The Monitor Practice Programme: is non-invasive management of dental caries in private practice cost-effective?

BACKGROUND: The objective of this research was to assess the efficacy and cost-effectiveness of a non-invasive approach to dental caries management in private dental practice. METHODS: Private dental practices from a variety of locations in New South Wales were randomly allocated to either non-invasive management of caries, or continue with usual care. Patients were followed for three years and caries incidence assessed. A patient-level decision analytic model was constructed to assess the cost-effectiveness of the intervention at two years, three years, and hypothetical lifetime. RESULTS: Twenty-two dental practices and 920 patients were recruited. Within the clinical trial there was a significant difference in caries increment favouring non-invasive therapy at both two and three years. Efficacy was independent of age, gender, medical concerns, fluoride history, or previous history of dental caries, in a population of patients attending for treatment in private dental practices, in a variety of locations both urban and rural. Cost per DMFT avoided estimate was A$1287.07 (two years), A$1148.91 (three years) decreasing to A$702.52 in (medium) and A$545.93 (high) risk patients (three years). CONCLUSIONS: A joint preventive and non-invasive therapeutic approach appears to be cost-effective in patients at medium and high risk of developing dental caries when compared to the standard care provided by private dental practice.

Leptin, but not adiponectin, is a predictor of recurrent cardiovascular events in men: results from the LIPID study.

OBJECTIVE: To investigate the relationships between plasma leptin and adiponectin levels and recurrent cardiovascular events (cardiovascular death, nonfatal myocardial infarction and stroke) in men with earlier acute coronary syndromes. DESIGN, SUBJECTS AND MEASUREMENTS: A nested case-control study examined circulating leptin and adiponectin levels in plasma obtained 4-6 years after entry into the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial. Plasma was assayed from 184 men who suffered recurrent events within 4.4 years after blood collection and 184 matched controls who remained free of further events. The association between cardiovascular events and the explanatory variables was examined by conditional logistic regression analysis. RESULTS: Relative risk (RR) increased across increasing leptin quartiles; the highest quartile compared with the lowest quartile was related to the highest risk (P for trend=0.002); the increased risk remained after adjustment for risk factors (P=0.018) or for obesity (P=0.038), but in the final model (adjusted for randomized treatment, other drugs, LIPID risk score, age and body mass index), the risk was attenuated (RR=1.61, 95% CI: 0.72-3.57, P for trend=0.34). Adiponectin did not predict cardiovascular events. Subjects randomly allocated to pravastatin had 6% lower leptin levels (P=0.04) than those allocated to placebo. CONCLUSION: Plasma leptin was a significant and independent predictor of recurrent cardiovascular events (cardiovascular death, nonfatal myocardial infarction and stroke) in men with earlier acute coronary syndromes.

Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins.

BACKGROUND: Results of previous randomised trials have shown that interventions that lower LDL cholesterol concentrations can significantly reduce the incidence of coronary heart disease (CHD) and other major vascular events in a wide range of individuals. But each separate trial has limited power to assess particular outcomes or particular categories of participant. METHODS: A prospective meta-analysis of data from 90,056 individuals in 14 randomised trials of statins was done. Weighted estimates were obtained of effects on different clinical outcomes per 1.0 mmol/L reduction in LDL cholesterol. FINDINGS: During a mean of 5 years, there were 8186 deaths, 14,348 individuals had major vascular events, and 5103 developed cancer. Mean LDL cholesterol differences at 1 year ranged from 0.35 mmol/L to 1.77 mmol/L (mean 1.09) in these trials. There was a 12% proportional reduction in all-cause mortality per mmol/L reduction in LDL cholesterol (rate ratio [RR] 0.88, 95% CI 0.84-0.91; p<0.0001). This reflected a 19% reduction in coronary mortality (0.81, 0.76-0.85; p<0.0001), and non-significant reductions in non-coronary vascular mortality (0.93, 0.83-1.03; p=0.2) and non-vascular mortality (0.95, 0.90-1.01; p=0.1). There were corresponding reductions in myocardial infarction or coronary death (0.77, 0.74-0.80; p<0.0001), in the need for coronary revascularisation (0.76, 0.73-0.80; p<0.0001), in fatal or non-fatal stroke (0.83, 0.78-0.88; p<0.0001), and, combining these, of 21% in any such major vascular event (0.79, 0.77-0.81; p<0.0001). The proportional reduction in major vascular events differed significantly (p<0.0001) according to the absolute reduction in LDL cholesterol achieved, but not otherwise. These benefits were significant within the first year, but were greater in subsequent years. Taking all years together, the overall reduction of about one fifth per mmol/L LDL cholesterol reduction translated into 48 (95% CI 39-57) fewer participants having major vascular events per 1000 among those with pre-existing CHD at baseline, compared with 25 (19-31) per 1000 among participants with no such history. There was no evidence that statins increased the incidence of cancer overall (1.00, 0.95-1.06; p=0.9) or at any particular site. INTERPRETATION: Statin therapy can safely reduce the 5-year incidence of major coronary events, coronary revascularisation, and stroke by about one fifth per mmol/L reduction in LDL cholesterol, largely irrespective of the initial lipid profile or other presenting characteristics. The absolute benefit relates chiefly to an individual's absolute risk of such events and to the absolute reduction in LDL cholesterol achieved. These findings reinforce the need to consider prolonged statin treatment with substantial LDL cholesterol reductions in all patients at high risk of any type of major vascular event.

The relationship between physician cost and functional status in the elderly.

OBJECTIVE: To explore the relationship between functional status and physician cost (general practitioner/specialist) in an elderly population. DESIGN, SETTING AND PARTICIPANTS: A longitudinal study involving 328 patients aged 65 years or over admitted to medical and surgical wards of a Sydney metropolitan hospital over a 10-month period. MAIN OUTCOME MEASURES: Two predictive cost models were developed using multiple linear regression analyses. Nine predictors were modelled including functional status (Short Form 36; SF-36) and major diagnostic categories. These models were then applied to the Australian SF-36 norms to produce a profile of cost by level of functioning. RESULTS: After adjusting for potential confounders, five variables were found to be predictive of general practitioner cost at a 5% significance level. Females and age were positively associated, whereas case note mention of post-discharge services and high SF-36 vitality and role emotional scores were negatively predictive. For specialist cost, five variables were statistically significant. The SF-36 domains of physical functioning and mental health were positively associated. Higher vitality, role emotional scores and case note mention of post-discharge services were negatively associated. CONCLUSIONS: Cost models can be used to highlight the differences between general practitioner and specialist attendances, guide future physician care of the aged, and facilitate informed decision making.