CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne
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To provide guidelines for the institution and maintenance of a continuous subcutaneous narcotic infusion program for cancer patients with chronic pain through an analysis of the narcotic requirements and treatment outcomes of patients who underwent such therapy and a comparison of the costs of two commonly used infusion systems. ⋯ Continuous subcutaneous infusion of opioid drugs with the use of a portable programmable pump is safe and effective in selected patients who have failed to respond to standard medical treatment of their cancer pain. Dose titration may require rapid dose escalation, but this is usually well tolerated. For most communities embarking on such a program a programmable infusion system will be more cost-effective than a disposable system.
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To evaluate the accuracy, reliability, clinical effectiveness and economic impact of bedside pulse oximetry and capnometry as used routinely in the adult critical care environment. ⋯ Pulse oximetry may expedite accurate and continuous monitoring of oxygenation at the bedside of the critically ill adult patients. Nevertheless, there are clinical limitations, and caution is needed before oximeters are accepted for routine use. The routine bedside use of capnometry should be discouraged.
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The Manitoba Medical Review Committee is a peer review body that monitors the patterns of practice of the province's 1800 physicians in order to prevent and control overservicing. This study examined the effectiveness of the committee in reducing the unnecessary use of complete examinations, regional examinations, special calls, nursing-home visits and diagnostic testing. ⋯ In most cases the decrease was not offset by increases in other services or in the number of patients. The estimated savings resulting from the utilization review amounted to more than $2 million during the 4-year period.
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Because economic evaluations of health care services are being published with increasing frequency it is important to (a) evaluate them rigorously and (b) compare the net benefit of the application of one technology with that of others. Four "levels of evidence" that rate economic evaluations on the basis of their methodologic rigour are proposed. They are based on the quality of the methods used to estimate clinical effectiveness, quality of life and costs. ⋯ A grade B technology costs less than $20,000 per quality-adjusted life-year (QALY), a grade C one $20,000 to $100,000/QALY and a grade D one more than $100,000/QALY. Many issues other than cost effectiveness, such as ethical and political considerations, affect the implementation of a new technology. However, it is hoped that these guidelines will provide a framework with which to interpret economic evaluations and to identify additional information that will be useful in making sound decisions on the adoption and utilization of health care services.