A cost-minimisation analysis of performing point-of-care ultrasonography on patients with vaginal bleeding in early pregnancy in general practice: a decision analytical model

Background Spotting and light vaginal bleeding are common and usually harmless symptoms in early pregnancy. Still, vaginal bleeding may be the first sign of an abortion and often causes distress to pregnant women and leads to an expectation of an ultrasonography examination of the uterus. As point-of-care ultrasonography (POCUS) is increasingly being integrated into general practice, these patients may be clinically evaluated and managed by general practitioners (GPs). This can potentially reduce referrals of patients from the primary to the secondary healthcare sector resulting in societal cost-savings. The primary purpose of this study was to investigate whether the accessibility of POCUS in general practice for patients with vaginal bleeding in early pregnancy is cost-saving compared to usual practice where GPs do not have access to POCUS. A secondary purpose of this study was to estimate a remuneration for GPs performing POCUS on these patients in general practice. Methods A cost-minimisation analysis was based on a decision tree model reflecting the two alternatives: general practice with and without GPs having access to POCUS. The robustness of the model results was investigated using probabilistic sensitivity analysis and the following deterministic sensitivity analyses: one-way analyses for the model input parameters and a scenario analysis with a change from a societal to a healthcare sector perspective. An expected remuneration reflecting the add-on cost of Danish GPs performing POCUS was estimated based on the related costs: cost of an ultrasonography scanner, GP’s time consumption, ultrasonography training, and utensils per scanning. Results The difference in average cost between the two alternatives from a societal perspective was estimated to be €110, in favour of general practice with GPs using POCUS. The deterministic sensitivity analyses demonstrated robustness of the results to plausible changes in the input parameters. The expected remuneration for performing POCUS in this specific setting was estimated to be €32 per examination. Conclusion Having GPs perform POCUS on patients with vaginal bleeding in early pregnancy is cost-saving compared to usual practice. The results should be taken with caution as this study was based on early modelling with uncertainties associated with the input parameters in the model.

Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study

Background Older people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously. Methods In this study, video-telehealth consultation was added to an existing program, the Aged Care Emergency (ACE) program, aiming at further reducing Emergency Department (ED) visits and hospital admissions. This controlled pre-post study introduced video-telehealth consultation as an additional component to the ACE program for acutely unwell residents in RACs. Usual practice is for RACs and ACE to liaise via telephone. During the study, when the intervention RACs called the ED advanced practice nurse, video-telehealth supported clinical assessment and management. Five intervention RACs were compared with eight control RACs, all of whom refer to one community hospital in regional New South Wales, Australia. Fourteen months pre-video-telehealth was compared with 14 months post-video-telehealth using generalized linear mixed models for hospital admissions after an ED visit and ED visits. One thousand two hundred seventy-one ED visits occurred over the 28-month study period with 739 subsequent hospital admissions. Results There were no significant differences in hospital admission or ED visits after the introduction of video-telehealth; adjusted incident rate ratios (IRR) were 0.98 (confidence interval (CI) 0.55 to 1.77) and 0.89 (95% CI 0.53 to 1.47) respectively. Conclusions Video-telehealth did not show any incremental benefit when added to a structured hospital avoidance program with nursing telephone support. Trial registration The larger Aged Care Emergency evaluation is registered with ANZ Clinical Trials Registry, ACTRN12616000588493.

Acupuncture In The Real World: Evaluating a 15-Year NADA Auricular Acupuncture Service For Breast Cancer Survivors Experiencing Hot Flushes And Night Sweats As a Consequence of Adjuvant Hormonal Therapies

PurposeWhile clinical trials provide valuable data about efficacy of interventions, findings often do not translate into clinical settings. We report real world clinical outcomes of a 15-year service offering breast cancer survivors auricular acupuncture to manage hot flushes and night sweats (HFNS) associated with adjuvant hormonal treatments. This service evaluation aims to 1) assess whether usual practice alleviates symptoms in a clinically meaningful way and 2) compare these results with scientific evidence. MethodsData were analysed from 415 referrals to a service offering women eight standardised treatments using the National Acupuncture Detoxification Association (NADA) protocol. Outcome measures administered at baseline, end of treatment (EOT), and four- and 18- weeks after EOT included Hot Flush Diaries, Hot Flush Rating Scale (HFRS) and Women’s Health Questionnaire (WHQ).Results2285 treatments were given to 300 women; 275 (92.3%) completed all eight treatments. Median daily frequency of HFNS reduced from 9.6 (IQR 7.3) to 5.7 (IQR 5.8) at EOT and 6.3 (IQR 6.5) 18 weeks after EOT. HFRS problem rating showed a clinically meaningful reduction of ≥2 points at all measurement points. WHQ showed improvements in several symptoms associated with the menopause. Two adverse events were reported, neither were serious. Results are comparable to published research.ConclusionThis first analysis of a long-term auricular acupuncture service compares favourably with outcomes of other studies for reducing HFNS frequency and associated menopausal symptoms. In day-to-day clinical practice, NADA appears to be a safe effective intervention for breast cancer survivors.

A Targeted Approach to Improve Asthma Control Using Community Pharmacists

Background: Building on lessons learnt from evidence-based community pharmacy asthma management models, a streamlined and technology supported Pharmacy Asthma Service (PAS) was developed to promote the integration of the service into routine practice.Objective: This study investigates the efficacy of the PAS in improving asthma symptom control and other health outcomes.Methods: A two-arm pragmatic cluster randomized controlled trial was implemented in 95 pharmacies across three Australian States. Participants were adults with poorly controlled asthma as per the Asthma Control Questionnaire (ACQ), with or without allergic rhinitis. Patients within the PAS arm engaged in four consultations with the pharmacist over a 12-month period. An evidence-based algorithm guided pharmacies, via a trial specific software, to deliver a series of interventions targeting three issues underpinning uncontrolled asthma (medication use and adherence, inhaler technique, and allergic rhinitis management) to patient clinical asthma status and patient need. Comparator arm patients received a minimal intervention likened to usual practice involving referral of eligible patients to the GP and two follow-up consultations with their pharmacist to collect comparative data.Results: In total, 143 of 221 PAS patients (65%) and 111 of 160 comparator patients (69%) completed the trial. Improvements in asthma control were achieved in both the PAS (mean difference (MD) in ACQ from baseline = −1.10, p <.0001) and comparator (MD in ACQ from baseline = −0.94, p <.0001) arms at the trial end; however, there were no significant differences between the two arms (MD = −0.16, 95% CI −0.41 to 0.08, p = 0.19). Patients’ quality of life in the PAS arm improved significantly when compared with the comparator arm (MD in Impact of Asthma on Quality-of-Life Questionnaire (IAQLQ) = −0.52, 95% CI −0.89 to −0.14, p = 0.0079).Conclusion: Despite the PAS achieving a greater improvement in patients’ quality of life, the pharmacist-led service and usual practice arm produced comparable improvements in asthma control. These results ask us to reflect on current standards of usual care, as it appears the standard of asthma care in usual practice has evolved beyond what is reported in the literature.

FIELD RESEARCH AND VISUAL RECORDING OF RELIGIOUS PRACTICES IN THE SOVIET PERIOD (CASE STUDY OF THE FILM AND VIDEO ARCHIVES OF THE ESTONIAN NATIONAL MUSEUM)

The article describes and analyzes film and video materials containing information on the topic of religious practices of the Finno-Ugric peoples in the Soviet period. The main sources of the research are archival audiovisual records created by the staff of the Estonian National Museum in the period from the 1960s to the early 1990 s, as well as field diaries of participants in the Finno-Ugric expeditions. This was the time when official atheism prevailed in the Soviet Union, the main blow of which was directed primarily at the churches. At the same time, this was a period when open persecution of traditional rituals was not observed, and the study of the worldview aspects of the traditional culture of different ethnic groups was strongly encouraged by ethnology. On the basis ofaudiovisual materials, the article analyzes which fragments of the religious practices of the Finno-Ugric peoples are reflected in the museum archives, and which methods were used by researchers to record different rituals. Much attention is paid to building the relationship between the ethnologist and the bearer of the tradition in the field, as well as the special role of the local mediator in the study of religious rituals through a film or video camera. The considered examples of collecting audiovisual material confirm that in the Soviet period, in contrast to today's digital technologies and the usual practice of photographing and filming various (including sacred) events, researchers with a camera were not always welcomed at prayers. In the audiovisual study of religious rites, the process of adaptation to the environment of the culture under study and the effect of building a first impression acquired particular importance for ethnologists, largely related to the authority of the local mediator who brought them to prayers.

Control of Non-instantaneous Degrading Inventory under Trade Credit and Partial Backlogging

Inventory management is an extremely difficult task. It has become usual practice for a provider during the last few decades to provide a retailer with a credit term. In this article, a non-instantly degradable products inventory system is built with a price-sensitive demand and a Weibull credit term allocation reduction rate. Some backlogged deficiencies are permitted. The aim is to maximize the total profit in this study by taking three cases into account. Numerical examples, graphical representations and sensitivity analysis demonstrate the application of the approach developed in this study.

Cost-Utility Analysis of the Integrated Care Models for the Management of Hypertension Patients: A Quasi-Experiment in Southwest Rural China

Background: Hypertension has become the second-leading risk factor for death worldwide. However, the fragmented three-level “county–township–village” medical and healthcare system in rural China cannot provide continuous, coordinated, and comprehensive health care for patients with hypertension, as a result of which rural China has a low rate of hypertension control. This study aimed to explore the costs and benefits of an integrated care model using three intervention modes—multidisciplinary teams (MDT), multi-institutional pathway (MIP), and system global budget and performance-based payments (SGB-P4P)—for hypertension management in rural China.Methods: A Markov model with 1-year per cycle was adopted to simulate the lifetime medical costs and quality-adjusted life-years (QALYs) for patients. The interventions included Option 1 (MDT + MIP), Option 2 (MDT + MIP + SGB–P4P), and the Usual practice (usual care). We used the incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB), and net health benefit (NHB) to make economic decisions and a 5% discount rate. One-way and probability sensitivity analyses were performed to test model robustness. Data on the blood pressure control rate, transition probability, utility, annual treatment costs, and project costs were from the community intervention trial (CMB-OC) project.Results: Compared with the Usual practice, Option 1 yielded an additional 0.068 QALYs and an additional cost of $229.99, resulting in an ICER of $3,373.75/QALY, the NMB was –$120.97, and the NHB was −0.076 QALYs. Compared with the Usual practice, Option 2 yielded an additional 0.545 QALYs, and the cost decreased by $2,007.31, yielding an ICER of –$3,680.72/QALY. The NMB was $2,879.42, and the NHB was 1.801 QALYs. Compared with Option 1, Option 2 yielded an additional 0.477 QALYs, and the cost decreased by $2,237.30, so the ICER was –$4,688.50/QALY, the NMB was $3,000.40, and the NHB was 1.876 QALYs. The one-way sensitivity analysis showed that the most sensitive factors in the model were treatment cost of ESRD, human cost, and discount rate. The probability sensitivity analysis showed that when willingness to pay was $1,599.16/QALY, the cost-effectiveness probability of Option 1, Option 2, and the Usual practice was 0.008, 0.813, and 0.179, respectively.Conclusions: The integrated care model with performance-based prepaid payments was the most beneficial intervention, whereas the general integrated care model (MDT + MIP) was not cost-effective. The integrated care model (MDT + MIP + SGB-P4P) was suggested for use in the community management of hypertension in rural China as a continuous, patient-centered care system to improve the efficiency of hypertension management.

How do I Perceive the Silences in my one-to-one Music Therapy Sessions

<p>Music therapy research is predominantly focused on the sounds and words that occur in sessions. The role and place of silence within usual practice is not so well covered in research literature. In this research, I used an auto-ethnographic approach and thematic analysis to try and understand how I perceive the silences in my own individual music therapy sessions with learners at a high school. This approach allowed me to connect with my own personal experience with silence, as it is a highly subjective and context dependent phenomena and tool. I perceived silence in nine major themes. Findings suggest I tend to ‘observe’ the learners when silences occur, for a variety of reasons, and this seems to contrast with my previous understanding of my therapeutic approach. Specifically, I found that I am more behaviourally focussed than I realised before I began my research journey, particularly in the way that I write and recall events in the therapy room. The research process enabled me to find out more about my personal relationship with silence, and to some degree a personal truth about myself.</p>

How do I Perceive the Silences in my one-to-one Music Therapy Sessions

<p>Music therapy research is predominantly focused on the sounds and words that occur in sessions. The role and place of silence within usual practice is not so well covered in research literature. In this research, I used an auto-ethnographic approach and thematic analysis to try and understand how I perceive the silences in my own individual music therapy sessions with learners at a high school. This approach allowed me to connect with my own personal experience with silence, as it is a highly subjective and context dependent phenomena and tool. I perceived silence in nine major themes. Findings suggest I tend to ‘observe’ the learners when silences occur, for a variety of reasons, and this seems to contrast with my previous understanding of my therapeutic approach. Specifically, I found that I am more behaviourally focussed than I realised before I began my research journey, particularly in the way that I write and recall events in the therapy room. The research process enabled me to find out more about my personal relationship with silence, and to some degree a personal truth about myself.</p>

Life Cycle Assessment of alkali activated materials: preliminary investigation for pavement applications

The capital investment in the US for construction and maintenance of the infrastructure road network is $150 billion/year. Investments in OECD countries will likely stabilize, while other countries will face an exponential growth of investments for infrastructures driven by the development of metropolitan cities. Continued “business-as-usual” practice for portland and asphalt cement concrete pavement construction ignores the increasing warning calls for the identification of more sustainable and less energy intensive paving materials. Alkali activated materials concrete (AAM) have been studied with growing interest during the last three decades. AAM show promising results in terms of mechanical performance, while also having a global warming potential impact 30-80% less than that of portland cement concrete. The global warming potential of AAM is closely dependent on the: 1) activating solution used to activate the raw material and 2) origin of the raw material. Specifically, the impact of the transport for both of these components is ~ 10% of its global warming potential. Hence, to increase the adoption of AAM for pavements, it is fundamental to analyze the existing literature to clarify the link between environmental impact and mechanical performance, identifying opportunities for applications that are tailored to the local availability of raw material.