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Dictionary of Evidence-based Medicine 47 of the second questionnaire and simultaneous feedback of the information to the respondents; (iv) analysis of the results of the second questionnaire and, if necessary, further iteration with more questionnaires until consensus is achieved. Feedback of the information to the respondents at each stage; (v) presentation of the consensus results; (vi) make forecast. Deterministic models (see Stochastic model) Discounting In economic analyses, the fact that costs that are incurred sooner are more keenly felt than those that are incurred later (a phenomenon referred to as 'positive rate of time preference') is taken into account by discounting costs as they accrue over time. Costs of alternative therapies, with different time profiles, can therefore be expressed uniformly in terms of present values. The formula used for discounting is as follows: where P = present value, r = discount rate and a value between 3% and 5% is often recommended, C 3 ,C 2 ,C 3 ,...,C n are the costs in year 1, 2, 3,...,n. Disease management Disease management is a systematic population-based approach to identifying those at risk, intervening using the best systematically reviewed evidence and measuring patient outcomes once an intervention is in effect. Important operational aspects include (i) the development of clear clinical guidelines; (ii) agreement on the part of providers and patients to participate; (iii) establishment of an efficient and effective information infrastructure; (iv) well-designed and tested interventions; (v) a logical plan for the collection of outcomes (Epstein RS, McGlynn MG (1997) Disease management. What is it Disease Management and Health Outcomes. 1: 3-10). Domain In quality of life assessments, a domain is a range of observables used to measure a particular construct. For example, one can refer to a physical function domain which includes a range of items aimed at defining that
48 Dictionary of Evidence-based Medicine particular construct. Similarly, in scales such as the Short-Form 36 scale, we have domains for constructs such as mental health and social functioning. Dominance (in economic assessments) In economic assessments of health care, one is normally concerned with ranking alternative interventions and various types of methods are available (see Cost benefit analysis, Cost-effectiveness analysis, Cost minimization analysis or Cost utility analysis). Irrespective of which method is used, the ranking is based on some cost to benefit ratio. A dominated alternative is one which is less effective and more costly than another or when its incremental cost-effectiveness ratio is higher than that of the next more effective treatment (Karlsson G, Johannesson M (1996) The decision rules of cost-effectiveness analysis. Pharmacoeconomics. 9: 113-20). Drug development The drug development process is a complicated and expensive one. It has been estimated that on average it costs over two hundred million dollars to bring a drug to the market. Figure 6 illustrates the various steps in the process. Studies in humans are often classified into stages. Phase I studies are those undertaken to define the disposition of a new drug in healthy volunteers. Phase II studies are those undertaken in small numbers of patients as pilots for subsequent larger studies and for defining the most appropriate doses. Phase III studies are often referred to as definitive or pivotal efficacy studies as these are undertaken with a view to confirming the efficacy suggested by Phase II studies. One to three thousand patients may be involved. The results of those studies form the basis for marketing licence applications. Since clinical trials on relatively small numbers of subjects are unlikely to reveal rare adverse side-effects, post-marketing (Phase TV) studies are undertaken to identify such problems. Sometimes during wider use of a new drug, it appears that the drug has additional therapeutic effects. New trials (Phase Ilia) are then undertaken to assess these. If confirmed, the drug company concerned can apply to have the indications for the drug widened. Drug development and evaluation committee reports (see DEC reports)
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Page 4 and 5: Preface This book was conceived at
Page 6 and 7: A Ability to pay Ability to pay is
Page 12 and 13: Figure I Audit: Clinical audit cycl
Page 14 and 15: B Balanced design In an experiment,
Page 66 and 67: Figure 9 Concept of externality Dic
Page 72 and 73: G Game theory Game theory, first de
Page 86 and 87: I ICD (see International Classifica
Page 94 and 95: K Keynes, John Maynard (1883-1946)
Page 100 and 101: M Macroeconomics Macroeconomics is
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N N of I trial An N of 1 trial is a
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o OBM (see Opinion-based medicine)
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Figure 25 Measuring quality of life
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S Scarcity Scarcity is often referr
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T TDM (see Therapeutic drug monitor
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u Unique value effect This term is
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Z Z variate A random variable which
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