Physicians' acceptance of telemedicine constitutes a prerequisite for its diffusion on a national scale. Based upon the Theory of Interpersonal Behavior, this study was aimed at assessing the predictors of physicians' intention to use telemedicine in their clinical practice. All of the physicians involved in the RQTE, the extended provincial telemedicine network of Quebec (Canada) were mailed a questionnaire to identify the psychosocial determinants of their intention to adopt telemedicine. Confirmatory factor analysis (CFA) was performed to assess the measurement model and structural equation modelling (SEM) was applied to test the theoretical model. The adapted theoretical model explained 81% (P
A patient-level Markov decision model was used to simulate a virtual cohort of 500,000 women 40 years old and over, in relation to osteoporosis-related hip, clinical vertebral, and wrist bone fractures events. Sixteen different screening options of three main scenario groups were compared: (1) the status quo (no specific national prevention program); (2) a universal primary prevention program; and (3) a universal screening and treatment program based on the 10-year absolute risk of fracture. The outcomes measured were total directs costs from the perspective of the public health care system, number of fractures, and quality-adjusted life-years (QALYs). Results show that an option consisting of a program promoting physical activity and treatment if a fracture occurs is the most cost-effective (CE) (cost/fracture averted) alternative and also the only cost saving one, especially for women 40 to 64 years old. In women who are 65 years and over, bone mineral density (BMD)-based screening and treatment based on the 10-year absolute fracture risk calculated using a Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool is the best next alternative. In terms of cost-utility (CU), results were similar. For women less than 65 years old, a program promoting physical activity emerged as cost-saving but BMD-based screening with pharmacological treatment also emerged as an interesting alternative. In conclusion, a program promoting physical activity is the most CE and CU option for women 40 to 64 years old. BMD screening and pharmacological treatment might be considered a reasonable alternative for women 65 years old and over because at a healthcare capacity of $50,000 Canadian dollars ($CAD) for each additional fracture averted or for one QALY gained its probabilities of cost-effectiveness compared to the program promoting physical activity are 63% and 75%, respectively, which could be considered socially acceptable. Consideration of the indirect costs could change these findings.
To assess and compare the cost effectiveness of three different strategies for prenatal screening for Down's syndrome (integrated test, sequential screening, and contingent screenings) and to determine the most useful cut-off values for risk.
Computer simulations to study integrated, sequential, and contingent screening strategies with various cut-offs leading to 19 potential screening algorithms.
The computer simulation was populated with data from the Serum Urine and Ultrasound Screening Study (SURUSS), real unit costs for healthcare interventions, and a population of 110 948 pregnancies from the province of Québec for the year 2001.
The contingent screening strategy dominated all other screening options: it had the best cost effectiveness ratio ($C26,833 per case of Down's syndrome) with fewer procedure related euploid miscarriages and unnecessary terminations (respectively, 6 and 16 per 100,000 pregnancies). It also outperformed serum screening at the second trimester. In terms of the incremental cost effectiveness ratio, contingent screening was still dominant: compared with screening based on maternal age alone, the savings were $C30,963 per additional birth with Down's syndrome averted. Contingent screening was the only screening strategy that offered early reassurance to the majority of women (77.81%) in first trimester and minimised costs by limiting retesting during the second trimester (21.05%). For the contingent and sequential screening strategies, the choice of cut-off value for risk in the first trimester test significantly affected the cost effectiveness ratios (respectively, from $C26,833 to $C37,260 and from $C35,215 to $C45,314 per case of Down's syndrome), the number of procedure related euploid miscarriages (from 6 to 46 and from 6 to 45 per 100,000 pregnancies), and the number of unnecessary terminations (from 16 to 26 and from 16 to 25 per 100,000 pregnancies).
Contingent screening, with a first trimester cut-off value for high risk of 1 in 9, is the preferred option for prenatal screening of women for pregnancies affected by Down's syndrome.
Cites: Int J Technol Assess Health Care. 2007 Winter;23(1):138-4517234028
We analyzed the cost-effectiveness (CE) and performances of commonly used prenatal Down syndrome (DS) screening strategies.
We performed computer simulations to compare 8 screening options by applying empirical data from Serum, Urine, and Ultrasound Screening Study trials on the population of 110,948 pregnancies. Screening strategies outcomes, CE ratios, and incremental CE ratios were measured.
The most CE DS screening strategy was the contingent screening method (CE ratio of Can$26,833 per DS case). Its incremental CE ratio compared to the second-most CE strategy (serum integrated screening) was Can$3815 per DS birth detected. Among the procedures respecting guidelines, our results identified the combined test as the screening strategy with the highest CE ratio (Can$47,358) and the highest number of procedure-related euploid miscarriages (n = 71).
In regard to CE, contingent screening is the best choice. The combined test, which is the most popular screening strategy, shows many limitations.
The purpose of this study was to determine the most cost-effective option to prevent alloimmunization against the Rh factor.
A virtual population of Rh-negative pregnant women in Quebec was built to simulate the cost-effectiveness of preventing alloimmunization. The model considered four options: (1) systematic use of anti-D immunoglobulin; (2) fetal Rh(D) genotyping; (3) immunological determination of the father's Rh type; (4) mixed screening: immunological determination of the father's Rh type, followed if positive by fetal Rh(D) genotyping. Two outcomes were considered, in addition to the estimated costs: (1) the number of babies without hemolytic disease, and (2) the number of surviving infants.
In a first pregnancy, two options emerged as the most cost-effective options: systematic prophylaxis and immunological Rh typing of the father, with overlapping confidence intervals between them. In a second pregnancy, the results were similar. In all cases (first or second pregnancy or a combination of the two) fetal genotyping was not found to be a cost-effective option.
Routine prophylaxis and immunological Rh typing of the father are the most cost-effective options for the prevention of Rh alloimmunization. Considering that immunological typing of the father would probably not be carried out by the majority of clinicians, routine prophylaxis remains the preferred option. However, this could change if the cost of Rh(D) fetal genotyping fell below $140 per sample.
No cost-effectiveness evaluation of pit and fissure sealants has ever been carried out in Quebec. The objective of this study was to simulate a publicly funded program of pit and fissure administration, either in the public or private sectors, and compare these hypothetical situations with the current one, i.e., a publicly funded, school-based selective program.
A Markov model was developed using a virtual population of 8-year-old children that was monitored over a time span of 10 years. The incremental cost per child without decay was computed.
The current situation and a publicly funded program in the public sector were more cost-effective than the other option: a universal, publicly funded, private practice. However, the most cost-effective option varied, depending on the incidence of decay and the proportion of children identified as being at high-risk for decay.
By implementing a school-based program of universal pit and fissure sealant application, access to preventive dental care could be improved at an equivalent cost-effectiveness to the current one.
This study aims to describe emotional distress and quality of life (QoL) of patients at different phases of their lung cancer and the association with their family physician (FP) involvement.
A prospective study on patients with lung cancer was conducted in three regions of Quebec, Canada. Patients completed, at baseline, several validated questionnaires regarding their psychosocial characteristics and their perceived level of FP involvement. Emotional distress [profile of mood states (POMS)] and QoL [European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30)] were reassessed every 3-6 months, whether patients had metastasis or not, up to 18 months. Results were regrouped according to cancer phase. Mixed models with repeated measurements were performed to identify variation in distress and QoL.
In this cohort of 395 patients, distress was low at diagnosis (0.79?±?0.7 on a 0-4 scale), raising to 1.36?±?0.8 at the advance phase (p?
This quasi-experimental research aims to (1) evaluate the implementation process of a community nursing care management model and (2) assess the effects of this model on patients followed at home.
Two community healthcare centers had introduced a community nursing care management model in their practice (experimental groups), whereas another health community care center with no experience with such a model served as a control group. The community nursing care management model included clinical pathways designed for a clientele who had been hospitalized for cardiac surgery.
Even though the implementation process was challenging, the community nursing care management model was found useful enough to be integrated into routine nursing home care practice after cardiac surgery. Although the effects produced by this systematic home care program on the clientele did not differ significantly from those produced by usual nursing care, there was a positive effect for the clientele recorded on all measurement indicators used.
The introduction of the nursing care management model enabled nurses to structure the care provided and reduced interindividual variation. The application of this program also proved to be an opportunity to initiate and assimilate new professional roles. Additional studies should be conducted to assess its effectiveness in home care for other health problems.
Mental health policies, advocating outpatient as well as community mental health care for the severely mentally ill, are aiming towards health system cost containment and patient quality of life. Programs with cognitive behavioral therapy, such as the Integrated Psychological Therapy (IPT), added to standard medical therapy for patients with schizophrenia have been associated with improved outcomes. A Quebec version of the IPT program was integrated in outpatient clinics and improvements were observed in overall symptoms, subjective experiences, cognitive and social functioning, and quality of life. In light of these results we deemed it relevant to describe the health system cost and patient resource use associated with the program. The costs related to IPT have not been previously reported and this study will elucidate on effective health services and budget allocation needed to include IPT.
To describe health care resource use and related costs associated with participating in an IPT program included as standard medical therapy in nine clinical settings.
A cohort of patients with schizophrenia participating in the IPT program were followed up to one year preceding the start of the program and concurrently until the end to compare the resource use and costs incurred by patients with schizophrenia during their participation. A health and social service system and patient perspective was adopted, and the medical and non-medical costs associated with the IPT program were measured. Valuation (2001 CDN dollars) was based on information provided by provincial billing systems. Statistical differences were assessed using the Wilcoxon signed-rank test.
The IPT program induced a one time fixed cost (2347 dollars) for the training of mental health professionals and costs related to patient participation (1350 dollars). Our results show that there was an average decrease in health care system resource use per patient during the IPT program (26,133 dollars) as opposed to the preceding year (26,750 dollars). There was a significant decrease in the number of visits and in physician fees paid out to psychiatrists, the number of hospitalizations and related costs, and visits to the emergency department per patient during the IPT program as compared to the preceding year. No significant difference was observed in patient related costs which averaged 7295 dollars and 7537 dollars, before and during the IPT program, respectively.
Although the IPT program induces a one time fixed cost for training, the integration of IPT, as part of an individualized standard medical therapy, is associated with a change from inpatient towards outpatient resource use with no significant increase in health system related costs.
Given clinical and quality of life improvements, the findings suggest that offering IPT to more patients with severe mental illness may prove more cost beneficial by decreasing the health system related costs per user in the long term.
Additional research is needed to examine in parallel the long-term clinical and cost impact of the IPT program in different clinical settings (young adults to long term mentally ill). This will elucidate to which patient population IPT is most cost-effective.