Association of Medicare's Bundled Payments for Care Improvement initiative with patient-reported outcomes.

OBJECTIVE: To determine whether the Bundled Payments for Care Improvement (BPCI) initiative affected patient-reported measures of quality. DATA SOURCES: Surveys of Medicare fee-for-service beneficiaries discharged from acute care hospitals participating in BPCI Model 2 and comparison hospitals between October 2014 and June 2017. Variables from Medicare administrative data and the Provider of Services file were used for sampling and risk adjustment. STUDY DESIGN: We estimated risk-adjusted differences in patient-reported measures of care experience and changes in functional status, for beneficiaries treated by BPCI and comparison hospitals. DATA COLLECTION: We selected a stratified random sample of BPCI and matched comparison beneficiaries. We fielded nine waves of surveys using a mail and phone protocol, yielding 29 193 BPCI and 29 913 comparison respondents. PRINCIPAL FINDINGS: Most BPCI and comparison survey respondents reported a positive care experience and high satisfaction. BPCI respondents were slightly less likely than comparison respondents to report positive care experience or high satisfaction. Despite these differences in care experience, there was no difference between BPCI and comparison respondents in self-reported functional status approximately 90 days after hospital discharge. CONCLUSIONS: These findings reduce concerns that BPCI may have unintentionally harmed patient health but suggest room for improvement in patient care experience.

Oxidative stress and antioxidant defense responses of Etroplus suratensis to acute temperature fluctuations.

Fishes are always exposed to various environmental stresses and the chances of succumbing to such stresses are of great physiological concern. Any change in temperature from the ambient condition can induce various metabolic and physiological changes in the body. The present study evaluates the effects of temperature induced stress on the antioxidant profile of Etroplus suratensis such as superoxide dismutase, catalase, glutathione peroxidase and lipid peroxidation. Fishes of same size were kept in a thermostatized bath at three different temperature regimes viz 16°C, 27°C (ambient temperature) and 38°C for 72h. These temperatures were selected based on the CT Max (Critical Thermal Maximum) and CT Min (Critical Thermal Minimum) exhibited by E. suratensis. Superoxide dismutase and catalase activity was found maximum in brain and muscle respectively during the 48th hour of exposure in fishes kept at 38°C. At 16°C the antioxidant response of glutathione peroxidase was maximum in muscles, whereas the lipid peroxidation rate was found to be high in gills compared to other tissues. The profound increase in the levels of oxidative stress related biomarkers indicate that the thermal stressors severely affected oxidative state of E. suratensis by the second day of experiment. Such down-regulation of redox state accompanied with the induction of oxidative stress cascade may lead to physiological damage in various tissues in fishes, in vivo. However current data indicate that a transition to low and high temperature environment from ambient condition severely affected the levels and profile of the antioxidant markers overtime in E. suratensis.

AMSSM scientific statement concerning viscosupplementation injections for knee osteoarthritis: importance for individual patient outcomes.

Osteoarthritis (OA) is a disabling disease that produces severe morbidity reducing physical activity. Our position statement on treatment of knee OA with viscosupplementation injection (hyaluronic acid, HA) versus steroid (intra-articular corticosteroids, IAS) and placebo (intra-articular placebo, IAP) is based on the evaluation of treatment effect by examining the number of participants within a treatment arm who met the Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) criteria, which is different and more relevant than methods used in other reviews which examined if the average change across the treatment groups were clinically different. We performed a systematic literature search for all relevant articles from 1960 to August 2014 in the MEDLINE, EMBASE and Cochrane CENTRAL. We performed a network meta-analysis (NMA) of the relevant literature to determine if there is a benefit from HA as compared with IAS and IAP. 11 papers met the inclusion criteria from the search strategy. On NMA, those participants receiving HA were 15% and 11% more likely to respond to treatment by OMERACT-OARSI criteria than those receiving IAS or IAP, respectively (p<0.05 for both). In the light of the aforementioned results of our NMA, the American Medical Society for Sport Medicine recommends the use of HA for the appropriate patients with knee OA.

AMSSM Scientific Statement Concerning Viscosupplementation Injections for Knee Osteoarthritis: Importance for Individual Patient Outcomes.

OBJECTIVE: Osteoarthritis (OA) is a disabling disease that produces severe morbidity reducing physical activity. Our position statement on treatment of knee OA with viscosupplementation injection [hyaluronic acid (HA)] versus steroid [intra-articular corticosteroid (IAS)] and placebo [intra-articular placebo (IAP)] is based on the evaluation of treatment effect by examining the number of subjects within a treatment arm that met the Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) criteria, which is different and more relevant than methods used in other reviews which examined if the average change across the treatment groups was clinically different. DATA SOURCES: We performed a systematic literature search for all relevant articles from 1960 to August 2014 in the MEDLINE, EMBASE, and Cochrane CENTRAL. We performed a network meta-analysis (NMA) of the relevant literature to determine if there is a benefit from HA as compared with IAS and IAP. MAIN RESULTS: Eleven articles met the inclusion criteria from the search strategy. On NMA, those subjects receiving HA were 15% and 11% more likely to respond to treatment by the OMERACT-OARSI criteria than those receiving IAS or IAP, respectively (P < 0.05 for both). CONCLUSIONS: In light of the aforementioned results of our NMA, the American Medical Society for Sport Medicine recommends the use of HA for the appropriate patients with knee OA.

Popliteal Artery Entrapment Syndrome.

Popliteal artery entrapment syndrome (PAES) may be implicated as a cause of lower leg pain in active individuals. Though a relatively rare syndrome, it is likely underdiagnosed. History often includes exertional lower leg pain, cramping, and/or paresthesias rather quickly relieved by rest, though examination may be benign. When suspected, imaging is recommended to assess anatomic variations versus functional entrapment of the artery in the calf. Because there are a number of diagnostic modalities available, it seems prudent to begin with noninvasive testing, such as ultrasound with Doppler and provocative maneuvers. Thereafter, advanced imaging (magnetic resonance imaging/magnetic resonance angiography) or arteriography may help identify a specific anatomic obstruction. Once confirmed, surgical exploration has historically been the treatment of choice, though less invasive interventions have been proposed. Though most patients reportedly return to high-level training, decision-making remains highly individualized. Further study of younger, active individuals with PAES will help to further define these criteria.

The Global Burden of Potential Productivity Loss from Uncorrected Presbyopia.

PURPOSE: The onset of presbyopia in middle adulthood results in potential losses in productivity among otherwise healthy adults if uncorrected or undercorrected. The economic burden could be significant in lower-income countries, where up to 94% of cases may be uncorrected or undercorrected. This study estimates the global burden of potential productivity lost because of uncorrected functional presbyopia. DESIGN: Population data from the US Census Bureau were combined with the estimated presbyopia prevalence, age of onset, employment rate, gross domestic product (GDP) per capita in current US dollars, and near vision impairment disability weights from the Global Burden of Disease 2010 study to estimate the global loss of productivity from uncorrected and undercorrected presbyopia in each country in 2011. To allow comparison with earlier work, we also calculated the loss with the conservative assumption that the contribution to productivity extends only up to 50 years of age. PARTICIPANTS: The economic modeling did not require the use of subjects. METHODS: We estimated the number of cases of uncorrected or undercorrected presbyopia in each country among the working-age population. The number of working-age cases was multiplied by the labor force participation rate, the employment rate, a disability weight, and the GDP per capita to estimate the potential loss of GDP due to presbyopia. MAIN OUTCOME MEASURES: The outcome being measured is the lost productivity in 2011 US dollars resulting from uncorrected or undercorrected presbyopia. RESULTS: There were an estimated 1.272 billion cases of presbyopia worldwide in 2011. A total of 244 million cases, uncorrected or undercorrected among people aged <50 years, were associated with a potential productivity loss of US $11.023 billion (0.016% of global GDP). If all those people aged <65 years are assumed to be productive, the potential productivity loss would be US $25.367 billion or 0.037% of global GDP. Correcting presbyopia to the level achieved in Europe would reduce the burden to US $1.390 billion (0.002% of global GDP). CONCLUSIONS: Even with conservative assumptions regarding the productive population, presbyopia is a significant burden on productivity, and correction would have a significant impact on productivity in lower-income countries.

Effect of Minimalist Footwear on Running Efficiency: A Randomized Crossover Trial.

BACKGROUND: Although minimalist footwear is increasingly popular among runners, claims that minimalist footwear enhances running biomechanics and efficiency are controversial. HYPOTHESIS: Minimalist and barefoot conditions improve running efficiency when compared with traditional running shoes. STUDY DESIGN: Randomized crossover trial. LEVEL OF EVIDENCE: Level 3. METHODS: Fifteen experienced runners each completed three 90-second running trials on a treadmill, each trial performed in a different type of footwear: traditional running shoes with a heavily cushioned heel, minimalist running shoes with minimal heel cushioning, and barefoot (socked). High-speed photography was used to determine foot strike, ground contact time, knee angle, and stride cadence with each footwear type. RESULTS: Runners had more rearfoot strikes in traditional shoes (87%) compared with minimalist shoes (67%) and socked (40%) (P = 0.03). Ground contact time was longest in traditional shoes (265.9 ± 10.9 ms) when compared with minimalist shoes (253.4 ± 11.2 ms) and socked (250.6 ± 16.2 ms) (P = 0.005). There was no difference between groups with respect to knee angle (P = 0.37) or stride cadence (P = 0.20). When comparing running socked to running with minimalist running shoes, there were no differences in measures of running efficiency. CONCLUSION: When compared with running in traditional, cushioned shoes, both barefoot (socked) running and minimalist running shoes produce greater running efficiency in some experienced runners, with a greater tendency toward a midfoot or forefoot strike and a shorter ground contact time. Minimalist shoes closely approximate socked running in the 4 measurements performed. CLINICAL RELEVANCE: With regard to running efficiency and biomechanics, in some runners, barefoot (socked) and minimalist footwear are preferable to traditional running shoes.

Use of the analytic hierarchy process for medication decision-making in type 2 diabetes.

AIM: To investigate the feasibility and utility of the Analytic Hierarchy Process (AHP) for medication decision-making in type 2 diabetes. METHODS: We conducted an AHP with nine diabetes experts using structured interviews to rank add-on therapies (to metformin) for type 2 diabetes. During the AHP, participants compared treatment alternatives relative to eight outcomes (hemoglobin A1c-lowering and seven potential harms) and the relative importance of the different outcomes. The AHP model and instrument were pre-tested and pilot-tested prior to use. Results were discussed and an evaluation of the AHP was conducted during a group session. We conducted the quantitative analysis using Expert Choice software with the ideal mode to determine the priority of treatment alternatives. RESULTS: Participants judged exenatide to be the best add-on therapy followed by sitagliptin, sulfonylureas, and then pioglitazone. Maximizing benefit was judged 21% more important than minimizing harm. Minimizing severe hypoglycemia was judged to be the most important harm to avoid. Exenatide was the best overall alternative if the importance of minimizing harms was prioritized completely over maximizing benefits. Participants reported that the AHP improved transparency, consistency, and an understanding of others' perspectives and agreed that the results reflected the views of the group. CONCLUSIONS: The AHP is feasible and useful to make decisions about diabetes medications. Future studies which incorporate stakeholder preferences should evaluate other decision contexts, objectives, and treatments.

An international comparison of stakeholder motivation to implement liver cancer control.

BACKGROUND: The World Health Organization offers clear guidance on the development of national cancer control programmes based on a country's level of resources, yet the motivation to implement such programmes may be driven by factors other than resources. OBJECTIVES: To compare stakeholder motivation to implement a national liver cancer control programme and assess if variation in motivation was associated with stakeholder characteristics or with national indicators of need and resources. METHODS: Relevant stakeholders were purposively selected from 13 countries (Australia, China, France, Germany, Italy, Japan, Nigeria, South Korea, Spain, Taiwan, Thailand, Turkey and USA) to participate in a structured survey on liver cancer control. Respondents included 12 individuals working in clinical, 5 in policy and 3 in advocacy roles from each country. Stakeholders' motivation was measured using a scale grounded in expectancy theory and knowledge gained during previous qualitative interviews. Comparisons across countries and respondent characteristics were conducted using hierarchical regression. Country level motivation scores, holding constant individual level covariates, were correlated with indicators of need and resources and tested using Pearson's correlation coefficients. RESULTS: In total, 260 stakeholders, equally drawn from the study countries, completed the survey (45% response rate). At the national level, motivation was highest in Nigeria, Thailand and China (P < 0.001), and lowest in Italy (P < 0.001) and Germany (P = 0.003). Higher motivation was observed among stakeholders working at the international level relative to the local level (P = 0.017). Motivation was positively associated with a country's relative burden of liver cancer (P = 0.015) and negatively associated with their level of resources (P = 0.018). CONCLUSIONS: This study provides the first empirical evidence on the motivation of stakeholders to implement national cancer control programmes. Furthermore, we demonstrate that motivation is more clearly associated with a country's cancer control needs rather than resources.

Patient preferences for noninsulin diabetes medications: a systematic review.

OBJECTIVE: An evidence-based synthesis of patient preferences for management of hyperglycemia is needed. Our objective was to systematically review patient preferences for noninsulin diabetes medications in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: We searched the PubMed, Embase, CINAHL, and EconLit databases for articles published on or before 23 January 2013. We included English-language studies of adult patients with type 2 diabetes that assessed patient preferences for diabetes medication treatment. Titles, abstracts, and articles were reviewed by at least two independent reviewers. Study data and quality were abstracted with standard protocols. RESULTS: Of 2,811 titles identified in our original search, 10 articles met inclusion criteria for the systematic review. Studies were conducted from 2007 to 2012 among diverse patient populations in the U.S., Sweden, Denmark, and the U.K. Methods used to assess patient preferences included discrete choice experiments (e.g., conjoint analysis), time tradeoff exercises, standard gamble, and patient surveys. Key attributes of diabetes medication associated with patient preferences included treatment benefits (e.g., glycemic control and weight loss/control), treatment burden (e.g., administration, frequency, and cost), and side effects (e.g., weight gain, gastrointestinal effects, and hypoglycemia). CONCLUSIONS: Various clinical and quality of life-related factors influence patient preferences for noninsulin diabetes medications. Treatment efficacy with regard to glycemic control and weight loss/control and the risk of treatment-related hypoglycemia and gastrointestinal effects are reported to be important drivers of patient treatment selections. Future work is needed to identify practical methods for incorporating patient preferences into treatment decision making and patient-centered care.

Patient preferences for the treatment of type 2 diabetes: a scoping review.

BACKGROUND: As more studies report on patient preferences, techniques are needed to identify, assess and, eventually, synthesize results from a diverse set of methodologies. Data on patient preferences are valuable to decision makers in a variety of ways. Preferences for outcomes can be used to inform decision and cost-effectiveness models, while preferences for treatments can inform patient-centered outcomes research (PCOR) and patient-centered care. OBJECTIVES: This project sought to identify and assess the literature reporting on the treatment preferences of adult patients with type 2 diabetes. In addition to cataloging the preference elicitation methods used, we developed and assessed a novel quality assessment checklist for preference-based studies. DATA SOURCES: PubMed, EMBASE, CINAHL, and EconLit databases were searched to identify studies examining patient preferences for medications for type 2 diabetes studies published since inception of each database. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: The review protocol specified inclusion of studies reporting diabetes-treatment preferences among adults with type 2 diabetes, using a range of preference measurement methods. Studies were excluded if participants were not patients with type 2 diabetes and if treatments were not pharmacological therapies targeting glycemic control, or if no primary preference information was collected. Two investigators independently reviewed titles, abstracts, and articles sequentially to select studies for data abstraction based on the inclusion and exclusion criteria. Disagreements were resolved by consensus. STUDY APPRAISAL AND SYNTHESIS METHODS: Data on study country, year, number of respondents, preference elicitation method, number of attributes, subgroup analyses, and funding source were abstracted into standardized tables. A novel checklist (PREFS) was used to assess the data quality and validity across different types of preference studies by assessing the following: purpose of the study; respondent sampling; explanation of preference assessment methods; findings reported for total sample; and significance testing. Each item was scored, and an aggregate score was then calculated (ranging from 0 to 5). RESULTS: Of the 2,100 unique citations, 61 met the inclusion criteria. The studies used conjoint analysis (n = 10), time trade-off (n = 6), standard gamble (n = 2), contingent valuation (n = 1), other stated preference methods (n = 39), and revealed preferences (n = 5). Sample sizes ranged from 27 to 14,033, with an average of 562 respondents, and two-thirds included a subgroup analysis. Most studies were conducted in one country, predominantly the USA (n = 27), UK (n = 14), Canada (n = 10), and Germany (n = 7), while 14 were conducted in multiple (2-18) countries across two or more countries. There was an increase in the annual rate of studies published over time from the time of the first publication in 1985 (p = < 0.01). Most (n = 52) studies were funded by pharmaceutical or device companies, with government, academic, association, and hospital sources also funding studies. One study met all five of the PREFS criteria and 12 met four; yet four studies met none of the criteria. The average was 27. LIMITATIONS: Currently, preferences reviews are limited by the mixed quality in the reporting of studies, the publication bias inherent in the literature, a lack of guidelines to conduct various methods, and the difficulty of synthesizing results from different studies. Our study is also limited by its focus on English language articles. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: This study provides the first systematic evaluation of the methods used in the broad existing body of research into patient preferences for type 2 diabetes medications and can serve as a primary source of information for decision makers. Future work is necessary to assess the utility of the results of reviews of preference information and to develop best-practice guidelines for the reporting of, and methods of conducting, preference studies and systematic reviews of such studies. REGISTRATION: This systematic review was registered with PROSPERO (registration number CRD42012002285).

Can public reporting impact patient outcomes and disparities? A systematic review.

OBJECTIVE: Recent US healthcare reforms aim to improve quality and access. We synthesized evidence assessing the impact that public reporting (PR), which will be extended to the outpatient setting, has on patient outcomes and disparities. METHODS: A systematic review using PRISMA guidelines identified studies addressing the impact of PR on patient outcomes and disparities. RESULTS: Of the 1970 publications identified, 25 were relevant, spanning hospitals (16), nursing homes (5), emergency rooms (1), health plans (2), and home health agencies (1). Evidence of effect on patient outcomes was mixed, with 6 studies reporting a favorable effect, 9 a mixed effect, 9 a null effect, and 1 a negative effect. One study found a mixed effect of PR on disparities. CONCLUSION: The evidence of the impact of PR on patient outcomes is lacking, with limited evidence that PR has a favorable effect on outcomes in nursing homes. There is little evidence supporting claims that PR will have an impact on disparities or in the outpatient setting. PRACTICE IMPLICATIONS: Health systems should collect information on patient-relevant outcomes. The lack of evidence does not necessarily imply a lack of effect, and a research gap exists regarding patient-relevant outcomes and PR.

Stakeholder perspectives on European priorities for comprehensive liver cancer control: a conjoint analysis.

BACKGROUND: As liver cancer incidence and mortality remain high in many parts of Europe, a more comprehensive response is required to reduce the burden. Expert stakeholders should be involved in the design of responses because they have important insights about potentially effective responses and will be affected by policy changes. We aimed to prioritize liver cancer control strategies based on European liver cancer stakeholders' views of which strategies would have the greatest impact in a comprehensive liver cancer control plan. METHODS: One hundred liver cancer clinical, policy and advocacy stakeholders from France, Germany, Italy, Spain and Turkey were surveyed. Respondents completed 12 conjoint choice tasks in which they chose which of two subsets of 11 strategies would have the greatest impact in their country. RESULTS: All strategies were considered likely to have a positive impact (P < 0.01). The highest priority strategy was monitoring of at-risk populations, followed by centres of excellence, clinical education, multidisciplinary management, national guidelines, measuring social burden, public awareness, risk assessment and referral, research infrastructure and access to treatments. CONCLUSIONS: Canvassing stakeholder views through a conjoint analysis survey provided a robust quantitative prioritization that can complement traditional qualitative consultation processes. The prioritized strategies provide a logical starting point for decision makers considering developing national plans or collaborative efforts to achieve comprehensive liver cancer control in Europe.

Is letrozole superior to clomiphene for ovarian stimulation prior to intrauterine insemination?

OBJECTIVE: To compare the efficacy of letrozole with clomiphene citrate for ovarian stimulation prior to intrauterine insemination. METHODS: A total of 272 patients underwent 362 cycles of stimulation prior to IUI from January 2009 to May 2011. One hundred and twenty-six patients (170 cycles) received letrozole 5 mg and 146 patients (192 cycles) received clomiphene citrate 100 mg for 5 days starting on day 3 of the cycle. Intrauterine insemination was done 36 ± 4 h after hCG injection in 99 patients (131 cycles) in the letrozole group and 115 patients (136 cycles) in the clomiphene group. The number of mature follicles and serum E2 levels was monitored on the day of hCG. Endometrial thickness was noted on the day of hCG and IUI as well. The pregnancy rate, the miscarriage rate, and other parameters were evaluated only for patients who underwent IUI. RESULTS: The mean number of mature follicles was significantly more in the clomiphene group (1.66 ± 1.69 vs. 1.41 ± 1.53) than in the letrozole group. No significant difference in endometrial thickness on the day of hCG administration was found; however, endometrial thickness was statistically significantly higher in the clomiphene group on the day of IUI (9.28 ± 1.43 vs. 8.77 ± 1.34). Serum E(2) levels on the day of hCG were statistically significantly higher in the clomiphene group (501.09 ± 2.45 vs. 214.79 ± 2.43 pg/ml). Pregnancy rate was 9.2 %/cycle and 12.12 %/patient in the letrozole group, and 8.1 %/cycle and 9.5 %/cycle in the clomiphene group; these differences were not statistically significant. CONCLUSION: This study found no superiority of letrozole over clomiphene when used for ovarian stimulation and IUI.

Systematic assessment of benefits and risks: study protocol for a multi-criteria decision analysis using the Analytic Hierarchy Process for comparative effectiveness research.

BACKGROUND: Regulatory decision-making involves assessment of risks and benefits of medications at the time of approval or when relevant safety concerns arise with a medication. The Analytic Hierarchy Process (AHP) facilitates decision-making in complex situations involving tradeoffs by considering risks and benefits of alternatives. The AHP allows a more structured method of synthesizing and understanding evidence in the context of importance assigned to outcomes. Our objective is to evaluate the use of an AHP in a simulated committee setting selecting oral medications for type 2 diabetes.  METHODS: This study protocol describes the AHP in five sequential steps using a small group of diabetes experts representing various clinical disciplines. The first step will involve defining the goal of the decision and developing the AHP model. In the next step, we will collect information about how well alternatives are expected to fulfill the decision criteria. In the third step, we will compare the ability of the alternatives to fulfill the criteria and judge the importance of eight criteria relative to the decision goal of the optimal medication choice for type 2 diabetes. We will use pairwise comparisons to sequentially compare the pairs of alternative options regarding their ability to fulfill the criteria. In the fourth step, the scales created in the third step will be combined to create a summary score indicating how well the alternatives met the decision goal. The resulting scores will be expressed as percentages and will indicate the alternative medications' relative abilities to fulfill the decision goal. The fifth step will consist of sensitivity analyses to explore the effects of changing the estimates. We will also conduct a cognitive interview and process evaluation.  DISCUSSION: Multi-criteria decision analysis using the AHP will aid, support and enhance the ability of decision makers to make evidence-based informed decisions consistent with their values and preferences.

Prioritizing strategies for comprehensive liver cancer control in Asia: a conjoint analysis.

BACKGROUND: Liver cancer is a complex and burdensome disease, with Asia accounting for 75% of known cases. Comprehensive cancer control requires the use of multiple strategies, but various stakeholders may have different views as to which strategies should have the highest priority. This study identified priorities across multiple strategies for comprehensive liver cancer control (CLCC) from the perspective of liver cancer clinical, policy, and advocacy stakeholders in China, Japan, South Korea and Taiwan. Concordance of priorities was assessed across the region and across respondent roles. METHODS: Priorities for CLCC were examined as part of a cross-sectional survey of liver cancer experts. Respondents completed several conjoint-analysis choice tasks to prioritize 11 strategies. In each task, respondents judged which of two competing CLCC plans, consisting of mutually exclusive and exhaustive subsets of the strategies, would have the greatest impact. The dependent variable was the chosen plan, which was then regressed on the strategies of different plans. The restricted least squares (RLS) method was utilized to compare aggregate and stratified models, and t-tests and Wald tests were used to test for significance and concordance, respectively. RESULTS: Eighty respondents (69.6%) were eligible and completed the survey. Their primary interests were hepatitis (26%), hepatocellular carcinoma (HCC) (58%), metastatic liver cancer (10%) and transplantation (6%). The most preferred strategies were monitoring at-risk populations (p<0.001), clinician education (p<0.001), and national guidelines (p<0.001). Most priorities were concordant across sites except for three strategies: transplantation infrastructure (p=0.009) was valued lower in China, measuring social burden (p=0.037) was valued higher in Taiwan, and national guidelines (p=0.025) was valued higher in China. Priorities did not differ across stakeholder groups (p=0.438). CONCLUSIONS: Priorities for CLCC in Asia include monitoring at-risk populations, clinician education, national guidelines, multidisciplinary management, public awareness and centers of excellence. As most priorities are relatively concordant across the region, multilateral approaches to addressing comprehensive liver cancer would be beneficial. However, where priorities are discordant among sites, such as transplantation infrastructure, strategies should be tailored to local needs.

Needs for hepatocellular carcinoma control policy in the Asia-Pacific region.

BACKGROUND: Hepatocellular carcinoma (HCC) is particularly burdensome in the Asia-Pacific region, however, cross-country comparisons have been limited to somewhat unreliable epidemiological measures. We conducted a comparative needs assessment for HCC control policy to inform HCC control efforts in the Asia-Pacific region. The aims were to identify regional needs, to compare overall competence across the region, and to identify which needs were concordant across the region. METHOD: Using the self-explicated method, a stated-preference approach, clinical experts from Australia, China, Japan, Korea, Taiwan, and the United States valued ten previously identified dimensions of HCC control: clinical education; risk assessment; HBV strategy; HCV strategy; life-style risk factors; national statistics; funding for screening; funding for treatment; political awareness; and public awareness. Results were normalized and analyzed using Z-scores and ANOVA, with concordance of need across the region tested via the F-test. RESULTS: Seventy-two respondents, equally drawn from the study sites, completed the survey (response rate: 36%). Respondents were hepatologists (39%), oncologists (21%), radiologists (17%), surgeons (17%), and other specialists (7%) who were involved in liver cancer control at local/regional (35%) national (44%) or international (21%) levels. In aggregate, the most significant needs were political awareness, public awareness, and life-style risk factors (all p<0.001). Significant differences in aggregate competence were observed across the region (p<0.001), with better than expected competence reported by respondents from Taiwan (p<0.001), Japan (p=0.006), and Korea (0.041), and close to expected competence reported by respondents from Australia, China, and USA (all p>0.05). There were differences in the extent of needs across the region (p<0.05) on all dimensions except funding for screening, clinical education and life style risk factors. CONCLUSIONS: As the first comparative needs assessment for HCC for the Asia-Pacific region, our results can inform national and cross-national priorities for intervention and facilitate the identification of best practices. Regional efforts to control HCC should adopt as objectives the needs for greater political and public awareness and improved management of lifestyle risk factors because these are the most significant needs, and are shared concerns across the region.

Development of a congestive heart failure protocol in a rehabilitation setting.

A number of patients in a rehabilitation setting were being transferred to acute-care facilities with a diagnosis of congestive heart failure (CHF). A transfer penalty was charged to the rehabilitation facility based on each patient's length of stay. A multidisciplinary team was assembled with physician support to address the problem. The team's goal was to develop a CHF protocol with guidelines that would allow for more frequent nursing assessments and reporting to physicians. The protocol interventions were initiated consistently and monitored on each shift. These interventions allowed for more timely assessment and treatment of patients with signs and symptoms of CHF. As a result, the number of patients being transferred to acute-care hospitals has decreased, allowing patients to complete their rehabilitation process without interruption. The decreased number of patients being transferred to the acute-care setting has resulted in fewer transfer penalties for the rehabilitation facility.