Although most outcomes were equally good, important differences between obstetrician and nurse-midwife care remained after multivariate analysis.

Results suggest that patients with symptoms of diabetic gastroparesis experience notable HRQOL impairment and that symptomatic relief with domperidone is accompanied by improvements in HRQOL that can be sustained over 4 weeks of treatment.

Purpose: To analyze the direct medical costs associated with epilepsy in the US using a cost-of-illness analysis that incorporates both a patient-based approach and a population-based approach. Methods: Patient-based or ‘bottom-up’ analysis relied on information provided by a panel of experienced epilepsy clinicians to determine the number and type of medical resources used by individuals with epilepsy. Population-based or ‘top-down’ analysis relied on cost estimates from a nationally representative sample in the 1987 National Medical Expenditure Survey. Results: The average annual cost per individual in the patient-based analysis was $1,490. The average annual cost per individual in the population-based analysis was $1,510 with average yearly costs per adult of $1,480 and $1,740 per child. New cases of epilepsy are associated with costs of $362 million for the first year of treatment; existing cases of epilepsy are estimated to cost the US nearly $2 billion. Conclusions: The results of this study indicate incident cases are more than twice as expensive as prevalent cases, and the need to properly care for epilepsy patients is increasingly important in today’s health care environment, where the emphasis is on providing effective treatments while simultaneously lowering the costs.

Prevention of stroke in patients with atrial fibrillation (AF) requires long-term anticoagulation therapy, and warfarin is currently the only option. Previous studies have indicated that patients are generally satisfied with long-term warfarin therapy; however, this research is mostly limited to simple questions, or modified Likert scales. Psychometric research on measuring satisfaction with medical treatment has indicated that multi-dimensional measures are generally more reliable and sensitive to treatment differences. This qualitative study, conducted in the US, UK, and Spain, was performed to explore the specific treatment satisfaction domains related to warfarin therapy. Interviews were conducted with patients (N=28) who were receiving long-term warfarin therapy for the prevention of stroke in AF, or had discontinued therapy. The interviews, developed from conceptual models, focussed on the patients’ experiences and satisfaction with warfarin therapy. Patients received warfarin for an average of 6 years, with 22% receiving treatment for >5 years. Warfarin therapy was reported to reduce patients’ quality of life, with 28% reporting an impact on their work, 32% an effect on their ability to travel, and 57% experiencing effects on their leisure activities, often because of alcohol restrictions. Domains that were important to patient satisfaction were identified, including monitoring, bruising/bleeding, and the psychological impact of therapy. The requirement for frequent monitoring was a burden in nearly half of the patients (43%); in the majority of these patients (57%), this was due to the amount of time spent attending the clinic. Unsurprisingly, working patients reported monitoring as more of a burden than those who did not work (65% vs 31%). The location and frequency of monitoring affected patients’ perceptions of the burden; patients attending anticoagulation clinics (rather than primary care surgeries), and those attending more than once a month, reported greater inconvenience. However, many patients, particularly those who had been taking warfarin for longer, felt reassured by monitoring. Bruising and/or bleeding was a worry to 17% of patients, with 28% reporting being embarrassed by it, and many patients choosing clothes that covered their bruises. The psychological impact of warfarin therapy was illustrated by the number of patients reporting concern about drug interactions (50%), with one-fifth (21%) worried about the warfarin dose they had been prescribed. Knowledge that their warfarin therapy required alcohol and dietary restrictions was demonstrated by 39% and 28% of patients, respectively; however, some patients thought that dietary restrictions were to encourage weight loss, and 15% of patients reported that the restrictions were a burden. Furthermore, many elderly patients, particularly in the UK and Spain, were unaware that the purpose of their warfarin therapy was for stroke prevention. Patients that had discontinued treatment gave reasons including a feeling of dependence on warfarin, bruising and bleeding, monitoring, and diet and alcohol restrictions. Patients in this study recognized that warfarin is currently the only therapy available to them, and made adjustments to their lifestyles accordingly. However, warfarin adversely affects the quality of life of patients with AF because of the practicalities and psychological impact of therapy. An anticoagulant that does not require frequent monitoring, with limited food and drug interactions would represent a significant advance for patients with AF.

While there have been signifi cant health gains in recent years, disparities between Indigenous and non-Indigenous populations remain unacceptably high. Levels of type II diabetes for example have reached serious proportions with increasing rates in young people. Treatment protocols play an important part in the alleviation of illnesses but should be seen as part of a wider spectrum of approaches. A framework for understanding and alleviating chronic illness among Maori places importance on the recognition of multiple causalities and consequential parallel interventions. Within the framework three broad principles have been recognised: integrated solutions, distinctive pathways, and goals that empower. An important theoretical platform has been the application of both Indigenous knowledge and medical science to health and a readiness by practitioners to work at the interface between the two systems.