Cost-effectiveness Analysis of the Dental RECUR Pragmatic Randomized Controlled Trial: Evaluating a Goal-oriented Talking Intervention to Prevent Reoccurrence of Dental Caries in Children.

BACKGROUND: The formation of dental caries is the most common chronic disease in children, and is preventable. The oral health-related quality of life has an immense impact on an individual's daily functioning, well-being or overall quality of life. OBJECTIVES: This study aims to investigate the cost effectiveness of the Dental RECUR Brief Negotiated Interview for Oral Health (DR-BNI). This 30-minute therapeutic "talk" by a dental nurse with a parent/guardian was compared with a placebo-controlled intervention in preventing reoccurrence of dental caries in children who have had a primary tooth extracted. METHODS: An economic model was developed to simulate the clinical progression of dental caries among children who have previously had a primary tooth extracted. The analysis was conducted using the UK NHS perspective. The main outcome was the incremental cost-effectiveness ratio (ICER) based on the quality-adjusted life years (QALYs). Estimates of costs and probabilities were obtained from the DR-BNI multicentre randomised controlled trial (RCT), while QALY values were obtained from published literature. Univariate and probabilistic sensitivity analyses were conducted to assess the uncertainty of the result and robustness of the model. Affordability and risk-aversion of the intervention were investigated to help decision makers make the best possible choices. RESULTS: With an intervention cost of £6.47, the results from the RCT showed the healthcare cost for the DR-BNI intervention was £115.90 per child while the control had a healthcare cost of £119.46 per child. The QALYs gained for the prevention of reoccurrence of dental caries was higher in the DR-BNI intervention arm by 0.023 QALYs; thus, the DR-BNI was the dominant intervention. At willingness to pay threshold of £3500/QALY gained, a maximum probability of being cost effectiveness is achieved at 86%. The secondary analysis showed a cost-savings of £20.94 per participant for the prevention of at least one filling or extraction. Affordability results showed that the DR-BNI programme is affordable to the UK health system at a moderately low budget. CONCLUSIONS: This study shows the proactive talking intervention to have a very moderate cost and to be effective in providing better health related quality-of-life gains. The intervention is cost savings with a dominant ICER even with a 200% increase in the cost of intervention. The NHS will be providing better oral health for children at a better net monetary benefit-to-risk ratio by adopting the DR-BNI intervention in preventing the reoccurrence of dental fillings and extractions for each participant. TRIAL REGISTRATION: This trial was registered prospectively on 27th September 2013 with the trial registration number ISRCTN 24958829.

Player acceleration and deceleration profiles in professional Australian football.

This study aimed to determine the validity and reliability of global positioning system (GPS) units for measuring a standardized set of acceleration and deceleration zones and whether these standardized zones were capable of identifying differences between playing positions in professional Australian football. Eight well trained male participants were recruited to wear two 5 Hz or 10 Hz GPS units whilst completing a team sport simulation circuit to measure acceleration and deceleration movements. For the second part of this article 30 professional players were monitored between 1-29 times using 5 Hz and 10 Hz GPS units for the collection of acceleration and deceleration movements during the 2011 and 2012 Australian Football League seasons. Players were separated into four distinct positional groups - nomadic players, fixed defenders, fixed forwards and ruckman. The GPS units analysed had good to poor levels of error for measuring the distance covered (<19.7%), time spent (<17.2%) and number of efforts performed (<48.0%) at low, moderate and high acceleration and deceleration zones. The results demonstrated that nomadic players and fixed defenders perform more acceleration and deceleration efforts during a match than fixed forwards and ruckman. These studies established that these GPS units can be used for analysing the distance covered and time spent at the acceleration and deceleration zones used. Further, these standardized zones were proven to be capable of distinguishing between player positions, with nomadic players and fixed defenders required to complete more high acceleration and deceleration efforts during a match.

Movement demands and match performance in professional Australian football.

This study examined the relationship between coaches' perception of match performance and movement demands in Australian Football. Movement demands were collected from 21 professional players over 12 matches during one Australian Football League season, with 69 player files collected. Additionally, match events relative to playing time and distance covered, along with player physical characteristics were collected. Based on coaches subjective rating of match performance (out of 20), relatively high calibre (HC) players (≥ 15/20) were compared with relatively low calibre (LC) players (≤ 9/20) for all variables. The HC players were older (+17%, p=0.011), spent a greater percentage of time performing low-speed running (+2%, p=0.039), had more kicks (38%, p=0.001) and disposals (35%, p=0.001) per min and covered less distance per kick (- 50%, p=0.001) and disposal (- 44%, p=0.001) than the LC group, with the effect sizes also supporting this trend. Further, HC players covered less distance (- 14%, p=0.037), spent less percentage of time (- 17%, p=0.037) and performed fewer (- 9%, p=0.026) efforts per min high-speed running than LC players, which was further confirmed by the effect sizes. Movement demands and match events are related to coaches' perception of match performance in professional Australian Football. Further, high levels of involvement with the football appeared to be more important to performance than high exercise speed.

The effect of obesity on outcome of unrelated cord blood transplant in children with malignant diseases.

Obesity has become a pandemic, affecting both children and adults. We sought to determine the effect of obesity among 200 children who were prospectively enrolled on a multicenter cord blood transplant (CBT) trial. All patients received myeloablative preparative regimens. Children were classified into groups according to body mass index percentile. Normal weight was defined as body mass index between the 5th and 85th percentile (n=117), overweight between the 85th and 95th percentile (n=35) and obesity above 95th percentile (n=39) for age and gender. A total of 55 patients (27%) had AML, 113 patients (57%) had ALL and 32 patients (16%) had other malignant diseases. There was no evidence for a difference in all major characteristics among the groups. Time to neutrophil and platelet engraftment, TRM, risk of acute GVHD, disease-free survival and OS were not significantly different in overweight or obese patients compared with normal weight patients. There was a trend towards increased risk of chronic GVHD in obese patients (P=0.05) compared with normal weight patients. In conclusion, there is insufficient evidence from this sample that obesity has an effect on multiple outcomes after unrelated CBT in children with malignant diseases.

Alpha1-adrenergic receptor mRNA and inflammatory mediator expression in circulating leucocytes after cardiac surgery.

Vasodilation after coronary artery bypass surgery is a common complication. Inflammatory mediators influence the expression of alpha1-adrenergic receptors. Do patients requiring high doses of postoperative inotropic support have down-regulated alpha-adrenergic receptors? Is there a characteristic pattern of preoperative inflammatory mediator expression that could predict a complicated course after the operation? Forty-four patients undergoing cardiac bypass surgery with extracorporeal circulation were prospectively investigated. Five perioperative blood samples were taken (preoperative, two hours, 12 hours, 36 hours and 72 hours postoperative). The leucocyte mRNA-expression of the three alpha1-adrenergic receptor subtypes (A, B and D) and 11 different pro-inflammatory mediators were investigated with the real-time reverse transcriptase polymerase chain reaction. The patients were divided into three groups (No-noradrenaline [No-NA]= 0 microg/min, Low-noradrenaline [Low-NA]=0.1-7 microg/min, High-noradrenaline [High-NA] >7 microg/min), according to their postoperative noradrenaline requirements. Preoperatively, alpha1(A)-receptor expression was 4.9-fold (High-NA) and 18.7-fold (Low-NA) higher than the No-NA group (P=0.005) and plasma noradrenaline levels were higher in the High-NA group (P=0.005). Across all groups at 12 hours after the operation, alpha1(A) -receptor expression decreased to approximately one-fifth of preoperative levels (P=0.01); but with greater duration and magnitude of relative decrease in the High-NA group. Patients in the No-NA group had significant postoperative increases in leucocyte inflammatory mediator expression for IL-1beta, TLR4, TREM, MPO, MMP9 and TNF genes, whereas the changes in the Low-NA and High-NA groups were not significant. Low preoperative levels of noradrenaline and low expression of alpha1(A)-adrenoreceptors in leucocytes was associated with less probability of requiring noradrenaline support after cardiac surgery.

NT-pro BNP secretion and clinical endpoints in cardiac surgery intensive care patients.

The primary objective of this study was to determine the pattern of N-Terminal pro brain natriuretic peptide (NT-pro BNP) secretion pre and post cardiac surgery and then to investigate the correlation between levels of serum NT-pro BNP and postoperative clinical and biochemical endpoints. This was a prospective observational study performed at a tertiary centre in New Zealand, examining 118 adult patients undergoing cardiac surgery. Interventions included blood samples for NT-pro BNP and troponin-T taken 48 hours prior to operation and 12, 36 and 72 hours postoperatively. The plasma NT-pro BNP levels increased fourfold postoperatively, to plateau at 36 to 72 hours. Preoperative NT-pro BNP levels correlated with ventilation time (r = 0.46), length of stay in intensive care unit (r = 0.59), total perioperative noradrenaline dose (r = 0.55), but not with postoperative atrial fibrillation or mortality. Using multivariate analysis, serum NT-pro BNP levels at 36 hours were associated with increased noradrenaline dose (P = 0.001), decreased preoperative ejection fraction (EF) Group (P = 0.013) and elevated preoperative NT-pro BNP (P < 0.001). Factors not associated with NT-pro BNP levels at 36 hours include the operation type, bypass and cross-clamp times, use of milrinone and troponin-T We conclude that NT-pro BNP levels increased markedly after cardiac surgery and that high preoperative NT-pro BNP levels are associated with a slow postoperative recovery, but do not predict the occurrence of postoperative atrial fibrillation or mortality. Myocardial ischaemia is an unlikely cause of the NT-pro BNP elevation, because no correlation existed between troponin-T and NT-pro BNP levels.

Development of an in vitro model of excess intracellular reactive oxygen species.

These investigations characterize an in vitro model for generating excess intracellular reactive oxygen species (ROS). This novel model may be useful in the identification and delineation of cellular mechanisms associated with aging due to the link between age and excess oxidative events. The human cell line, MCF7, was stably transfected using the pSV3.neo plasmid housing a gene encoding the Aequorea victoria green fluorescent protein (GFP). Transfected cells were analyzed for maintenance of GFP over time, showing stability of the GFP gene. These studies demonstrate that the presence of fluorescing GFP significantly increases intracellular ROS, creating oxidative stress in these cells. Antioxidant supplementation was evaluated to determine the effectiveness of intracellular H2O2 reduction. The results demonstrate that supplementation with a potent antioxidant, such as reduced glutathione, protects cells from oxidative damage by decreasing intracellular concentrations of H2O2. This model for intracellular generation of excess ROS establishes a clear method by which the utility of antioxidant supplementation to protect against intracellularly generated reactive oxygen species may be evaluated.

Generation and partial characterization of a transformed cetacean cell line.

A primary epithelial cell line, DK1, established from renal tissue of a spontaneously aborted female Atlantic bottlenose dolphin was transfected with linearized pSV3.neo, an SV40 virus-derived plasmid encoding large tumor antigen (Tag). Transfected cells were grown in cetacean culture medium supplemented with 400 microg/ml geneticin (G418), and individual clones were selected using cloning rings. DKN1 was the first clone to be evaluated for future research use, and has been continuously cultured for 8 years. Intracellular cytokeratin and the expression of Tag were determined in DKN1, and cell growth was evaluated under different concentrations of l-glutamine, glutathione, and N-acetylcysteine. DKN1 cells did not require high levels of l-glutamine as previously reported for cetacean cells, and addition of antioxidants at the concentrations used in this study (2.0mM) decreased the rate of cell division. These data suggest strongly that these immortalized bottlenose dolphin epithelial cells have different levels of, and requirements for, glutathione than would be considered normal for terrestrial mammalian cells, do not require high levels of l-glutamine as previously suggested for dolphin cells, and exhibit decreased levels of cell growth and viability in high levels of the antioxidant GSH and its precursor, NAC.

Episodes in action: linking the cost and quality of nonsurgical coronary revascularization.

By dissociating episodes into four types of risk (i.e., risk of occurrence, clinical risk, technical risk, and utility risk) financial incentives can be created that reward good clinical judgement, superior technical quality, and efficient health care delivery. Using a computer-generated simulation of 100,000 episodes of nonsurgical coronary revascularization (i.e., PTCA), global fees were assigned to each patient, and the relation between clinical performance and financial success was explored for 100 hypothetical practices. Good sensitivity and specificity were achieved in assessing clinical performance. Financial incentives were found to favor providers of appropriate, effective, and efficient care.

Detection of bacteraemia in critically ill patients using 16S rDNA polymerase chain reaction and DNA sequencing.

OBJECTIVE: To confirm the sensitivity of the polymerase chain reaction (PCR) technique (versus blood cultures) and to gain a better understanding of the incidence of true- and false-positive results when using this technique. DESIGN: Observational study. SETTING: Fourteen-bed, level 3 intensive care unit. PATIENTS: Hundred twenty-six critically ill adult patients. Hundred ninety-seven blood culture and PCR samples taken as clinically indicated for suspected sepsis, according to routine ICU protocol. MEASUREMENTS AND RESULTS: The PCR product (16SrDNA: 341F-1195R) was sequenced and compared with a database of known species (Genebank) to identify the bacterial nucleic acid. The PCR or blood culture result was classified as a true-positive if there was other microbiological or clinical supporting evidence.

Risk-adjusted measurement of primary cesarean sections: reliable assessment of the quality of obstetrical services.

A two-hospital system reported widely disparate Cesarean section rates in its component institutions. Statistical analysis determined that the apparent discrepancy was due primarily to patient-related factors. When risk-adjusted, both hospitals' rates were indistinguishable from expected rates. Reporting Cesarean section rates without appropriate risk adjustment yields potentially misleading results. Since reliable risk adjustment currently exists only for primary Cesarean sections, primary rates should be reported separately from "raw" rates for other procedures.

Laboratory values improve predictions of hospital mortality.

OBJECTIVE: To compare the precision of risk adjustment in the measurement of mortality rates using: (i) data in hospitals' electronic discharge abstracts, including data elements that distinguish between comorbidities and complications; (ii) these data plus laboratory values; and (iii) these data plus laboratory values and other clinical data abstracted from medical records. DESIGN: Retrospective cohort study. SETTING: Twenty-two acute care hospitals in St Louis, Missouri, USA. STUDY PARTICIPANTS: Patients hospitalized in 1995 with acute myocardial infarction, congestive heart failure, or pneumonia (n = 5966). MAIN OUTCOME MEASURES: Each patient's probability of death calculated using: administrative data that designated all secondary diagnoses present on admission (administrative models); administrative data and laboratory values (laboratory models); and administrative data, laboratory values, and abstracted clinical information (clinical models). All data were abstracted from medical records. RESULTS: Administrative models (average area under receiver operating characteristic curve=0.834) did not predict death as well as did clinical models (average area under receiver operating characteristic curve=0.875). Adding laboratory values to administrative data improved predictions of death (average area under receiver operating characteristic curve=0.860). Adding laboratory data to administrative data improved its average correlation of patient-level predicted values with those of the clinical model from r=0.86 to r=0.95 and improved the average correlation of hospital-level predicted values with those of the clinical model from r=0.94 for the administrative model to r=0.98 for the laboratory model. CONCLUSIONS: In the conditions studied, predictions of inpatient mortality improved noticeably when laboratory values (sometimes available electronically) were combined with administrative data that included only those secondary diagnoses present on admission (i.e. comorbidities). Additional clinical data contribute little more to predictive power.

Anthem Blue Cross and Blue Shield's coronary services network: a managed care organization's approach to improving the quality of cardiac care for its members.

OBJECTIVE: To describe a managed care organization's efforts to improve value for its members by forming a coronary services network (CSN). DESIGN: To identify high-quality facilities for its CSN, Anthem Blue Cross and Blue Shield reviewed claims data and clinical data from hospitals that met its general quality standards. An external firm measured and risk-adjusted applicant hospitals' mortality rates. Hospitals that demonstrated superior performance were eligible to join the CSN. In 1996, 2 years after the CSN was formed, clinical outcomes of participants and new applicants were analyzed again by the same external firm. PATIENTS AND METHODS: Data on more than 10,000 consecutive (all-payer) inpatients discharged after coronary bypass surgery in 1993 were collected from 16 applicant hospitals using a uniform format and data definitions. This analysis was expanded to 23 participating and applicant hospitals that discharged more than 13,000 patients who underwent either bypass surgery or coronary revascularization in 1995. We compared risk-adjusted routine length of stay (a measure of efficiency), mortality rates, and adverse outcome rates between CSN and non-CSN facilities. RESULTS: From 1993 to 1995, overall length of stay in the network decreased by 20%, from 12.3 to 9.8 days (P < or = 0.01) and severity-adjusted mortality rates decreased by 7.3%, from 2.9% to 2.7%. Initially, facilities outside the network had comparable efficiency but much higher mortality. However, they improved so much in both measures that their severity-adjusted mortality rate for bypass surgery in 1995 was no more than 10% higher than that of CSN hospitals. CONCLUSION: The creation of a statewide CSN that emphasized and improved the level of performance among providers ultimately benefited the carrier's managed care members. The desirability of participation was evidenced by an increase in the number of applicant hospitals over the 2 years. This may have stimulated quality improvement among competing providers in the region and among CSN facilities themselves.

Meet the mandate to measure clinical quality.

The mandate for health care organizations to be accountable for quality, as well as price, is now unavoidable. The Joint Commission's ORYX project is requiring every hospital to measure clinical outcomes of a majority of its patients within the next three years. This mandate can be met best with systems of clinical outcomes measurement that provide valid, reliable risk adjustment; yield meaningful information about many different diseases and procedures; and measure more than mortality or cost--all using primarily billing data. New outcomes measurement tools with all of these capabilities are available and have already enabled quality improvement in dozens of hospitals across the U.S.

Predictions of hospital mortality rates: a comparison of data sources.

BACKGROUND: Comparing hospital mortality rates requires accurate adjustment for patients' intrinsic differences. Commercial severity systems require either administrative data that omit vital clinical facts about patients' conditions at hospital admission or costly, time-consuming abstraction of medical records. The validity of supplementing administrative data with laboratory data has not been assessed. OBJECTIVE: To compare risk-adjusted mortality predictions using administrative data alone; administrative data plus laboratory values; and the combination of administrative, laboratory, and clinical data. DESIGN: Retrospective cohort study. SETTING: 30 acute care hospitals. PATIENTS: 46,769 patients hospitalized with acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia. MEASUREMENTS: Each patient's probability of dying was estimated by using administrative data only (unrestricted administrative models), administrative data restricted to secondary diagnoses that are unlikely to be hospital-acquired complications (restricted administrative models), restricted administrative data plus laboratory data (laboratory models), and restricted administrative data plus laboratory and abstracted clinical data (clinical models). RESULTS: The unrestricted administrative models predicted death better than the restricted administrative models (average areas under the receiver-operating characteristic [ROC] curves, 0.87 and 0.75, respectively) and as well as the laboratory models and the clinical models (average areas under the ROC curves, 0.86 and 0.87, respectively). The good mortality predictions obtained by using the unrestricted administrative models result from inclusion of hospital-acquired complications that commonly precede death. The laboratory models ranked 93% of patients and 95% of hospitals in a manner similar to the clinical models; in comparison, rankings provided by the laboratory models were similar to those provided for 75% of patients and 69% of hospitals by the unrestricted administrative models and for 72% of patients and 77% of hospitals by the restricted administrative models. CONCLUSIONS: Adding laboratory data (often available electronically) to restricted administrative data sets can provide accurate predictions of inpatient death from acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia. This alternative avoids the cost of data abstraction and the serious errors associated with using administrative data alone.

Forming a coronary services network on the basis of quality of care.

An Ohio insurance company's initiative to emphasize risk-adjusted clinical outcomes as criteria for selecting and reimbursing members of a network is stimulating a new emphasis on quality of care throughout the market area. Hospitals inside the network are cooperating to improve their collective results, while providers on the outside have launched major quality improvement programs in the effort to become measurably competitive with these centers of excellence. This case study in network selection demonstrates a new role for fiscal intermediaries in health care.

Care of patients with upper gastrointestinal hemorrhage in academic medical centers: a community-based comparison.

BACKGROUND & AIMS: A common perception among purchasers is that academic medical centers are inefficient and overutilize technology; however, little empirical information exists. The aim of this study was to compare treatment and outcomes of patients with upper gastrointestinal hemorrhage admitted to major teaching hospitals and other hospitals in a large metropolitan area. METHODS: Data on 3801 consecutive eligible patients admitted to five major teaching hospitals and 25 other hospitals from 1991 to 1993 were obtained by review of medical records. Admission severity of illness was measured using validated multivariable models. RESULTS: Rates of upper endoscopy were somewhat lower among the 1004 patients discharged from fellowship hospitals, compared with the other 2797 patients (82.9% vs. 85.6%; P < 0.05), and the use of other procedures was similar. Although patients admitted to fellowship hospitals tended to have a higher severity of illness, both unadjusted (6.3 +/- 9.0 vs. 7.1 +/- 7.5 days; P < 0.01) and risk-adjusted length of stay were somewhat shorter. Mortality rates were similar between hospitals, and patients admitted to fellowship hospitals were somewhat less likely to be transfused. CONCLUSIONS: In patients with upper gastrointestinal hemorrhage, teaching hospitals do not appear to provide inefficient care or overutilize expensive treatments when compared with community facilities. These findings are noteworthy at a time when viability of academic centers and fellowship training is threatened.

Important considerations in using indicators to profile providers.

The demand is accelerating for information about the clinical performance of providers. In the more competitive and value-sensitive marketplace that is already developing, purchasers (consumers, employers, and insurers) of health care services will require more information to better assess the relative value of providers' (professional and hospital) services. The cornerstone of a wise, value-based strategy in selecting health care services is careful assessment of each provider's performance based on detailed, quantitative data in the form of clinical indicators. The use of indicators to profile the comparative performances of providers allows purchasers to compare as well as to influence provider performance.

Standardization of terms and analytic methods for performance evaluation: achievable goal or impossible dream?

Communication about health care management is severely limited by the usage of words borrowed from the diverse professional groups that have contributed to the field. This article suggests development of a glossary of terms to eliminate much of the current confusion in discussions of outcomes, reduce redundancy, and form the basis for interdisciplinary understanding. As a starting point, some major concepts are discussed that warrant further refinement and definition. Also highlighted is the need for standards in describing and evaluating systems designed to measure outcomes of health care, with the goal of enabling consumers to compare these systems meaningfully.