Improving the contributions of technology assessment to the health care system of the U.S.A.

Summary Based on 14 case studies of highly effective therapies and the reasons they succeeded less frequently than they could, we propose a variety of steps to improve the health care system of the U.S.A. Whatever proposal emerges from current national debates until innovations are shown to be safe and effective, they should not be supported; when slightly better technologies are much more expensive than other good ones we need to consider appropriate choices carefully; simplified billing and bookkeping would reduce our costs; when a technology is rapidly introduced cautionnary measures may be needed; tracking immunization and repairing their omissions requires a new system; educational programs such as seen effective in hypertension should be applied in other areas such as vaccination; in organ transplantation the nation should consider “presumed consent”; our payment system sometimes creates perverse incentives and therefore needs review; and the preferences of the public in allocation of health resources need to be discovered once the public is informed about the issues. Research supported by Andrew W. Mellon Foundation.     

提高高等医学院校临床教学质量的若干思考

提高医学院校的临床教学质量应做好四个方面的工作:提高认识、增强教学意识,调动临床教学工作的积极性;加强临床教师队伍的建设,注重提高临床教学效果;加强临床教学管理规范化制度化建设;深化临床教学改革。     

江苏省综合性医院临床医生对新医改认知研究

为了解江苏省综合性医院临床医生对新医改现状的看法,评价新医改在江苏省内的实施进展和效果,该研究选取了新医改部分重点问题,采用自设计问卷,调查江苏省内7家三级综合性医院和7家二级综合性医院临床医生,运用描述性分析和卡方检验辅助分析研究结果。发现66.5%的医生更希望政府医改经费投入能侧重于医务人员劳动收入;对家庭医生签约服务的认知度及成效评价低于分级诊疗及医联体建设;认为医患关系和看病难、看病贵问题略有改善的医生分别占20.3%、24.9%、27.9%。需正确认识医务人员认知差异及原因;重视医务人员权益、优化薪酬管理制度;加强家庭医生签约服务的宣传和推广;丰富医联体间活动形式;建立及时有效的临床医生反馈机制。     

党务公开在党的生活中的定位

党务公开是马克思主义政党的本质要求,是工人阶级政党开放性品格的重要体现。推进党务公开是我党对历史方位的深刻认识和正确把握提出的新要求,是顺应时代发展潮流的必然选择,是坚持和实践科学、民主、依法执政的现实路径,是增强党的先进性和活力,有效预防和惩治腐败的重要手段。     

Treatment Choice With Trial Data: Statistical Decision Theory Should Supplant Hypothesis Testing

Abstract

A central objective of empirical research on treatment response is to inform treatment choice. Unfortunately, researchers commonly use concepts of statistical inference whose foundations are distant from the problem of treatment choice. It has been particularly common to use hypothesis tests to compare treatments. Wald’s development of statistical decision theory provides a coherent frequentist framework for use of sample data on treatment response to make treatment decisions. A body of recent research applies statistical decision theory to characterize uniformly satisfactory treatment choices, in the sense of maximum loss relative to optimal decisions (also known as maximum regret). This article describes the basic ideas and findings, which provide an appealing practical alternative to use of hypothesis tests. For simplicity, the article focuses on medical treatment with evidence from classical randomized clinical trials. The ideas apply generally, encompassing use of observational data and treatment choice in nonmedical contexts.     

Enacting reflective and deliberative practices in action research

ABSTRACT

We consider action research as a form of deliberative policy analysis. This analysis explores a “reconstruction clinic” in which stakeholders and public officials engaged memories, hopes and obligations as they sought to resolve controversies over details of policy implementation. We ask how institutional design shaped participants’ reflective and deliberative progress. Reflection in action can prompt not only changes in cognitive frames, but new behavioural capacities for action. Deliberative practices can shape new relationships between parties through the work of apology, recognition, appreciation, and emergent collaboration.     

Integrating self-care into clinical practice with trauma clients

ABSTRACT

Self-care is recognized as an important aspect of social work practice. Beginning in educational settings, developing social workers are encouraged to learn about and practice self-care. However, self-care is typically promoted through strategies and approaches outside of the practice context. Social workers are oftentimes encouraged to use individualized self-care plans, which often feature a variety of relaxation and secondary techniques; focus on self-awareness and self-reflection; and have proper use of supervision. Although these strategies are invaluable, they do little to directly benefit the social worker during direct practice or while in session with a client which is a time period when clinicians are particularly vulnerable to distress or burnout. The importance of real-time self-care strategies is particularly critical for clinicians, especially those who engage in trauma work, given the sensitivity of topics that clients may have endured or benefit from assistance in processing. Further, little information has been published on the use of self-care techniques during a session with a client or in a clinical context. The purpose of the present paper is to discuss self-care strategies that can be useful both outside of and within a clinical setting and present a model of such strategies that focus on integrating self-care in clinical practice particularly for those engaging in trauma work. The paper will conclude by discussing the relevancy of the developed model in practice.     

Randomization tests in recursive response-adaptive randomization procedures

In a randomized clinical trial, response-adaptive randomization procedures use the information gathered, including the previous patients' responses, to allocate the next patient. In this setting, we consider randomization-based inference. We provide an algorithm to obtain exact p-values for statistical tests that compare two treatments with dichotomous responses. This algorithm can be applied to a family of response adaptive randomization procedures which share the following property: the distribution of the allocation rule depends only on the imbalance between treatments and on the imbalance between successes for treatments 1 and 2 in the previous step. This family includes some outstanding response adaptive randomization procedures. We study a randomization test to contrast the null hypothesis of equivalence of treatments and we show that this test has a similar performance to that of its parametric counterpart. Besides, we study the effect of a covariate in the inferential process. First, we obtain a parametric test, constructed assuming a logit model which relates responses to treatments and covariate levels, and we give conditions that guarantee its asymptotic normality. Finally, we show that the randomization test, which is free of model specification, performs as well as the parametric test that takes the covariate into account.     

A Study of Clinical Change in Individual Career Counseling

This study examined the clinical significance of career counseling effects. Participants were 111 university students (83% women) who participated in individual career counseling sessions at their university. All participants completed the French version of the Outcome Questionnaire–30.2 (OQ‐30.2; Lambert, Finch, Okiishi, & Burlingame, 2005) immediately before the 1st session (pretest) and at the beginning of the last session (posttest). The OQ‐30.2 assesses 3 client life domains: subjective discomfort, problems in interpersonal relationships, and problems in social role satisfaction. Using Jacobson and Truax’s (1991) statistical approach to assessing clinical change, the authors compared clients’ pretest OQ‐30.2 scores with their posttest scores. Among clients with a “dysfunctional” score (n = 59) at the study’s inception, 34% recovered and 14% improved, whereas 41% of clients with functional scores (n = 52) at the study’s inception improved. The results suggest that individual career counseling can make a difference in the lives of many clients; they also highlight the importance of further outcome research that accounts for possible variability in clients’ responses to career counseling.