40 research outputs found
Equity and efficiency preferences of health policy makers in China - a stated preference analysis
No full textBackground Macroeconomic growth in China enables significant progress in health care and public health. It faces difficult choices regarding access, quality and affordability, while dealing with the increasing burden of chronic diseases. Policymakers are pressured to make complex decisions while implementing health strategies. This study shows how this process could be structured and reports the specific equity and efficiency preferences among Chinese policymakers.Methods In total, 78 regional, provincial and national level policymakers with considerable experience participated in a discrete choice experiment, weighting the relative importance of six policy attributes describing equity and efficiency. Results from a conditional logistic model are presented for the six criteria, measuring the associated weights. Observed and unobserved heterogeneities were incorporated and tested in the model. Findings are used to give an example of ranking health interventions in relation to the present disease burden in China.Results In general, respondents showed strong preference for efficiency criteria i.e. total beneficiaries and cost-effectiveness as the most important attributes in decision making over equity criteria. Hence, priority interventions would be those conditions that are most prevalent in the country and cost least per health gain.Conclusion Although efficiency criteria override equity ones, major health threats in China would be targeted. Multicriteria decision analysis makes explicit important trade-offs between efficiency and equity, leading to explicit, transparent and rational policy makin
Health care priority setting in Norway a multicriteria decision analysis
No full textBackground
Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles.
Methods
In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas.
Results
The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health.
Conclusions
Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions
Should laparoscopic approach be proposed for large and/or potentially malignant adrenal tumors?
No full textINTRODUCTION:
Laparoscopic adrenalectomy (LA) is safe and effective for small, benign, functioning tumors. Whether it should be performed for other adrenal tumors is questionable. The aim of this study was to evaluate and compare the complications and results of 150 consecutive LAs performed either for small benign tumors or for large and/or potentially malignant tumors.
METHODS:
Between June 1994 and August 1998, we performed 150 LAs in 142 patients. We used a transperitoneal flank approach in the lateral decubitus position. Initially, our indications for LA were limited to small (<4 cm) benign tumors (group I, n=102): 56 aldosteronomas, 33 Cushing's syndrome, 11 pheochromocytomas and 2 nonfunctional tumors. Progressively, based on increasing experience, LA was also proposed for tumors larger than 4 cm or potentially malignant (group II, n=48): 5 Cushing's syndrome, 1 androgen-producing tumor, 14 pheochromocytomas and 28 nonfunctional tumors. Preoperative demonstration of invasive extra-adrenal carcinoma remained an absolute contraindication for LA.
RESULTS:
Mean tumor size was 21.1 mm in group I and 51.6 mm in group II. All tumors in group I were benign. Six of the 48 tumors in group II were malignant (12.5%). The rate of complication was, respectively, 7.8% and 8.3% in groups I and II. The rate of conversion was, respectively, 4.9% and 6.2% in groups I and II. Mean operative time was 131 min in group I and 129 min in group II. The endocrinopathy was cured in all patients. To date, no recurrences have been observed.
CONCLUSIONS:
LA can be proposed for large (<12 cm) or potentially malignant adrenal tumors provided preoperative investigations have not demonstrated invasive carcinoma. An open procedure should be performed instead if local invasion is observed at the start of the operation
Surgical management of adrenal tumours lessons from a 10 years personal experience
No full textpeer reviewedObjective : To review our personal experience of the last 10 years with adrenal surgery in order to define the
indications of laparoscopic adrenalectomy (LA) and open adrenalectomy (OA), respectively.
Patients and methods : From November 1993 to June 2003, we performed 105 adrenalectomies on 97 patients (29 males
and 68 females). The lesions resected were preoperatively considered non-secreting in 47 cases (45%) and hormonally
active in 58 cases (55%). In 78 patients (80%), LA was performed and 84 adrenal glands were resected. In 19 patients
(20%), OA was considered the best modality of resection and 21 adrenal glands were resected. The average tumour size
was 37.2 mm (range 25-90) in LA group and 82.6 mm (30-260) in the OA group. All the LA were performed using a
trans-peritoneal approach. Depending on the particularities of the lesions and of the patients, the OA were performed
by anterior or lumbar incisions.
Results : There was no mortality. Conversion from LA to open surgery was necessary in two patients. Mean operating
time was 110 minutes for LA and 135 minutes for OA. Two (2.6%) patients suffered complications after LA and 4
(19%) after OA.
Conclusions : In our experience, trans-peritoneal LA proved to be a safe and reliable procedure for benign adrenal disease.
In our institution, it has become the gold standard technique for the resection of adrenal tumours, except for those
suspected or proven malignant
L'hyperaldostéronisme primaire. Mise au point et traitement raisonnés.
No full textpeer reviewedDepuis la découverte par Jérôme Conn, en 1954, de l'adénome sécréteur d'aldostérone (ou aldostéronome), neuf variétés ou associations particulières d'hyperaldostéronisme primaire ont été décrites. La manifestation principale de ce désordre endocrinien est l'hypertension artérielle, réfractaire aux thérapeutiques habituelles. Cependant, certains types d'hyperaldostéronisme sont sensibles à la chirurgie qui éradique cette hypertension et ses conséquences. Il importe donc de distinguer ces différentes variétés grâce aux moyens d'investigations actuellement à notre disposition afin d'appliquer le traitement le plus judicieux dans chaque cas
The Diagnostic Accuracy of High Resolution Ultrasound Imaging for Detection of Secondary Hyperparathyroidism in Patients with Chronic Renal Failure
No full textUltrasound is one of the preferred modalities for evaluation of the parathyroid glands. This study was undertaken to determine the accuracy of high resolution ultrasound for secondary hyperparathyroidism in patients with chronic renal failure. From March 2008 to March 2009, ninety-one hemodialysis patients were examined by high resolution ultrasound (14 MHz) of the parathyroid glands in comparison to parathyroid hormone level. 43.9% of patients showed enlarged parathyroid glands with an average of 8.7 mm. The mean parathyroid hormone level of patients with enlarged parathyroid glands on sonography was 503 ± 450 pg/ml. We observed a significant correlation between parathyroid hormone level and enlarged parathyroid glands (P<0.0001). Sensitivity and specificity of sonography for detection of secondary hyperparathyroidism were 62.5% and 85.7% respectively. In conclusion, our study showed that high resolution sonography is a useful noninvasive method for the evaluation of secondary hyperparathyroidism in patients on hemodialysis and that sonographically enlarged glands may be a measure of severity of secondary hyperparathyroidism
Bilateral neck exploration under hypnosedation. A new standard of care in primary hyperparathyroidism?
No full textpeer reviewedOBJECTIVE: The authors review their experience with initial bilateral neck exploration under local anesthesia and hypnosedation for primary hyperparathyroidism. Efficacy, safety, and cost effectiveness of this new approach are examined. BACKGROUND: Standard bilateral parathyroid exploration under general anesthesia is associated with significant risk, especially in an elderly population. Image-guided unilateral approaches, although theoretically less invasive, expose patients to the potential risk of missing multiple adenomas or asymmetric hyperplasia. Initial bilateral neck exploration under hypnosedation may maximize the strengths of both approaches while minimizing their weaknesses. METHODS: In a consecutive series of 121 initial cervicotomies for primary hyperparathyroidism performed between 1995 and 1997, 31 patients were selected on the basis of their own request to undergo a conventional bilateral neck exploration under local anesthesia and hypnosedation. Neither preoperative testing of hypnotic susceptibility nor expensive localization studies were done. A hypnotic state (immobility, subjective well-being, and increased pain thresholds) was induced within 10 minutes; restoration of a fully conscious state was obtained within several seconds. Patient comfort and quiet surgical conditions were ensured by local anesthesia of the collar incision and minimal intravenous sedation titrated throughout surgery. Both peri- and postoperative records were examined to assess the safety and efficacy of this new approach. RESULTS: No conversion to general anesthesia was needed. No complications were observed. All the patients were cured with a mean follow-up of 18 +/- 12 months. Mean operating time was <1 hour. Four glands were identified in 84% of cases, three glands in 9.7%. Adenomas were found in 26 cases; among these, 6 were ectopic. Hyperplasia, requiring subtotal parathyroidectomy and transcervical thymectomy, was found in five cases (16.1%), all of which had gone undetected by localization studies when requested by the referring physicians. Concomitant thyroid lobectomy was performed in four cases. Patient comfort and recovery and surgical conditions were evaluated on visual analog scales as excellent. Postoperative analgesic consumption was minimal. Mean length of hospital stay was 1.5 +/- 0.5 days. CONCLUSIONS: Initial bilateral neck exploration for primary hyperparathyroidism can be performed safely, efficiently, and cost-effectively under hypnosedation, which may therefore be proposed as a new standard of care
