Ethical considerations in researching user views

Researching user views has become a central plank of UK cancer and palliative care policy, not least because it is recognized that current systems for treatment reflect inadequately the experiences and concerns of cancer patients. This paper examines the process of accessing user views about cancer and palliative care from an ethical perspective, drawing by way of example on a study of outcomes associated with Macmillan nursing. A moral theory framework is used to discuss some of the issues involved in trying to achieve ethically sound practice and some essentially political issues that frame the process of accessing users' views are highlighted. The paper recommends that models of research be developed for accessing user views that are congruent with the values and philosophies of supportive and palliative care. This requires striking a fine balance between the ethical duties of providing care and support, nurturing independence and autonomy, and achieving research outcomes that are rigorous while also being accessible and meaningful to users. It also requires developing an understanding of the social, political and economic context of research enquiry with users.

Palliative care and policy in England: a review of health improvement plans for 1999-2003

Since 1987 health authorities in England have been required to make plans for palliative care provision, but their record in doing so has been patchy. The production of health improvement plans (HlmPs), in which each health authority must set out its priorities and actions designed to improve the health and well-being of its local population, provides an opportunity to examine the extent to which palliative care provision in the NHS is regarded as a priority by policy makers in England. This paper reports on a structured documentary review of the HlmPs published by the 99 health authorities in England. The review indicates that at the moment, in spite of the longstanding duty placed on health authorities to develop strategic plans for palliative care and to assess the level of local palliative care needs, not all have made significant progress in this direction. Among those that do have plans for palliative care, the vast majority of these plans are for people with cancer. What emerges most clearly is a sense in which specialist palliative care, especially for non-cancer patients, is perceived as an 'optional extra' by many health authorities rather than an integral and essential part of the overall supportive care strategy which they clearly are at pains to develop.

Multivitamin use and colon cancer mortality in the Cancer Prevention Study II cohort (United States)

OBJECTIVE

Multivitamins contain several nutrients, including folic acid, which are hypothesized to reduce colon cancer risk. Previous epidemiologic studies have suggested that effects of multivitamins containing substantial amounts of folic acid (introduced in 1973) may not be evident until 15 or more years since first use.

METHODS

We examined the association between daily multivitamin use and colon cancer mortality among 806,397 US men and women in the Cancer Prevention Study II cohort who completed a questionnaire at enrollment in 1982 and were followed for mortality through 1998.

RESULTS

After multivariate adjustment, multivitamin use at enrollment showed little association with colon cancer mortality. After 15 years since first use of a multivitamin potentially containing folic acid, we observed slightly decreased risk of colon cancer mortality (rate ratio (RR) = 0.89, 95% confidence interval (CI) 0.80-0.99). Consistent with previous reports, this association was stronger among participants consuming two or more alcoholic drinks per day (RR = 0.71, 95% CI 0.56-0.91).

CONCLUSION

Our results are consistent with a modest reduction in colon cancer mortality associated with use of folic acid-containing multivitamins among moderate to heavy alcohol users.

Impact of troponin T determinations on hospital resource utilization and costs in the evaluation of patients with suspected myocardial ischemia

The evaluation and triage of patients with suspected myocardial ischemia in the emergency department remains challenging and costly. Previous studies of cardiac troponins have focused predominantly on patients with chest pain and have not randomized patients to different diagnostic strategies. Eight hundred fifty-six patients with suspected myocardial ischemia were prospectively randomized to receive a standard evaluation, including serial electrocardiographic and creatine phosphokinase-MB determinations (controls) or a standard evaluation with the addition of serial troponin T determinations (troponin group). The primary end points were length of stay and hospital charges. Significant reductions in length of hospital stay were seen in troponin T patients both with (3.6 vs 4.7 days; p = 0.01) and without (1.2 vs 1.6 days; p = 0.03) acute coronary syndromes compared with controls. Total hospital charges were reduced in a similar fashion in troponin patients with and without acute coronary syndromes ($15,004 vs $19,202; p = 0.01, and $4,487 vs $6,187; p = 0.17, respectively) compared with controls. Troponin patients without acute coronary syndromes had fewer hospital admissions (25% vs 31%; p = 0.04), whereas troponin patients with acute coronary syndromes had shorter telemetry and coronary care unit lengths of stay (3.5 vs 4.5 days; p = 0.03) compared with controls. Thus, utilization of troponin T in a broad spectrum of emergency department patients with suspected myocardial ischemia improves hospital resource utilization and reduces costs.

Actions for wrongful birth and wrongful life

This paper discusses wrongful birth and wrongful life actions taken under the common law of negligence in the United States, Canada, England and Australia. The paper explains the nature of the actions and offers comments on the legal and ethical issues. In particular, it considers the problem of identifying the harm suffered by the parents of an unwanted child and explores some of the questions posed by the law's attempts to assign responsibility following the birth of a normal or a disabled child.

Vitamin C and vitamin E supplement use and colorectal cancer mortality in a large American Cancer Society cohort

Some recent epidemiological studies have suggested that use of vitamin C or vitamin E supplements, both of which are important antioxidants, may substantially reduce the risk of colon or colorectal cancer. We examined the association between colorectal cancer mortality and use of individual vitamin C and E supplements in the American Cancer Society's Cancer Prevention Study II cohort. We used proportional hazards modeling to estimate rate ratios among 711,891 men and women in the United States who completed a self-administered questionnaire at study enrollment in 1982, had no history of cancer, and were followed for mortality through 1996. During the 14 years of follow-up, 4404 deaths from colorectal cancer occurred. After adjustment for multiple colorectal cancer risk factors, regular use of vitamin C or E supplements, even long-term use, was not associated with colorectal cancer mortality. The combined-sex rate ratios were 0.89 [95% confidence interval (CI), 0.73-1.09] for 10 or more years of vitamin C use and 1.08 (95% CI, 0.85-1.38) for 10 or more years of vitamin E use. In subgroup analyses, use of vitamin C supplements for 10 or more years was associated with decreased risk of colorectal cancer mortality before age 65 years (rate ratio = 0.48; 95% CI, 0.28-0.81) and decreased risk of rectal cancer mortality at any age (rate ratio = 0.40; 95% CI, 0.20-0.80). Our results do not support a substantial effect of vitamin C or E supplement use on overall colorectal cancer mortality.

Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered

OBJECTIVE

To evaluate whether applying pressure equivalent to that of pressure immobilisation bandages (PIB) causes release of additional venom from discharged jellyfish nematocysts.

DESIGN

In-vitro experiment--the venom beads released from electrically activated Chiropsalmus sp. nematocysts were viewed under direct microscopy before and after applying 40 mmHg pressure (replicating the pressure of PIB); and saline washings of discharged nematocysts before and after applying pressure were tested for toxicity (time to ventricular standstill after injecting into live prawns).

RESULTS

Applying 40 mmHg pressure caused the venom beads to visibly increase in size, consistent with pressure expressing further venom from the discharged nematocysts. First washings of the nematocyst shafts before compression produced ventricular standstill in prawns within 60 seconds (n=3); second washings did not produce standstill during 540 seconds of observation (n=3); and washings after applying 40 mmHg pressure showed a return of toxicity, with ventricular standstill in all prawns within 180 seconds (n=3).

CONCLUSION

Discharged nematocysts are by no means empty and harmless. Applying pressure results in further release of nematocyst venom. The currently recommended practice of applying PIB in the initial treatment of patients stung by a jellyfish may exacerbate the envenomation, and thus should not be recommended.

Getting the questions right: an example of loss of validity during transfer of a brief screening approach for depression in the elderly

Screening for depression in the elderly has been advocated to improve detection and management. This article summarises the trend towards briefer screening instruments, and the integration of mental health screening with other assessments. The study aimed to validate a single question depression screen which has previously shown adequate sensitivity and specificity in a new context: a multi-faceted assessment instrument used by nurse practitioners within a community sample of over 75 year olds. The GMS-AGECAT computerised interview assessment was used as a 'gold standard' to determine the accuracy of the depression question in this new setting. Three hundred and twenty-eight patients were screened by their own nurse practitioners, of whom 100 consenting patients underwent a further interview with a research assistant using the GMS-AGECAT. The prevalence of depression was 30%, the sensitivity of the question was 67%, and its specificity 60% (compared with 88% and 71% previously). Responses indicating disability and loneliness were more closely correlated with depression than the depression screen itself. Relevant factors may include: the derivation of the question, the effect of a different sample, altered reliability when used by multiple interviewers, differing patient expectations, and the wording and context of the question within the multi-faceted screening instrument. Depression screening questions need repeated validation when used in different contexts. Patient and staff expectations may influence how screening instruments are used in practice in a way that may also alter reliability. Further studies are needed to establish the causes of loss of validity when screening approaches are used in new settings.

A tool to improve quality of reporting published economic analyses

OBJECTIVES

To test the feasibility of obtaining a baseline level of quality of reporting for cost-utility analysis (CUA) studies using the British Medical Journal economic submissions checklist, test interrater reliability of this tool, and discuss its longer term implications.

METHODS

CUA studies in peer-reviewed English language journals in 1996, assessed using the British Medical Journal checklist, a quality index, and interrater reliability correlations.

RESULTS

Forty-three CUA studies were assessed, with 23 checklist items acceptable and 10 items inadequate. Lowest quality scores were reported in specialist medical journals. Proportional agreement between assessors was over 80%.

CONCLUSIONS

The British Medical Journal checklist is a feasible tool to collect baseline information on the quality of reporting in journals other than the British Medical Journal. Editors of specialist medical journals are in greatest need of economic guidance. If handled carefully, they might consider adopting the British Medical Journal checklist.

Quality of life related to fear of falling and hip fracture in older women: a time trade off study

OBJECTIVE

To estimate the utility (preference for health) associated with hip fracture and fear of falling among older women.

DESIGN

Quality of life survey with the time trade off technique. The technique derives an estimate of preference for health states by finding the point at which respondents show no preference between a longer but lower quality of life and a shorter time in full health.

SETTING

A randomised trial of external hip protectors for older women at risk of hip fracture.

PARTICIPANTS

194 women aged >/= 75 years enrolled in the randomised controlled trial or who were eligible for the trial but refused completed a quality of life interview face to face.

OUTCOME MEASURES

Respondents were asked to rate their own health by using the Euroqol instrument and then rate three health states (fear of falling, a "good" hip fracture, and a "bad" hip fracture) by using time trade off technique.

RESULTS

On an interval scale between 0 (death) and 1 (full health), a "bad" hip fracture (which results in admission to a nursing home) was valued at 0.05; a "good" hip fracture (maintaining independent living in the community) 0.31, and fear of falling 0.67. Of women surveyed, 80% would rather be dead (utility=0) than experience the loss of independence and quality of life that results from a bad hip fracture and subsequent admission to a nursing home. The differences in mean utility weights between the trial groups and the refusers were not significant. A test-retest study on 36 women found that the results were reliable with correlation coefficients within classes ranging from 0.61 to 0.88.

CONCLUSIONS

Among older women who have exceeded average life expectancy, quality of life is profoundly threatened by falls and hip fractures. Older women place a very high marginal value on their health. Any loss of ability to live independently in the community has a considerable detrimental effect on their quality of life.

Are preferences over health states complete?

Most applied work in health economics accepts, if only implicitly, the axiom of completeness. Preferences over health states or health services are assumed to be well formed. They are effectively 'data' waiting to be collected. An alternative perspective suggests that values are initially incomplete and are constructed rather than just revealed in the process of answering choice-related questions such as willingness to pay or standard gambles. What might appear as measurement error may, therefore, be a more deliberate process of reflection and deliberation. This paper reports on a study that assessed the completeness of health preferences. The results show a mixed pattern. For most of the sample, values were stable over repeat administration, suggesting completeness. However, one-third of participants deliberately changed their answers and suggested that the interview process had forced them to think about their values more deeply. While it is premature to draw conclusions from this small sample, the suggestion is that completeness cannot be taken for granted.

An efficient, adaptive method of measuring loudness growth functions

This paper presents a new categorical loudness scaling procedure that differs from previously published loudness scaling procedures by (i) adaptively selecting a new set of levels for each new sequence, (ii) deriving levels that are equispaced on the loudness scale, and (iii) using a continuous scale with few labels. A major advantage of the adaptive procedure is that the individual dynamic range need not be measured prior to loudness testing. The adaptive procedure proved to be time efficient and to produce complete loudness functions from Not heard to Uncomfortably loud for normal hearing and hearing impaired subjects. The pattern of short-term and long-term reliability was similar to that reported for non-adaptive loudness scaling procedures. Three presentations produced a stable loudness function. Normative curves for one octave babble-noise at six test frequencies are presented and compared to normative data obtained with a selection of published categorical scaling procedures.

Raising the quality of cost-utility analyses: lessons learnt and still to learn

Heightened awareness by health care funders of the need to find more efficient ways of using scarce health care resources has led to greater demand for evidence of cost-effectiveness. Implicit in this demand is that evidence is generated using clear reporting and accepted methods. The research reported here updates an earlier review of published cost-utility analyses (CUAs) to address whether previously identified gaps in reporting have diminished over time. Raising CUA standards requires systematic and regular reviews of published material to allow adequate monitoring and evaluation. There is also a need to 'appraise the appraisers' in the sense of reviewing peer-review processes. This is particularly so in those journals which are growing in importance as outlets for economic evaluation information. The findings from this study indicate continuing variation in the quality of reporting. At the lower end of this spectrum improvements could be made in the reporting of comparators, in the clarity of effectiveness evidence, in the assignment of utility weights to health states and in reporting of sensitivity analysis. CUAs published in peer-reviewed specialist medical journals were more likely to be lower in quality suggesting guidance on the appraisal of economic submissions needs to be extended to the editors of these particular journals. These findings could be used to help to target attempts to raise the quality of evidence-based CUA information.