Evidence-Based Medicine applied to the control of communicable disease incidents when evidence is scarce and the time is limited.

Control of acute communicable disease incidents demands rapid risk assessment, often with minimal peer-reviewed literature available but conducted in the public's view. This paper explores how methods of evidence-based medicine (EBM) can be applied in this scenario to improve decision making and risk communication. A working group with members from EBM organisations, public health institutions and the European Centre for Disease Prevention and Control used a six-stage framework for rapid risk assessments: preparation, risk detection/verification, risk assessment, development of advice, implementation, and evaluation. It concluded that data from observational studies, surveillance and modelling play a vital role in the evidence base. However, there is a need to further develop protocols and standards, to perform, report and register outbreak investigations more systematically and rigorously, and to allow rapid retrieval of the evidence in emergencies. Lack of evidence for risk assessment and advice (usual for new and emerging diseases) should be made explicit to policy makers and the public. Priorities are to improve templates for reporting and assessing the quality of case and outbreak reports, apply grading systems to evidence generated from field investigations, improve retrieval systems for incident reports internationally, and assess how to communicate uncertainties of scientific evidence more explicitly.

Capacities, practices and perceptions of evidence-based public health in Europe.

Evidence-based methodologies are used to synthesise systematic high-quality evidence and were first applied in clinical practice. Evidence-based public health, however, is still in its early stages. The European Centre for Disease Prevention and Control sought the insight of European organisations working and providing services in the field of public health on current practices, capacities, perceptions and predictions of evidence-based public health. A survey was sent to 76 organisations. A response rate of 36% was achieved, representing 27 organisations from 16 countries. Systematic reviews were the most commonly offered service, followed by health technology assessments and rapid assessments. Of 25 respondents, 13 believed that evidence-based methodologies were poorly integrated into public health. The main perceived barriers to the further development of evidence-based public health included 'lack of formalised structure or system', 'resource constraints' 'lack of understanding of evidence-based methodologies by policy makers' and 'lack of data'. Nevertheless, 22 of 27 respondents believed that evidence-based methodologies will play an increasingly important role in public health in future. However, several barriers need to be overcome. Consistent frameworks and consensus on best practices were identified as the most pressing requirements. Steps should be taken to address these barriers and facilitate integration and ultimately public health policies.

Applicability of evidence-based practice in public health: risk assessment on Q fever under an ongoing outbreak.

With reference to the Q fever outbreak in the Netherlands in 2009-10, we tested if an evidence-based approach, comparable to the methodology used in clinical medicine, was appropriate for giving public health advice under time constrains. According to the principles of evidence-based methodologies, articles were retrieved from bibliographic databases and categorised by type and size, outcome, strengths and limitations. The risk assessment was conducted in two months and involved six staff members. We retrieved and read 559 abstracts and selected approximately 150 full text articles. The most striking finding was the lack of sound scientific evidence behind standard treatment regimes for Q fever in pregnancy. Difficulties in applying existing evidence rating systems and in expressing uncertainties were identified as problems during the process. By systematically assessing the evidence on several questions about Q fever, we were able to draw new conclusions and specify earlier statements. We found it difficult to grade the mostly observational studies with the known evidence-based grading systems. There is need to develop new methods for grading evidence from different sources in the field of public health. We conclude that an evidence-based approach is feasible for providing a risk assessment within two to three months.

Health technology assessment and implications for clinical practice: the case of prostate cancer screening.

We describe an initiative to disseminate evidence from systematic reviews about the clinical effectiveness of prostate cancer screening to general practitioners and urologists in Norway. The Norwegian Centre for Health Technology Assessment invited The Norwegian Medical Association, The Norwegian Cancer Society, The Norwegian Board of Health, The Norwegian Urological Cancer Group and The Norwegian Patient Association to develop and disseminate clinical practice recommendations. The clinical effectiveness of prostate cancer screening has been assessed in nine independent systematic reviews, which are summarized in a joint INAHTA report. The conclusion was that there is no evidence from appropriately designed trials that early detection and treatment of prostate cancer can reduce mortality, morbidity or improve quality of life. The number of prostate-specific antigen (PSA) tests analysed in Norway increased by 47% [corrected] from 1996 to 1999; at the county level the increase ranged from 12 to 48%. On this background we disseminated leaflets with information about PSA and prostate cancer to 4100 general practitioners and specialists in urology. The main message was, i) PSA should not be taken in healthy men, ii) if the test is wanted, the physician is obliged to give information about the possible consequences. Despite efforts to anchor the information campaign within the mentioned organizations, this met with notable opposition from The Norwegian Urological Society. A survey among agencies within the INAHTA network showed that more than half of the countries within this collaboration have implemented guidelines or recommendations on prostate cancer screening. In conclusion, evidence obtained through an international collaboration such as the INAHTA collaboration may be used to develop and implement national guidelines or recommendations.

Impact of payment method on behaviour of primary care physicians: a systematic review.

OBJECTIVE: To review the impact of payment systems on the behaviour of primary care physicians. METHODS: All randomised trials, controlled before and after studies, and interrupted time series studies that compared capitation, salary, fee-for-service or target payments (mixed or separately) that were identified by computerised searches of the literature. Methodological quality assessment and data extraction were undertaken independently by two reviewers using a data checklist. Study results were qualitatively analysed. RESULTS: Six studies met the inclusion criteria. There was considerable variation in the quality of reporting, study setting and the range of outcomes measured. Fee-for-service resulted in a higher quantity of primary care services provided compared with capitation but the evidence of the impact on the quantity of secondary care services was mixed. Fee-for-service resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but lower patient satisfaction with access to a physician compared with salary payment. The evidence of the impact of target payment on immunisation rates was inconclusive. CONCLUSIONS: There is some evidence to suggest that how a primary care physician is paid does affect his/her behaviour but the generalisability of these studies is unknown. Most policy changes in the area of payment systems are inadequately informed by research. Future changes to doctor payment systems need to be rigorously evaluated.

Target payments in primary care: effects on professional practice and health care outcomes.

BACKGROUND: The method by which physicians are paid may affect their professional practice. Although payment systems may be used to achieve policy objectives (e.g. improving quality of care, cost containment and recruitment to under-served areas), little is known about the effects of different payment systems in achieving these objectives. Target payments are a payment system which remunerate professionals only if they provide a minimum level of care. OBJECTIVES: To evaluate the impact of target payments on the professional practice of primary care physicians (PCPs) and health care outcomes. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register; the Cochrane Controlled Trials Register; MEDLINE (1966 to October 1997); BIDS EMBASE (1980 to October 1997); BIDS ISI (1981 to October 1997); EconLit (1969 to October 1997); HealthStar (1975 to October 1997) Helmis (1984 to October 1997); health economics discussion paper series of the Universities of York, Aberdeen, Sheffield, Bristol, Brunel, and McMaster; Swedish Institute of Health Economics; RAND corporation; and reference lists of articles. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series analyses of interventions comparing the impact of target payments to primary care professionals with alternative methods of payment, on patient outcomes, health services utilisation, health care costs, equity of care, and PCP satisfaction with working environment. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Two studies were included involving 149 practices. The use of target payments in the remuneration of PCPs was associated with improvements in immunisation rates, but the increase was statistically significant in only one of the two studies. REVIEWER'S CONCLUSIONS: The evidence from the studies identified in this review is not of sufficient quality or power to obtain a clear answer to the question as to whether target payment remuneration provides a method of improving primary health care. Additional efforts should be directed in evaluating changes in physicians' remuneration systems. Although it would not be difficult to design a randomised controlled trial to evaluate the impact of such payment systems, it would be difficult politically to conduct such trials.

Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians.

BACKGROUND: It is widely believed that the method of payment of physicians may affect their clinical behaviour. Although payment systems may be used to achieve policy objectives (e.g. cost containment or improved quality of care), little is known about the effects of different payment systems in achieving these objectives. OBJECTIVES: To evaluate the impact of different methods of payment (capitation, salary, fee for service and mixed systems of payment) on the clinical behaviour of primary care physicians (PCPs). SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register; the Cochrane Controlled Trials Register; MEDLINE (1966 to October 1997); BIDS EMBASE (1980 to October 1997); BIDS ISI (1981 to October 1997); EconLit (1969 to October 1997); HealthStar (1975 to October 1997) Helmis (1984 to October 1997); health economics discussion paper series of the Universities of York, Aberdeen, Sheffield, Bristol, Brunel, and McMaster; Swedish Institute of Health Economics; RAND corporation; and reference lists of articles. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series analyses of interventions comparing the impact of capitation, salary, fee for service (FFS) and mixed systems of payment on primary care physician satisfaction with working environment; cost and quantity of care; type and pattern of care; equity of care; and patient health status and satisfaction. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Four studies were included involving 640 primary care physicians and more than 6400 patients. There was considerable variation in study setting and the range of outcomes measured. FFS resulted in more primary care visits/contacts, visits to specialists and diagnostic and curative services but fewer hospital referrals and repeat prescriptions compared with capitation. Compliance with a recommended number of visits was higher under FFS compared with capitation payment. FFS resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but patients were less satisfied with access to their physician compared with salaried payment. REVIEWER'S CONCLUSIONS: It is noteworthy that so few studies met the inclusion criteria. There is some evidence to suggest that the method of payment of primary care physicians affects their behaviour, but the findings' generalisability is unknown. More evaluations of the effect of payment systems on PCP behaviour are needed, especially in terms of the relative impact of salary versus capitation payments.

[HIV-prevalence in Mutoko, Zimbabwe. A study among pregnant women and patients with sexually transmitted diseases]. / HIV-prevalens i Mutoko, Zimbabwe. En studie blant gravide og pasienter med kjønnssykdommer.

The Ministry of Health and Child Welfare in Zimbabwe has carried out a number of surveys in different districts of Zimbabwe to determine the extent of the HIV-epidemic. In Mutoko district such a study was carried out to determine the HIV-prevalence among pregnant women and patients with sexually transmitted diseases. The results show that 25% of the pregnant women were HIV-positive. The highest prevalence is found among women between 25 and 30 years, and women who were pregnant for the second or third time, where more than 35% were HIV-positive. Of the patients with sexually transmitted diseases, 50% were found to be HIV-positive. The HIV-prevalence was higher among men than among women, and higher among single patients than among married patients. For patients who had genital ulcers the HIV-prevalence was 67%.

[Experiences and strategies of AIDS preventive work in Mudzi and Mutoko. Experiences from 2 rural districts in Zimbabwe]. / Erfaringer og strategier i det AIDS--forebyggende arbeid i Mudzi og Mutoko. Erfaringer fra to landdistrikter i Zimbabwe.

PIP: In the districts of Mudzi and Mutoko in Zimbabwe, 25% of pregnant women and 50% of patients with sexually transmitted diseases are infected with HIV. A major challenge of AIDS prevention work lies in changing sexual behavior by local planning and organization and school education in order to halt the most important routes of transmission. The International Aid Fund of Students and Academicians (SAIH) has been involved in health care work in Mutoko and later Mudzi since 1980. The authors, Norwegian doctors, worked there during 1991-93. In Mutoko there are two small mission hospitals in addition to the Mutoko District Hospital with 140 beds. Furthermore, there are 14 health care clinics of varying sizes and quality. Most have 2-4 health workers and at least one nurse. Mudzi is without a hospital; health care is provided from 19 health clinics. It is partly accepted that men can have several sexual partners, and prostitution is not regarded negatively. The socioeconomic changes have loosened erstwhile stronger sexual mores. The AIDS prevention campaign laid the emphasis on courses for health workers and village leaders with health education and campaigns in schools, villages, and district centers using audiovisual aids. Survey showed that the knowledge about HIV and AIDS was high, but there were about 8000-10,000 sexually transmitted diseases in Mutoko a year. In 1992, courses were held for traditional healers, teachers, church leaders, party members, and rural health workers. School children received the highest priority because their sexual behavior is not yet established. Community village workers numbered 140 in Mutoko and 124 in Mudzi who are paid to carry out AIDS prevention work two days a week. In 1992, in Mutoko 333 and in Mudzi 140 HIV tests were carried out, of which 74% and 90%, respectively, were positive. A campaign will be organized for voluntary testing of symptom-free population, and an HIV center is needed with same-day test results.^ieng