bluuebunny/crossref_metadata_2025 huggingface dataset:
Diffusion of Medical Devices in Primary Health Care in Sweden
Authors: Persson Jan , Borgquist Lars
Published: March 2009

An inventory of the availability of medical devices and laboratory tests at primary health care centers in Sweden is reported. The availability is shown to depend on a number of medical, economic, societal, and organizational factors describing primary health care. Technical performance of devices, risk management, and training of users need special attention with regard to these applications.
Towards a User- Friendly Future: The Impact of Information Technology within Primary Health Care
Authors: Harvey John D.
Published: March 2009

The use of computers in primary care in the United Kingdom has developed without coordination. The present situation is described. The proposal is that policies for improving primary care will be enhanced by appropriate application of information technology. Benefits and obstacles are identified; practical proposals for effective development are listed.
Patient-Centered Redesign: More Collaborative Clinical Input Into Capital Budget Decisions
Authors: Stetler Cheryl B. , Fagan John , Hanson Monica , Biancamano John , Curry Stephen
Published: March 2009

As part of a restructuring program at a large, acute care hospital, a new, collaborative form of clinical management called triads has been initiated. Members of these collaborative management teams are being collectively empowered to better enable them to establish a continuously improving, cost-effective clinical service. This article describes the impact of this new structure on the capital budgeting process in changing a centralized, committee-based system of decision making with limited clinical nursing input to one that is increasingly decentralized, interdisciplinary, and focused on patients.
Cost-Effective Primary Care Providers: An Important Component of Health Care Reform
Authors: Prescott Patricia A.
Published: March 2009

Planning for a cost-effective mix of providers is an important aspect of health care reform. Currently, there are too many specialists and insufficient numbers of primary care providers. Nurses in advanced practice roles are an important resource for expanding the nation's supply of primary care providers.
Nurses and Technology: Maintaining a Balance Between Intervention and Nurturing for Childbearing Women
Authors: Cook Sarah Sheets
Published: March 2009

Invasive and noninvasive medical technology are employed frequently in the health care of women, particularly childbearing women, often without any demonstrable benefit. Nurses are in a position to be advocates for their childbearing patients and to define and implement a realistic balance between supportive or facilitative caring and technical interventions.
The Relevance of Socioeconomic and Health Policy Issues to Clinical Research: The Case of MRI and Neuroradiology
Authors: Larson Eric B. , Kent Daniel L.
Published: March 2009

Magnetic resonance imaging (MRI) is a high-cost, new technology with great potential for improving patient care. The lack of a coherent public policy for MRI, or its predecessor computed tomography (CT), has caused considerable problems. Lack of an enunciated public policy has led to inconsistent reimbursement and reimbursement levels that develop in haphazard ways. Furthermore, diffusion has been unpredictable and has led to geographical excesses and deficiencies.

Technology assessments of MRI, although numerous, have used inconsistent criteria to rate MRI's clinical efficacy. The lack of methodologically sound studies of MRI severely hampered early evaluation. This article examines these problems and suggests that the medical profession take a stronger leadership role in developing policies for expensive, promising new diagnostic technologies. The profession should promote, demand, and perform rigorous clinical evaluations of new technologies, and help develop a consensus regarding the criteria for what constitutes a clinically valuable advance in diagnostic technology.
Technology Assessment Ativities in Sweden
Authors: Calltorp Johan , Smedby Björn
Published: March 2009

A rapidly growing interest in medical technology assessment has been noted in Sweden during the last 5 years. This interest is reflected both in a variety of research efforts and in new organizational arrangements for coordination and stimulus of research. A special area of concern is a group of mechanisms to make the results of assessment useful to medical practitioners and in the political and administrative process within health care.
Cost-effectiveness Analysis of Strategies for Colorectal Cancer Screening in Japan
Authors: Shimbo Takuro , Glick Henry A. , Eisenberg John M.
Published: March 2009

To determine the cost-effectiveness of colorectal cancer screening strategies in Japan and to determine the influence of long-term compliance with screening programs on the selection of strategies, the natural history of a simulated cohort of 40-year-old Japanese of both genders was modeled with and without colorectal cancer screening until age 75 years. Survival, number of complications, and direct medical costs were compared among several combinations of screening examinations. In addition, the age of initiating screening was varied, as was the long-term compliance rate. Strategies using immunoiogical fecal occult blood test were found to be the most cost-effective. Immunological fecal occult blood test followed by colonoscopy, if positive, would save 24.05 (5.88 discounted) days of life and cost 28,420 yen (US $210) per screened person, thus offering a cost-effectiveness ratio of 1.765 million yen (US $13,100) per year of life saved. If long-term compliance is 100%, initiating screening at age 40 years offers more years of life saved and a low incremental cost of screening. However, if more likely dropout rates are considered, initiation at age 40 years is dominated by later initiation of screening.
Health Economic Analysis of the Neonatal Screening Program in Japan
Authors: Hisashige Akinori
Published: March 2009

In Japan, a nationwide mass screening system for neonatal metabolic diseases was established in 1977. This system consisted of screening programs for five main congenital metabolic diseases, including phenylketonuria (PKU). To evaluate the efficiency of the mass screening system, a costbenefit analysis of the screening program for PKU (as a typical case in Japan) was carried out. The costs of the detection and the treatment program were compared with the projected benefit (avoided costs) that results from prevention of the mental retardation associated with the disorders due to PKU. Costs and benefits were discounted at an annual rate of 7%. Assuming that the incidence of PKU was 1/80,500 and the total number of infants screened was 1.2 million, net benefits for the screening program were $283,000, and the cost-benefit ratio was 1:2.5. The sensitivity analysis for the incidence of PKU showed that the cost-benefit ratios exceeded one.
Culture, Conflict, and Cost:Perspectives on Brain Death in Japan
Authors: Feldman Eric A.
Published: March 2009

Japanese surgeons have performed only one heart transplant in the quarter century since the procedure was developed. Possessing the requisite training and technology, transplant surgeons have been stymied by several factors that elude professional and political solution. Most critically, the lack of a brain death standard limits the availability of transplantable organs. Mistrust of the medical profession, traditional outlooks on death, and the primacy placed on consensual decision making have fueled debate about brain death and transplantation. Volatile and value laden, these issues have overwhelmed the discussion of health care resources, equal access to high-technology medical procedures, and insurance coverage for transplantation.
National Structures in the Delivery of Rehabilitation Technology Services
Authors: Lorentsen Øivind
Published: March 2009

Abstarct

The delivery of rehabilitation services requires an infrastructure if service provision is to be given any priority. This article discusses some characteristics of handicaps, technical aids, the service delivery process, and habilitation/rehabilitation, and recommends developments of national structures for service delivery based upon the characteristics of rehabilitation technology, user need, and the country frameworks.
Communication AIDS for the Speech Impaired:Cost and Quality-of-Life Outcomes of Assessment Programs Provided by Speciaiist Communication Aids Centers in the United Kingdom
Authors: Tolley Keith , Leese Brenda , Wright Ken , Hennessy Sue , Rowley Corinne , Stowe Janet , Chamberlain Ann
Published: March 2009

Abstarct

An evaluation was conducted of the approaches, costs, and quality-of-life outcomes associated with communication aid assessment programs for the speech-impaired provided by specialist Communication Aids Centres (CACs) in the United Kingdom. The average costs of CAC assessment programs was £410 per client, which is not excessive. There was evidence of moderate quality-of-life benefits from clients' use of the recommended aids.
Cost-Utility Analysis of Assistive Technologies in the European Commission's Tide Program
Authors: Brodin Håkan , Persson Jan
Published: March 2009

Abstarct

Socioeconomic evaluation is an issue dealt with in the European Commission's research program TIDE. The principles of cost-utility analysis have been examined for usability in the assessment of rehabilitative technologies. A case study, the choice of a type of wheelchair, is described to demonstrate how estimates of utility can be derived and how cost-utility ratios can be used to guide decision making.
A Comparison of the Patient-Borne Costs of Therapy with Gamma Globulin given at the Hospital or at Home
Authors: Gardulf Ann , Möller Gudrun , Jonsson Egon
Published: March 2009

Abstarct

The major aim of this study was to estimate and compare the patient-borne costs of lifelong subcutaneous gamma globulin therapy at the hospital and at home. Thirty patients were included and the data were collected with a questionnaire. The introduction of self-therapy at home reduced the total yearly costs by approximately 50% and the out-of-pocket expenses for the palients by 85%.
Introduction
Authors: Orleans Miriam , Hemminki Elina
Published: March 2009

In this issue investigators and commentators from Australia, the United Kingdom, the Netherlands, Sweden, and the United States consider some of the many issues being studied and discussed by advocates of appropriate technology in obstetrics.
Assisted Conception: Health Services and Evaluation
Authors: Lancaster Paul A. L.
Published: March 2009

Comparison of assisted conception in Australia, the United Kingdom, and the United States indicates that further rapid growth in services is likely in many countries. Better data on pregnancy rates and the outcome of pregnancy, as well as standardized reporting of national results, are needed to monitor the effectiveness of treatment.
Health Care and Medical Technology in Nigeria: An Appraisal
Authors: Erinosho Olayiwola A.
Published: March 2009

The objective of the study was to ascertain the extent of utilization of medical technologies (defined as equipment) used in various health care institutions in Nigeria. The study also investigated the factors accounting for use of and under- and nonutilization of this equipment. Sixteen major and minor health care institutions were surveyed. The outcomes of the study indicate that not less than a third of the equipment was out of order at the time of the study. A number of factors are responsible for nonutilization of this equipment. They include lack of infrastructural facilities such as piped water, storage, and power supply; poor handling by badly trained staff; and the low priority that is accorded to maintenance. The study leads to the important conclusion that the local culture is unable to sustain the technologies that are procured.
Assessment of Coronary Bypass Surgery and Percutaneous Transluminal Coronary Angioplasty
Authors: Preston Thomas A.
Published: March 2009

Coronary bypass surgery developed as another in a line of surgical procedures dating back more than 60 years. The medical profession at first assessed this procedure with time-honored anecdotal techniques. Gradually, for a variety of reasons, improved methods of comparisons worked their way into assessments of bypass surgery. Randomized controlled trials met resistance but have been very influential. Assessment of percutaneous transluminal coronary angioplasty has benefited from the knowledge generated during the last 25 years, but clinicians have been slower to apply the most advanced techniques.
The Technology Of Mammography: Misunderstood and Underutilized
Authors: Fox Sarah A. , Kimme-Smith Carolyn , Kios Dennis S.
Published: March 2009

This article reviews milestones in the technological development of mammography since 1970. Mammography is particularly underutilized as a screening procedure for breast cancer and the reasons for its continued inappropriate and under use are explored. Although there are some known barriers to increased utilization among the female adult population, the majority of barriers reside within the domain of referring physicians. Remedies to address the low referral rates for screening mammography are outlined for federal agencies, radiology groups, mammography equipment companies, medical schools, and philanthropic groups. Until the developers of technological procedures such as mammography appreciate that the application of a technology and its appropriate utilization by professionals and the public are important to consider when the technology is developed, utilization rates may not do justice to the technology's potential.
Substitution of Magnetic Resonance Imaging for Computed Tomography: An Exploratory Study
Authors: Peddecord K. Michael , Janon Edward A. , Robins Jon M.
Published: March 2009

Deapite the importance of understanding factors related to physician adoption and use of diagnostiv technologies, relatively few studies have been published. Results of a two-year study of the adoption of magnetiv resonance imaging (MRI) and its substitution for computed tomography scanning (CT) are presented. The literature on physician adoption and use of technologu is used to provide a frame-work for this study. Differences in adoption and substitution among medical specialties, early versus late adopters, and high versus low users of MRI are examined. Results show that neuerologists and internists more rapidly adopt MRI and substitute it for CT than do orthopedists and other surgical specialists. Referral of higher number of patients is the best predictor of more rapid substitution. Physicians who were late adopters more quickly substituted MRI for CT. The cost and social implications of empirical versus “ideal” substitution rates are discussed along with various regulatory, technology assessment, and finicial strategies influence substitution. The role of individual physicians, radiologists, and specialty societies in determining substitution rates is also discussed.
New Tools for the Herpes Virologist
Authors: Harmenberg Johan , Levén Barbro , Hinkula Jorma , Ohlsson Eva , Sundqvist Vivi-Anne , Wahren Britta
Published: March 2009

Herpes viruses are responsible for a wide spectrum of infections ranging from cold sores, genital herpes, and chicken pox to disseminated herpes infections in normal and more commonly in immunocompromised patients. Symptoms range from mildly distressing and uncomfortable to severe and life-threatening. The sophistication of virological methods is increasing. Specific types, classes, and subclasses of antibodies to viruses can now be determined, as well as the reactivity of T-lymphocytes. It is possible to detect herpes virus type-specific antibodies (to HSV-l or HSV-2) in a blood sample using the simple and inexpensive enzyme-linked immunosorbent assay (ELISA). The virus is usually type-determined rapidly and currently susceptibility or resistance to antiviral compounds can be defined in vitro. Such assays of antiviral resistance have been shown to be quick and effective. Effective antiviral therapies have been developed against a number of viral diseases. The concomitant need for isolation and evaluation of resistance patterns of herpes virus against different antiviral compounds appears to be of considerable importance. Pure clinical observations are no longer sufficient to distinguish the types, since HSV-l may be present in the genital region and HSV-2 at upper parts of the body–contrary to common belief.
The Canadian Physiotherapy Quality of Care Project: Analysis of a Derailed Project
Authors: Miles-tapping Carole , Rennie G. A. (sandy)
Published: March 2009

The Physiotherapy Quality of Care Project was a project of the Canadian Physiotherapy Association, sponsored by the Canadian government to ensure the quality of physiotherapy. A consensus committee of physiotherapy educators and managers developed and tested an instrument to measure changes in patients' functional status during physiotherapy. Despite scientific development and wide distribution, this technology was not adopted. Alternative methods, which were heavily marketed, gained nationwide use instead.
Analyzing Errors in Practice: A Vehicle for Assessing and Enhancing the Quality of Care
Authors: Deusinger Susan S.
Published: March 2009

Failures are inevitable in health care. When failure occurs as a result of practitioner error, quality in patient care may be compromised. This article proposes that analyzing clinical errors may contribute to quality assurance. Examples from physical therapy illustrate how information gained from analyzing errors can enhance patient care.
Development of a Program for the Treatment of Chronic Pain and Anxiety: A Learning Process Leading from Unsound to Sound Assessment
Authors: Torrestad Agneta , Håkanson Margareta , Axelli Tomas
Published: March 2009

The development and assessment, over a 10-year period, of a technology for group treatment of patients with chronic pain and anxiety is described. Positive results, such as a decrease of symptoms and improved self-confidence, have stimulated diffusion of the technology to colleagues and have increased our own involvement in the organization of services.
The Relationship of Technology Assessment and Utilization: Electromyographic Feedback Instrumentation as a Model
Authors: Wolf Steven L.
Published: March 2009

Biofeedback instrumentation has been a growing part of physical therapy practice for 20 years, and physical therapists have contributed to researching its efficacy in treating varying conditions. The application of biofeedback to the treatment of stroke was marked by some early difficulties with the quality of the electronics, but sophisticated contemporary equipment can do much more than was originally envisioned. The importance of relating quantified movement-based data to functional measures is projected as a high priority if appropriate reimbursement for physical therapy services with biofeedback is to continue in the future.
Making Information Accessible and Useful to Practicing Clinicians: Problem-Knowledge Coupling
Authors: Zimny Nancy J.
Published: March 2009

Assessments of health care technology will lead to improvements in patient services only if this information is actually used by clinicians. Traditional methods of planning treatment that rely solely on memory limit the clinician's access to and use of the full available body of knowledge in the field. An alternative approach using a computer-assisted methodology is presented as a way to overcome traditional limitations and promote the development and diffusion of knowledge.
Treatment of Symptomatic Cholelithiasis in France: A Decision Analysis Comparing Cholecystectomy and Biliary Lithotripsy
Authors: Fendrick A. Mark , De Pouvourville Gérard , Bitker Caterine , Pelletier Gilles
Published: March 2009

To determine the potential role of extracorporeal shock wave lithotripsy (ESWL) in the treatment of symptomatic gallstone patients in France, a simulation model evaluated the health and economic effects of three different treatment strategies. Decision analysis of conventional cholecystectomy alone and either of two strategies using a combination of biliary lithotripsy and conventional cholecystectomy reveals that a strategy employing biliary ESWL results in a significant number of successfully treated patients, thus avoiding the risks and costs of abdominal surgery. Moreover, cost analysis shows that expanding the use of lithotripsy to all patients for whom the procedure is indicated increases the average cost per successfully treated patient, but, more importantly, decreases the overall costs incurred by the cohort. From a societal viewpoint, a policy using biliary ESWL in appropriate patients is superior to one of cholecystectomy alone, from both clinical and economic perspectives.
Genetic Technology in Health Care: A Global View
Authors: Galjaard Hans
Published: March 2009

Clinical genetics services have become an integrated part of health care in nearly all European countries. The emphasis has been on postnatal cytogenetic, biochemical, and DNA diagnosis of congenital disorders, carrier detection, genetic counseling, and prenatal diagnosis. Use has been satisfactory, and very few ethical problems have arisen, apart from moral objections against abortion by minority groups. The progress of human gene mapping is associated with new perspectives in clinical genetics and will enable the identification of people at risk of major adult diseases. This prospect has caused some concern about psychosocial and ethical issues that are being dealt with in different ways in various postindustrial societies. In future decades, however, 95% of the world's population increase will occur in developing countries. In most of these countries, a low per capita income, female illiteracy, low rates of contraceptive use, teenage pregnancy, and religious and traditional cultural factors are major complications of implementing genetic services at a global level. There are, however, some exceptions, which are discussed.
Assessing Genetic Technologies: Two Ethical Issues
Authors: Murray Thomas H.
Published: March 2009

Assessment of the impact of genetic technologies requires an understanding of the ethical issues that such technologies raise, which in turn requires an understanding of the social context of genetics. This article discusses 10 factors that characterize the social context of contemporary genetics, and considers two presumptions that usually are unquestioned—first, that more choice is always better; second, that what can be improved should be improved. Recent experience with genetic screening and testing to increase reproductive choice indicates that it is sometimes an ambiguous good. Prenatal testing, which has been guided by an ideology of nondirective counseling, will become increasingly problematic as the menu of possible genetic tests grows longer, because nondirectiveness offers no way to distinguish between significant disease and parental whim. In the realm of reproduction, more choice may also come to mean increasing parental responsibility to have genetically “healthy” offspring. Technologies intended to improve health outcomes may also be used for non-health-related goals—such as to increase athletic performance or to capitalize on social prejudices. Genetic technologies increasingly will challenge the troubled distinction between therapy and enhancement.
Techniques in Current Use in Prenatal Diagnosis
Authors: Chitty Lyn S. , Bobrow Martin
Published: March 2009

Prenatal diagnosis is now offered to the majority of pregnant women in Europe and the United States. Advances in obstetric and laboratory techniques mean that increasing numbers of conditions can be diagnosed prenatally; indeed, gene carriers can be identified before pregnancy in some cases. Current obstetric and laboratory techniques for prenatal screening and diagnosis of genetic disorders are discussed.
DNA Diagnosis in Oncology
Authors: Rowley Janet D.
Published: March 2009

Our understanding of the genetic changes that transform normal cells into malignant cells is increasing at a remarkable pace. Some of the changes involve detectable cytogenetic aberrations, whereas others are identifiable only at the molecular level. Many of the structural cytogenetic changes have also been defined molecularly because the genes involved have been cloned. Thus, we are approaching the stage in which the DNA obtained from tumor tissue can be analyzed to detect the presence of a series of chromosomal and molecular alterations. These studies provide important information regarding the precise diagnosis of the tumor type as well as prognostic information about the likely response to therapy and survival.
Research Methods for Obtaining Primary Evidence
Authors: Jaeschke Roman , Sackett David L.
Published: March 2009

The use of new therapeutic and diagnostic technologies has become commonplace in modern medical practice. To avoid both clinical disappointment and the waste of money, health, and lives, the introduction of these technologies will have to be based on evidence that these technologies will do more good than harm. The evidence supporting their use should be derived using research methods designed to deal with placebo effects, confounders, and biases. Some of these methods, and the rationale for their use, are discussed in this article. Although the value of evidence derived from randomized controlled trials is stressed, the importance of reviewing critically the methodological details of such trials and interpreting their results with caution is emphasized. The benefits and risks of relying on case-control and cohort studies are reviewed.
Selection and Evaluation of Empirical Research in Technology Assessment
Authors: Chalmers Thomas C. , Hewett Peg , Reitman Dinah , Sacks Henry S.
Published: March 2009

Technology assessment involves application of the scientific method to the practice of medicine. Finding all of the assessment reports in a given field is not an easy task. Proper evaluation of those assessments requires the conduct of a prospective experiment in which the sources and results are blinded when the choice is made of papers to exclude and to include, and the process should be carried in duplicate. There are several available data bases for carrying out the search, but because of problems they should be supplemented by reference to the bibliographies of pertinent published articles. Clinical trials included in meta-analyses should be graded by quality and thus facilitate sensitivity analyses. Attention must be paid to the possibility of publication bias. Finally, the advent of meta-analysis makes it desirable to begin randomized controlled trials in areas of uncertainty, even when there is no possibility that individual investigators will encounter enough patients to draw valid conclusions.
Outcome-Based Equity in the Treatment of Colon Cancer Patients in Finland
Authors: Hakama Matti , Karjalainen Sakari , Hakulinen Timo
Published: March 2009

The differences in survival rates of colon cancer patients between hospital districts were used as an indicator of equity in cancer treatment in Finland. The merits of two different assessment methods were evaluated. The large variation was mainly due to confounding by age and the extent of the disease and to random variation.
Head Injury: Variability of Course and Presence of Confounding Factors
Authors: Kaufman Howard H. , Bretaudierre Jean-Pierre , Rowlands Brian J. , Stein Debra K. , Bernstein David P. , Wagner Karen A. , Gildenberg Philip L.
Published: March 2009

Review of a large data base on 76 patients who had suffered head injuries and whose metabolic changes were being studied demonstrated the variability of their neurological courses and the importance of considering confounding factors in the analysis of such a group. It was apparent that many such patients continue to change neurologically and functionally for long periods of time, and that their ultimate outcome cannot be determined for at least 1 year. The study demonstrates the inherent complexity of a group of patients with head injuries and the need to use sophisticated statistical tools and a computer to demonstrate whether apparent trends are statistically valid in light of confounding factors and variabilities. Failure to take this complexity into account seems to be a major factor in many of the ongoing controversies in research on head injuries. A possible solution to the problem of potential biases introduced by lost patients would be to develop a method to use government records to obtain current addresses for patients involved in federally funded research.
Pharmaceutical Prescriptions in Italy
Authors: Garattini Silvio
Published: March 2009

Pharmaceutical prescriptions are quite different in four European countries: Italy, France, Germany, and the United Kingdom. In particular, in 1992, among the 50 most sold products by value, only seven active principles are common to these four countries. In Italy, in 1994, there has been a substantial change in pharmaceutical prescriptions, since, for the first time, drugs have been reimbursed by the National Health System (NHS) on the basis of efficacy. As a result of this new policy, the 50 most-sold products by value have changed dramatically in the first five months of 1994. The pharmacologic and economic implications of this change are discussed.
The Distribution of “Big Ticket” Medical Technologies in OECD Countries
Authors: Lázaro Pablo , Fitch Kathryn
Published: March 2009

Five “big ticket” medical technologies (BTTs) in 1990 were compared in the 24 OECD countries in relation to population, the number of physicians, gross domestic product (GDP), and health care expenditures (HCE). Wide variations were observed between and within countries for all measures. Regression analysis revealed that HCE explains part of the variation in the distribution of computed tomography scanners (excluding Japan), magnetic resonance imaging units, and radiation therapy units (R2 between 0.40 and 0.69), but not extracorporeal shock wave lithotripters. To a lesser extent, GDP was also found to correlate with the distribution of these technologies, but no correlation was found with number of physicians. Other factors affecting the diffusion of these technologies are proposed for study.
A Comparison of the Investment in Hospital-Based Obstetrical Ultrasound in Wales and Washington State
Authors: Rosenblatt Roger A. , Dawson Andrew J. , Larson Eric H. , Tressler Carolyn J. , Jones Anthony , Hart L. Gary , Nesbitt Thomas S.
Published: March 2009

The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines—approximately two machines per 1,000 births—was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care.
Cost-Effectiveness of Laser Ablation of the Prostate:Premature Evaluation
Authors: Jackson Terri , Street Andrew , Costello Anthony , Crowe Helen
Published: March 2009

A cost-effectiveness study compared visual laser ablation of the prostate (VLAP) with transurethral resection (TURP). Achieving equivalent outcomes, VLAP was more expensive than TURP. The result was sensitive to various assumptions, suggesting that VLAP might prove to be the preferred technology. Problems inherent in economic evaluation of emerging technologies are discussed.
Principles of Cost-Effective Resource Allocation in Health Care organizations
Authors: Weinstein Milton C.
Published: March 2009

Cost-effectiveness analysis (CEA) is a method of economic evaluation that can be used to assess the efficiency with which health care technologies use limited resources to produce health outputs. However, inconsistencies in the way that such ratios are constructed often lead to misleading conclusions when CEAs are compared. Some of these inconsistencies, such as failure to discount or to calculate incremental ratios correctly, reflect analytical errors that, if corrected, would resolve the inconsistencies. Others reflect fundamental differences in the viewpoint of the analysis. The perspectives of different decision-making entities can properly lead to different items in the numerator and denominator of the cost-effectiveness (C/E) ratio. Producers and consumers of CEA need to be more conscious of the perspectives of analysis, so that C/E comparisons from a given perspective are based upon a common understanding of the elements that are properly included.
Dealing with Discounting: An Application to the Cost-Effectiveness of Intracoronary Thrombolysis with Streptokinase
Authors: Martens Léon , Doorslaer Eddy Van
Published: March 2009

By introducing discounting in the DEALE method, we reanalyze a recent publication on the cost-effectiveness of early thrombolytic therapy with intracoronary streptokinase after acute myocardial infarction. We show that failure to discount gains in life expectancy results in a serious overestimation of the cost-effectiveness of this technology.
A Desktop Expert System for the Differential Diagnosis of Dementia: An Evaluation Study
Authors: Plugge Leonard A. , Verhey Frans R. J. , Jolles Jellemer
Published: March 2009

Evince-I is a desktop expert system for the differential diagnosis of dementia, implemented on a personal computer. It is intended to assess the effectiveness of this new technology in modeling a psychiatrist who uses international guidelines for diagnosing dementia. EVINCE-I was tested in diagnosing 19 patients with varying stages of dementia and 10 patients showing other disorders except dementia. EVINCE-I and the human expert were in perfect agreement on the diagnosis of dementia and correlated highly on the diagnosis of dementia of the Alzheimer type and multiple infarct dementia. EVINCE-I thus offers important possibilities as a tool in investigating the data and procedures used by the human expert.
Health Care Technology Assessment in the Netherlands
Authors: Gelijns Annetine C. , Rigter Henk
Published: March 2009

Our present-day health sectors are increasingly characterized by both rapid technological change and growing visibility of its considerable consequences in terms of the quality and costs of health care. Improved health care decision-making in such an environment requires adequate and timely information on the benefits, risks, and costs of health care technology. Whereas traditionally, technology assessment focused predominantly on evaluating efficacy and (short-term) safety in a more or less “controlled” environment, an interesting shift in emphasis is now occurring. There is a growing recognition that improved information is also needed on the health and economic outcomes of technology as used in everyday clinical practice, i.e., on its effectiveness, cost-effectiveness, and long-term safety in normal “uncontrolled” daily medical life. Moreover, because the treatment of particular clinical conditions (such as stable angina, gallstones, or prostatism) increasingly involves choices among alternative diagnostic and therapeutic options, these assessments should ideally provide effectiveness and cost-effectiveness information for all the various technological alternatives involved.
International Variation in Intervention Rates: What Are the Implications for Patient Selection?
Authors: Black Nick , Glickman Mark E. , Ding Jiao , Flood Ann Barry
Published: March 2009

While international variations in intervention rates are well recognized, little is known about their implications for patient selection. This paper describes an exploratory study in which the probability of undergoing an elective intervention (surgery for benign prostatic hyperplasia) in an area in the United Kingdom was compared with an area in the United States. It found that the area with high intervention rates was associated with higher levels of surgery in men with low levels of need who are unlikely to gain much benefit.
Prostheses for Primary Total Hip Replacement:A Critical Appraisal of the Literature
Authors: Cowley Delma E.
Published: March 2009

Eighty-one published papers on the performance of prostheses in total hip replacement were appraised. Sound methodology was demonstrated in 1 of 8 randomized controlled trials and 4 of 17 nonrandomized comparative studies. Of 56 case series without controls, 32 met the appraisal criteria, but these are intrinsically less useful. The published literature does not provide solid evidence for the superiority of cement-free or hybrid prostheses over modern cemented types.
Assessment of Waiting Time and Priority Setting by Means of a National Register
Authors: Lundström Mats , Stenevi Ulf , Thorburn William
Published: March 2009

To increase access to care for cataract patients in Sweden, it was decided, starting in 1992, that all cataract patients listed for surgery and with priority should have their cataract extraction performed within three months. To evaluate the effect of this waiting time guarantee, a National Cataract Register (NCR) was initiated in late 1991. In 1992, 81% of all cataract extractions performed in Sweden were reported to the NCR; in 1993 this figure was 92%. Reasons for this high participation ratio are discussed. In 1993, 74.4% (range between different clinics, 40–99%) of the patients with priority had their operation performed within three months. Great variation in visual acuity and age was found in patients with priority among the different surgical units.
Cost-Effectiveness of Breast Cancer Screening in Spain
Authors: Plans Pedro , Casademont Laura , Salleras Luis
Published: March 2009

In the last several years, the development of an effective breast cancer screening procedure has increased the possibility of the early detection of this cancer. We investigated the cost-effectiveness of a breast cancer screening program to screen 100,000 women 50–64 years of age in Catalonia (Spain). The cost-effectiveness ratio was measured in terms of the cost per cancer detected comparing program costs to the estimated number of cancers detected. We assumed a participation rate, sensitivity, and specificity of 70%, 92%, and 94%, respectively, and that 0.36 breast cancers could be detected per 100 women screened. We estimated a total cost of $2.1 million with $1.4 million for the mammographic stage and $0.7 million for the detection of the true positive mammographic results. The cost per woman screened was $30. We estimated that 252 cases of breast cancer could be detected with the program. The cost-effectiveness ratio obtained in this study was $8,424 per cancer detected. Sensitivity analysis has shown that cost-effectiveness results are sensitive to the variations in the following variables: specificity, cancer detection rate, and screening costs. In planning preventive programs, breast cancer screening should be considered one of the priorities.
Assessing the Quality of Randomized Controlled Trials:Current Issues and Future Directions
Authors: Moher David , Jadad Alejandro R. , Tugwell Peter
Published: March 2009

Assessing the quality of randomized controlled trials is a relatively new and important development. Three approaches have been developed: component, checklist, and scale assessment. Component approaches evaluate selected aspects of trials, such as masking. Checklists and scales involve lists of items thought to be integral to study quality. Scales, unlike the other methods, provide a summary numeric score of quality, which can be formally incorporated into a systematic review. Most scales to date have not been developed with sufficient rigor, however. Empirical evidence indicates that differences in scale development can lead to important differences in quality assessment. Several methods for including quality scores in systematic reviews have been proposed, but since little empirical evidence supports any given method, results must be interpreted cautiously. Future efforts may be best focused on gathering more empirical evidence to identify trial characteristics directly related to bias in the estimates of intervention effects and on improving the way in which trials are reported.
Abdominal and Vaginal Radical Hysterectomy Among U.S. Women aged 65 Years and Older
Authors: Amini Saeid B. , Weight Steven A. , Yuan Zhong , Rimm Alfred A.
Published: March 2009

Unlike most European and Asian countries, radical vaginal hysterectomy (RVH) is not performed often in the United States, especially among older women. To examine the changes in RVH over the years, trends in hospital stay, hospital charges, and patient survival, we studied women aged 65 years and older undergoing RVH and compared them with patients receiving radical abdominal hysterectomy (RAH). During the study period there were a total of 288 RVH surgeries compared with 4,835 RAH surgeries. There were no significant changes in the number or proportion of RVH patients over 8 years (p =.50, trend test). On the average, RVH patients were significantly older and had shorter hospital stays. Among patients without cancer, there were no significant differences in the age, race, or survival of patients having either RVH or RAH. Similar results were obtained for patients with cancer.
Evaluation of the Regular Practice of Breast Cancer Screening in a Health Area
Authors: Cosp Xavier Bonfill , Castillejo Mercé Marzo , Crivillé Melcior Sentís , Mir Ramon Rossell , Cistaré Xavier Gallardo , Masip Ramon Florensa , Ferrer Elena Rivero , Quiroga Coloma Moreno
Published: March 2009

Breast cancer screening has proved to be efficacious only in clinical trials or structured programs. However, little is known of its effectiveness as a regular practice. This study is an assessment of breast cancer screening in regular practice in a Spanish area of 350,000 inhabitants through analysis of existing sources of information. It is evident that this screening is insufficient, inefficient, very variable, nonspecific, and probably ineffective, although there is insufficient information to prove it. The immediate implementation of a well structured and accredited screening program is essential to overcome the current limitations.
Priority Classification of Patients According to a Modified ‘Norwegian Model’
Authors: van Assendelft Alexander H. W.
Published: March 2009

A priority classification was evaluated according to a modified “Norwegian model.” Many diseases do not belong to any specific priority category based only on the diagnosis. The classification also depends on the condition's type, site, and phase as well as the patient's age and overall condition. Savings cannot be achieved by the model used because 89% of the patients belonged to the priority categories I–III, the care of which can be classified as necessary.
Repeated Testing: An Overview and Analysis
Authors: Sox Harold C.
Published: March 2009

Physicians often obtain the same test over and over again. This article first considers screening tests, such as mammographic screening for breast cancer, and describes several proposals for finding the interval that best balances cost, harms, and benefits. The same principles apply to monitoring a patient for recurrence of a disease, such as bladder cancer. The article closes with a theoretical consideration of the circumstances for repeating a test once to check a surprising value.
Why go see the Doctor?:Care Goes From Office to Home as Technology Divorces Function from Geography
Authors: Stoeckle John D. , Lorch Stephen
Published: March 2009

Two functions of home care, assistance to improve disabled and aged patients' mobility and function, and self-care that includes treatment, screening-monitoring, exercise assistance, and information exchange, are described, as are the technologies used for these functions. Social and economic pressures as well as professional rationales that expand the use of technologies at home are noted, as is their impact on the site of care and on the patient-doctor relationship.
Low-Cost Technologies and Public Policy
Authors: Shine Kenneth I.
Published: March 2009

The evaluation of low-cost technologies is complicated by the difficulty of understanding what is meant by “low” cost. Low unit costs may lead to the widespread use of a technology that results in high aggregate costs. It is often more useful to consider the value than the cost of a technology, recognizing that this value may change, depending upon the group to whom it is applied as well as the factors that are measured. Public policy should attempt not only to control costs but also to obtain the greatest value for expenditures in health care by supporting the development of methodologies to define value, reimbursement strategies that emphasize cost-effectiveness, and clinical guidelines that can reduce variation in practice.
Costs and Effectiveness of Extracorporeal Gallbladder Stone Shock Wave Lithotripsy Versus Laparoscopic Cholecystectomy: A Randomized Clinical Trial
Authors: Barkun Alan N. , Barkun Jeffrey S. , Sampalis John S. , Caro Jaime , Fried Gerald M. , Meakins Johnathan L. , Joseph Lawrence , Goresky Carl A. ,   The McGill Gallstone Treatment Group
Published: March 2009

Thirty-five patients were randomized to extracorporeal shock-wave lithotripsy (ESWL) and 25 to laparoscopic cholecystectomy (LC). Stone disappearance occurred in only 12 of 32 ESWL patients [38% (95% Cl: 21–56%)] during a 15-month follow-up. Greater incremental gains in quality of life after 6 months were observed among LC patients (p <.01). Total duration of disability was 6.8 ± 8.5 days for ESWL, and 22.7 ± 16.6 days for LC (p <.01). Nine (28%) patients crossed over electively to the LC group, but only 44% of these underwent LC within the next 3 years. ESWL cost Can $58.9/ day of disability saved. ESWL is limited by its selective applicability and modest stone disappearance rate. Its cost-effectiveness is largely dependent on patient acceptance of recurrent episodes of biliary colic due to the persistence of stone fragments.