A study was initiated to investigate the impact of information dissemination in Illinois upon the projected rise in the cesarean birth rate over the period from 1986 through 1988. The total cesarean birth rate in Illinois had not changed significantly during this period, whereas the rate of vaginal births after cesarean sections (VBAC) increased by 58.4% (p <.001). Information dissemination may have contributed to stemming an increase in the cesarean birth rate in Illinois while promoting VBAC deliveries.

Objectives: To identify core issues that contribute to the gap between pre-marketing clinical research and practice as seen from the perspective of medical practice, as well as possible changes and potential barriers for closing this gap.

Methods: Interviews with 47 physicians and pharmacists who were liaised to drug regulation through their role in the pre- and post-marketing shaping of new cardiovascular drugs. Data were analyzed using methods of grounded theory and analytical evaluations.

Results: Six core issues were identified that referred to the standards in drug regulation, the organization of the regulatory system, and conflicting interests. Pre-marketing trials should focus more on populations and research questions relevant to medical practice. In particular, variability in drug responses between subgroups of patients and demonstration of effectiveness should become major principles in drug regulation. An interactive post-marketing process in which public interests are represented was considered necessary to further guide research and development according to the needs in daily practice. Strategies for change could be applied within the present system of drug regulation, or affect its basic principles. Regulatory authorities were primarily identified to initiate changes, but many other parties should be involved. Barriers for change were identified regarding differences in interests between parties, organizational matters, and with respect to broader healthcare policies.

Conclusions: Based on the respondents' opinions, there is a need to focus regulatory standards more on the needs in medical practice. Therefore, regulatory authorities should further develop their influence in the pre- and post-marketing drug development process, together with other parties involved, in order to bridge the gap between clinical research and medical practice.

Objectives: To study the effects of health financing systems on patient care-seeking behavior in rural China.

Methods: A multistage sampling method was used to select county, township, and village health facilities. A total of 1,232 outpatients was interviewed during two weeks.

Results: Health-financing systems appeared to influence patient behavior. In the insured group, the proportion of patients being hospitalized was higher than that in the uninsured group. Among the different insurance schemes, the private insurance group had the highest proportion of self-medication, but the cooperative insurance group had the lowest; the government insurance group had the most delay days, but the cooperative insurance group had the fewest. A logistic regression analysis suggested that only “out-of-pocket” payment might decrease the access to hospitalization.

Conclusions: The empirical data suggest that health-financing systems appear to influence patient behavior for prescription and access to health care, especially some costly health care, that is, hospitalization. The data also suggest that China needs to increase the coverage of health insurance, especially in rural areas to improve the access to health care.This article resulted from a collaborative research project between IHCAR, Karolinska Institutet and School of Public Health, Fudan University (former Shanghai Medical University)-Health care financing in transitional society-financially supported by the Swedish International Development Cooperation Agency (Sida). Many thanks to Vinod Diwan, Lennart Bogg, and Göran Tomson at IHCAR and Clas Rehnberg at the Stockholm School of Economics for their assistance in the preparation of the article.

Objective: The aim of this study was to elicit willingness to pay (WTP) for allergen-specific subcutaneous injection immunotherapy (SCIT) in a cohort of respondents suffering from allergic-rhinoconjunctivitis (a-RC)/asthma, and to investigate how patients self-select to SCIT according to need.

Methods: A random sample of the general population was screened for a-RC/asthma and asked if they were willing to consider SCIT. They were asked to state their WTP for SCIT by way of a discrete choice question (DC-q), an open-ended WTP question (o-WTP-q), and questions relating to their sociodemographic background and the severity of their a-RC/asthma. The characteristics of respondents demanding SCIT were compared with the characteristics of respondents who have actually received SCIT to establish possible barriers to demand.

Results: Our results suggest that respondents do well in self-selecting themselves to SCIT on the basis of need according to disease burden measured in terms of a-RC classification, number of contacts with a general practitioner, number of sick days, and potential quality-adjusted life-year loss. Mean WTP for SCIT was estimated at €655 (median, €267) (o-WTP-q) and €903 (95 percent confidence limit, 348–1,459) (DC-q).

Conclusion: Characteristics of respondents, who consider SCIT and are willing to pay for SCIT, suggest that allergy sufferers select themselves appropriately according to need and not according to other characteristics, such as income or education. There is a significant discrepancy between those who hypothetically consider SCIT and those demanding SCIT in real life. This study suggests that there are barriers to entry related to age and education, but not to income.

Over the past decade the Office of Medical Application of Research (OMAR) of the National Institutes of Health has developed the consensus development conference (18) to assess technologies in cases where the scientific community has been unable, or unwilling, to reach a firm position as to efficacy but which require some better form of assessment than expert opinion (8). Another paper in this issue describes the principles that underlie such conferences (9).

Technologies that promise to enhance the stability of vaccines are likely to be determined by the product-specific physical structure and biological functions of the specific vaccine immunogens. Research may define the extent to which the stability of oral poliovirus vaccine may be improved by the addition of certain antiviral components that bind to the poliovirus capsid or by the application of novel drying technologies.

Proteinuric hypertension is an important cause of maternal and perinatal mortality. Eclampsia cannot always be prevented. The likelihood of identifying a new case of proteinuric hypertension at any particular visit is very low using traditional antenatal care schedules, and care could be focused on women at higher risk.

Background: The most effective sources to search to identify adverse effects data for medical devices are currently unknown.

Methods: The included studies from a systematic review of the safety of recombinant human bone morphogenetic protein-2 (rhBMP-2) for spinal fusion were used for analysis. For each source searched, a record was made for each relevant publication of whether it was retrieved by the search strategy used and whether it was available in the database but not retrieved. To account for multiple publications of the same study, a record was made of the relevant studies identified. The sensitivity, precision, and number needed to read were calculated as well as the minimum combination of sources to identify all the publications or studies.

Results: There were eighty-two publications (forty-nine studies) included in the systematic review. Only one article was available in a database searched but not retrieved by our search strategy. Science Citation Index (SCI) and EMBASE both achieved the highest sensitivity (62 percent), followed closely by MEDLINE/PubMED (56 percent). With the search strategies used, the minimum combination of sources needed to identify all the publications was SCI, EMBASE, CENTRAL, and either MEDLINE or PubMED, in addition to reference checking, contacting authors and an automated current awareness service. In relation to identifying all the relevant studies, the minimum combination of studies was similar with the exclusion of CENTRAL.

Conclusions: To identify all the relevant publications or studies included in this case study systematic review, several different sources needed to be searched.

Hypertension during pregnancy, defined as a diastolic blood pressure of at least 90 mm Hg, occurs in about 7% of Western countries. Primiparity and familial factors are the most important risk factors. Fifty percent of women experienced blood pressure elevation as late as the last month of pregnancy.

An educational model is presented that stresses the importance of the interaction between individual characteristics and intentional educational influences on outcome variation. This model is exemplified by an interventional study of patients with insulin-dependent diabetes mellitus who, despite long-term conventional medical treatment, had been unable to achieve satisfactory hemoglobin Aic levels. Treatment modes and their importance for understanding variations in outcomes are discussed from the interactional perspective suggested in the model.

Technological advances by developed countries are producing safer, more potent vaccines. In addition, the transfer of the technology of vaccine production to some developing countries has been taking place during the past five decades, thereby making possible the participation of developing countries in the production and supply of the essential biologicals that are required for immunization programs. Examples of successful transfers of technology, the decisive elements and factors that contribute to the transfers, and the major obstacles to such transfers are presented.

The paper considers the economic characteristics of technology and suggests a categorization based on the economic nature of particular technologies and their effect on the product health care that may be helpful in considering the economics of technology in hospitals.

It reviews the range of economic forces that might be expected to apply to the use of technology in the hospital setting, and notes some of the evidence to support such hypotheses. In considering the limited evidence from the United Kingdom and elsewhere in Europe, the paper contrasts its focus on socio-political, institutional, and organizational factors, rather than the direct economic factors considered in the United States work.

It suggests that the multiplicity of forces at work make cross-national, empirical, and policy analyses very difficult. Indeed, without more economic appraisal the effect of differences in technology adoption cannot be evaluated.

Background: Relative effectiveness has become a key concern of health policy. In Europe, this is because of the need for early information to guide reimbursement and funding decisions about new medical technologies. However, ways that effectiveness (does it work?) and efficacy (can it work?) might differ across health systems are poorly understood.

Methods: This study proposes an analytical framework, drawing on production function theory, to systematically identify and quantify the determinants of relative effectiveness and sources of variation between populations and healthcare systems. We consider how methods such as stochastic frontier analysis and data envelopment analysis using a Malmquist productivity index could in principle be used to generate evidence on, and improve understanding about, the sources of variation in relative effectiveness between countries and over time.

Results: Better evidence on factors driving relative effectiveness could: inform decisions on how to best use a new technology to maximum effectiveness; establish the need if any for follow-up post-launch studies, and provide evidence of the impact of new health technologies on outcomes in different healthcare systems.

Conclusions: The health production function approach for assessment of relative effectiveness is complementary to traditional experimental and observational studies, focusing on identifying, collecting, and analyzing data at the national level, enabling comparisons to take place. There is a strong case for exploring the use of this approach to better understand the impact of new medicines and devices for improvements in health outcomes.

Objective: The aim of this study was to investigate malaria elimination in Ethiopia. Ethiopia has planned to eliminate malaria by 2015 in areas of unstable malaria transmission and in the entire country by 2020. However, there is a shortage and maldistribution of the health workforce in general and malaria experts in particular. Training, motivating, and retaining the health workforce involved in malaria control is one strategy to address the shortage and maldistribution of the health workforce to achieve the goal of elimination.

Methods: Policy options include the following: (i) in-service training (educational outreach visits, continuing education meetings and workshops, audit and feedback, tailored interventions, and guideline dissemination) may improve professional practice; (ii) recruiting and training malaria specialists together with academic support, career guidance, and social support may increase the number of malaria experts; and (iii) motivation and retention packages (such as financial, educational, personal, and professional support incentives) may help motivate and retain malaria professionals.

Results: Implementation strategies include the following: (i) massive training of health personnel involved in malaria elimination and malaria experts (requiring special training) at different levels (national, sub-national, District & community levels), and (ii) recruiting highly qualified health personnel and retention and motivation mechanisms are needed.

Conclusions: The lack of adequately trained human resources and personnel attrition are major challenges to effectively implement the planned multi-faceted malaria elimination by 2020 strategy in Ethiopia. Although a reduction in malaria incidence has been observed in the last 3-4 years, maintaining this success and achieving the malaria elimination goal with the present human resource profile will be impossible. A clear strategy for developing the capacity of the health workers in general, and malaria experts in particular, and retaining and motivating staff are crucial for malaria control and elimination.

The need to progress and innovate in health technology assessment (HTA) is a must in a continuously changing environment. The HTAi Policy Forum reflected on two specific areas for development where it was thought there was need for careful consideration and deliberation during the main annual meeting in February 2016. The study by Husereau et al. (1) in this journal presents the discussions resulting from this Forum. To further share the deliberations of the Forum and with a view to opening this debate to the wider HTA community, a panel session during the HTAi Annual Meeting in Tokyo was organized. Presentations at the panel included a summary of the HTAi Policy Forum discussions and perspectives from a patient, a representative of healthcare system provider, and a representative from an HTA organization and industry. This letter presents the issues raised in the panel session.

Objectives: The aim of this study was to examine the empirical and methodological cost-effectiveness evidence of surgical interventions for breast, colorectal, or prostate cancer.

Methods: A systematic search of seven databases including MEDLINE, EMBASE, and NHSEED, research registers, the NICE Web site and conference proceedings was conducted in April 2012. Study quality was assessed in terms of meeting essential, preferred and UK NICE specific requirements for economic evaluations.

Results: The seventeen (breast = 3, colorectal = 7, prostate = 7) included studies covered a broad range of settings (nine European; eight non-European) and six were published over 10 years ago. The populations, interventions and comparators were generally well defined. Very few studies were informed by literature reviews and few used synthesized clinical evidence. Although the interventions had potential differential effects on recurrence and mortality rates, some studies used relatively short time horizons. Univariate sensitivity analyses were reported in all studies but less than a third characterized all uncertainty with a probabilistic sensitivity analysis. Although a third of studies incorporated patients’ health-related quality of life data, only four studies used social tariff values.

Conclusions: There is a dearth of recent robust evidence describing the cost-effectiveness of surgical interventions in the management of breast, colorectal and prostate cancers. Many of the recent publications did not satisfy essential methodological requirements such as using clinical evidence informed by a systematic review and synthesis. Given the ratio of potential benefit and harms associated with cancer surgery and the volume of resources consumed by these, there is an urgent need to increase economic evaluations of these technologies.