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By U. Angar. School of the Museum of Fine Arts, Boston.

For example generic procardia 30mg mastercard heart disease or out of shape, the direct costs of latter study were very high generic 30mg procardia visa cardiovascular disease nursing journal articles, and few costs were considered treatment failure may be higher in psychiatric practice than in the analysis. On the other hand, the tendency of psychiatrists to data are needed about the extent to which patients, knowing use higher and possibly more effective doses of TCAs than that the pills are not lethal, might substitute methods of primary care prescribers do would likely favor the cost-effec- suicide that are even more deadly than TCA overdoses. Simi- However, recently emerging epidemiologic data appear to larly, it may be less likely in psychiatric practice than in suggest that newer antidepressants may have a favorable im- primary care that the greater tolerability of SSRIs and the pact on death by suicide when all methods, not just over- reduced requirement for dose titration would offset costs doses, are taken into account (57–60). Prospective randomized cost- The available data that may be confidently brought to bear effectiveness experiments in psychiatric practice could ad- on the two cost-effectiveness questions posed in the intro- dress the substantially different environment of specialty duction are surprisingly sparse. Similarly, although the data on the treatment of depres- More prospective studies are clearly needed. Most of the sion in the United States are limited, those on the cost- retrospective studies and the simulations contain methodo- effectiveness of the newer antidepressants in other countries, logic limitations sufficient to generate significant concern especially developing countries, are still more limited. Additionally, the studies include randomized studies outside the United States have com- diverse variations in almost all the elements of cost-effective- pared newer and older antidepressants. Some of the simula- ness analysis, so that cross-comparisons and aggregate con- tions and none of the administrative database studies focus clusions are very difficult to make. However, if we must on other developed countries, such as Canada and the Euro- draw conclusions fromthe current data, we would suggest pean nations. The many ways in which the treatment of the following tentative conclusions. Acquisition costs for the newer medications are newer antidepressants cost-effective as first-line treatment generally lower in countries other than the United States fromthe health care systemperspective? Nevertheless, price may still put the newer antidepres- use of the newer antidepressants within primary care prac- sants out of reach for most of the population in some devel- tice in the United States may be roughly equally effective oping countries (64). The organization of health care sys- and also cost-neutral in terms of direct medical resource tems varies greatly, and the potential of the newer costs to the health care system. The recently published long- antidepressants to offset costs could also vary greatly across termdata fromthe only randomized study support this view countries. Prospective randomized cost-effectiveness experi- (26), and the simulations and retrospective studies, with all ments in countries other than the United States would make their limitations, do not contradict it. However, because it possible to evaluate whether cost-effectiveness conclusions the data are sparse and contain multiple methodologic prob- are widely applicable. Economic comparisons of the pharmacotherapy and none of the studies is prospective. Acta Psychiatr Scand 1998;97: costs were not comprehensive in some studies, being limited 241–252. Mirtazapine—a pharmacoeco- porting QALYs, the outcome rates were taken from expert nomic review of its use in depression. Pharmacoeconomics 2000; opinion panels, or utility determinations were uncertain. Fluoxetine—a pharmacoeconomic review Most of these studies have numerous other methodologic of its use in depression. Sertraline—a pharmacoeconomic evaluation substitution of suicide methods, enhancement of work pro- of its use in depression—reply. Pharmacoeconomics 1997;11: ductivity, and reduction of absenteeismand family burden. However, if the newer antidepressants are in fact health care 14. Paroxetine—a pharmacoeconomic evaluation of its use in depression. Pharmacoeconomics 1995;8: resource cost-neutral in the health care system, the chance 62–81. Health care systemhealth resource cost neu- depression: a metaanalysis [see Comments]. Can J Psychiatry trality clearly suggests similar cost neutrality in total health 1996;41:613–616. Comparison of ex- tended-release venlafaxine, selective serotonin reuptake inhibi- source costs to society also are borne by the health care tors, and tricyclic antidepressants in the treatment of depression: system. It is likely that society reaps benefits not seen from a meta-analysis of randomized controlled trials. Clin Ther 1999; the health care systemperspective, including decreased use 21:296–308.

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Tis fnal chapter highlights the dominant themes of the report and proposes a set of actions – frst order 30 mg procardia overnight delivery cardiovascular disease genetic, on the conduct of research buy cheap procardia 30mg line heart disease rates by country, with a focus on national health research systems and second, to support research nationally and internationally (Box 5. Research – essential for universal coverage and a source of inspiration for public health Te question “how can we reach universal health coverage? On the road to universal coverage, taking a methodical approach to formulating and answering questions is not a luxury but a necessity; it is the source of objective evidence that can inform health policy and practice. However, research is more than an essential tool; it is also a source of inspi- ration and motivation in public health. Te discoveries made by research stir 129 Research for universal health coverage Box 5. Principal questions and actions on research for universal health coverage This box identifies the key questions about research for universal health coverage that arise from discussion in the main text, together with some important actions that can be taken to help answer the questions. Questions on research Improving the coverage of health services: ■ How can essential health services and fnancial risk protection be made accessible to everyone? How do wider service coverage and better financial protection – and ultimately universal health coverage – lead to better health? Measuring the coverage of health services: ■ What indicators and data can be used to monitor progress towards universal coverage of essential health services and financial risk protection in each setting? Actions on the conduct of research, mainly within national health research systems Setting research priorities: ■ Set priorities for research, especially at national level, on the basis of evaluations of the major causes of ill-health. Strengthening research capacity: ■ Give priority to recruiting, training and retaining the people who do research; research staff are the foremost asset of any research enterprise. Setting standards: ■ Refine and implement codes of practice to carry out ethical and responsible research in each setting. Translating research into policy and practice: ■ Embed research within policy-making processes in order to facilitate the dialogue between science and practice. Ensuring participation and public understanding of research: ■ Include broad representation from society in the process of research governance. Actions to support research, nationally and internationally Monitoring research: ■ Develop national and international research observatories to compile and analyse data on the process of doing research (funding, priorities, projects, etc. Financing research: ■ Develop improved mechanisms for raising and disbursing funds for research, either through existing national and international bodies or by creating new ones. Managing and governing health research: ■ Systematically evaluate management and governance in national and international health research systems, assessing whether mechanisms exist to carry out the essential functions above (on priorities, capacity, stand- ards and translation). First, following progress towards universal the development of a new high-efcacy menin- gococcal A conjugate vaccine (MenAfriVac), health coverage 100 million people were vaccinated across the African meningitis belt within two years (2, 3). The services that make up a None of the rising indicators of research national health system are usually too numer- activity described in Chapter 2 is, on its own, a ous to monitor comprehensively. The practi- guarantee of products and strategies that will help cal alternative is to choose a set of measurable us reach universal health coverage. Collectively, coverage indicators to represent, as tracers, the however, these upward trends signal the grow- overall quantity, quality and equitable delivery ing volume of information and evidence that will of the services to be provided, including ways infuence health policy and practice in low- and to ensure financial protection. Most countries around pragmatic interpretation of universal coverage the world now have, at least, the foundations on in any given setting so that each representa- which to build efective national health research tive intervention, whether a health service or systems. Some have much more than the founda- a mechanism of financial protection, is acces- tions; they have thriving research communities. However, when coverage is partial, questions will grow as the changing causes of ill- some people may beneft more than others. For health are tracked by new interventions and tech- this reason, measures of coverage should reveal, nologies. Te response to previous successes and not simply the average accessibility of services in new challenges is to formulate a more ambitious a population, but also the coverage among difer- defnition of universal coverage – a new research ent groups of people classifed by income, gender, agenda – and to generate yet more evidence to ethnicity, geography and so on. Seeking uni- that the greatest progress in providing services versal health coverage is a powerful mechanism for maternal and child health has been made by for continuing to seek better health. Tis is a form of “progressive universalism” in which The path to universal the poorest individuals gain at least as much as health coverage, and the the richest on the way to universal coverage (6).

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