Egon Jonsson

Chronic lower limb ischaemia. A prospective randomised controlled study comparing the 1-year results of vascular surgery and percutaneous transluminal angioplasty (PTA)

In a prospective randomised study, performed over a 6-year period, 102 patients with severe lower limb ischaemia or claudication resistant to exercise training were randomised either to percutaneous transluminal angioplasty (PTA) or vascular surgery. Only patients who could be treated by both methods were included, constituting only 5% of the total number of patients treated during this period. The two groups were similar regarding age, severity of symptoms and diabetes. The immediate and 1-year results showed similar success and complication rates. There was, however, a significantly shorter hospital stay for patients treated with PTA. Due to early complications and initial failures PTA should, however, only be used in institutions where vascular surgical facilities are available since PTA demands access to such treatment.

Evaluation of randomized controlled trials on complementary and alternative medicine.

OBJECTIVES Use of complementary and alternative medicine (CAM) is growing in all Western countries. The goal of this study was to evaluate quality of randomized controlled trials (RCTs) of CAM interventions for specific diagnoses to inform clinical decision making. METHODS MEDLINE and related databases were searched for CAM RCTs. Visual review was done of bibliographies, meta-analyses, and CAM journals. Inclusion criteria for review and scoring were blinded RCT, specified diagnosis and intervention, complete study published between January 1, 1966 and July 31, 1998 in an English-language, peer-reviewed journal. Two reviewers independently scored each study. RESULTS More than 5,000 trials were found, but only 258 met all study inclusion criteria. The main cause for rejection (> 90%) was that the study was not an RCT or had no blinding. Mean score across 95 diagnosis/intervention categories was 44.7 (S.D. +/- 14.3) on a 100-point scale. Ordinary least-squares regression found date of publication, biostatistician as author or consultant, published in one of five widely read English-language medical journals and diagnosis/intervention category of hypertension/relaxation as significant predictors of higher scores. CONCLUSIONS The overall quality of evidence for CAM RCTs is poor but improving slowly over time, about the same as that of biomedicine. Thus, most services are provided without good evidence of benefit.

SUMMARY REPORT OF THE ECHTA/ECAHI PROJECT

Health technology assessment (HTA) seeks to inform health policy makers by using the best scientific evidence on the medical, social, economic, and ethical implications of investments in health care. Technology is broadly defined to include the drugs, devices, medical, and surgical procedures used in health care, as well as measures for prevention and rehabilitation of disease, and the organizational and support systems in which health care is provided.

EXECUTIVE SUMMARY OF THE ECHTA/ECAHI PROJECT

Health technology is an indispensable part of any nations healthcare system. During the past 50 years, all member states that comprise the European Union have increased their technological base for health care, both in terms of knowledge and by investments in equipment, devices, and pharmaceuticals. Generally, this process has gone well. However, several problems have emerged related to the acquisition, diffusion, and use of modern health technology. Concerns have been also raised about the effectiveness and efficiency of already established procedures in health care.

Economic evaluation of a Swedish medical care program for hypertension.

A Hypertension Care Program, developed in cooperation between physicians and nurses in both primary care and at the hospitals in the area, was implemented in the Skaraborg County, Sweden in 1977. The Program, which provided for the establishment of hypertensive clinics at outpatient units and referral to medical clinics, was clearly aimed towards giving nurses increased responsibility for hypertensive care. The Skaraborg Program has been evaluated from several important perspectives. A terminal population study showed better blood pressure control among the hypertensive patients within the program area than within the control area. The economic evaluation indicates that hypertensive care according to the Program is somewhat less resource demanding than conventional hypertensive care. Since the medical effects of hypertensive care were improved without increased demand for resources, the structured Care Program was more cost-effective than conventional care.

Health policy on bone density measurement technology in Sweden and Australia

The possible adverse consequences of osteoporosis, particularly hip fractures, are a considerable health concern that is particularly relevant for elderly women. Bone density measurement is a method to assess bone mineral that has grown rapidly in recent years in both Sweden and Australia. The types of technologies adopted, their location and their level of use reflect the characteristics of the different health care systems, health technology assessments and policies adopted by health authorities. The health policy issues related to use of these technologies are complex and include consideration of who should be examined and treated, potential risks and benefits, machine performance, patient compliance and evidence of benefit.

Implications of minimally invasive therapy

Minimally invasive therapy (MIT) is a new approach to conditions that previously would have been treated by open surgery. It is made possible by developments in endoscopes, medical imaging and vascular catheters. Minimally invasive therapy has many implications for the health system, as it makes it possible to perform many procedures on an outpatient basis or with a short hospital stay. In addition, surgical training is not always necessary to carry out MIT procedures, which means that other specialties such as internal medicine and radiology have become involved in the field. Minimally invasive therapy has already led to conflicts between different specialties in some countries. It also is giving further stimulus to the reduction in numbers of hospital beds. On the other hand, full implementation of MIT requires attention to the system of out-of-hospital care, which generally is not prepared to monitor patients after discharge or to deal with complications that may arise. Quality of care in the out-of-hospital setting also needs attention.

Distributing Medical Care Services: Coronary Care Units in the United States and Sweden

Planning in the United States is based on an institutions perceived need, whereas in many other countries it is based on population need. These unique approaches to planning have led to widely differing distributions of facilities and services. Planning by the U.S. method leads to a more generous provision of services than does population-based planning. In both planning systems, the planning process appears of paramount importance, while the fundamental questions of effectiveness outcome and impact of medical care services are usually ignored. Even population-based planning either cannot or will not deal with the conflict between professional desire for highly developed technology on the one hand and treatment effectiveness on the other. Nevertheless, population-based planning has at least the virtue of providing a less expensive yet more efficient system. Physicians and the public appear able to adjust to the quite different resource provisions of the two planning systems; both the abundant U.S. supply and the restricted supply in Sweden are perceived as adequate.

CAT scanners: the Swedish experience.

&NA; Today, managers are being asked to analyze and justify the costs for new and expensive equipment. In the case of the CAT Scanner, however, there has been very little “hard” information available. To fill the gap, the authors present the findings of several Swedish studies that compare the uses and the costs of the CAT Scanner with other diagnostic techniques.

Utilization of Coronary Care Units in Sweden

Coronary care unit usage has expanded rapidly in all high income countries with little attention to effectivity or cost. A study of six randomly chosen Swedish units showed that larger units in teaching hospitals had significantly lower age-adjusted mortality rates, higher proportions of myocardial infarction patients, and greater productivity and efficiency. Comparisons with a study from the United States showed better results in the Swedish hospital units according to all variables measured. Although proof of effectiveness of CCUs is lacking, their continued use is assured. A less than optimal solution is a rational distribution of units based upon epidemiologically determined need, while stressing good organization and efficiency.