New Web Log

I have not been able to correct the problems with this blog's layout and functioning. wellecon2 is my new blog. http://wellecon.blogspot.com/

About Blogging

Hits
Type blog into google and you get over150 million hits. Blogging gets more than 9 million. Weblog gets you 40 plus million while web log gives you in excess of 20 million.

In the Dictionary
According to Wired magazine “Bloggers had a great year.” they go on to say that Merriam-Webster, the dictionary publisher, declared "blog" – a word- "noun (short for Weblog) (1999) : a website that contains an online personal journal with reflections, comments and often hyperlinks provided.

So What is blogging?
Ask Bruce! Will tell you. Along with a bit on why to blog and the history of blogging. http://www.bbc.co.uk/webwise/askbruce/articles/browse/blogging_1.shtml
More on what blogging and its history here http://www.tokyoshoes.com/blogclass/

For A Practical Guide to Blogging see Greg Knollenberg http://www.writerswrite.com/journal/jul02/gak16.htm

Please be careful you could loose your job.-
This wired article talks about posting content that your employer does not agree with. http://www.wired.com/news/culture/0,1284,65912,00.html

Listen to the guy who worked for Waterstone’s and got sacked- "It is a big personal blow to me to lose my job and it also has grave implications beyond that - for anybody who works for any company and blogs, which is thousands of people." The story posted in the Gguardian is an intresting read and a cautionary tale. (Blogger sacked for sounding off Waterstone's says bookseller brought firm into disrepute.) http://www.guardian.co.uk/online/weblogs/story/0,14024,1388466,00.html



Public Health Blogs
This one is actually called Public Health Weblog
http://depts.washington.edu/hswork/phblog/phblog_0904.html

The behaviour and health blog at johns hopkins uni is definitely worth a visit.
http://bhblog.jhsph.edu/

The Public Health Press
http://publichealthpress.blogspot.com/

Here are some functions blog can fulfill according to effect measure
(http://effectmeasure.blogspot.com/- this site seems concentrate on the spread of viruses- influenza in particular- however there many other posts of interest to public health practioners)

Filter information from the web and elsewhere pertinent to our point of view and of use and interest to the public health community;
Provide context for that information;
Provide alternate points of view (challenging the conventional wisdom or the unspoken assumptions that get in the way of finding "out of the box" solutions);
Encourage argument, examination and evaluation of important issues for the purpose of fashioning a coherent point of view that can be framed and efficiently and effectively communicated;
Accrue an audience specifically interested and attuned to that point of view, which may be small, but if coordinated can exert significant influence and leadership.

If you want to try your hand at blogging you can start at Blogger (it's free!):
http://www.blogger.com/

No Smoking!

Fired for smoking?

Interesting article about people being fired because they refused to submit to testing that would allow the employer to determine if they were smokers. Raises issue about limits to which an employer can/ should go in ensuring that you are healthy and productive.
http://blog.fastcompany.com/archives/2005/01/25/jobs_up_in_smoke.html

A Medscape piece about promoting wellness of employees to save the company money. (registration needed to access it)
http://www.medscape.com/viewarticle/492362_print
A bit about an experience implementing a non-smoking policy. http://businessjournal.net/stories/020697/health.html
This is the story they ran before that one about smoking at work. http://businessjournal.net/health197.html

Site with links on quitting smoking. http://www.tobaccofree.org/quitlinks.htm

Center for Disease Control on Tobacco
http://www.cdc.gov/tobacco/index.htm

Wired on the WHO anti-smoking treaty. http://www.wired.com/news/medtech/0,1286,58941,00.html

Story of a whistleblower-
As head of research and development of America's third largest tobacco company Jeffrey Wigand had access to info about "how the company misled consumers about the highly addictive nature of nicotine, how it ignored research indicating that some of the additives used to improve flavor caused cancer, how it encoded and hid documents that could be used against the company in lawsuits brought by sick or dying smokers" http://www.fastcompany.com/articles/2002/05/wigand.html

Violence in Primary Healthcare and its Prevention

Violence in the workplace is an important issue as can be seen by the occupational health and safety, labour and other health-related information on the topic. Also the issue seems to be receiving increasing attention, possibly in part due to the increase in litigation following incidents in the workplace. In the healthcare setting it is clear that violence or the threat of violence is perceived to be a significant issue by staff in most if not all contexts. A lot of the work that has been done on the issue of violence on healthcare providers has dealt with Accident and Emergency Department and Psychiatric services. However there seems to be acknowledgement that Community-Based workers are also at significant risk.

My interest in this is that I work in primary care where, anecdotally, there is significant concern about violence. We were actually asked to put together guidlines for the prevention of violence in primary care. The challenge however is to respond to a problem for which I am aware of no organised, reliable local information. To find out what the current reality and perceptions are we will need to organise a survey, get info from police and from clinic records. There will also likely be benefit from pushing for a formal system for recording incidents of violence and aggression. We are going to need to find out what the literature says around violence in primary healthcare and its' prevention. The following are that we would have to consider topics for searching for information on: Violence in Healthcare, Violence in the workplace, Violence in the healthcare setting of this country (unlikely to find much but heard that there was a MSc thesis done by Accident and Emergency trainee), Violence in the Polyclinics, Violence Prevention strategies, Assessing the Extent and Impact of Violence in the Polyclinic/Workplace, Violence Management/Response, The Violent Patient.

Not wanting to reinvent the wheel- a fair amount of info can be taken from various source that have done reviews and have programmes/ guidelines in place: NHS Zero Tolerance Website http://www.nhs.uk/zerotolerance/dealing/index.htm, New South Wales in Australia Taskforce on Prevention and Management of Violence in the Health Workplace http://www.health.nsw.gov.au/communications/campaigns/antiviolence.html and the International Labour Organisation, http://www.ilo.org/public/english/dialogue/sector/techmeet/mevsws03/mevsws-cp.pdf
From The USA, Occupational Safety and Health Administration Website, Violence in Healthcare Module http://www.osha.gov/SLTC/etools/hospital/hazards/workplaceviolence/viol.html
BMA : violence at work : the experience of UK doctors
http://www.bma.org.uk/ap.nsf/Content/violence
Royal College of Psychiatrists' clinical practice guidelines : management of imminent violence
http://www.psychiatry.ox.ac.uk/cebmh/guidelines/violence/violence_full.html

Seems like folks from the following should be on board at some stage:
Epi/psyche/legal/security(police)/occupational health/labour union

The issue is definitely within the perview of the Ministry of Health although I am not sure under which stragetic goals it best fits. The other things that increase these thoughts becoming action taken by the powers that be include: If a large number of persons perceive that the problem exists or there is a significant increase in the numbers that do so, If people perceive the problem to be very severe or of significantly increasing severity.

An epi collegue has agreed to help with the survey. So the first thing is to get the information from the survey (we are looking for survey instruments that can be adapted), get info records of clinics, from police records and to call for formal systems for documenting incidents, looking at current violence prevention and documentation systems where they exist and looking at existing or potential hazards. Not much about prevention yet as we need to assess what is happening before moving on to that aspect.

Generalisability of Health Technology Assessment Reports

The following information was gathered from a review of the literature conducted in 2003 on generalisability of effectiveness, cost effectiveness, full economic evaluations; multinational clinical trials, economic evaluations, international cost comparisons and papers on methodology among others.
Healthcare has become more effective and more ambitious and in many cases significantly more expensive.

There has been an increased awareness of the fact that resources are limited and that there should be a responsibility to make sure that they are well used. In order to ensure we make the best use of the resources we need to evaluate health interventions.


Because of the abundance of health impacting interventions available it is likely to be challenging for all except the most wealthy contexts to do all of their own assessments. This is likely to be a particular challenge for developing countries. As a result it may be important to be able to have a way of transferring, adapting or reinterpreting the findings of health technology assessments done by developed countries in developing countries. There aught to be a simple way of adapting HTAs from one country to another. Or at least assessing which HTA's are transferable.

Several factors were found in guidelines of the generalisability of HTAs. The most important of these were detailed reporting of unit prices and discount rates; and reporting costs and resources separately; clear information on what was done; similarity between study and target population (in terms of definitions; costs; perspective; patient characteristics and preferences common or;) minimal sensitivity of result to reasonable change in key parameters and standard method. Therefore it may be useful to have guidelines based on these as a means of assessing the best available evidence on whether HTAs are generalisable.

Further work needs to be done to determine the special issues that may be of relevance when generalising from developed to developing countries.

Michael Drummond's book (oxford university press 2001)Economic Evaluation in Health Care: Merging Theory with Practice has a chapter on transferablity of economic evaluation results

Assessing Generalisability by Location in Trial-Based. Cost-Effectiveness Analysis: the Use of Multilevel Models. Andrea Manca Scupher and others
http://www.herc.ox.ac.uk/DEEM/Bristol/Manca.pdf

See page 61 in the GUIDELINES FOR ECONOMIC EVALUATION OF PHARMACEUTICALS: CANADA 2nd Edition November 1997 http://www.farmacoeconomia.com/articulos/canada.pdf

I find this to be a very facinating subject and am certainly interested in hearing your coments
eap

The following are references that were located when doing the review. Those marked E were excluded because they did not meet inclusion criteria, I incuded, Ed were excluded as they became available only after the review was completed. Many of the authors cite drummond who certainly has published the most on this topic.

E-1 How to do (or not to do)… Cost effectiveness guidelines: which ones to use? Walker, D. Health Policy and Planning. 16:1(2001): 113-121.

E-2 A multinational pharmacoeconomic evaluation of acute major depressive disorder (MDD): a comparison of cost-effectiveness between Vanlafaxine, SSRIs and TCAs. Doyle, J. et al, 2001

I-3 Economic Analysis alongside clinical trials: bias in the assessment of economic outcomes, Ellwein, L and Drummond, M.. International Journal of Technology Assessment in Health Care, 12:4 (1996); 691-697.

E-4 Health Technology Assessment: The pharmaceutical Industry perspective. Schubert, F. International Journal of Technology Assessment in Health Care, 18:2 (2002), 184-191

E-5 Elements for assessment of telemedicine applications. Ohinmaa, A, Hailey, D and Roine, R. International Journal of Technology Assessment in Health Care. (IJTAHC), 17:2 (2001), 190-202.

E-6 Probabilistic sensitivity analysis in cost-effectiveness: An application from a study of vaccination against pneumococcal bacteremia in the elderly. Whang et al. IJTAHC, 14:1 (1998), 145-160

E-7 A short history of inahta. /Hailey,D and Menon,D. International Journal of Technology Assessment in Health Care, 14:1 (1999), 236-242.

E-8 Transferability of Health Technology Assessment with particular emphasis on developing countries. Attinger, E and Panarai, R. IJTAHC, 4:1 (1988), 545-554.

I-9 Generalisability of clinical trials in otitis media with effusion. Rovers, M et al. International Journal of Paediatric Otorhinolaryngology. 60 (2001), 29-40

I-10 Issues in the cross-national assessment of health technology. Drummond, M. et al. I JTAHC, 8:4 (1992), 671-682

I-11Estimating Country-Specific Cost-Effectiveness from Multinational Clinical Trials. Wilke, R et al. Health Economics 7 (1998): 481-493

I-12 Economic Evaluation of communicable disease interventions in developing countries: a critical review of the published literature Walker, D and Fox-Rushby, J. Health Policy and Planning 16:1 (2000): 113-121.

E-13 Can resource use be extracted from randomise controlled trials to calculate cost? A review of smoking cessation interventions in general practice Rigby, K, Silagy, C. and Crockett, A. International Journal of Technology Assessment in Health Care, 12:4 (1996), 714-720.

E-14 Economic Analysis of Tirilazad mesylate for aneurysmal subarachnoid haemorrhage: Economic Evaluation of a Phase III Clinical Trial in Europe and Australia. Glick, H et al. International Journal of Technology Assessment in Health Care, 14:1 (1998), 145-160.

I-15 Economic Evaluation alongside multinational clinical trials: Study consideration s for GUSTO IIB, Jonsson,B. and Weinstein, M., International Journal of Technology Assessment in Health Care, 13:1 (1997), 49-58.

I-16 Results of the Economic Evaluation of the FIRST study: A multinational Prospective Economic Evaluation. Schulman, K. et al. International Journal of Technology Assessment in Health Care, 12:4 (1996), 698-713.

I-17 The internationalization of health technology assessment. Menon, D. and Marshall, D. International Journal of Technology Assessment in Health Care, 12:1 (1996), 45-51.

E-18 Pharmacoeconomic Studies: Pitfalls and Problems. De Graeve, D and Nonneman, W. International Journal of Technology Assessment in Health Care, 12:1 (1996), 22-30.

I-19 Cost-utility analysis of open versus laparoscopic groin hernia repair: results from a multicentre randomised clinical trial. Medical Research Council Laparoscopic Groin Hernia Trial Group. British Journal of Surgery. 88, (2001) 663-661

I-20 A multinational pharmacoeconomic analysis of oral therapies for onychomcosis. Arikian, S. et al. British Journal of Dermatology 130 (Suppl. 43) (1994): 35-44.

E-21Comparison of analytic approaches for the economic evaluation of new technologies alongside multicentre clinical trials. Taira, D. et al. American Heart Journal 145 (2002): 452-8. United States of America.

I-22International economic analysis of primary prevention of cardiovascular disease with pravastatin in WOSCOPS. Caro, J et al. European Heart Journal (1999) 20, 263-268.

I-23 The cost of HIV prevention strategies in developing countries. Sonderland, N. et al. Bulletin of the World Health Organisation, 71:5 (1993): 595-604.

E-24 Pharmacoeconomic and Health Policy: Current applications and prospects for the future Greenberg, P et al. Pharmacoeconomics 16: 5 pt 1 (1999): 425-432.

I-25 Pharmaceutical Care Programmes for the Elderly: Economic Issues. Crealey, G. et al. Pharmacoeconomics. 21:7 (2003): 455-465

I-26 Uncertainty in the economic evaluation of health care technologies: the role of sensitivity analysis. Briggs, A. et al. Health Economics 3: (1994) 95-104.

E-27 Evaluacion de la tecnologia empleada en la atencion de la salud. Infante, A. Pan American Journal of Public Health 2:5 (1997) 363-372.

E-28 Application of Strengths, weakness, opportunities and threats analysis in the development of a health technology assessment programme. Gibis, B. et al. Health Policy 58 (2001): 27-35.

I-29 Analysing differences in the cost of treatment across centres within economic evaluations. Coyle, D and Drummond, M. International Journal of Technology Assessment in Health Care 17:2 (2001), 155-163.


I-30 Analysis of the eligibility of published economic evaluations for transfer to a given health care system: Methodological approach and application to the French health care system. Spath, H. et al. Health Policy 49 (1999): 161-177

I-31 Design and analytic considerations in determining the cost effectiveness of early intervention in asthma from multinational clinical trial. Sullivan, S. et al. Controlled Clinical Trials 22 (2001): 420-437

I-32 International collaboration in health technology assessment: a study of technologies used in management of osteoporosis. Hailey, D. and Menon, D. Health Policy 43 (1998) 233-241.

I-33 Intensive care use in developing countries a comparison between a Tunisian and a French unit. Nouria. Intensive Care Medicine 24 (1998): 1444-1551

I-34 Indirect costs of disease: an international comparison. Van Rojien, L. et al. Health Policy 33 (1995): 15-29,

I-35 An international comparison of costs and outcomes of psychiatric care: Research and policy implications. Dickey, B. and Scott, J. Journal of Mental Health (1997) 6(3): 251-263.

I-36 Rispiridone Olanzapine Drug Outcomes studies in Schizophrenia (RODOS): health economics results of an international naturalistic study. Kasper, S et al. International Clinical Psychopharmacology 16 (2001): 189-196.

I-37 Analysis of costs and cost effectiveness in multinational trials. Koopmanschap, M. Touw, K. and Rutten , F. Health Policy 58 (2001): 175-186.

E-38 Economic Evaluations of Hepatitis B Immunisation: a global review of recent studies. Beutels, P. Health Economics 10 (2001): 751-774

E-39 Potential solutions to the problems of conducting systematic reviews of new health technologies. Moher, D. and Schachter, H. Journal of the Canadian Medical Association 166:13 (2002): 1674-1675

E-40 Economic Evaluation alongside N-of-1 trials: getting closer to the margin. Karnon, J. and Qizilbash, N. Health Economics 10: 79-82 (2001).

E-41Centre Specific or average unit costs in multicentre studies? Journal Some theory and simulation. Raikou, M et al. Health Economics 10 (2001): 79-82

E-42 A comparison of economic modelling and clinical trails in the economic evaluation of cholesterol modifying pharmacotherapy. Morris, S. Health Economics 6 (1997): 589-601

E-43 Cost and cost effectiveness of HIV/AIDS prevention strategies in developing countries: is there an evidence base? Walker, D. Health Policy and Planning. 18:1 (2003): 4-17.

I-44 Economics and the evaluation of health care programmes: generalisability of methods and implications for generalisability of results. Birch, S. and Gafni, A. Health Policy 64 (2003) 207-219.

I-45 Development of the WHO guidelines on generalised cost-effectiveness analysis. Murray, C. et al. Health Economics 9 (2000): 235-251

I-46 Critical Issues in the economic evaluation of interventions against communicable diseases. Hutubussy, R., Bendib, L and Evans, D. Acta Tropica 78 (2001) 191-206.

I-47 Pharmacy Benefit management: Enhancing the applicability of pharmacoeconomic for optimal decision-making. Mullins, D. and Wang, J. Pharmacoeconomics. 20:1(2002): 9-21

I-48 The Generalisability of Pharmacoeconomic Studies, Mason, J., Pharmacoeconomics, 11:6 (1997): 503-514

E-49 A New Decision Model for Cost-Utility Comparisons of Chemotherapy in Recurrent Metastatic Breast Cancer, Hutton, J. et al, Pharmacoeconomics, 9, Suppl. 2 (1996): 8-20

E-50 Effective Utilisation of Pharmacoeconomics for Decision-makers. Bentkover, J. and Corey, R., Pharmacoeconomics, 10: 2 (2002): 75-80,

I-51Towards a better understanding of multinational economic evaluations, Anonymous, Drugs and Therapy Perspectives, 18:10 (2002): 20-24

I-52 A Comparative economic analysis of pegylated liposomal doxorubicin versus topotecan in ovarian cancer in the USA and the UK, Smith, D. H. et al., Annals of Oncology 13 (2002): 1590- 1507,

I-53 An international survey of the health economics of IVF and ICSI. Collins, J. A. Human Reproduction Update 8:3 (2002): 265-277

I-54 Directly observed treatment for multi-drug resistant tuberculosis: an economic evaluation in the United States of America and South Africa, Wilton, P. et al., International Journal of Tuberculosis and Lung Disease 5:12 (2001): 1137-1142

I-55 Methods for economic evaluation alongside a multicentre trial in developing countries: a case study from the WHO Antenatal Care Randomised Controlled Trial, Mugford, M. et al., Paediatric and Perinatal Epidemiology, 12, Suppl. 2 (1998): 75-97

E –56 Cochrane Reviews and Systematic Reviews of Economic Evaluations: Amantadine and Rimantadine in the Prevention and Treatment of Influenza, Jefferson, T., Pharmacoeconomics 12, Suppl. 1 (1999): 85-89

I-57 Technology Assessment in Developing Countries. Tan-Toress, T., World Health Forum. 6 (1995): 74-76

I-58 Economic Evaluation of meloxicam (7.5 mg) versus sustained release diclofenac (100mg) treatment for osteoarthritis: a cross-national assessment for France, Italy and the UK. Jansen, R. et al. British Journal of Medical Economics 11 (1997): 9-22.

Ed-59 A tale of two (or more) cities: geographic transferability of pharmacoeconomic data. O’Brein, B. American Journal of Managed Care. 3 Suppl. (1997) S33-S39

Ed-60 Economic evaluation of health programmes: application of the process to developing countries. Mills, A. World Health Statistics Quarterly 38: 4 (1985) 368-382

Ed-61 Survey and examples of economic evaluation of health programmes in developing countries. Mills, A. World Health Statistics Quarterly 38:4 (1985) 402-431

Ed-62 Economic Evaluation of programmes or interventions in the management of rheumatoid arthritis: Defining a consensus based reference case. Maetxel, A. Journal of Rheumatology. 30:4(2001) 890-896

Ed-63 Treatment and Comparison Groups in an Evaluation of Vocational Rehabilitation: Comparability, Costs and Other Issues [A Cost Effectiveness Evaluation of the Federal-State Vocational Rehabilitation Program-Using a Comparison Group]. Englander, V. American Economist. 28:2 (1984) 71-73.

Ed-64 Small area variation in the use of common surgical procedures. An international comparison of New England, England and Norway. NEJM 1982, 307, 1310

Ed-65. Resource costing for multinational neurologic clinical trials: methods and results. Schulman K, Health Economics 7(1998): 629-638.


Ep-66 Mammography screening as a method for the early detection of breast cancer, Gibis et al, German Institute for Medical Documentation and Information 1998

Ed-67 Trials and Tribulations. Emerging issues in the design of economic evaluations alongside clinical trials. Coyle D et al. IJTAHC 1998:14, 135-144

Ed-68 Comparing cost effectiveness across countries: the model of acid-related disease. Drummond, M. Pharmacoeconomics 1992: 5,60-67

Ed-69 Pharmacoeconomic component of a clinical trial conducted in Latin America. Reinharz, D et al. IJTAHC 17:4 (2001), 571-578

Ed- 70 Generalising from trials. Analysing centre selection bias in a breast screening trial. Johnston K, Gerard K and Brown J IJTAHC 14(3) 1998, 484-504

Ed- 71 MEDTAP Database of International Unit Costs. Medtap international available at http://www.medtap.com/Products/unitcost.cfm

Ep-72 The portability of economic evaluations page 51 in CCOHTA Guidelines for the conduct of economic assessments of health care, Canadian Co-ordinating Office for Health Technology Assessment. 1997.

Ep-73 Consultancy on Health Technology Assessment for Ministry of Health Trinidad and Tobago. Banken, R., November 2001

Ep-74 Low back pain: Frequency, Management, and Prevention from a HTA perspective. Danish institute for health technology assessment. DIHTA 1999: 1:1

Ed-75 Economic evaluation in the critical care literature: Do they help us improve the efficiency of our unit? Heyland et al. Critical Care Medicine. 24 (1996): 1591-8

Ed- 76 An exercise in the feasibility of secondary economic analysis. Jefferson T et al. Health Economics. 5 (1996): 155-65

Ed-77 Economic Analysis of clinical trials in cancer: are they helpful to policy makers? Bennet, CL, et al. Stem Cells 12 (1994): 424-9

Ed-78 European School of Oncology Advisory Report to the Commission of the European Communities for Europe against Cancer Programme: Cost Effectiveness in Cancer Care. Williams et al. European Journal of Cancer. 31A (1995): 1410-24

Ed-79 Some factors to consider when using the results of economic evaluation studies at the population level. Leidl, R. IJTAHC 10 (1994): 467-478

Ed-80 Making cost assessments based on RCTs more useful to decision-makers. Balutussen et al. Health Policy 37(1996): 163-183

Ed-81 Cost-effectiveness of clinical diagnosis: venography and non-invasive testing of patients with symptomatic deep- vein thrombosis. Hull et al. NEJM. 304 (1981): 1561-67

Ed-84 Design, analysis and presentation of multinational economic studies: the need for guidance. Pang, F. Pharmacoeconomics. 20:2 (2002) 75-90

Ed-85 Analysis alongside clinical trials: Reviewing the methodological issues. Drummond, M and Davies, S. IJTAHC. 7 (1991): 561-73

Complexity Science and Healthcare

What Is Complexity?
http://www.prototista.org/E-Zine/WhatisComplexity.htm
Complexity science is a new way health-care professionals are looking at their systems for understanding and improvement.

Complexity Science encourages healthcare leaders to work with, rather
than against, overwhelming complexity by focusing on relationship
building, organizational values and culture, and widespread participa-
tion, rather than tight integration, formalization, and centralized
decision-making. The leader serves the organization by making sense
of a complex world, rather than providing neat answers that promise
success.
JIM BEGUN, PH.D

Introduction to the Basic Concepts of Complexity Science
http://www.codynamics.net/intro.htm
some excerpts:
Complexity views all groups of living creatures, including people in organizations, as complex adaptive systems.
A system is a group of two or more parts which interact to function as a whole.
Complex groups of living things and their behaviors are complicated
Adaptive living systems constantly adapt to their changing environments.
Feedback Impacts Systems
This occurs in two forms: balancing, which keeps the system stable by limiting change (like a thermostat), and reinforcing, which intensifies the change or activity.)

Emergence Complex living systems exhibit behaviors and characteristics that are different from the behaviors and characteristics of the parts or members.

Self-Organization People naturally recognize their interdependence and work together to accomplish shared goals or tasks. They do not always have to be told what to do.

Powerful Attractors As a complex system adapts to its environment, a preferred state or way of doing things is discovered, and the whole system converges on that pattern.

BMJ has several articles by paul plsek
http://bmj.bmjjournals.com/searchall/all

Plsek PE, Wilson T. Complexity, leadership, and management in healthcare organisations.BMJ. 2001 Sep 29;323(7315):746-9.

Plsek PE, Greenhalgh T.Complexity science: The challenge of complexity in health care.BMJ. 2001 Sep 15;323(7313):625-8.

New England Complex Systems Institute
COMPLEX SYSTEMS IN SCIENCE AND SOCIETY:Healthcare/Medical System ( there are some interesting papers on this site)
http://necsi.org/cxworld/healthcare.html

Plexus Institute
fostering the health of individuals, families, organizations, and our natural environment by helping people use concepts emerging from the new science of complexity
http://www.plexusinstitute.com/


Complexity Science and Analysis of Health Care Delivery Systems
http://order.ph.utexas.edu/McDaniel.pdf

Evidence Based Health Services: An
Introduction to Complexity Thinking
www.liv.ac.uk/ccr/conferences/Oct1_NHScomplex_conf.pdf

Leadership and Transformation Require a Taste for Complexity http://www.physiciancareerventures.com/physician_leader_complexity.htm

Conference on Complexity and Health Care The Robert Wood Johnson Foundation http://www.rwjf.org/reports/grr/032705s.htm

Book- COMPLEXITY AND HEALTHCARE an introduction
Edited by Kieran Sweeney and Frances Griffiths
http://www.radcliffe-oxford.com/books/bookdetail.asp?ISBN=1+85775+559+6

HTA in developing countries

It is apparent that developed countries engage in health technology assessments as means of informing decisions about programmes with major implications. One can refer to the membership of the International Network of Agencies for Heath Technology Assessment (INAHTA: http://www.inahta.org/inahta_web/index.asp)
Some of those who accept that the use of HTA is of potential benefit have argued that HTA is not relevant to developing countries. (Attinger 1988) They suggest that this is so because HTA developed in response to the needs of developed countries and therefore may not be suitable for looking at the types of issues in the ways that may be appropriate to developing countries. They add that there may be the danger that if HTA is incorrectly applied to developing countries technologies would be adopted that work well in first world countries but for various reasons will not be of benefit in the third world. (PAHO 1989)

There are some further challenges that may face developing countries wishing to engage in HTA.

Resource Limitation
Among the challenges facing developing countries is the issue of resource limitation. By this we refer to the relative and or absolute shortage of financial, human and other resources. These shortages may manifest themselves in terms of technical and administrative personnel, lack of infrastructure. In many third world countries the financial resources available are actually shrinking. (PAHO 1989).
In terms of human resources a few issues need to be highlighted. Because of the relatively small sizes of some developing countries human resources can be particularly difficult. The cost of training health professionals can be quite steep. Some of the countries have experienced “brain drain” as many of their highly qualified nationals seek to better themselves financially in developed countries. Fortunately even is such regions there may be universities which provide for training areas of relevance to HTA such as public health, health economics and other clinical and allied heath disciplines. (PAHO 1997) This may be supported by investigations such as one into the possibility of Trinidad and Tobago (a developing country in the Caribbean) conducting Health technology Assessment. That report suggested that the basic skills and expertise for HTA were available in the wider Caribbean region. (Banken 2001)

Morbidity patterns
Many of the health problems faced by the populations of the less-developed regions of the world are quite different from those in the more-developed ones due to eradication or significant reduction. In one situation (developing country) the technologies may be focusing on saving life at minimal cost while the other (developed country) may be aimed at making life more comfortable but adding very little if anything to the length. One of the implications of this is that technologies that are assessed in the developed world may be in fact of minimal relevance to the underdeveloped world. (PAHO 1989)
Several developing countries have been seeing shifts in their illness profiles towards those of developed countries. ) To the extent that the illnesses that afflict the developing jurisdictions are similar to those of the developed world there may be a similarity in the interventions that should be considered in remedying them.

Cultural diversity
There is interaction between culture and the value system, resulting from this culture may affect the effectiveness of any particular. Culture affects the perception of health and disease and the acceptability of different forms of health interventions. This can be particularly seen in the case of technologies that require participation, such as education. (Paho 1989) There are varying cultures in the Caribbean both within different states and within states as a result of the patterns of migration to the islands. In the two main groups in terms of numbers are those of East Indian ancestry and those of African ancestry. Differences still remain despite years of living together and intermarrying. As may be seen in religious affiliation and festivals. (PAHO 1998)

Political systems
It is suggested that because fewer of the developing countries are democracies it is less likely that there is a social force that keeps the leadership in check by open discussion of decisions and their implications. This is one of the reasons why the potential impact of a health technology assessment should be ascertained before deciding to conduct it. (PAHO 1989) All of the countries of the English-speaking Caribbean are democracies in terms of espousing the parliamentary system and the holding of periodic competitive, free and fair elections. In addition freedom of speech and freedom of the press contribute to a situation in which the leaders are required to justify their plans and actions. It is therefore likely that HTAs conducted or adopted will have significant positive impact. (PAHO 1998)

Healthcare system structures
Whether the health care system is centrally controlled or not may affect the implications of doing HTA. There may be more potential for HTA findings to have wide reaching impacts in systems that are centrally controlled as opposed to situations where responsibility is fragmented. (PAHO 1998)


Availability of information and data
In many developing countries there is a severe lack of appropriate accurate timely local information. This contributes to making it particularly difficult to do any local HTA of value. (Paho 1998)

Technological capacity
Although some of the larger developing countries have produced some of their own health technologies a significant portion of the technologies used are imported from developed countries. The ability of these countries to create local solutions to local health challenges will be affected by, existing capacity, raw materials and expertise in all aspects of technology development. (Paho 1989) There is likely to be a range of abilities of developing countries to generate their own interventions. It is likely that in developing countries there needs to be dependence on developed countries for a significant amount of technology.

Social technologies
This refers to ‘soft’ technologies such as capability in the following: information management capability, administration, and organisation in addition to legislation and regulation. It may be particularly important to put social technologies in developing countries through there is the possibility of them being more politically sensitive than “hard” technologies. (PAHO 1989)
There is likely to be a range of capacities in the soft technologies. This may be an area in which countries may benefit from the assistance of international development agencies.

References

Attinger, E and Panerai, R. Transferability of Health Technology Assessment with particular emphasis on developing countries. International Journal of Technology Assessment in Health Care (INJTAHC) 4 (1988) 545-554

Banken, R. Consultancy on Health Technology Assessment. Final Report, November, 2001. Ministry of Health Trinidad and Tobago

Pan American Health Organisation (PAHO), Developing Health Technology Assessment in Latin America and the Caribbean, PAHO Division of Health Systems and Services Development, Washington, 1998

Online Resources

HTA 101 INTRODUCTION TO HEALTH TECHNOLOGY ASSESSMENT
www.nlm.nih.gov/nichsr/hta101/hta101.pdf
Etext on Health Technology Assessment (HTA) Information Resources compiled & edited by Leigh-Ann Topfer and Ione Auston http://www.nlm.nih.gov/nichsr/ehta/

National Coordinating Centre for Health Technology Assessment http://www.ncchta.org/

Catalan Agency for Health Tecnology Assessment and Research http://www.aatrm.net/html/en/Du8/index.html

A special edition of reprints from the International Journel of Technology Assessment in Health Care with particular relevance to developing countries. http://www.mtppi.org/reports.php?repid=045

Directory of Health Technology Assessment Organizations Worldwide published by Medical Technology & Practice Patterns Institute and WHO Washington, DC, 1998 http://165.158.1.110/english/hsp/hsptec3.htm

Technology assessment and transfer for district health systems
http://www.who.int/health-services-delivery/performance/accreditation/20000629a.htm

November 25, 2004 Health Technology Assessment: Bridging Global Evidence to Local Issues: 3rd Asian Regional HTA Conference http://www.philhealth.gov.ph/qa/htaconference2004/

Maylaisia’s HTA programme
http://www.moh.gov.my/Medical/HTA/overview.htm

1st HTA Workshop for Latin America Mexico City November 20 - 21, 2004
www. aetmis.gouv.qc.ca/fr/publications/ congres/Abstract%20F-02A.pdf

International Society of Technology Assessment in Health Care www.istahc.net

International Network of Agencies for Health Technology Assessment www.inahta.org

Next post: The Generalisabity or Transferablity of HTA

Health Technology Assessment

The first in a series on the topic of HTA in which we will look at the following questions.

What is Health Technology Assessment? 1

What are the issues with HTA as it relates to developing countries? 2

What determines whether a HTA report is generalisable? 3

Technology assessment in health care is a multidisciplinary field of policy analysis. It studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology. (INHTA. 2002)

‘Technology’ is not necessarily referring to expensive pieces of equipment.

Technology is the practical application of scientific knowledge. (Szczepura 1996) Initially Health Technology meant “drugs, equipment and medical devices, medical and surgical procedures along with the organisation and support systems” needed for their use in looking after patients. The term now includes all technologies in personal health care (of ill and healthy) and makes explicit the knowledge and skills needed for the use of those technologies. (PAHO 1998) Most health care technologies can be thought of as belonging to one of the following categories: drugs, devices or equipment, medical and surgical procedures, support systems, and organisational and managerial systems. (Goodman 1998)

Is Health Technology Assessment Research?

Although there is occasionally the need to commission research to support the HTA process generally it does not seek to generate new knowledge or new solutions and therefore is not research (PAHO 1998)
Purpose of HTA

According Banta the goal of technology assessment is to provide policy makers with information on policy alternatives (Banta and Luce, 1993). Stevens and Milne are more specific in saying that the purpose of HTA is to help services that have an impact on health meet the objectives of the decision makers. (Stevens 2001). There are several ways that HTA can be used to support decisions including:

Advising a regulatory body about whether to allow commercial use of a drug, device or other technology

Assisting health care financiers and providers in determining which technologies should be funded and / if how much they should pay

Providing useful information for patients, clinicians and health care providers on appropriate use of various health interventions

Guiding managers of health care institutions in their acquisition and management of health technologies

Advising health officials contemplating public health programmes (Goodman 1998)


Do we need HTA?

It is becoming more and more apparent that not all health interventions make large contributions to health at reasonable cost but rather many new technologies make minimal impact on health at vast cost. (Gray 2001, Pencheon 2001, Panerai 1989)To control costs without negatively affecting health we have to make a concerted effort to obtain reliable and relevant information. Some of the major reasons cited for the interest and increase in use of HTA are:
The acknowledgement that there are variations in clinical practice that is not entirely accounted for by clinical/ epidemiological, uncertainty, acceptability and diversity.
Significant uncertainty about the real impact on health of many widely used health technologies.

The fact that new interventions are being introduced more rapidly that in the past along with pressure from industry to adopt them. (Szcepura, 1996)
Over the past few years we have seen significant world-wide increases in resource implications of providing health care (attributed to various factors: ageing population, business savvy of drug and medical device manufacturers among others) combined with an awareness of the limitations of resources. (PAHO 1998) It is also useful to bear in mind that the aims of individual patients, groups of patients with the same problem and the elected representatives may be in conflict. This is likely to be so because: each individual or group of individuals with a common health problem will tend to try to maximise the allocation of resources to their problems, while the representative of the public at large will be expected to allocate resources in ways that are transparent and that maximise equity of access. (Gray 2001)

Types of HTA

One of the issues with HTA is that it is despite the fact that it was originally intended for assessments to be comprehensive this is seldom done. These “partial” technology assessments tend to look at impacts that are of particular interest and their scope is influenced by resource constraints. (Goodman 1998)
It is generally accepted that there are three perspectives from with a HTA can be done. The orientations are not always distinct; they may overlap and complement each other. It is suggested that a good HTA should contain elements of all three. (Goodman 1998, Szczepura 1996)

Technology-Oriented Assessments are intended to determine the characteristics or impacts of a particular technology.
Problem-Oriented Assessments are intended to assess how best to manage a particular type of problem for which there are alternative and/or complementary technologies as possible solutions
Project-oriented Assessments focus on the need for or use of an intervention in a institution, programme or other designated project.

What do we assess in HTA?

Where as the traditional technology assessment may have focused on the social impact, health technology assessments zero in on safety, cost and effectiveness. This is so because of the fact that healthcare technologies tend to be insulated from the rules of the market economy. Typically products in other areas survive only as they are competitive in terms of price and performance. In health care it tends to be the health care professional or institution that determines what is provided (PAHO 1989)

The following characteristics have been taken from Goodman’s discussion of the Properties and Impacts assessed in HTA. (Goodman 1998)

Technical qualities- these include performance, conformity with design specifications, reliability, ease of use and related measures.

Clinical safety- this is a judgement of the acceptability of risk in specific clinical situations.

Efficacy and /or effectiveness- how well the technology will contribute to the improvement of patient health outcomes in idealised study settings (efficacy) and in everyday practice (effectiveness)

Economic attributes or impacts- microeconomic attributes include costs, prices, charges and payment levels accompanying individual technologies they may also include comparison of resource use and benefits for alternative technologies. The macroeconomic concerns involve the impacts of technologies on national or state wide health care costs, effects on the spending between different health programmes or between health and other areas, or the impact on the delivery mechanisms for health care.
Social, legal, ethical and/ or political impacts
Some technologies as a direct result of their being used in life threatening situations, being reproduction related or the need to allocate scarce resource intensive technologies. (Szczepura 1996, Goodman 1998)

References
Banta, H. D Luce, B. Health Care Technology and its Assessment: An International Perspective, Oxford University Press, Oxford, 1993

Drummond, M. et al Methods for the Economic Evaluation of Health Care Programmes, 2nd ed. Oxford University Press, London, 1997

Gold, M. Et al (eds.) Cost- Effectiveness in Health and in Medicine . Oxford University Press, New York, 1996

Goodman, C., TA 101 Introduction to Health Care Technology Assessment, National Library of Medicine, 1998
Available from national library medicine: http://www.nlm.nih.gov/nichsr/outreach.html#ta101
Accessed: 4/12/02

Muir Grey, J. Evidence-based health care. How to make policy and management decisions. 2 ed. Harcourt publishers, London, 2001


Stevens, A. and Miline, R. Evaluating Health Care Technologies. Chapter 5.3 p 300-308 in Pencheon et al ed. Oxford Handbook of Public Health Practice, Oxford University Press, Oxford, 2001

Szczepura, A and Kankaanpaa (eds.) Assessment of Health Care Technologies: Case Studies, Key Concepts and Strategic Issues, John Wiley and Sons limited, West Sussex, 1996

Resources
International Journal of Technology Assessment in Health

Web Resources
Center for Reviews and Dissemination- Health Technology Assessment (HTA) Database http://www.york.ac.uk/inst/crd/htahp.htm
The NHS Health Technology Assessment Programme http://www.ncchta.org/HowToOrderHTAMonos.htm
Canadian Coordinating Office for Health Technology Assessment http://www.ccohta.ca/entry_e.html
Healtb Technology on the Web
www.ahfmr.ab.ca/hta/hta-publications/ infopapers/Internet_sources_of_information.pdf
Training
Material for a course (now inactive) on HTA
The University of Birmingham in the UK offers a MSc in HTA http://www.bham.ac.uk/PublicHealth/htamasters/
INTERNATIONAL MASTER'S PROGRAM IN HTA & Management? Offered by universities of McGill, Montreal and Ottawa in Canada , Barcelona in Italy and Cattolica del Sacro Cuore in Italy
http://www.hta-master.com/en/intro.html
In the next post we will look at issues relating to conducting HTA in developing countries

Evidence-Based Healthcare

Evidence-based healthcare:
A quick and dirty guide
by E. A. Phillips, BSc, MBBS, MPH
e.arthurphillps@gmail.com

What is Evidence- based Healthcare, Evidence-based Primary Care, Evidence-based Medicine, Evidence-Based...?

•The process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions.
•It's about integrating individual clinical expertise and the best external evidence
•Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
•Despite differing definitions, its central tenet remains the appropriate integration of relevant best practice (usually based on published research findings when available) into clinical practice.
•Obviously this is not a new process — we have always tried to combine ir clinical expertise, patients' values and the best available evidence.


History of evidence based… in four lines.
•A group of doctors who wanted to improve patient care, and base their practices on the best evidence. (Wanting to base practice on best evidence sounds strange- isn’t practice based on the best evidence? Estimates of what is evidence based range from 10% to 80%)
•We have gone from one Medline citation in 1992 to more than 13 000 in 2004.


Does it work?
Since we are talking about evidence we must ask if Evidence-based... results in better health outcomes. Um Ah. Hmm. This is a little embarassing. The reality is that it seems reasonable that it should but we really don't know.

•An intensive 3 day course on evidence based medicine for doctors from various backgrounds and training level led to a clinically meaningful improvement of knowledge and skills (Fritsche et al 2002)
•Evidence-based medicine makes good sense in theory and while there is no good evidence that it improves patient outcomes (very difficult to arrange a good study of this- ethics contamination ect) it is clear that patients that receive effective interventions do better than those that do not. (Straus 2000)


•The context- Why do we need?.. Do we need evidence based healthcare?

•daily need for information to answer clinically important questions
•traditional information sources are no longer adequate
•clinicians’ up-to-date knowledge decreases over time as increasing amounts of new knowledge is published in increasing numbers of journals
•time demands of clinical work and sifting through the volume of published information make it difficult to find and assimilate new knowledge


What do I need to practice EBM?
Right. So supposing you were interested in practicing evidence based.. in a formal way- what would you need to do?
(The following is from Phillips and Sladek 2004)
Attitudes
Consider alternatives to your practice
Be willing to challenge existing practices
contemplete unanswered questions as they arise
Commit to life-long learning acknowledging that new research knowldge may change current understandings

Knowledge
Know what the "best-evidence" would look like to answer your question (research methodologies, strengths, weaknesses, potential biases
Know where to search for answers (databases)
Know how to assess the quality of published information for its validity and relevance (critical appraisal)

Skills
Be able to decide which question(s) you need to pursue in the published literature
Be able to frame a question so that is answerable
Be able to search databases effectively (searching skills)


The original definition of Evidence-based Healthcare (Sackett et al). (1) is distinctly process-orientated, and has probably been the most commonly expressed in the literature. They identified five essential steps: (i) asking an answerable question; (ii) finding the best evidence to answer that question; (iii) critically appraising that evidence; (iv) integrating it with expertise and the patient’s individual requirements; and then (v) evaluating effectiveness of the search for the evidence as well as the outcomes of the application of the evidence.



Doing versus Using
Should you attempt to do the formal Evidence-based thing yourself. All those skills. Formulating a question. Looking for an answer. Assessing the answer. Applying the answer. Assessing the process. Is there an alternative?

•Are the skills of searching for, assessing research necessary? Time, effort understanding….”it is difficult to picture the general practitioner, medical registrar, or even less the tyro casualty officer, asking the patient to wait while he or she boots the computer and searches the medical literature, starting with a couple of systematic reviews and delving into an article published in Revista Médica Española, for example, only to do the same during the next consultation and, possibly, repeating the process next week, as an important new contribution may have appeared.” IVAN MOSELEY2001
•Alternative: to access and use secondary sources of pre-assessed evidence


Finding the best evidence
•Advantages and disadvantages of the following: colleagues, experts, textbooks, journals, internet
•Question – problem.- how would you describe a group of patients similar to mine? Intervention which main intervention am I considering?. comparison- what is the main alternative?. Outcome- what do I hope to accomplish?
•Is there an up to date systematic review?

Criticism of Evidence-based...

Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom.
The difficulty with which the approach can be applied by busy doctors, especially those in primary care.
Shortage of coherent, consistent scientific evidence
Difficulties in applying evidence to the care of individual patients
Barriers to the practice of high-quality medicine (funds and other resources)
The need to develop new skills (epidemiology, economics, qualitative research)
Limited time and resources (time, access to information resources ect)



References:

•Evidence based medicine: what it is and what it isn't BMJ 1996;312:71-72 (13 January) Editorial
•What is evidence-based practice? Progress in Palliative Care, 1 February 2004, vol. 12, no. 1, pp. 6-9(4)Ruth M. Sladek and Paddy A. Phillips
•Seven Alternatives to Evidence-Based Medicine. The Oncologist, Vol. 6, No. 4, 390-391, August 2001. David Isaacs, Dominic Fitzgerald
•Effect of an Evidence-based Medicine Seminar on Participants' Interpretations of Clinical Trials A Pilot Study Academic Medicine (2000) 75: 1212-1214. Philip Schoenfeld, David Cruess and Walter Peterson
•Evidence-based medicine: a commentary on common criticisms CMAJ • October 3, 2000; 163 (7) Sharon E. Straus and Finlay A. McAlister


Further Reading:

Arri Coomarasamy, Khalid S Khan, What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review, BMJ 2004;329:1017 (30 October), doi:10.1136/bmj.329.7473.1017
•Trisha Greenhalgh How to read a paper: Assessing the methodological quality of published papers BMJ, Aug 1997; 315: 305 - 308.
•Trisha Greenhalgh How to read a paper : getting your bearings (deciding what the paper is about) BMJ, Jul 1997; 315: 243 - 246.
•Trisha Greenhalgh How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses) BMJ, Sep 1997; 315: 672 - 675.(actually the entire greenhalgh series- diagnostic tests, cost studies, statistics intro I+II, drug trials ect)

EBM Resources


Databases: Best Evidence Clinical Evidence, Cochrane Library, DARE, OVID EBMR
Journals: ACP Journal Club, Bandolier, Evidence Based Cardiovascular Medicine /Dentistry /Eye Care /Healthcare/ Medicine/ Mental Health/ Nursing
EBM Online. Evidence-Based Medicine (http://ebm.bmjjournals.com/) The same editorial team produces both EBM and ACP Journal Club using the same procedures, but the intended audience of each journal is different. The first is intended for use in Europe by generalists while the second one is intended for use in North America by internists.
Florida State University (medical informatics programme) has a web page called Evidence-Based Medicine Resources http://med.fsu.edu/informatics/EBM.asp
Books How to Read a Paper byTrisha Greenhalgh’s is based on her BMJ articles has received excellent reviews it costs about $20 USD
Evidence Based Medicine--How to Practice and Teach EBM David L Sackett et al

Prostate Cancer Screening

Prostate Cancer and Screening: An Update
December 19th 2004
Phillips, Erwin Arthur

•What do we know about prostate cancer?
•When does it make sense to screen?
•What do we tell patients?


•Prostate Cancer is a leading cause of mortality and morbidity worldwide


Risk Factors include:
•High animal fat and protein
•Family History
•Ethnicity


Clinical Features:

Most often asymptomatic
Lower urinary tract symptoms (BPH)
Frequent urination, especially at night
Inability to urinate
Trouble starting or holding back urination
A weak or interrupted flow of urine
Painful or burning urination
Blood in the urine or semen
Painful ejaculation
Frequent pain in the lower back, hips, or upper thighs


Diagnosis is by:

•Digital Rectal Examination (DRE)
•Prostate Specific Antigen (PSA)
•Transrectal ultrasound with or without Biopsy (TRUS)


Other than the size of the prostate and the age of the person PSA may be raised by the following:
Urinary Tract Infections, ejaculation or vigorous exercise in the past 48 hours, biopsy of the prostate in the past 6 weeks and DRE in the past 48 hours


Treatment of Prostate Cancer

Considering grade and stage, age and health, values and feelings (about benefits and harms of each option. )
•Radical Prostatectomy
•Radical Radiotherapy
•Conservative Management


Prevention (this is controversial)

•Diet (lowfat)
•Exercise ??
•Screening(this is very controversial)
•High Intensity Focused Ultrasound (experimental)


Lets talk a little bit more about screening
In 1968 Wilson and Junger came up with some guidelines to help those making decisions about implemeting screening programmes. While 1968 is a very long time ago not much has changed. The guidelines continue to be valuable. This is what they said:

The condition is an important health problem
Its natural history is well understood
It is recognisable at an early stage
Treatment is better at an early stage
A suitable test exists
An acceptable test exists
Adequate facilities exist to cope with abnormalities detected
Screening is done at repeated intervals when the onset is insidious
The chance of harm is less than the chance of benefit
The cost is balanced against benefit


Guidelines
The reality is that there is alot of controversy about the benefits of screening for prostate cancer. (That is looking for illness in people who do not have symptoms) If we for example look at the following organisations' positions on prostate cancer screening(PCS) you would find acknowledged that the info supporting its benefits is very limited if not non-existant. Interestingly enough Cancer Societies and Urologists continue to push prostate cancer screening. Hopefully this has nothing to do with the fact that they have financial incentive to do so and instead is explained by thier inability to understand the published information on the subject. "No randomized clinical trials have ever demonstrated that early detection and aggressive treatment of prostate cancer reduce mortality;
The treatments usually mobilized after a positive PSA test and biopsy (radical prostatectomy, radiation therapy or castration) are associated with severe side effects including impotence and incontinence." Berry 2001

Some of the bodies that have opinions and make recomendations about PCS:
American Cancer Society http://caonline.amcancersoc.org/cgi/content/full/53/1/27#SEC6U.S. Preventive Services Task Force http://www.ahcpr.gov/clinic/uspstf/uspsprca.htm
US Centers for Disease Control http://www.cdc.gov/cancer/prostate/prostate.htm UK NHS Screening http://www.cancerscreening.nhs.uk/
Australia http://www7.health.gov.au/pubs/ahtac/prostate.htm
University of California Irvine http://www.ucihealth.com/news/UCI%20Health/prostate.htm Canada http://www.prostatecancer.ca/english/living/screening.html

Recommendations
In theory PCS may help. There is not solid evidence that it does. There is evidence that it may cause harms. We need to communicate this effectively to the public as opposed to saying it is a cure-all or a complete waste of time. Several large studies are underway with preliminary results due out in 2006 and difinitive around 2015. For now we need informed consent clearly explaining the risks and potential benefits.

•PSA+ DRE offered annually from age 50
•Informed decision (pros and cons)
•High risk from 45
•Greater risk from 40

References

•Nelson, W. G. et al Mechanisms of Disease: Prostate Cancer, New England Journal of Medicine 2003:339;366-81
•Mazhar, D and Waxman J Review:Prostate Cancer, Postgraduate Medical Journal 2002; 78,590-595
•Kakehi, Y. Watchful waiting as a treatment option for localised prostate cancer in the PSA era, Review Article, Japanese Journal of Clinical Oncology 2003; 33(1) 1-5
•Sabichi, A L et al, Frontiers in Cancer prevention Research, Cancer Research 63, 5649-5655, September 2003
•Selly S et al, Diagnosis Management and Screening of Early Localised Prostate Cancer Health Technology Assessment 1997, Vol 1; No 2


Further Reading (prostate)

•Watson E, Jenkins L, Bukach C Austoker J. The PSA test and prostate cancer: Information for primary care. NHS Cancer Screening Programmes, Sheffield 2002
•Tudiver F,et al What influences family physicians’ cancer screening decisions when practice guidelines are unclear or conflicting? The Journal of Family Practice, September 2002 Vol 51, No 9
•Summary of Evidence Last Modified: 10/20/2004
National Cancer Institute- www. Cancer.gov (see prostate cancer, prevention, screening, treatment and levels of evidence)
•Prostate Cancer Screening Australian Health Technology Advisory Committee Report http://www7.health.gov.au/pubs/ahtac/prostate.htm
•Russell Harris, MD, MPH and Kathleen N. Lohr, PhD Screening for Prostate Cancer: An Update of the Evidence for the U.S. Preventive Services Task Force, Annals of Internal Medicine 3 December 2002 Volume 137 Issue 11 Pages 917-929

Further Reading (Screening)


•NHS (UK) Screening Programme. http://www.cancerscreening.nhs.uk/
•Sennfalt K, Sandblom G, Carlsson P, Varenhorst E,Costs and Effects of Prostate Cancer Screening in Sweden: A 15-year follow-up of a randomized trial Scandinavian Journal of Urology & Nephrology. 38(4):291-298, 2004.Guide to Clinical Preventive Services http://www.ahrq.gov/clinic/cps3dix.htm
•Greenhalgh T, How to read a paper: Papers that report diagnostic or screening tests BMJ 1997;315:540-543

Feel free to contact me at:
e.arthurphillips@gmail.com

If it walks like a duck....

What is a quack? By Quack we are here referring to someone who is pretending be competent/ knowledgable/ authorised to dispense medical advice and knowingly or otherwise is giving bogus information.

The following site is named Quackwatch. They aim to be "Your Guide to Quackery, Health Fraud, and Intelligent Decisions" It is US oriented. Stephen Barrett, M.D the editor of the site really seems to be a a campaign against quackery. The section of the site that looks at quackery should be particularly interesting http://www.quackwatch.org/

The Medicines and Healthcare products Regulatory Agency is a UK organisation. It is
The executive agency of the Department of Health protecting and promoting public health and patient safety by ensuring that medicines, healthcare products and medical equipment meet appropriate standards of safety, quality, performance and effectiveness, and are used safely.
http://www.mhra.gov.uk/

The US Federal Trade Comission works for the consumer to prevent fraudulent, deceptive and unfair business practices in the marketplace and to provide information to help consumers spot, stop and avoid them. They have a page on 'Miracle' Health Claims that they have put out with the Food and Drug Administration. It is a well laid out website with links to othere relevant material. http://www.ftc.gov/bcp/conline/pubs/health/frdheal.htm

Some cool sites

The following are some cool links:

• Good intro/ overview of evidence-based medicine http://www.mja.com.au/public/issues/174_05_050301/craig/craig.html
• American College of Preventive Medicine http://www.acpm.org/
• American Academy of Family Physicians http://www.aafp.org/
• National Information Center on Health Services Research and Health Care Technology, National Library of Medicine (U.S.) http://www.nlm.nih.gov/nichsr/outreach.html
• UK Public Health Evidence base website- http://www.hda.nhs.uk/evidence/
• The Cochrane Library, as they say "The best single source of reliable Evidence about the effects of health care" (you have to live in the UK, in a developing country or subscribe) http://cochrane.bireme.br/cochrane/main.php?lang
• Faculty of Public Health (UK) http://www.fphm.org.uk/\

i'm getting tired so I will probably post tommorow

The NEWSTART

This is my first blog. I must say thanks to blogger for making it look so easy. (Have no idea how this will look.)

The plan is to use this blog as a place to post musings on topics of interest to me. These will likely include Public Health, Primary Care, Health Economics and Evidence-Based Healthcare.

I am currently working between public health and primary care in a developing country.