In South Africa, significant changes in health care have taken place since the first democratic elections in 1994. The change had lead to a position of integrated service delivery with specific reference to primary health care. Increasingly in developing countries, the private sector impacts significantly on the rights to education and the highest attainable standard of health. Inappropriate prescribing e.g. prescribing a drug without an acceptable indication, specifying an incorrect dosage, schedule or duration of treatment, duplicating therapeutic agents and prescribing drugs without adequate regard to potential interactions, can cause adverse outcomes, deplete health care resources, compromise the quality of care and possible increase in health costs. One approach monitoring prescribing practices is drug utilisation review. The general objective of this study was to review and interpret aspects of drug usage patterns in a private primary health care setting, with special reference to the top ten diagnoses made and the top twenty medicine items prescribed as well as the associated costs. A quantitative, retrospective drug utilisation review as well as certain aspects of managed and primary health care, pharmacoeconomics, pharmacoepidemiology, medicine formularies and standard treatment guidelines were reviewed in the literature as a base for the study. The results of the empirical study showed that 83648 patients consulted at the nine medicentres during the study period (1 January to 31 December 2001). A total number of 132591 patient visits (consultations) were made, 140723 medical conditions (diagnoses) performed and 516177 medicine items prescribed during the study period. Analysis of medicine usage patterns and associated costs of the top ten diagnoses made and top twenty medicine items prescribed in the study population, revealed the following: The top ten diagnoses determined accounted for 29.07% of the total number of diagnoses made, . a total medicine treatment cost accounting for 32.11% in the study population, . the top twenty medicine items determined accounted for 56.23% of the total medicine items prescribed and . a total medicine treatment cost accounting for 28.63% in the study population. The highest prevalence of diagnoses made and medicine items prescribed was found in age groups 4 and 5 (Le. patients between the ages of 19 to 40 years) and was also found to be more prevalent in the female than in the male population. In completion of the research, recommendations to review the medicentres medicine treatment protocols and on provision of primary health care education were made. Reference to the investigation of environmental factors is also made. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2004.

Health is a fundamental human right. Access to health care, which includes providing a population with safe, effective, good quality drugs at the least possible cost, is a prerequisite to realising that right. Drugs or medicines play a fundamental role in the effectiveness, efficiency and responsiveness of health care systems. Drugs also constitute a major recurrent expense in both state-run and private sector health care. To ensure that health care workers prescribe the most cost-effective drugs through the essential drugs list, training, as well as evaluation and monitoring systems must be regarded as important elements of containing costs. Pharmaceutical benefit management programmes such as pharmacoeconomics, drug utilisation review (DUR), evidence-based medicine and disease management have emerged as tools to ensure cost-effective selection and use of drugs, particularly for chronic diseases. These managed care tools are often investigated to determine whether new technologies or interventions are appropriate and have "value". Affordable prices of medicines, on their own, however, do not ensure access to medicines. Also important are reliable procurement, distribution and storage systems, and appropriately trained personnel to manage these components of drug management. Poorly regulated drug supply systems can have serious consequences such as antibiotic resistance, problems with safety or quality and most importantly wastage, as it is believed that a significant proportion of drugs purchased by the state in South Africa find their way into the private sector market through a "grey market". The general objective of this study was to review and analyse the cost and medicine usage of the "top twenty" pharmaceutical products according to the monthly pharmaceutical purchasing reports of the Department of Health in the North West Province. The research can be classified as retrospective and quantitative. The data used for the analysis were obtained over a two-year study period (1 Apr 2000 - 28 Feb 2002) from the private provider operating the medical stores in the North West Province. The results of the empirical investigation, showed the total number of "top twenty" products appearing during the study period amounted to 460 different products having a total purchasing cost of R 66,263,674.51 representing 37.2% (n = R 178,163,061.50) of all pharmaceutical products purchased during the two-year period. Through analysis it was found, when classified according the Anatomical Therapeutic Chemical (ATC) therapeutic main group, antihypertensives had the highest quantity purchased for year one (20.69%; n = 134,515,640) with cough and cold preparations revealing the highest purchasing quantity for year two (40.55%; n = 103,567,031) of all "top twenty" pharmaceuticals during the study period. Antibacterials for systemic use presented with the highest cost percentages for both years, representing 20.68% (n = R35, 568,221.31) and 16.72% (n = R 31,370,435.51) respectively. Hydrochlorothiazide presented with the highest purchasing quantity for both years when classified according to chemical substance with, Methyldopa having the highest purchasing cost for year one followed by vaccine Hib-DTP 10 dose vial (Haemophilus influenzae type B vaccine-diphtheria, pertusis and tetanus vaccine) for year two. Furthermore it was also found that the majority of the "top twenty" products were in the oral dosage form. Finally it was concluded that drugs used in the treatment of hypertension and cardiac failure were the most utilised in comparison to other "top twenty" products during the study period. Possible misappropriation based on the defined daily dose of the "top twenty" products might have occurred. In completion of this study, recommendations for future research were made. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2004.

Introduction: Based on the perceived risk to newborns and pregnancy outcomes associated with certain drugs, women may be hesitant to prescribe and take drugs during pregnancy. In cases like these, pregnant women may seek treatment using natural health products (NHPs) as alternatives to drugs. Unfortunately, evidence of safety in pregnancy and lactation is unknown for many NHPs. Objectives: To review the present state of evidence on the safety of NHPs during pregnancy and lactation. To create a new system to validate evidence on NHPs during pregnancy and lactation designed to affect medical decision. Methodology: NHPs were systematically reviewed and in some cases, meta-analyzed for evidence of safety during pregnancy and lactation. Results: In total, 79 NHPs were systematically reviewed and 2 NHPs were meta-analyzed in order to determine the evidence of safety in pregnancy and lactation. Despite the presence of data (72/79 NHPs in pregnancy and 53/77 NHPs in lactation), the quality of the data was generally poor. Using evidence-based medicine principles, a new system of evaluating evidence was established for studies involving NHPs in pregnancy and lactation. A number of NHPs were identified as being of potential risk in pregnancy. A number of NHPs were identified as potentially being apparently safe in pregnancy and lactation. Blue cohosh is of potential concern for harm in pregnancy given an apparent dose-dependant relationship. Conclusion: There is a large knowledge gap on the safety of NHPs in pregnancy, even more so in lactation. The new system for evaluating NHP safety in pregnancy and lactation will require validation. In order to improve the knowledge gap, future studies are proposed on NHPs in pregnancy and lactation as part of the newly formed MotherNature research network.

Introduction: Based on the perceived risk to newborns and pregnancy outcomes associated with certain drugs, women may be hesitant to prescribe and take drugs during pregnancy. In cases like these, pregnant women may seek treatment using natural health products (NHPs) as alternatives to drugs. Unfortunately, evidence of safety in pregnancy and lactation is unknown for many NHPs. Objectives: To review the present state of evidence on the safety of NHPs during pregnancy and lactation. To create a new system to validate evidence on NHPs during pregnancy and lactation designed to affect medical decision. Methodology: NHPs were systematically reviewed and in some cases, meta-analyzed for evidence of safety during pregnancy and lactation. Results: In total, 79 NHPs were systematically reviewed and 2 NHPs were meta-analyzed in order to determine the evidence of safety in pregnancy and lactation. Despite the presence of data (72/79 NHPs in pregnancy and 53/77 NHPs in lactation), the quality of the data was generally poor. Using evidence-based medicine principles, a new system of evaluating evidence was established for studies involving NHPs in pregnancy and lactation. A number of NHPs were identified as being of potential risk in pregnancy. A number of NHPs were identified as potentially being apparently safe in pregnancy and lactation. Blue cohosh is of potential concern for harm in pregnancy given an apparent dose-dependant relationship. Conclusion: There is a large knowledge gap on the safety of NHPs in pregnancy, even more so in lactation. The new system for evaluating NHP safety in pregnancy and lactation will require validation. In order to improve the knowledge gap, future studies are proposed on NHPs in pregnancy and lactation as part of the newly formed MotherNature research network.

Clinical decision rules improve health care fidelity, benefit patients, physicians and healthcare systems, without reducing patient safety or satisfaction, while promoting cost-effective practice standards. It is critical to appropriately and consistently apply clinical decision rules to realize these benefits. The objective of this thesis was to understand how physicians use the Ottawa Ankle Rules to guide radiography decision-making. The study employed a clinical judgment survey targeting members of the Canadian Association of Emergency Physicians. Statistical analyses were informed by the Brunswik Lens Model and Social Judgment Analysis. Physicians’ overall agreement with the ankle rule was high, but can be improved. Physicians placed greatest value on rule-based cues, while considering non-rule-based cues as moderately important. There is room to improve physician agreement with the ankle rule and use of rule-based cues through knowledge translation interventions. Further development of this Lens Modeling technique could lend itself to a valuable cognitive behavioral intervention.

This thesis addresses questions of how to incorporate quality of care, represented by disutility-bearing effects such as mortality, morbidity and re-admission, in measuring relative performance of public hospitals. Currently, case-mix funding and performance, measured with costs per case-mix adjusted separation, hold hospitals accountable for costs, but not effects, of care, creating economic incentives for quality of care minimising cost per admission. To allow an appropriate trade-off between the value and cost of quality of care a correspondence is demonstrated between maximising net benefit and minimising costs plus decision makers??? value of disutility events, where effects of care can be represented by disutility events and hospitals face a common comparator. Applying this correspondence to performance measurement, frontier methods specifying disutility events as inputs are illustrated to have distinct advantages over output specifications, allowing estimation of: 1. economic efficiency conditional on the value of avoiding disutility events. 2. technical, scale and congestion sources of net benefit efficiency; 3. best practice peers over potential decision makers??? value of quality; and 4. industry shadow price of avoiding disutility events. The accountability this performance measurement framework provides for effects and cost of quality of care are also illustrated as the basis for moving from case-mix funding towards a funding mechanism based on maximising net benefit. Links to evidence-based medicine in health technology assessment are emphasised in illustrating application of the correspondence to comparison of multiple strategies in the cost-disutility plane, where radial properties as shown to provide distinct advantages over comparison in the cost-effectiveness plane. The identified performance measurement and funding framework allows policy makers to create economic incentives consistent with evidence-based medicine in practice, while avoiding incentives for cream-skimming and cost-shifting. The linear nature of the net benefit correspondence theorem allows simple inclusion of multiple effects of quality, whether expressed as not meeting a standard, functional limitation or disutility directly. In applying the net benefit correspondence theorem to hospitals a clinical activity level is suggested, to allow correspondence conditions to be robustly satisfied in identification of effects with decision analytic methods, adjustment for within DRG risk factors and data linkage to effects beyond separation.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Thesis (Ph. D.)--University of New South Wales, 2004. / Also available online.

Les interventions visant l'arrêt du tabac ont réalisé des progrès importants. Pourtant, des facteurs minorent le maintien de l'arrêt du tabac à long terme, en particulier l'existence d'un trouble dépressif. Cette thèse étudie la contribution de la pratique d'activité physique en tant que facteur protecteur de la rechute dans le cadre du sevrage tabagique. Les études longitudinales 1 et 2 explorent l'impact de l'activité physique sur la rechute tabagique à long terme, chez des fumeurs avec ou sans trouble dépressif. L'étude 1 retrouve un effet protecteur de l'interaction antidépresseur - activité physique sur la rechute chez des fumeurs tout venant (n= 227). L'étude 2 met en exergue le rôle protecteur de l'activité physique chez des fumeurs touchés par un trouble dépressif (n= 133) ainsi que le niveau d'éducation, la prise d'anxiolytiques et d'antidépresseurs, ainsi que les tentatives d'arrêt précédentes. L'étude 3 évalue l'efficacité d'un programme d'activité physique adapté couplé à du conseil comme traitement adjuvant de l'arrêt du tabac chez des fumeurs touchés par un trouble dépressif. Cet essai clinique randomisé contrôlé (n = 70) a été réalisé au sein du CHRU de Montpellier. Le critère de jugement principal est l'abstinence continue trois mois après le début de l'intervention. L'analyse en intention de traiter souligne une différence en fin de programme (OR = 0.14 ; 95% CI .02 - .72 ; p = .018) et une différence non significative à trois mois (OR = 0.87 ; 95% CI .62 – 1.21 ; p = .08).Pour conclure, nous faisons l'état des mécanismes testés empiriquement expliquant l'effet de l'activité physique sur la consommation de tabac et la dépression. Nous proposons des pistes méthodologiques pour construire des modélisations et des interventions dans le domaine de la santé à partir d'une approche transdisciplinaire. / Current depressive disorders are associated with a lower likelihood of quitting smoking and with greater likelihood of smoking relapse.The aim of this thesis project was to study the protective role of physical activity on relapse rate after a smoking-cessation program. Studies 1 and 2 have explored the role of physical activity on relapse at long term in smokers with and without depressive disorders. First study has shown a significant interaction between antidepressant and physical activity as protecteur factor on relapse (n= 227) among smokers recruited at the smoking-cessation unit of Montpellier University Hospital. Second study has confirmed that physical activity was a protector factor on relapse in smokers with depressive disorders. Furthermore, antidepressants, anxiolytics, level of education, and number of attempts to quit were associated with relapse. The efficacy of exercise intervention and counseling as an adjuvant therapy in smoking cessation for smokers with current depressive disorders (n= 70) has been investigated in third study. Compared with control subjects, exercise subjects achieved significantly higher levels of continuous abstinence at the end of treatment (OR = 0.14 ; 95% CI .02 - .72 ; p = .018) while results were not significant at 3 months following treatment (OR = 0.87 ; 95% CI .62 – 1.21 ; p = .08). We have also reviewed the current literature investigating the mechanisms between exercise-depression and exercise-smoking. Methodological and transdisciplinary approaches are proposed to developp future studies.

Made available in DSpace on 2015-07-22T20:50:53Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-08-25. Added 1 bitstream(s) on 2015-08-11T03:26:30Z : No. of bitstreams: 1 Publico-433a.pdf: 1769146 bytes, checksum: 7d3c9197425322c43a18b4e96ab013f9 (MD5). Added 1 bitstream(s) on 2015-08-11T03:26:30Z : No. of bitstreams: 2 Publico-433a.pdf: 1769146 bytes, checksum: 7d3c9197425322c43a18b4e96ab013f9 (MD5) Publico-433b.pdf: 1363680 bytes, checksum: 563de8fdde057166c08b9703bab9f47f (MD5). Added 1 bitstream(s) on 2015-08-11T03:26:30Z : No. of bitstreams: 3 Publico-433a.pdf: 1769146 bytes, checksum: 7d3c9197425322c43a18b4e96ab013f9 (MD5) Publico-433b.pdf: 1363680 bytes, checksum: 563de8fdde057166c08b9703bab9f47f (MD5) Publico-433c.pdf: 1188043 bytes, checksum: 44ced167120130176ef99f2f7f1cc59c (MD5) / Introdução: O Ronco é o ruído causado pela vibração da úvula, palato e paredes faríngeas durante a inspiração, cujas causas envolvem diversos fatores. Objetivo: O tratamento do ronco pelos métodos para aumento do tônus muscular da via aérea superior tem sido controverso e pouco relatado, portanto uma revisão sistemática em busca de evidências é necessária para avaliar a efetividade destes métodos. Método: Revisão sistemática de ensaios clínicos randomizados ou quasi-randomizados, duplo-cegos para o tratamento do ronco, com métodos que visam o aumento do tônus da via aérea superior, tais como fonoterapia e fisioterapia. Desfechos: diminuição ou cura do ronco, qualidade do sono, qualidade de vida e efeitos adversos. Resultados: Três estudos elegíveis foram potencialmente analisados, porém nenhum deles foi capaz de prover evidência científica suficiente para favorecer a intervenção. As análises objetivas de um estudo demonstraram melhora do ronco, entretanto as subanálises objetivas e as análises subjetivas demonstraram resultados controversos. Os efeitos adversos não foram relatados. Conclusão: Não existe evidência científica suficiente para sustentar a recomendação de métodos para aumentar o tônus muscular da via aérea superior no tratamento do ronco. Ensaios clínicos randomizados bem elaborados são necessários para avaliarmos a efetividade de tais métodos e uma padronização com métodos mundialmente aceitos de intervenção para o ronco seriam necessários para pesquisas futuras. Palavras-chave: Ronco, distúrbios do sono, tratamento, revisão. / TEDE / BV UNIFESP: Teses e dissertações