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Context: Two widely used antithyroid drug (ATD) regimes for Graves' disease (GD) include the 'block & replace' (B&R) regime (a fixed high-dose of ATD combined with levothyroxine) and the 'titration' regime (a titrating dose of ATD). Anecdotally, it is believed that B&R is less prone to fluctuating thyroid function., Objective: To study whether, in routine clinical practice, the B&R regime, compared with the titration regime, is associated with more stable thyroid function., Methods: We retrospectively analysed case-records for 450 patients treated with ATDs for GD at a secondary care hospital. Exclusion criteria included treatment with ATDs for <6 months, thyrotoxicosis due to other causes, treatment with radioiodine or thyroidectomy and pregnancy., Results: Two hundred and twenty three patients were treated with the B&R regime ('B&R group'), 149 with the titration regime ('titration group') and 78 with both regimes. The number of thyroid function tests (TFTs) performed per year (mean(SD): 3·2(1·2) vs 3·4(1·5); adjusted mean difference = -0·4; 95% CI: -0·7 to -0·1; and P = 0·008) and the number of hospital clinic visits per year (mean (SD): 2·9 (1·0) vs 3·2 (1·3); adjusted mean difference = -0·4; 95% CI: -0·7 to -0·2; and P = 0·002) were lower in the B&R group than the titration group. The number of abnormal TFT results per year was similar in the two groups (mean(SD): 1·8(1·3) vs 1·8(1·4); adjusted mean difference = 0·05; 95%CI: -0·3 to 0·4; and P = 0·74)., Conclusions: In this retrospective study, there was little evidence that patients under B&R have more stable thyroid function. Further data from prospective studies, however, are needed to confirm this finding., (© 2014 John Wiley & Sons Ltd.)

Drawing on wider sociologies of risk, this article examines the complexity of clinical risks and their management, focusing on risk management systems, expert decision-making and safety standards in health care. At the time of this study preventing venous thromboembolism (VTE) among in-patients was one of the top priorities for hospital safety in the English National Health Service (NHS). An analysis of 50 interviews examining hospital professionals' perceptions about VTE risks and prophylaxis illuminates how National Institute for Health and Clinical Excellence (NICE) guidelines influenced clinical decision-making in four hospitals in one NHS region. We examine four themes: the identification of new risks, the institutionalisation and management of risk, the relationship between risk and danger and the tensions between risk management systems and expert decision-making. The implementation of NICE guidelines for VTE prevention extended managerial control over risk management but some irreducible clinical dangers remained that were beyond the scope of the new VTE risk management systems. Linking sociologies of risk with the realities of hospital risk management reveals the capacity of these theories to illuminate both the possibilities and the limits of managerialism in health care., (© 2014 The Authors. Sociology of Health & Illness © 2014 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd.)

Objectives: In January 1999, a new institutional structure for Poland's health care system was laid out, instigated by the dramatic change in both the political and economic system. Following the dissolution of state socialism, private financing of health care services was encouraged to fill an important role in meeting rising consumer demand and to encourage a more efficient use of resources through competition and private initiative. However, from the outset of the intended transformations, systemic limitations to the privatization process hindered progression, resulting in varying rates of privatization amongst the distinct health care sectors. The aim of this paper is to describe the privatization process and to analyze its pace and differences in strategic approach in all major health care sectors., Methods: Policy analysis of legislation, government directives, and published national and international scientific literature on Polish health reforms between 1999 and 2012 was conducted., Results: The analysis demonstrates a clear disparity in privatization rates in different sectors. The pharmaceutical industry is fully privatized in 2012, and the ambulatory and dental sectors both systematically increased their private market shares to around 70% of all services provided. However, despite a steady increase in the number of private hospitals in Poland since 1999, their overall role in the health care system is comparatively limited., Conclusions: Unclear legal regulations have resulted in a gray area between public and private health care, where informal payments impede the intended function of the system. If left unchanged, official health care in Poland is likely to become an increasingly residual service for the worst-off population segments that are unable to afford the legal private sector or the informal payments which guarantee a higher quality service in the public sector., (Copyright © 2013, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc.)

Background: Responding to the obesity epidemic requires robust evidence to help prioritize the allocation of scarce resources to preventive interventions. The aim of this study was to evaluate interventions that promote healthy weight [defined as reduction in body mass index (BMI) or percentage body fat] in general populations (unselected by weight) using a comprehensive meta-analysis. Interventions with both single and multiple components were considered., Methods: Studies were first identified through well-conducted systematic reviews complemented by a search for single studies in five large medical databases up to 6 November 2008. Sixty-eight controlled studies were included. For each intervention type and age group, all relevant studies were pooled in a random effects meta-analysis., Results: In children, the highest reductions in mean BMI were achieved through promoting reduced television viewing [-0.27 kg/m(2) (95% CI -0.4 to -0.13 kg/m(2))]. Programmes combining physical activity, specifically themed or general health education and nutrition achieved a lower reduction [-0.1 kg/m(2) (95% CI -0.17 to -0.04 kg/m(2))]. Other interventions had high heterogeneity or showed no statistically significant reduction in outcomes. In adults, single component interventions were found to reduce both outcome measures. Their mean percentage body fat was reduced through education by -1.22% (95% CI -1.92 to -0.52)., Conclusion: The evidence for the effectiveness of promoting healthy weight in general populations is limited, though multi-component interventions in schools and encouraging reduced children's television viewing are promising strategies. Improving the reporting of outcomes is vital, as imputation of inadequately reported measures may have contributed to the observed heterogeneity. Longer follow-up is essential for understanding policy relevance.

Background: Rheumatoid arthritis is a chronic inflammatory condition that affects the joints causing unpredictable episodes of pain, stiffness and disability. People with rheumatoid arthritis usually require lifelong specialist follow-up but frequently have periods when their disease can be managed through self-care or that provided by their general practitioner. Compared to the traditional clinician-driven care in rheumatoid arthritis, patient-initiated care has proven to be more beneficial in terms of reducing unnecessary medical reviews, providing greater satisfaction to patients and staffs and maintaining the patient's physical and psychological status. We aim to evaluate the implementation of a patient-initiated review system in a routine secondary care rheumatology service in a public hospital in England, where patients get the opportunity to self-manage their disease by requesting specialist reviews at times of need instead of clinician-scheduled appointments., Methods/design: Three hundred and eighty patients attending routine review at Plymouth Hospitals NHS Trust will be randomised to either enrol immediately into a patient-initiated review system (direct access group), or to be seen regularly by a clinician at the hospital (regular clinician-initiated group). Patients (or their general practitioner) in the direct access group can arrange a review by calling a rheumatology nurse-led advice line that enables telephone delivered clinical advice, or where appropriate, an appointment with a rheumatologist within 10 working days. Patients in the regular clinician-initiated group will attend their planned appointments at regular intervals during the intervening period of 12 months. The primary outcome of interest is patient satisfaction; secondary outcomes include service use, waiting times and clinical measures. Semi-structured, in-depth interviews will be conducted with a subset of patients and staff with the aim of identifying facilitators/barriers in implementing patient-initiated clinics., Discussion: The implementation of a patient-initiated review system in routine care rheumatology will replace the fixed clinician-driven review system with a more flexible patient-driven system where patients usually self-manage their disease, but can request prompt help when required. We believe that this study will enable a comparison of the changes in local services and will be helpful in exploring the benefits/drawbacks of such implementation, thus providing lessons for implementation in other hospitals and for other chronic diseases.

Yemen is a low-middle-income country where more than half of the population live in rural areas and lack access to the most basic health care. At US$40 per capita, Yemen's annual total health expenditure (THE) is among the lowest worldwide. This study analyses the preconditions and options for implementing basic social health protection in Yemen. It reveals a four-tiered healthcare system characterised by high geographic and financial access barriers mainly for the poor. Out-of-pocket payments constitute 55% of THE, and cost-sharing exemption schemes are not well organised. Resource-allocation practices are inequitable because about 30% of THE gets spent on treatment abroad for a small number of patients, mainly from better-off families. Against the background of a lack of social health protection, a series of small-scale and often informal solidarity schemes have developed, and a number of public and private companies have set up health benefit schemes for their employees. Employment-based schemes usually provide reasonable health care at an average annual cost of YR44 000 (US$200) per employee. In contrast, civil servants contribute to a mandatory health-insurance scheme without receiving any additional health benefits in return. A number of options for initiating a pathway towards a universal health-insurance system are discussed., (Copyright © 2012 John Wiley & Sons, Ltd.)

Background: Migration and ethical recruitment of health care workers is receiving increased attention worldwide. Europe's aging population is creating new opportunities for medical doctors for finding employment in other countries, particularly those of a better standard of living., Methods: We conducted a survey among 1214 medical students in five out of eleven universities in Poland with medical schools in October 2008. A series of statistical tests was applied to analyse the characteristics of potential migrants. Projections were obtained using statistical analyses: descriptive, multifactorial logistic regression and other statistical methods ., Results: We can forecast that 26-36% of Polish medical students will emigrate over the next few years; 62% of respondents estimated the likelihood of emigration at 50%. Students in their penultimate year of study declared a stronger desire to migrate than those in the final year. At the same time, many students were optimistic about career opportunities in Poland. Also noted among students were: the decline in interest in leaving among final year students, their moderate elaboration of departure plans, and their generally optimistic views about the opportunities for professional development in Poland., Conclusions: The majority of Polish students see the emigration as a serious alternative to the continuation of their professional training. This trend can pose a serious threat to the Polish health care system, however the observed decline of the interest in leaving among final year students, the moderate involvement in concrete departure plans and the optimistic views about the opportunities for professional development in Poland suggest that the actual scale of brain drain of young Polish doctors due to emigration will be more limited than previously feared.

Rationale: The purpose of this study is to analyse the effectiveness of flupentixol compared to other first- and second-generation antipsychotics for the treatment of schizophrenia in routine care., Method: A retrospective cohort study was conducted using administrative data from four sickness funds covering 12.6 million insured. Patients discharged from hospital in 2003 with an ICD-10 diagnosis of schizophrenia were followed for 12 months. Rehospitalisation during follow-up was analysed using a hurdle regression model. Treatment costs were defined as cost of pharmaceutical and cost of inpatient care. Two thousand eight hundred ninety insured were included, of which 177 were treated with flupentixol during follow-up, while 429 and 2,284 were treated with other first-and second-generation antipsychotics, respectively., Results: Compared to patients treated with flupentixol (21.0 days), predicted hospitalisation did not differ significantly for patients treated with other first- (21.3 days, p = 0.8313) or second-generation antipsychotics (25.6 days, p = 0.4035). Predicted treatment costs for the average patient were 4,193 Euro if treated with flupentixol, 4,846 Euro if treated with other first-generation antipsychotic, and 6,523 Euro if treated with a second-generation antipsychotic. Second-generation antipsychotics showed a clear advantage over flupentixol concerning extrapyramidal symptoms co-medication., Conclusion: The effectiveness of flupentixol preventing relapse in patients with schizophrenia appears to be similar to that of other first- and second-generation antipsychotics. However, the low treatment costs for patients treated with flupentixol could be explained by the small number of patients with readmissions (70 insured) and the larger share of patients treated with its depot formulation.

In 1996, the Federal Law on Health Insurance (LAMal) was adopted in order to contain costs in Swiss health care. At the same time, the reform aimed to maintain or even improve solidarity and encourage institutional reform through new public management (NPM) and market mechanisms. More freedom in contractual conditions between insurers and providers and a clearer distinction of responsibilities between federal and regional (cantonal) authorities were stipulated to achieve efficiency, effectiveness, and transparency. The focus of this paper is an analysis of the effects of market reforms and NPM mechanisms introduced with the LAMal on the cost-containment, quality of care and equity objectives in the Swiss health care system.

Background: This study evaluates the cost-effectiveness of 64-slice computed tomography coronary angiography (CTCA) as an alternative to invasive diagnostic coronary angiography (CA) in an elective outpatient setting for patients otherwise referred to invasive diagnostic coronary angiography., Methods: Taking the perspective of the Australian health system we used a decision analytic model to integrate data on test accuracy along with complication rates, health state preference weights and health care costs. The analysis is pre-test risk stratified based on Bayes' theorem of conditional probability. Incremental cost-effectiveness ratios (ICER) are the study endpoints expressed as incremental costs per quality adjusted life year (QALY) gained., Results: The results indicate that CTCA is a cost-saving strategy offering a higher health related quality of life up to approximately 65% pre-test risk of coronary artery disease (CAD). Above that threshold the model predicts a cost-utility trade-off with every gain in health related quality of life through the use of CTCA as a rule-out test being associated with additional costs when compared to invasive diagnostic CA., Conclusion: This health economic analysis predicts computed tomography coronary angiography to be a cost-effective rule-out strategy in symptomatic patients at low to intermediate risk of significant obstructive coronary artery disease otherwise referred to invasive diagnostic CA.

Background: In two recent randomised clinical trials, a meta-analysis and in an effectiveness study analysing routine data from the U.S. Veterans Administration the superiority of the newer atypical drugs over typical antipsychotic drugs, concerning both their efficacy and their side-effect profile, has been questioned., Aims of the Study: To analyse the effectiveness and cost of atypical versus typical antipsychotic treatment for schizophrenia in routine care., Methods: Cohort study using routine care data from a statutory sickness fund with 5.4 million insured in Germany. To be included, patients had to be discharged with a diagnosis of schizophrenia in 2003 and fulfil membership criteria. Main outcome measures were rehospitalisation rates, mean hospital bed days, mean length of stay, cost of inpatient and pharmaceutical care to the sickness fund during follow-up and medication used to treat side-effects., Results: 3121 patients were included into the study. There were no statistically significant differences in the effectiveness of atypical and typical antipsychotics on rehospitalisation during follow-up (rehospitalisation rate ratio 1.07, 95% confidence interval 0.86 to 1.33). However, there were consistent observations of atypical antipsychotics being more effective for severe cases of schizophrenia (14.6% of study population; >61 prior bed days per year in 2000-2002) in the follow-up period, whereas for the other severity strata typical antipsychotics seemed more effective in reducing various rehospitalisation outcomes. Patients treated with atypical antipsychotics received significantly less prescriptions for anticholinergics or tiaprid (relative risk 0.26, 95% confidence interval 0.18 to 0.38)., Discussion: The effectiveness of atypical antipsychotics for schizophrenia on rehospitalisation measures appeared similar to that of typical antipsychotics. With the exception of severe cases, the higher costs for atypical antipsychotics were not offset by savings from reduced inpatient care. Major limitations include the lack of statistical power for subgroup analyses, the lack of clinical severity scale data and of life-course medical history data which both increase the risk of residual confounding by disease severity., Conclusions: This study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care., Implications for Health Care Provision and Use: From a clinical perspective, this study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care., Implications for Health Policies: Routine data studies can yield valuable information for policy decision-makers on the costs and the effectiveness of pharmaceuticals in routine care, complementing efficacy data from randomised clinical trials currently used for licensing and reimbursement decisions., Implications for Further Research: The non-significant differences in the effectiveness of atypical compared to typical antipsychotics according to severity of disease should be investigated in a prospective observational study or in a randomised clinical trial.

Background: The desire for evidence-based health policy and practice is well established. Routine population-based health information systems play a fundamental role to inform policy decisions and to evaluate their effectiveness., Methods: This paper presents three case studies of using population-based data in national health policy from three countries--USA (prescription drug safety), Australia (childhood immunization) and UK (hospital waiting times)--which were chosen to represent a diversity of health policy issues. The utilization of population-based databases and the social and political context in which the data were used are examined. Our goal was to summarize general lessons learned for policy decision-makers and other users and developers of population-based databases., Results: Key lessons presented include: the importance of political will in initiating and sustaining data collection and analysis at a national level; the types of decision-making factors databases can address; and how the data were integrated into the decision-making process., Conclusion: Population-based routine data provide an important piece of the mosaic of evidence for health policy decision makers. They can be used to assess the magnitude of the health problem, including which populations are most vulnerable; to develop policy goals; and to track and evaluate the effectiveness of health policy interventions.

One of the guiding principles of health policy in many European countries is equitable access to health care services. One of the life saving procedures is percutaneous transluminal coronary angioplasty (PTCA) performed after coronary angiography. Introducing payment for these procedures would limit access for low-income patients. Fortunately, despite political debate, invasive cardiology develops well in Poland. It is important to notice that within the European Union Polish citizens would be able to receive this treatment in other member states and, according to a European Court of Justice ruling, the costs would have to be reimbursed by the National Health Fund. The wider implication is that the 10 new EU member states now have to realise that health care is no longer a matter of national sovereignty - a fact legislators and health care managers in the 15 member states of the pre-accession EU are still struggling with.

Health interventions vary substantially in the degree of effort required to implement them. To some extent this is apparent in their financial cost, but the nature and availability of non-financial resources is often of similar importance. In particular, human resource requirements are frequently a major constraint. We propose a conceptual framework for the analysis of interventions according to their degree of technical complexity; this complements the notion of institutional capacity in considering the feasibility of implementing an intervention. Interventions are categorized into four dimensions: characteristics of the basic intervention; characteristics of delivery; requirements on government capacity; and usage characteristics. The analysis of intervention complexity should lead to a better understanding of supply- and demand-side constraints to scaling up, indicate priorities for further research and development, and can point to potential areas for improvement of specific aspects of each intervention to close the gap between the complexity of an intervention and the capacity to implement it. The framework is illustrated using the examples of scaling up condom social marketing programmes, and the DOTS strategy for tuberculosis control in highly resource-constrained countries. The framework could be used as a tool for policy-makers, planners and programme managers when considering the expansion of existing projects or the introduction of new interventions. Intervention complexity thus complements the considerations of burden of disease, cost-effectiveness, affordability and political feasibility in health policy decision-making. Reducing the technical complexity of interventions will be crucial to meeting the health-related Millennium Development Goals.

Background: In Europe important differences exist concerning policies for the prevention of common diseases. In most cases these cannot be explained by the underlying epidemiology. However, successful policies should have a measurable effect on disease epidemiology. There has been little research comparing the effect of national preventive policies on disease-specific mortality., Objectives: To describe the mortality trends for three health problems representing the three levels of prevention in Germany and in selected European countries, which are of interest for the disease under question. To relate epidemiological trends to preventive policies at the national level and at the level of the European Union (EU)., Methods: Comparison of age-standardized mortality rates for road traffic accidents, cervical cancer and diabetes mellitus in the period 1970-2002, using routine data. Analysis of disease-specific prevention policies in countries that deviate from the general trend in the EU, with a special focus on developments in Germany., Results: The development of mortality rates during the last 30 years for road traffic accidents, cervical cancer and diabetes mellitus varied substantially across Europe. Although the evidence linking specific public policies to epidemiological trends is sparse and often limited to ecological studies, a number of epidemiological changes can be plausibly linked to specific policies in the countries concerned., Conclusion: Successful preventive policies exist for all health problems reviewed. The current status of implementation of these policies can only be interpreted in the historical and political context of the countries concerned. The role of epidemiology to guide health policy decisions is under-utilized, as is the regulatory framework for disease and injury prevention at the level of the EU. Less formal policy measures such as European clinical guidelines are equally scarce. More rigorous comparative health services research is needed to formulate evidence-based policies for disease prevention.