean" (-£85/y) to "very clean" (+£60/y) than they were for reduced bleeding frequency (+£100/y) from "very often" (-£54/y) to "never" (+£36/y). The general population value routinely provided SP, even in the absence of reductions in bleeding on brushing. Dental care service providers must consider service user preferences, including preferences for both health and nonhealth outcomes, as a key factor in any service redesign. Furthermore, the results provide mWTP estimates that can be used in cost-benefit analysis of these dental care services.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Examining the association between surface bioburden and frequently touched sites in intensive care

BACKGROUND

Critical care patients are at increased risk of infection. Near-patient surfaces act as reservoirs of microbial soil, which may contain pathogens.

AIM

To correlate soil levels with hand-touch frequency of near-patient sites in an intensive care unit (ICU).

METHODS

Five sites around each bed in a 10-bed ICU were screened for total microbial soil (cfu/cm²) and Staphylococcus aureus every month for 10 months. Selected sites were infusion pump and cardiac monitor, left and right bedrails, and bed table. Ten 1 h covert audits of hand-touch frequency of these sites were performed in order to provide an average hand-touch count, which was modelled against soil levels obtained from microbiological screening.

FINDINGS

Seven of 10 staphylococci were found in conjunction with gross contamination of a specific site (P=0.005) and the same proportion from three most frequently touched sites (bedrails and bed table). There was a linear association between four sites demonstrating gross microbial contamination (>12 cfu/cm²) and mean number of hand-touch counts (P=0.08). The bed table was handled most but was not the most contaminated site. We suspected that customary placement of alcohol gel containers on bed tables may have reduced microbiological yield. Removing the gel container from one table confirmed its inhibitory effect on microbial contamination after rescreening (19% vs 50% >12 cfu/cm²: P=0.007).

CONCLUSION

Surface bioburden at near-patient sites in ICU is associated with hand-contact frequencies by staff and visitors. This supports the need for targeted hygienic cleaning in a high-risk healthcare environment.

Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists

OBJECTIVE

To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis.

METHODS

In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists.

RESULTS

Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48 years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK.

CONCLUSIONS

Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

"Doctor my eyes": A natural experiment on the demand for eye care services

Preventive health care is promoted by many organisations from the World Health Organisation (WHO) to regional and national governments. The degree of cost-sharing between individuals and the health care service affects preventive service use. For instance, out-of-pocket fees that are paid by individuals for curative services reduce preventive care demand. We examine the impact of subsidised preventive care on demand. We motivate our analysis with a theoretical model of inter-temporal substitution in which individuals decide whether to have a health examination in period one and consequently whether to be treated if required in period two. We derive four testable hypotheses. We test these using the subsidised eye care policy introduced in Scotland in 2006. This provides a natural experiment that allows us to identify the effect of the policy on the demand for eye examinations. We also explore socio-economic differences in the response to the policy. The analysis is based on a sample from the British Household Panel Survey of 52,613 observations of people, aged between 16 and 59 years, living in England and Scotland for the period 2001-2008. Using the difference-in-difference methodology, we find that on average the policy did not affect demand for eye examinations. We find that demand for eye examinations only increased among high income households, and consequently, inequalities in eye-care services demand have widened in Scotland since the introduction of the policy.

"Choice" and place of delivery: a qualitative study of women in remote and rural Scotland

OBJECTIVE

To explore women's perceptions of "choice" of place of delivery in remote and rural areas where different models of maternity services are available.

SETTING AND METHODS

Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services.

RESULTS

Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from "acceptors" to "active choosers." The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in "choice."

CONCLUSIONS

Provision of different models of maternity services may not be sufficient to convince women they have "choice." The paper raises fundamental questions about the meaning of "choice" within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Models of intrapartum care and women’s trade-offs in remote and rural Scotland: a mixed-methods study

OBJECTIVE

To explore women's preferences for, and trade-offs between, key attributes of intrapartum care models.

DESIGN

Mixed-methods study using discrete choice experiments (DCEs) and focus groups.

SETTING

The North of Scotland.

POPULATION

Women from the catchment areas of eight rural maternity units in the North of Scotland.

METHODS

Based on current policy, 'model of care' and 'time travelled' were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women's preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women's preferences for place of delivery.

MAIN OUTCOME MEASURES

Preferences for attributes of intrapartum care.

RESULTS

Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one's preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances.

CONCLUSIONS

In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women's preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women's preferences.

Fulvestrant in advanced breast cancer following following failure of tamoxifen and a third generation aromatase inhibitor

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Background: Endocrine therapy is a key modality in the management of estrogen receptor positive metastatic breast cancer. Fulvestrant (ICI 182,780) is an estrogen receptor downregulator. It has previously been shown to be as effective as anastrozole in patients who had previously progressed on tamoxifen. Methods: A retrospective study was carried out of metastatic breast cancer patients treated at Charing Cross Hospital between 2002–2005 who had received fulvestrant following treatment failure with tamoxifen and a third generation aromatase inhibitor. All patients were postmenopausal and received fulvestrant 250mg IM every 28 days. Measurable disease was assessed by response evaluation criteria in solid tumors (RECIST). Results: A total of 45 patients were identified with a median age of 60 (range 36 to 90). The ER status was known in 95% (n=43) of patients and was positive in all cases, it was unknown in 2% (n=2). At the time of commencing fulvestrant, 96% (n=43) had metastatic disease and 4% (n=2) locally advanced disease. All patients had received at least 2 lines of prior endocrine therapy (including adjuvant therapy), at time of starting fulvestrant the median number of prior regimens was 3 (range 3–5). Fulvestrant was administered for a median of 4 months (range 1 to 20 months), with 4 patients currently still receiving therapy as of 1 November 2006. Of the 45 patients, 2.2% (n=1) achieved a partial response, while 31% (n=14) achieved stable disease for at least 6 months. Thus, 33.3% (n=15) obtained clinical benefit (defined as PR or SD for at least 6 months). The response rates based on line of therapy will be presented. Of the 45 patients, 41 were evaluable for survival data. The median survival of the remaining patients from the start of fulvestrant therapy was 9 months (range 1 to 48 months). Of the 44 patients, 14% (n=6) remain alive. The treatment was well tolerated and toxicity data will be presented. Conclusions: Fulvestrant is well tolerated and is efficacious as treatment for advanced breast cancer that has failed tamoxifen and a third generation aromatase inhibitors.

No significant financial relationships to disclose.

Eliciting preferences for drug treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia

PURPOSE

There are 2 main medical preparations available for lower urinary tract symptoms resulting from benign prostatic hyperplasia (BPH). Choosing between an alpha-blocker and a 5alpha-reductase inhibitor requires trade-offs between their attributes or characteristics. We investigated the relative importance of and trade-offs between the attributes of the 5alpha-reductase inhibitor dutasteride and alpha-blockers in community dwelling men using a validated technique.

MATERIALS AND METHODS

A discrete choice experiment was administered to 211 men older than 40 years who were randomly selected from the general United Kingdom population. Attributes investigated in the discrete choice experiment were time to symptom improvement, sexual and nonsexual side effects, the risks of acute urinary retention (AUR) and surgery, cost and prostate size decrease. Using regression analysis the relative importance of these attributes, the trade-offs that men are willing to make between these attributes and the willingness to pay for each attribute were estimated.

RESULTS

All attributes were important to respondents. The most important attribute was side effects. The least preferred side effects was impotence, followed by decreased libido and dizziness. Respondents were willing to wait 13, 2 and 8 months longer for symptom improvement in exchange for decreased prostate size, and the risks of AUR and surgery, respectively. Men reporting moderate symptoms were less concerned about sexual side effects, time to symptom improvement and the risk of AUR compared with men reporting mild symptoms.

CONCLUSIONS

Given the attribute levels of BPH medical treatment, overall community dwelling men preferred the 5alpha-reductase inhibitor over alpha-blockers. In the interests of shared decision making it is important to consider the importance of eliciting the preferences of patients with BPH.

Precision placement of instruments for minimally invasive procedures using a “needle driver” robot

Medical practice continues to move toward less invasive procedures. Many of these procedures require the precision placement of a needle in the anatomy. Over the past several years, our research team has been investigating the use of a robotic needle driver to assist the physician in this task. This paper summarizes our work in this area. The robotic system is briefly described, followed by a description of a clinical trial in spinal nerve blockade. The robot was used under joystick control to place a 22 gauge needle in the spines of 10 patients using fluoroscopic imaging. The results were equivalent to the current manual procedure. We next describe our follow-up clinical application in lung biopsy for lung cancer screening under CT fluoroscopy. The system concept is discussed and the results of a phantom study are presented. A start-up company named ImageGuide has recently been formed to commercialize the robot. Their revised robot design is presented, along with plans to install a ceiling-mounted version of the robot in the CT fluoroscopy suite at Georgetown University.

Longitudinal analysis of feline leukemia virus-specific cytotoxic T lymphocytes: correlation with recovery from infection

Feline leukemia virus (FeLV) is a common naturally occurring gammaretrovirus of domestic cats that is associated with degenerative diseases of the hematopoietic system, immunodeficiency, and neoplasia. Although the majority of cats exposed to FeLV develop a transient infection and recover, a proportion of cats become persistently viremic and many subsequently develop fatal diseases. To define the dominant host immune effector mechanisms responsible for the outcome of infection, we studied the longitudinal changes in FeLV-specific cytotoxic T lymphocytes (CTLs) in a group of naïve cats following oronasal exposure to FeLV. Using (51)Cr release assays to measure ex vivo virus-specific cytotoxicity, the emerging virus-specific CTL response was correlated with modulations in viral burden as assessed by detection of infectious virus, FeLV p27 capsid antigen, and proviral DNA in the blood. High levels of circulating FeLV-specific effector CTLs appeared before virus neutralizing antibodies in cats that recovered from exposure to FeLV. In contrast, persistent viremia was associated with a silencing of virus-specific humoral and cell-mediated host immune effector mechanisms. A single transfer of between 2 x 10(7) and 1 x 10(8) autologous, antigen-activated lymphoblasts was associated with a downmodulation in viral burden in vivo. The results suggest an important role for FeLV-specific CTLs in retroviral immunity and demonstrate the potential to modulate disease outcome by the adoptive transfer of antigen-specific T cells in vivo.

Hepatitis B vaccines: assessment of the seroprotective efficacy of two recombinant DNA vaccines

BACKGROUND

In universal vaccination programs, when there is no postvaccination sero-1 logic assessment of response, there must be confidence that the vaccines used provide a high degree of seroprotection.

OBJECTIVE

This parallel analysis of 2 recombinant hepatitis B vaccines (Engerix B and Recombivax/HB-Vax II) was conducted to review the seroprotective efficacy of each vaccine in defined populations.

METHODS

Clinical studies of the 2 vaccines published as manuscripts or conference abstracts in the public domain between January 1986 and April 1999 were identified retrospectively by unrestricted screening of journals through BIOSIS, MEDLINE, and EMBASE and the Internet. Unpublished or internal company data were excluded to maintain impartiality. The studies were reviewed and analyzed. The studies were not assessed for quality other than a judgment of their eligibility for inclusion in the analysis. The primary outcome measure was the proportion of subjects in defined populations who showed an early seroprotective response to currently licensed vaccination schedules. Summary statistical analyses of seroprotective response rates and 95% CIs were calculated for each vaccine for each population. Seroprotective response was defined by an anti-hepatitis B surface antigen titer > or =10 IU/L measured between 1 and 3 months after the final vaccination. Because the study was designed specifically to review published immunogenicity data, safety data were not assessed. The study was not designed to demonstrate superiority of one vaccine over the other.

RESULTS

A total of 181 clinical studies representing 32,904 vaccinated subjects were reviewed and analyzed, of whom 24,277 had been vaccinated with Engerix B and 8627 vaccinated with Recombivax/ HB-Vax II. Seroprotection was achieved in 20,060 subjects (95.8%) with Engerix B and in 7774 subjects (94.3%) with Recombivax/HB-Vax II in the normal population vaccinated according to currently licensed 3-dose schedules. In a subgroup analysis, response rates in health care workers were 6492 subjects (94.5%) for Engerix B and 3245 subjects (92.2%) for Recombivax/HB-Vax II. Children and adolescents (1-19 years) showed the highest response rates to vaccination (4612 [98.6%], Engerix B; 2292 [98.9%], Recombivax/HB-Vax II). A total of 2875 infants (<1 year) (95.8%) achieved seroprotection with Engerix B; 701 (88.5%) achieved seroprotection with Recombivax/ HB-Vax II.

CONCLUSIONS

Hepatitis B vaccination programs using either Engerix B or Recombivax/HB-Vax II can achieve high seroprotective response rates, particularly in childhood and adolescence. Ideally, younger populations should be a primary target in current universal vaccination programs.

Pain in participants of adult day care centers: assessment by different raters

The aim of this study is to compare the assessment of pain in 200 elderly persons participating in five senior day care programs, as rated by family caregivers, day care staff members, and the participants themselves. Staff members and participants provided information in a face-to-face interview. Family members provided information about the participants and their demographic characteristics via a mailed questionnaire. Agreement rates among informants ranged between 63% and 69%, showing moderate agreement rates. Health status (as reflected in number of medications taken and the presence of a diagnosis of musculoskeletal disease) and depression were associated with ratings of pain by all the informants. The assessment of pain in the elderly population is very difficult and there is a need for reliable and valid pain assessments to be used by different raters. The relationship between pain, depression and other variables should be further explored.

New neurointerventional therapies for stroke patients

New neurointerventional procedures affect patient outcomes following stroke. Intraarterial thrombolysis, cerebral angioplasty, coils placed inside aneurysms, and vessel occlusion with embolic agents serve as options for stroke patients with conditions not as amenable to traditional surgical or medical management. By understanding these new neurointerventional therapies, critical care nurses can utilize a focused neurological assessment to intervene and maintain perfusion to the brain following the procedures.

Agitation among elderly persons at adult day-care centers: the experiences of relatives and staff members

Two hundred participants (mean age = 80 years) from five senior day-care centers were included in a study of agitation. Staff members at the centers and participants' relatives rated the frequency with which participants displayed agitated behaviors, via an expanded version of the Cohen-Mansfield Agitation Inventory. The most frequent behaviors noted were general restlessness, repetitious sentences, verbal interruptions, and pacing. A three-factor solution for staff members' ratings included (a) physically nonaggressive behaviors, including general restlessness and pacing; (b) verbally agitated behaviors, including complaining and constant requests for attention; and (c) aggressive verbal behaviors, including cursing and temper outbursts. A three-factor solution for relatives' ratings included (a) physically nonaggressive behaviors, including general restlessness and pacing; (b) verbally agitated behaviors, including constant requests for attention and related interruptions; and (c) aggressive behaviors, including cursing, grabbing, kicking, and pushing. The syndromes of both models showed similarity to the factors found in a nursing home population, although differences were also apparent.

The duration of the second stage of labour

Fetal outcomes following extended second-stage labour include respiratory acidosis, lower umbilical vein and artery pH, lactacidaemia and early neonatal seizures. Maternal outcomes following extended second-stage labour include postpartum haemorrhage, puerperal fever, backache, musculoskeletal problems, stress incontinence and denervation of the pelvic floor. It is suggested that intervention should be based on the use of judgement and skill rather than strict adherence to timetables.

Form, function and fibres: a preliminary study of the Swartkrans fossil birds

Fossil bird bones from the Swartkrans cave estimated at about one million years old have been identified to family level. Differences in humerus and sternum structure were noted. This led to an investigation into flight styles and behaviour as well as the muscle structure and function of the modern representatives of three families (Phasianidae - francolins; Columbidae - pigeons; Tytonidae - barn and grass owls) in an attempt to understand why the bones in these families were so distinctive.

SLIPS. A data base system for computer storage and analysis of phonological errors

The analysis of phonological errors made by normal individuals (slips of the tongue) and brain-damaged patients (paraphasias) is a challenging problem. SLIPS is an experimental data base system for computer storage and analysis of such errors. This paper introduces SLIPS and describes its main features. Some of the problems that arise in analyzing phonological error data are explained, and examples of their solution are presented.

Viral hepatitis: a four-year hospital and general-practice study in Sydney. 2. Transmission of viral hepatitis among residential contacts in Sydney

Clinical and serological study of household contacts of index patients suffering from acute viral hepatitis showed the high infectivity of hepatitis A viral (HAV) for susceptible contacts. The anti-HAV specific IgM developed in sera of 67% of susceptible children and 31% of susceptible adult contacts. Of 81 susceptible contacts whose sera became anti-HAV positive, 28.4% developed clinically overt hepatitis. Administration of human immunoglobulin reduced the rate of clinical expression of hepatitis A among susceptible contacts; it also appeared to reduce the actual infection rate. The infection rate among susceptible adult contacts of adult index cases suffering from hepatitis B was 24%. Of 25 susceptible contacts whose sera became HBV-marker positive, 24% developed clinical illness. Transmission occurred probably both by parenteral and non-parenteral means. It is currently not possible to determine susceptibility or seroconversion to hepatitis non-A non-B agents.

Viral hepatitis: a four-year hospital and general-practice study in Sydney 1. Epidemiological features, natural history, and laboratory findings

We studied 761 patients admitted to hospital with viral hepatitis between 1971 and 1974, and 53 patients with viral hepatitis seen in general practice in Sydney, following up some of them for one to two years. We evaluated factors contributing to each type of hepatitis. We noted differences in the patterns in hepatitis A, B and non-A non-B between Anglo-Saxon and non-Anglo-Saxon sectors of the community. All patients with hepatitis A regained normal liver function within 20 months of the acute illness. Of 115 hepatitis B patients seen at 12 months, 6% had chronic hepatitis Bs antigenaemia, 60% had developed anti-HBs antibodies, and 7.3% still had abnormal liver function. Of 20 non-A non-B patients followed for 12 months, liver function was still abnormal in three, but one of these had developed hepatitis B. The case fatality rate for the whole series was 0.66%.