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Hypothetical Patients (hypothetical + patient)
Selected AbstractsThe cost-effectiveness of continuous subcutaneous insulin infusion compared with multiple daily injections for the management of diabetesDIABETIC MEDICINE, Issue 7 2003P. Scuffham Abstract Aims To estimate the cost effectiveness of continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) for patients using insulin pumps. Methods We constructed a Markov model to estimate the costs and outcomes for patients with insulin-dependent diabetes (IDDM) treated with CSII using an insulin pump compared with MDI. Key parameters were obtained from the published scientific literature. The primary outcome was quality-adjusted life years (QALYs). Monte Carlo simulations were undertaken for 10 000 hypothetical patients over 8 years of monthly cycles (the expected life of a pump). Results Over an 8-year period an average patient could expect to gain 0.48 [standard deviation (sd) 0.20] QALYs using CSII compared with MDI. The additional cost over 8 years for this gain was £5462 (sd£897). The incremental cost per QALY was £11 461 (sd£3656). CSII was most cost-effective in patients who had more than two severe hypoglycaemic events per year and who required admission to hospital at least once every year. Cases where CSII might be not economically viable are cases where diabetes is well controlled with few severe hypoglycaemic events. Results were most sensitive to the number of hypoglycaemic events per patient and the utility weights used to estimate QALYs. Conclusion CSII is a worthwhile investment when targeted to those who might benefit most. Diabet. Med. 20, 586,593 (2003) [source] Diagnosing acute lung injury in the critically ill: a national survey among critical care physiciansACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 10 2009A. P. J. VLAAR Background: Incidence reports on acute lung injury (ALI) vary widely. An insight into the diagnostic preferences of critical care physicians when diagnosing ALI may improve identification of the ALI patient population. Methods: Critical care physicians in the Netherlands were surveyed using vignettes involving hypothetical patients and a questionnaire. The vignettes varied in seven diagnostic determinants based on the North American European Consensus Conference and the lung injury score. Preferences were analyzed using a mixed-effects logistic regression model and presented as an odds ratio (OR) with a 95% confidence interval. Results: From 243 surveys sent to 30 hospitals, 101 were returned (42%). ORs were as follows: chest X-ray consistent with ALI: OR 1.7 (1.3,2.3), high positive end-expiratory pressure (PEEP) (15 cmH2O): OR 5.0 (3.9,6.6), low pulmonary artery occlusion pressures (PAOP) (<18 mmHg): OR 4.7 (3.6,6.1), low compliance (30 ml/cmH2O): OR 0.7 (0.5,0.9), low PaO2/FiO2 (<250 mmHg): OR 9.2 (6.9,12.3), absence of heart failure: OR 1.2 (0.9,1.5), presence of a risk factor for ALI (sepsis): OR 1.0 (0.8,1.3). The questionnaire revealed that critical care physicians with an anesthesiology background differed from physicians with an internal medicine background with regard to hemodynamic variables when considering an ALI diagnosis (P<0.05). Conclusions: Dutch critical care physicians consider the PEEP level, but not the presence of a risk factor for ALI, as an important factor to diagnose ALI. Background specialty of critical care physicians influences diagnostic preferences and may account for variance in the reported incidence of ALI. [source] Effects of choice and relative frequency elicitation on overconfidence: further tests of an exemplar-retrieval modelJOURNAL OF BEHAVIORAL DECISION MAKING, Issue 2 2003Winston R. Sieck Abstract An experiment is reported in which participants rendered judgments regarding the disease states of hypothetical patients. Participants either reported likelihoods that patients had the target disease (no choice), or classified patients into disease categories and then reported likelihoods that their classifications were correct (choice included). Also, participants' likelihood judgments were made in response to either a probability probe question, or a relative frequency probe. Two distinct exemplar-memory models were compared on their ability to predict overconfidence under these procedures. Both propose that people learn and judge by storing and retrieving examples. The exemplar retrieval model (ERM) proposes that amount of retrieval drives choice inclusion and likelihood probe effects. The alternative model assumes that response error mediates choice inclusion effects. Choice inclusion and the relative frequency probe reduced overconfidence, but the combined effects were subadditive. Only the ERM predicted this pattern, and it further provided good quantitative fits to these results. Copyright © 2003 John Wiley & Sons, Ltd. [source] A study of nurses' inferences of patients' physical painJOURNAL OF CLINICAL NURSING, Issue 4 2006Benita Wilson BSc Aim., The aim of this study was to establish if postregistration education and clinical experience influence nurses' inferences of patients' physical pain. Background., Pain is a complex, subjective phenomenon making it an experience that is elusive and difficult to define. Evaluation of an individual's pain is the product of a dynamic, interactive process that frequently results in ineffective pain management. Educating nurses should address the deficit, however the clinical environment is thought to be most influential in the acquisition of knowledge. Design., A series of vignettes was used to consider nurses' inferences of physical pain for six hypothetical patients; these were employed within a self-administered questionnaire that also addressed lifestyle factors of patients in pain, general attitudes and beliefs about pain management and general knowledge of pain control. Method., One hundred questionnaires were distributed; 86 nurses returned the questionnaire giving a response rate of 86%. Following selection of the sample 72 nurses participated in the study: 35 hospice/oncology nurses (specialist) and 37 district nurses (general). Data analysis was carried out using SPSS and qualitative analysis of the written responses. Results., The specialist nurses tended to infer lower levels of physical pain than the general nurses when considering the patients in the vignettes. Conclusion., Education and clinical experience influence nurses' knowledge, attitudes and beliefs about pain. However, it would appear that the specialist nurses' working environment and knowledge base engenders a practice theory divide, resulting in desensitization to patients' physical pain. Relevance to clinical practice., It is suggested that the specialist nurses use defence mechanisms to protect them from the conflict that arises from working within the clinical environment. These cognitive strategies have the potential to ease cognitive dissonance for the nurse, but may increase patient suffering. [source] Proposal for a standardised identification of the mono-exponential terminal phase for orally administered drugsBIOPHARMACEUTICS AND DRUG DISPOSITION, Issue 3 2008Christian Scheerans Abstract The area under the plasma concentration-time curve from time zero to infinity (AUC0,inf) is generally considered to be the most appropriate measure of total drug exposure for bioavailability/bioequivalence studies of orally administered drugs. However, the lack of a standardised method for identifying the mono-exponential terminal phase of the concentration-time curve causes variability for the estimated AUC0,inf. The present investigation introduces a simple method, called the two times tmax method (TTT method) to reliably identify the mono-exponential terminal phase in the case of oral administration. The new method was tested by Monte Carlo simulation in Excel and compared with the adjusted r squared algorithm (ARS algorithm) frequently used in pharmacokinetic software programs. Statistical diagnostics of three different scenarios, each with 10,000 hypothetical patients showed that the new method provided unbiased average AUC0,inf estimates for orally administered drugs with a monophasic concentration-time curve post maximum concentration. In addition, the TTT method generally provided more precise estimates for AUC0,inf compared with the ARS algorithm. It was concluded that the TTT method is a most reasonable tool to be used as a standardised method in pharmacokinetic analysis especially bioequivalence studies to reliably identify the mono-exponential terminal phase for orally administered drugs showing a monophasic concentration-time profile. Copyright © 2007 John Wiley & Sons, Ltd. [source] The impact of prognosis without treatment on doctors' and patients' resource allocation decisions and its relevance to new drug recommendation processesBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 2 2008D. Ross Camidge What is already known about this subject ,,The dominant health economic units upon which new treatment funding decisions are made are the incremental cost per life year gained (LYG) or the cost per quality-adjusted life year (QALY) gained. ,,Neither of these units modifies the amount of health gained, by the amount of health patients would have had if they had not been given the treatment under consideration, which may unfairly undervalue the treatments for poor prognosis conditions. ,,How certain patients make decisions about their own treatment has previously been explored, but not how they, or doctors, would allocate hypothetical resource within a healthcare system given information on disease-treatment scenarios' prognoses with and without treatment. What this study adds ,,Information on prognosis without treatment is used within the resource allocation strategies of many doctors and most patients. ,,Individuals use this information in a variety of different ways and a single dominant strategy for quantitative modification of health units is not apparent. ,,Information on prognosis without treatment, or prognosis with standard treatment, is available from the control arm of randomized controlled clinical trials and should be used qualitatively to facilitate decision-making around the second inflexion point on cost per QALY/LYG acceptability curves. Aims Health economic assessments increasingly contribute to funding decisions on new treatments. Treatments for many poor prognosis conditions perform badly in such assessments because of high costs and modest effects on survival. We aimed to determine whether underlying shortness of prognosis should also be considered as a modifier in such assessments. Methods Two hundred and eighty-three doctors and 201 oncology patients were asked to allocate treatment resource between hypothetical patients with unspecified life-shortening diseases. The prognoses with and without treatment were varied such that consistent use of one of four potential allocation strategies could be deduced: life years gained (LYGs) , which did not incorporate prognosis without treatment information; percentage increase in life years (PILY); life expectancy with treatment (LEWT) or immediate risk of death (IRD). Results Random choices were rare; 47% and 64% of doctors and patients, respectively, used prognosis without treatment in their strategies; while 50% and 32%, respectively, used pure LYG-based strategies. Ranking orders were LYG > PILY > IRD > LEWT (doctors) and LEWT > LYG > IRD > PILY (patients). When LYG information alone could not be used, 76% of doctors prioritized shorter prognoses, compared with 45% of patients. Conclusions Information on prognosis without treatment is used within the resource allocation strategies of many doctors and most patients, and should be considered as a qualitative modifier during the health economic assessments of new treatments for life-shortening diseases. A single dominant strategy incorporating this information for any quantitative modification of health units is not apparent. [source] Cost effectiveness of pharmacogenetic testing for uridine diphosphate glucuronosyltransferase 1A1 before irinotecan administration for metastatic colorectal cancer,CANCER, Issue 17 2009Heather Taffet Gold PhD Abstract BACKGROUND: The objective of this study was to examine the cost effectiveness of using a pharmacogenetic test for uridine diphosphate glycosyltransferase 1A1*28 (UGT1A1*28) variant homozygosity before administering irinotecan to patients with metastatic colorectal cancer. METHODS: A decision-analytic model from the Medicare payer perspective followed hypothetical patients who were treated with combined 5-fluorouracil, leucovorin, and irinotecan. Under usual care, patients received a full dose of irinotecan. With genetic testing, irinotecan dosage was reduced 25% in homozygotes with the UGT1A1*28 variant allele. Test performance, chemotherapy toxicity, and quality-of-life weights were derived from clinical literature and product labels, and costs were derived from 2007 Medicare fee schedules. Chemotherapy efficacy after dose reduction, adverse event risk, and other parameters were varied in 1-way and probabilistic sensitivity analyses. The authors also calculated the value of investing in further studies of chemotherapy efficacy after homozygote dose reductions. RESULTS: Pretreatment genetic testing costs less ($272 savings per patient tested) and yields slightly improved quality-adjusted life expectancy (0.1 quality-adjusted day per patient tested; approximately 2 quality-adjusted hours). Results depended on treatment efficacy but not adverse event risk assumptions. The results indicated that testing would avoid 84 cases of severe neutropenia, including 4.4 deaths. At a threshold of $100,000 per quality-adjusted life year, the therapeutic efficacy of irinotecan in homozygotes after dose reduction had to be ,98.4% of full-dose efficacy for genetic testing to remain preferred. Future studies to determine whether this efficacy level can be achieved have an economic value of $22 million. CONCLUSIONS: The current results indicated that pharmacogenetic testing for UGT1A1*28 variant homozygosity may be cost effective, but only if irinotecan dose reduction in homozygotes does not reduce efficacy. Future studies to evaluate reduced-dose efficacy in homozygotes should be considered. Cancer 2009. © 2009 American Cancer Society. [source] | ||||||||||