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BACKGROUNDIn the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.METHODSWe conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.RESULTSAmong 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI), 0.46 to 1.07; P=0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).CONCLUSIONSAmong patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy.

OBJECTIVE:To study changes in health services consumption following substantial reduction in the availability of local emergency services in a small municipality population.METHOD:A dynamic cohort (21,000 residents of Viborg County, Denmark, of which 2,300 from Morsø municipality) was followed, 1997-2003. Data were extracted from administrative registries including information on individual use of emergency services and other hospital care, contact with GPs and socioeconomic background. Health services' use by the Morsø population was measured before reduction in emergency room opening hours, during a period of reduced opening hours and after closure, compared with the rest of Viborg County.RESULTS:Emergency service use did not change among Morsø municipality residents compared to other Viborg County residents. Compared to men in other parts of the county, Morsø men did not change their use of substitute health services. By contrast, Morsø women compared to the rest of Viborg county reduced their use of GP services in terms of face-to-face visits (β = -0.08, P = 0.020), telephone consultations (β = -0.11, P = 0.007), home visits (β = -0.48, P = 0.009), and their inpatient hospital utilization (β = -0.12, P = 0.022) during the period when emergeny services were only available in the daytime.CONCLUSIONS:Emergency services at neighbouring hospitals (40 kilometres distance) were able to compensate, in part, for the decreased local emergency service provision. Concurrent changes in health care utilization patterns were observed among local residents that varied by gender.

Quality-Adjusted Life Year (QALY) models are widely used for economic evaluation in the health care sector. In the first part of the paper, we establish an overview of QALY models where health varies over time and provide a theoretical analysis of model identification and parameter estimation from time trade-off (TTO) and standard gamble (SG) scores. We investigate deterministic and probabilistic models and consider five different families of discounting functions in all. This discussion includes questioning the SG method as the gold standard of the health state index, re-examining the role of the constant-proportional trade-off condition, revisiting the problem of double discounting of QALYs, and suggesting that it is not a matter of choosing between TTO and SG procedures as the combination of these two can be used to disentangle risk aversion from discounting. We find that caution must be taken when drawing conclusions from models with chronic health states to situations where health varies over time. One notable difference is that in the former case, risk aversion may be indistinguishable from discounting.

There is not much knowledge at present of the relative cost-effectiveness of health services offered in the Zimbabwean public health care sector. In addition, the information on the relative importance of diseases is less than complete. Such information may however be useful for assessing the efficiency of resources used in a situation of dwindling health care funds and increasing demand.The main objectives of this thesis were therefore to provide a more complete picture of the pattern of diseases in Zimbabwe as well as assessing the efficiency of resource utilisation in the public health care sector.A new health status indicator entitled Disability Adjusted Life Years (DALYs) was used to describe the level of ill health from the most common health problems in the Zimbabwean population in 1997. Epidemiological information was derived from multiple sources. The cause of death pattern was determined based on data from the Vital Registration System, which was adjusted for underreporting of human immunodeficiency virus (HIV) and reallocation of ill-defined causes. Non-fatal disease figures were estimated based on local disease registers, surveys and routine health service data supplemented by estimates from epidemiological studies from other settings if no Zimbabwean sources were available. Disease and public health experts were consulted about the identification of the best possible sources of information, the quality of these sources and the data adjustments made. Epidemiological information was utilised to calculate the burden of disease as measured by DALYs lost. HIV infection emerged from the information collected as the single most serious public health problem in Zimbabwe responsible for 49% of the total disease burden.In order to confirm some of the findings of the above study component, a small population survey was designed to estimate the population prevalence of serious health problems in an urban area of Zimbabwe through the application of verbal autopsy and morbidity interview techniques. The survey confirmed to some extent the pattern of diseases found in the nationwide study.Cost-effectiveness analysis and the calculation of cost-effectiveness ratios for the selected health interventions required information on the value of resources necessary for performing a health service of a given level as well as the effects in terms of improved health resulting from this particular health service. A total of 69 preventive and curative health interventions offered by the public health care sector was included in the analysis. Costing data were collected through visits to a sample of health centres, hospitals and vertical control programmes. Unit costs were calculated using a combination of the standard step-down costing methodology and the bottom-up costing approach. Effectiveness of health interventions was estimated based on published information on the efficacy of drugs and experts' advice on various factors such as coverage and compliance in order to reflect the actual situation in Zimbabwe. Effectiveness estimates were subsequently transformed into Disability-Adjusted Life Years (DALYs) lost. Very cost-effective interventions were available for some of the major health problems in Zimbabwe including pneumonia, diarrhoeal diseases, malaria and tuberculosis. Generally, the cost-effectiveness ratios calculated suggested that there was a good potential for improving the allocative efficiency in the health care sector. Possible strategies included a reallocation of resources from the interventions with high cost-effectiveness ratios to interventions with low cost-effectiveness ratios, ensuring that a given health problem was taken care of at the lowest level of the referral system as possible and to focus more on preventive health interventions. Finally, the research also revealed that it was possible to collect acceptable costing data within a relatively short time span. In contrast to this, evidence on the effectiveness of health services was in extremely short supply.

OBJECTIVES: Investigation of the relative impact of three factors expected to influence the future mortality burden in Greenland: demographic change, epidemiological transition and behavioural patterns. STUDY DESIGN: To identify general trends in public health status, evaluating the effect of public health campaigns and providing the basis for making predictions of future trends in the mortality burden data from the Greenlandic Death Causes Register to estimate Years of Life Lost (YLL) in the period 1976-1998 has been used. METHODS: YLL were estimated according to the Burden of Disease Method. Age standardised death rates were calculated per 10,000 person years. Regression analysis (ordinary least squares) using time as the explanatory variable was applied to project the time series 1976-1998 into the prediction period 1999-2028. RESULTS: The projections indicate that the demographic component in combination with behavioural patterns will have a dominant effect in the expected increase in the future burden of mortality. Relative to these two components, epidemiological transition will constitute a relatively insignificant impact on the future mortality burden in Greenland. CONCLUSION: Concerted multi-sectoral approaches and broad holistic health strategies related to health promotion and prevention today will strategically improve the capability of the Greenlandic society to manage the future disease burden from ageing via its health care sector and the institutional sector for care of the elderly.