摘要:

Occupational back pain is a widespread self-limited but recurring disease that generates major societal costs and impairs workplace productivity. However, this societal impact is mostly accounted for by a small fraction of patients with back pain who have prolonged absence from work, i.e. prolonged disability.Evidence from research from the past 2 decades has progressively shown that most efforts to prevent or cure the disease have limited results, explaining the expanding number of disability cases from back pain. However, recent evidence has also shed light on the causes of disability that are not only due to the patient's personal characteristics (physical and psychosocial), but also stem from the patient's environment in the disability problem − the workplace, the compensation system and even the healthcare delivery system.In addition, successful intervention studies have used an approach to disability prevention through patient reassurance and interventions linked to the workplace, instead of using a medical model of back pain treatment. It is evident that the present disease treatment paradigm should be replaced by a disability prevention paradigm for patients with subacute or chronic back pain to avoid unnecessary evolution towards prolonged disability.We propose a disability prevention management model to encourage clinicians, employers, unions and insurers, as well as researchers in the field, to work within the perspective of the disability paradigm.

ISSN:1173-8790    

出版商:ADIS    

年代:2001

数据来源: ADIS

摘要:

Hypertension is an important modifiable risk factor for cardiovascular disease. Despite compelling evidence for the benefits of various treatment strategies and an extensive program of public and professional education, management of hypertension remains suboptimal with marked interphysician variability and inconsistent application of clinical trial evidence. Clinical practice guidelines are often cited as a potential means to improve hypertension management, although trials evaluating the impact of guidelines for various conditions have reported mixed results. Multiple potential barriers to the successful implementation of guidelines exist: these can be broadly classified as arising from the clinician, the patient, the environment, or the guideline itself. The probability of successfully implementing a guideline is highest if multifactorial approaches are pursued, such as:the generation of locally endorsed evidence-based guidelines;dissemination of the guidelines by academic detailing;point-of-care reminder systems; andmultiple reinforcements via local opinion leaders and audit with patient-specific feedback.

ISSN:1173-8790    

出版商:ADIS    

年代:2001

数据来源: ADIS

摘要:

ObjectivesTo:calculate the number needed to screen (NNS) and community effectiveness of combination treatment (interferon-α plus ribavirin) compared with its efficacy of 28 to 45%;compare the cost of opportunistic hepatitis C virus (HCV) screening and combined treatment to prevent 1 high risk patient developing cirrhosis with the cost of liver transplantation; andput a cash value on how much purchasing authorities should bid in a commissioning round for new HCV treatments.DesignA financial option appraisal of liver transplantation versus opportunistic HCV screening and treatment;a financial/commissioning model from a purchaser’s perspective using the latest national and international standards/guidelines and audit reports.Setting and participantsWest Kent Health Authority (963 000 residents and 9 primary care groups). All patients at high risk of HCV presenting to health services in 1998/1999 who had an anti-HCV test.ResultsUsing current National Institute of Clinical Excellence (NICE) guidance (combined treatment for moderate to severe liver changes), about 113 479 high risk persons need to be screened and medically treated, costing about 50 947 pounds sterling (£) to prevent 1 patient developing cirrhosis in 10 to 20 years. The community effectiveness therefore is 0.00088%. The net present value (NPV) of HCV screening and combined treatment is −£32 471 to −£25 407 to prevent 1 patient developing cirrhosis compared with liver transplantation; and the marginal cost to fund current volumes is £54 000. In contrast, if current international standards were used (which advocates combined treatment for mild, moderate and severe liver changes), the NNS is 118 to prevent 1 high risk patient developing cirrhosis; the community effectiveness is 0.847%; the NPV is −£6479 to £584; and the variable cost to fund current volumes is £796 850.ConclusionThe community effectiveness of combined treatment, at best (i.e. using the international model), is 33 to 53 times less than its efficacy; HCV screening and drug treatment is more expensive than liver transplantation. Furthermore, the international model is a far more technically efficient pathway for delivering HCV care than that recommended by NICE guidance.

ISSN:1173-8790    

出版商:ADIS    

年代:2001

数据来源: ADIS

摘要:

Breast cancer is the most common malignancy affecting women and imposes a substantial economic burden on society. Estrogen is thought to play a major role in both the initiation and promotion of hormone dependent breast cancer, and a number of well recognized risk factors for breast cancer reflect increased cumulative estrogen exposure (e.g. early menarche, late menopause).Metastatic breast cancer is an incurable condition and the goals of treatment are to relieve symptoms, improve health-related quality of life and prolong life. Women with hormone receptor-positive disease are candidates for hormonal treatment. In contrast, chemotherapy is traditionally the treatment of choice in those with hormone receptor-negative disease or symptomatic visceral disease.Anastrozole is a highly selective nonsteroidal type II aromatase inhibitor that suppresses plasma and intratumoral estrogen levels. The results of 2 multicenter, randomized, double-blind trials have shown anastrozole to be at least as effective as tamoxifen in the first-line treatment of postmenopausal women with advanced breast cancer, although survival data are lacking. In the smaller of these trials, the median time to disease progression was significantly prolonged (p = 0.005) in anastrozole, compared with tamoxifen, recipients (11.1vs5.6 months), although combined analysis of the 2 trials revealed no significant difference between anastrozole and tamoxifen in terms of this end-point.Similarly, anastrozole has been shown to be at least as effective as megestrol in the second-line treatment of postmenopausal women with advanced breast cancer in 2 multicenter randomized studies. Combined analysis of the studies revealed a significant survival advantage (p < 0.025) for anastrozole 1 mg/day, compared with megestrol 40mg 4 times daily, recipients (estimated hazard ratio 0.78; 97.5% confidence interval 0.6 to <1).Tolerability is an important consideration in women with advanced breast cancer. The most common adverse events associated with anastrozole therapy were gastrointestinal disturbance, hot flushes, asthenia and pain. Anastrozole is associated with less vaginal bleeding and thromboembolic disease than tamoxifen and less bodyweight gain than megestrol. Anastrozole also appears to be a cost-effective option in the first- and second-line treatment of advanced breast cancer, although data are limited.ConclusionCurrent treatment guidelines support the use of anastrozole in the second-line treatment of postmenopausal women with advanced breast cancer. Although current treatment guidelines do not yet reflect this, data from recent, well designed studies demonstrate that anastrozole is likely to be a viable alternative to tamoxifen in the first-line treatment of postmenopausal women with advanced breast cancer.

ISSN:1173-8790    

出版商:ADIS    

年代:2001

数据来源: ADIS

ISSN:1173-8790    

出版商:ADIS    

年代:2001

数据来源: ADIS