bluuebunny/crossref_metadata_2025 huggingface dataset:
Mass Mammography: The Time for Reappraisal
Authors: Skrabanek Petr
Published: March 2009

Of the four randomized controlled trials of mass mammography completed to date, the New York HIP trial used obsolete technology and was not designed to assess mammography in the absence of physical examination; the Swedish Two-County trial had serious methodological flaws; the U.K. trial was incompletely documented but showed no significant benefit; and the Malmö trial, which was perfect in design and execution, showed no benefit.

Paradoxicially, with each successive trial and an increasing sophistication of mammography, the benefit of screening was becoming not greater but less. This may be summarized by comparing the number of women who would have to be offered mammography for one breast cancer death prevented or postponed in the respective trials: 5,000 in the HIP trial, 13,000 in the Two-County trial, 18,000 in the U.K. trial, and 68,000 in the Malmä trial.

The enthusiasts in favor of mass mammography have created an atmosphere of false optimism. They have not informed the public about the very small potential benefit nor about the risks associated with screening, especially the risks of false positive diagnoses and of unnecessary surgical operations. This is an unacceptable situation, and the ethical vacuum in which population screening takes place needs to be filled with guidelines to protect women who are “targeted” for screening.
Surgery to Prevent Stroke: High Hopes and Deep Disappointment
Authors: Jennett Bryan
Published: March 2009

Carotid endarterectomy and EC/IC bypass grafting have been widely adopted for patients considered at risk from stroke, without good evidence of efficacy. Unjustified claims for surgery usually derive from overestimating the dangers of the disease without surgery, while perioperative risks are underestimated. Inadequate follow-up and choosing irrelevant outcome measures often add to the confusion. All these factors apply to surgery for stroke. A trial of EC/lC bypass in 1,377 patients from three continents took 8 years to complete and showed no benefit in patients randomized to surgery. Reluctance to accept this result led to detailed critiques of this trial in several journals, largely based on the discovery that many patients had been operated on in some centers without having been randomized. In reply, the investigators showed that these cases did not affect the “resounding negativity of the results.” Lack of good data about the prognosis of patients with TlAs or minor strokes was the fundamental reason for so much misplaced surgical effort. This applies equally to carotid endarterectomy, for which large trials are currently being completed. Had there been a reliable data base of patients at risk of stroke, prospectively collected and followed, the efficacy of these two operations could have been determined much sooner, and inappropriate diffusion might have been prevented.
Consensus Development: An Historical Note
Authors: Perry Seymour
Published: March 2009

The National Institutes of Health (NIH) has always carefully limited its responsibilities to biomedical research and knowledge development, including clinical trials, dissemination of results of research, and training. Ten years ago, NIH undertook to examine its possible role in the evaluation of medical technologies.

In 1976, the U.S. Congress became alarmed over the increase in health care costs: in particular, that a number of expensive technologies, such as coronary artery bypass surgery and electronic fetal monitoring, had entered the delivery system without adequate study of their safety, efficacy, cost, or other implications. At the time, there was no formal structure or forum in either the executive branch of the government or in the private sector for seeking a consensus that a medical innovation was actually safe, beneficial, and ready to be transferred into the health care delivery system. Similarly, there was no structured process through which the parties who comprise the delivery system could meet with representatives of the research community to examine the medical-scientific issues surrounding a given innovation along with cost and cost- effectiveness, ethics, and other societal issues of importance to the system.
Whom to Treat First, and How Much is Enough?: Ethical Dilemmas that Physical Therapists Confront as They Compare Individual Patients' Needs for Treatment
Authors: Purtilo Ruth B.
Published: March 2009

When there is a scarcity of resources (therapists, modalities), the physical therapist must make decisions about whom to treat and why. This paper discusses ethical dilemmas confronting the therapist and addresses solutions based on approaches of procedural justice and distributive justice.
Translating Technology Assessment Into Policy: Conceptual Issues and Tough Choices
Authors: Deber Raisa B.
Published: March 2009

Conceptual issues arise in translating the results of technology assessment into policy. A 3 × 3 typology suggests that tough decisions occur when interventions promise increased benefit for increased cost or less benefit for less cost. These decisions are value based; technology assessment alone cannot determine who should receive an intervention and under what circumstances.
Technology Assessment in a User Perspective-Experiences with Drug Technology
Authors: Hansen Ebba Holme
Published: March 2009

Drugs have a central place among medical technologies, and medical technology assessment can learn from the established regulation of drug technology. This article outlines how users' experiences are not part of the basis on which decisions are made today, although this knowledge is imperative for identifying the problems that are not uncovered or foreseen by today's drug assessments. Further, users' interests might not be part of assessments that are based on the controlled clinical trial. A framework for drug technology assessments based on a user perspective is suggested.
Reflections on the Cost Consequences of the New Gene Technology for Health Policy
Authors: Rosenau Pauline Vaillancourt
Published: March 2009

This article presents a preliminary and necessarily tentative and subjective assessment of the impact of new gene technology on health care costs. In the short term, diagnosis and treatment of genetic disease are likely to increase costs. Treatment with nongene therapy will continue to be far less expensive than gene therapy where it is available. Research developments to monitor as indicators of forthcoming cost reductions in genetic therapy are set forth. Some forms of genetic screening may soon reduce health care costs, and an example is provided. Genetically engineered Pharmaceuticals are described and their impact on costs reviewed. Conditions under which they are likely to reduce health care costs are indicated.
Physicians' Influence on the Decision to Acquire Magnetic Resonance Imagers in Acute Care Hospitals
Authors: Friedman Leonard H. , Jorgensen Jane
Published: March 2009

The influences of four principal types of decision makers on the acquisition of magnetic resonance imagers were measured in hospitals in Southern California, Oregon, and Washington. We propose that of the decision makers assessed, physicians had the most influence on the acquisition of magnetic resonance imagers.
Evaluating Translations of Health Status Questionnaires: Methods From the IQOLA Project
Authors: Ware John E. , Keller Susan D. , Gandek Barbara , Brazier John E. , Sullivan Marianne ,   The IQOLA Project Group
Published: March 2009

There is growing demand for translations of health status questionnaires for use in multinational drug therapy studies and for population comparisons of health statistics. The International Quality of Life Assessment (IQOLA) Project is conducting a three-stage research program to determine the feasibility of translating the SF-36 Health Survey, widely used in English-speaking countries, into other languages. In stage 1, the conceptual equivalence and acceptability of translated questionnaires are evaluated and improved using qualitative and quantitative methods. In stage 2, assumptions underlying the construction and scoring of questionnaire scales are tested empirically. In stage 3, the equivalence of the interpretation of questionnaire scores across countries is tested using methods that closely approximate their intended use, and empirical results are compared. Data analyses from Sweden and the United Kingdom, as well as other research cited, support the feasibility of cross-cultural health measurement using the SF-36.
Some Statistical Methods for Combining Experimental Results
Authors: Laird Nan M. , Mosteller Frederick
Published: March 2009

Advances in science and technology are generally the product of multiple investigations. This article discusses statistical methods for combining empirical results from a series of different experiments or clinical investigations. We delineate the steps an assessor might take in combining data from different studies and provide references for topics not discussed in detail. The article reviews some of the most commonly used statistical techniques for combining results in the medical and social sciences.

The expressionmeta-analysisrefers to the practice of using statistical methods to combine the outcomes of a series of different experiments or investigations. The terminology arises because a meta-analysis uses a study as the unit of observation, and, thus, the data point for each study is itself a statistical summary based on an analysis of primary data.
A Bayesian Method for Synthesizing Evidence: The Confidence Profile Method
Authors: Eddy David M. , Hasselblad Vic , Shachter Ross
Published: March 2009

This article describes a collection of meta-analysis techniques based on Bayesian statistics for interpreting, adjusting, and combining evidence to estimate parameters and outcomes important to the assessment of health technologies. The result of an analysis by the Confidence Profile Method is a joint posterior probability distribution for the parameters of interest, from which marginal distributions for any particular parameter can be calculated. The method can be used to analyze problems involving a variety of types of outcomes, a variety of measures of effect, and a variety of experimental designs. This article presents the elements necessary for analysis, including prior distributions, likelihood functions, and specific models for experimental designs that include adjustment for biases.
Estimating Costs in the Economic Evaluation of Medical Technologies
Authors: Luce Bryan R. , Elixhauser Anne
Published: March 2009

The complexities and nuances of evaluating the costs associated with providing medical technologies are often underestimated by analysts engaged in economic evaluations. This article describes the theoretical underpinnings of cost estimation, emphasizing the importance of accounting for opportunity costs and marginal costs. The various types of costs that should be considered in an analysis are described; a listing of specific cost elements may provide a helpful guide to analysis. The process of identifying and estimating costs is detailed, and practical recommendations for handling the challenges of cost estimation are provided. The roles of sensitivity analysis and discounting are characterized, as are determinants of the types of costs to include in an analysis. Finally, common problems facing the analyst are enumerated with suggestions for managing these problems.
Direct Costs of Stroke for a Swedish Population
Authors: Persson Ulf , Sliverberg Raymunda , Lindgren Björn , Norrving Bo , Jadbäck Gun , Johansson Barbro , Puranen Britt-Inger
Published: March 2009

Direct costs were estimated for the treatment, rehabilitation, and nursing of 125 patients with first stroke in the Lund and Orup health districts (population of 200,191). Patients were followed from the onset of stroke in 1983 until October 31, 1985. The data were used to calculate the present value of the expected lifetime direct costs for an individual contracting his or her first stroke at various ages. For example, at the age of 72, these costs were estimated at SEK 283,000 for a man and SEK 561,000 for a woman. Hospital care was the major cost component (75% for males and 89% for females) at this age of onset. The results could be used to estimate the economic benefits of preventing new strokes, hence, forming part of a cost-effectiveness or cost-utility analysis. Together with prognoses of the expected developments in the incidence of stroke, they could also serve as the basis of forecasts of future costs of the health care and social service sectors.
A Consensus Development Conference on the Practice of Platelet Transfusion in the Netherlands
Authors: van Aken W. G. , van der Does J. A. , de Wit C. Dudok , van Everdingen J. J. E.
Published: March 2009

During the past 5 years, hospitals in several countries have experienced a significant increase in the use of platelet concentrates. In the Netherlands, e.g., the number of donor units of platelet concentrates rose from 59,000 in 1981 to almost 97,000 in 1984 at a cost of 5 million guilders (US $2,800,000) annually. This increased utilization has been attributed to such factors as chemo- and radiotherapy, major surgery, severe trauma, and bone marrow transplantation.

However, there was concern that in a significant number of patients, platelet concentrates are administered for no good reason, that the effect of platelet transfusions is often not adequately controlled, that insufficient care is taken to prevent side effects (notably alloimmunization), and that the quality control applied to platelet suspension is not optimal.
Case Study: Assessing Laparoscopic Cholecystectomy:The GVHS Experience
Authors: Juzwishin Donald W. M.
Published: March 2009

This article describes the experience at the Greater Victoria Hospital Society of assessing the appropriateness of introducing laparoscopic cholecystectomy (lap chole) within the framework of an established technology assessment process. Lap chole promised to deliver cost savings; however, these could only be realized by capitalizing on the reduced length of stay by removing the surgical beds from service. A cautionary note is raised as to whether the increased use of lap chole in the population is appropriate.
Case Study: Practical Tools for Improving Needs-Based Health Management and Technology Assessment: The PHC MAP Series
Authors: Wilson Ronald G.
Published: March 2009

This paper outlines the need for and development of a practical set of tools to improve needs-based health management and technology assessment. International reports have documented the lack of adequate information for the managerial process in primary health care. The components of the Primary Health Care Management Advancement Program (PHC MAP) Series, designed for both manual and computer applications, are described. The series has been widely pretested and is currently being implemented by many government health services and nongovernmental organizations worldwide. Information is included indicating how the PHC MAP materials may be obtained.
Why is the Pharmaceutical Industry Investing Increasing Amounts in Health Economic Evaluations?
Authors: Andersson Fredrik
Published: March 2009

Over the last few years, the pharmaceutical industry has financed an increasing number of health economic evaluations. The purpose of this article is to describe how and why the pharmaceutical industry is applying health economic evaluations. Seven different fields of application are identified, and the varying reasons for use are discussed.
Is there a Relationship between the Volume of Work Carried Out in Intensive Care and its Outcome?
Authors: Jones Jeremy , Rowan Kathy
Published: March 2009

This paper reports the results of a study of the association between volume of activity and patient outcome in 26 intensive care units in the United Kingdom. Hospital fatality rates showed a statistically significant (p =.016) negative association with volume. However, mean APACHE II scores, as a measure of the severity of case mix, were also negatively associated with volume (p =.021). Thus, one explanation of the lower death rates at higher volumes is that larger units admit less severely ill patients. For patients admitted immediately after surgery, the correlation between severity standardized mortality ratios and volume (while not significant, p <.1) suggests there may be a volume-output effect unexplained by severity.
The Evolution of Laparoscopic Surgery in Routine Health Care
Authors: Hirsch Naarilla , Hailey David
Published: March 2009

While laparoscopic cholecystectomy is now widely used, diffusion of other laparoscopic surgical methods has been more modest. Uptake of most laparoscopic methods has been influenced by considerations of effectiveness compared with open surgery, competing minimally invasive therapies, and the inconvenience and cost of technical change.
The Role of Perspective in Defining Economic Measures for the Evaluation of Medical Technology
Authors: Davidoff Amy J. , Powe Neil R.
Published: March 2009

Perspectives in an economic analysis of medical technology reflect who makes decisions about the use of or payment for medical resources. Commonly used perspectives include those of providers, insurers, the individual, and society. Perspective is a critical determinant of study design, affecting the time horizon, types of resources considered, and economic cost measures assigned to those resources. Individuals involved in technology assessment for either research or policy-making purposes should be aware of the complexities of defining costs from different perspectives.
The Internationalization of Health Technology Assessment
Authors: Menon Devidas , Marshall Deborah
Published: March 2009

Health technology assessment as a formalized set of activities has a relatively short history. At its current stage of development, it is clear that it has global dimensions and impact. In this paper we review the history of health technology assessment, its development as a form of health services research, and its “institutionalization.” We then identify the reasons for its internationalization, review current international initiatives, and propose actions to be taken to improve cooperation among countries.
Predicting Nursing Home Length of Stay and Outcome with a Resource-Based Classification System
Authors: Ljunggren Gunnar , Brandt Lena
Published: March 2009

The anticipated demographic changes with an increasing number of elderly force us to plan and use health care resources more efficiently. In this study we have used the components of a case-mix measure for nursing homes; the Resource Utilization Groups (RUG-II), to predict length of stay (LOS) and outcome in geriatric institutions. We have shown that the RUG categories and an activities of daily living (ADL) index differ significantly in both respects, but that other variables might be of more clinical value when establishing a prospective payment system, based on LOS in geriatric institutions.
A Cost-Effectiveness Analysis of Neonatal ECMO Using Existing Evidence
Authors: Howard Sarah , Mugford Miranda , Normand Charles , Elbourne Diana , Grant Adrian , Field David , Johnson Ann
Published: March 2009

A cost-effectiveness analysis is part of the U.K. ECMO Trial. In preparation for this analysis, existing evidence on the costs and effectiveness of neonatal ECMO was evaluated. ECMO appears to be more costly but may be more or less effective than conventional treatment. No case can be made for introducing ECMO before trial results are available.
Technology and Staffing in Japanese University Hospitals: Government Versus Private
Authors: Vogt William B. , Bhattacharya Layanta , Kupor Scott , Yoshikawa Aki , Nakahara Toshitaka
Published: March 2009

We examined staffing levels, acquisition of medical technologies, and utilization of those technologies in private and government teaching hospitals in Japan. Adjusting for size and case mix, we found that government hospitals acquire more technology, use that technology less, and employ a more highly skilled staff than do private hospitals.
Influences on the Quality of Published Drug Studies
Authors: Bero Lisa A. , Rennie Drummond
Published: March 2009

To practice evidence-based medicine, physicians need data on the clinical effectiveness, toxicity, convenience, and cost of new drugs compared with available alternatives. We give examples of published drug studies that are defective, sometimes because pharmaceutical industry funding has affected their content and quality. We make recommendations on how to avoid these defects.
Bias in the Analysis and Reporting of Randomized Controlled Trials
Authors: Stewart Lesley A. , Parmar Mahesh K. B.
Published: March 2009

The most reliable information on any type of medical intervention is provided by the results of randomized clinical trials (RCTs). In response to increasing pressure to make effective use of limited resources, increasing numbers of health professionals rely on the medical literature, in particular reports of RCTs. However, RCTs may be influenced by a number of factors that introduce bias during the conduct, analysis, and reporting of the trial. Trials may be described as random, when in fact only quasi-random means of treatment allocation have been used; patients may be selectively removed from the analysis; and the report may restrict presentation to or give undue emphasis to only the analyses that yield positive results. The implications of such bias are discussed with particular reference to the effect that they may have on reviews and meta-analyses.
Awareness of Providers' Use of New Medical Technology Among Private Health Care Plans in the United States
Authors: Powe Neil R. , Steiner Claudia A. , Anderson Gerard F. , Das Abhik
Published: March 2009

In a national survey of medical directors at 231 U.S. private health care plans that cover over two thirds of the privately insured population, we studied whether medical directors are aware when a new technology, such as laser therapy, is being used in procedures for which claims are submitted, the factors alerting them to such use, and the factors prompting them to make a specific coverage decision for the technology. We also examined possible associations between health plans' characteristics (HMO versus indemnity, size, profit status, and time in operation) and their medical directors' awareness of the use of technologies, factors alerting medical directors to their use, and factors prompting specific coverage decisions. The majority of plans were generally not aware that laser technology was being used when it was billed under a general billing code, raising the possibility that less effective or less safe technologies could be introduced rapidly into the treatment of insured populations. Nonprofit and older plans were less likely to be aware that lasers were used in some procedures than for-profit and younger plans.
Low-Cost Therapeutic Agents:Uses and Abuses
Authors: Bunker John P.
Published: March 2009

The past quarter century has seen a transformation of the pharmaceutical industry from blind empiricism to the design of drugs to act as agonists or antagonists at specific receptor sites. As truly effective technology, many have led to marked savings in cost. Savings have been achieved when therapeutic drugs, often highly specific, can be substituted for surgery and other invasive procedures and when therapeutic drugs can be used to prevent illness and the need for treatment. Further savings are achieved with the reduced prescription of ineffective drugs. It is estimated that therapeutic drugs and vaccines contribute about half of medicine's contribution to increased life expectancy and improved quality of life in this century at about 7% of national expenditures for medical care in the United States.
The Effect of Dissemination of Recommendations on Use: Preoperative Routines in Sweden, 1989—1991
Authors: Brorsson Bengt , Arvidsson Svante
Published: March 2009

The purpose of this study was to monitor changes in preoperative routines following recommendations given in 1989 by the Swedish Council on Technology Assessment and by the Swedish Consensus Conference on Preoperative Routines, both suggesting a more individualized utilization of preoperative testing. This was a multicenter, prospective, repetitive study conducted at seven Swedish hospitals providing surgical care. The subjects included all patients presenting at the operating theaters for surgical interventions requiring general or regional anesthesia. The main outcome measures were the frequency of reports of performed preoperative ECG, chest x-ray, and analysis of serum concentration of potassium. Before general recommendations were issued in 1989, 47% of the patients had had a preoperative ECG, 26% had had a chest x-ray, and in 61% serum potassium concentration had been measured. In 1991 these frequencies had been reduced by 5,6, and 9 percentage points, respectively (all figures given standardized for age and sex). Large differences were found between indidividual hospitals. Although recommendations suggesting a more restrictive and individualized utilization of preoperative testing have sparked important revisions in Swedish hospitals, there seems to be substantial potential remaining for further reduction of perfunctory use of preoperative screening.
The Prostatic Imperative and the Social Relations of Medical Technology
Authors: Willis Evan
Published: March 2009

A sociological approach to medical technology assessment is outlined in this paper, first in general and then with specific reference to controversies surrounding the use of prostate-specific antigen (PSA) testing to population screening for prostate cancer.
Economic Evaluation of Diagnostic Technology:Methodological Challenges and Viable Solutions
Authors: Sassi Franco , McKee Martin , Roberts Jennifer A.
Published: March 2009

The principles of economic evaluation are increasingly accepted by clinicians and policy makers as evidence from a significant number of studies becomes available to support their decisions. However, methods of assessment still need to be improved. This paper reports a comprehensive review of methodological challenges in the economic evaluation of diagnostic technology, where such challenges are more evident. This review formed the basis for a prioritized research agenda, with four main areas: modeling techniques for dealing with complexity; measures of the opportunity cost of shared resources; techniques for eliciting decision makers' utility functions for diagnostic tests; and ways of assessing the robustness of decisions. A number of methodoligical solutions are proposed, aimed at capturing elements and relationships that are usually neglected and fully recognizing the presence of an inductive cognitive component in decision-making processes.
The Status of Health Technology Assessment Worldwide: Results of an International Survey
Authors: Perry Seymour , Gardner Eric , Thamer Mae
Published: March 2009

Health technology assessment (HTA) has increasingly become a valuable tool to examine effectiveness, quality of care, patient outcomes, and cost-effectiveness of health care technologies. In 1994 and 1995, a survey was conducted to document the scope of worldwide HTA activities; 103 organizations from 24 countries responded. This paper summarizes the results of this international survey, including a description of each country's program, types of technologies assessed, methodologies used, and dissemination approaches. Results for Canada, the United States, and European and other countries are presented separately.
How Should we Research Unconventional Therapies?A Panel Report from the Conference on Complementary and Alternative Medicine Research Methodology, National Institutes of Health
Authors: Vickers Andrew , Cassileth Barrie , Ernst Edzard , Fisher Peter , Goldman Peter , Jonas Wayne , Kang Sung-Keel , Lewith George , Schulz Ken , Silagy Chris
Published: March 2009

Research in unconventional medicine requires a number of different questions to build up a “mosaic” of evidence. Choice of research design depends on the question being asked and is independent of the therapy under investigation. Despite the doubts of some practitioners, randomized trials are of value for determining certain questions in alternative medicine.
EUR-ASSESS Project Subgroup Report on Methodology:Methodological Guidance for the Conduct of Health Technology Assessment
Authors: Liberati Alessandro , Sheldon Trevor A. , Banta H. David
Published: March 2009

Health technology assessment (HTA) is primarily concerned with the consequences (benefits and costs) of health care and health policy decisions. Because decision making is complex and outcomes are often uncertain, it is helpful to attempt to assess the consequences. The quality of decisions can be improved by a process that provides a consistent framework for identifying and assessing health technologies.
Promoting Consumers' Demand for Evidence-Based Medicine
Authors: Domenighetti Gianfranco , Grilli Roberto , Liberati Alessandro
Published: March 2009

The widespread implementation of rationing and priority-setting policies in health care opposes the stochastic practice of medicine induced by professional uncertainty and professional vested interests in market-oriented clinical environments. It also clashes with consumers' overly optimistic and “mythical” view of the effectiveness of medicine, which is bound to support a potentially unlimited provision of health services. Thus, for consumers and society at large, it is necessary to create conditions favorable for a more conscious demand of evidence-based health care. In pursuit of this goal, we suggest the adoption of a community-oriented strategy based upon delivery of information to the public in order a) to generate greater awareness (“healthy skepticism”) among consumers, through disclosure of data on the true effectiveness of health care interventions and on the existing variation in their utilization, and b) to provide tools to empower consumers in dealing better with both the uncertainty in their own individual patient-physician relationships and with the health policy issues to be faced in the future. Such a community-oriented strategy could also reinforce and support, through the generation of a “bottom-up” pressure from consumers toward physicians, a wider adoption of evidence-based interventions by health care professionals. This paper, using data from surveys on public opinions and attitudes toward the practice of medicine, focuses on how consumer demand for more evidence-based medical practice can be promoted.
Economic Analysis of Tirilazad Mesylate for Aneurysmal Subarachnoid Hemorrhage:Economic Evaluation of a Phase III Clinical Trial in Europe and Australia
Authors: Glick Henry , Willke Richard , Polsky Daniel , Llana Ted , Alves Wayne M. , Kassell Neal , Schulman Kevin
Published: March 2009

This study used data from a multinational phase III randomized, double-blind, vehicle-controlled trial to evaluate the cost-effectiveness of tirilazad mesylate (Freedox®) in the treatment of aneurysmal subarachnoid hemorrhage. In men, therapy with 6 mg/kg per day of tirilazad mesylate was associated with significantly increased survival, increased cost of care, and ratios of cost per death averted that compare favorably with the ratios of other life and death interventions. In women, it appeared to have no effects on costs or survival. Further clinical studies may provide additional information about the cost-effectiveness of this intervention.
Recommendations for the Application of Bone Density Measurement: What Can You Believe?
Authors: Marshall Deborah A. , Sheldon Trevor A. , Jonsson Egon
Published: March 2009

This study examined the conclusions of published reports that review the literature and make recommendations about appropriate applications of bone density measurement. It is based on a survey of 22 organizations producing such reports between 1986 and Spring 1995. Overall, the application of bone density measurement for the diagnosis of osteoporosis was supported by 65% of reports, by 44% for the monitoring and follow-up of patients with previously diagnosed disease, and by 59% for monitoring and follow-up of patients receiving treatment that may affect their bone density. A smaller proportion of reports from government and public organizations compared with other types of organizations and a smaller proportion of reports using more rigorous methods supported the applications for bone density measurement identified in the survey. A larger proportion of the reports published after 1990 compared with those published between 1986 and 1990 support the applications of bone density measurement, with the exception of population screening. The results of this survey suggest that there is considerable disagreement about the potential applications of bone density measurement. Publicly funded organisations and those using more rigorous methods tended to be more conservative in their conclusions.
Assessment of Surgical Operations for Ductal Carcinoma In Situ of the Breast
Authors: Yin Xi Peng , Li Xiao Qing , Neuhauser Duncan , Evans James T.
Published: March 2009

The choice of surgical procedure for the treatment of ductal carcinoma in situ (DCIS) remains clinically based. A meta-analysis was used to synthesize the results of 24 published clinical studies. Partial breast tissue excision appears to be as efficacious as mastectomy for the treatment of DCIS of the breast.
A History of ISTAHC: A Personal Perspective on Its First 10 Years
Authors: Banta H. David , Perry Seymour
Published: March 2009

This reflection on the history of the International Society of Technology Assessment in Health Care is an effort to describe the creation of the Society and its first 10 years of activity. Without analyzing the forces that spurred the growth of technology assessment internationally or linking events, policies, and changes in the various countries, this essay focuses on the persons and events that surrounded the birth and growth of the Society in the past decade.
Assessing Medical Technology in Less-Developed Countries
Authors: Sideman Samuel , BenDak Joseph D.
Published: March 2009

Less developed countries (LDCs) are limited in medical resources. Medical technology and the management talent required to handle it play a particularly major role in their national health care and has significant economic, political, and ethical ramifications. This study of the assessment process of medical technology in the LDCs proposes a limited framework for the analysis of the major parameters involved, i.e., stakeholders, boundaries and constraints, goals and objectives, criteria to be met, performance measures, and measurement of performance. The importance of the intangible factors is elucidated.
Postoperative Artificial Nutrition: Overuse or Misuse?
Authors: Colin Cyrille , Lanoir Denise , Chambrier Cecile , Wilkinson Joan , McPherson Klim , Bouletreau Paul
Published: March 2009

The practice of postoperative artificial nutrition (PAN) in elective surgery was covered by a consensus conference in France (December 16,1994). Artificial nutrition was defined as the intake of at least two macronutrients (protein, lipid, and carbohydrate) through an artificial pathway (enteral/parenteral). The guidelines resulting from the conference (2) recommended prescribing artificial nutrition for only malnourished patients, patients with insufficient postoperative nutrient intake lasting 7 or more days, and patients with severe postoperative complications. These were similar to American guidelines produced in 1993 (1).
Depressive Illness and the Possibilities of Somatic Antidepressant Treatment
Authors: Mårtensson Björn
Published: March 2009

Depression constitutes a considerable mental health problem. Depression is too often unrecognized or unproperly treated, which causes distress, social impairment, and increased risk of mortality for the individual, and large costs for society. However, several efficient treatment modalities and strategies exist. Different somatic antidepressant treatments for short- and long-term therapy and their respective quality-of-life and economic aspects will be presented and discussed.
Involuntary Commitment as a Psychiatric Technology
Authors: Hiday Virginia Aldigé
Published: March 2009

In the process of involuntary commitment,1the state makes available its coercive power for use as a psychiatric technology. This application of the state's power is based on the idea that mental illness can make a person not only sick but also unaware of the illness, and dangerous or unable to care for his/her basic needs; thus, coercion may have to be used to secure the mentally ill person's and/or the public's safety, and to give treatment until the illness abates.
Assessing Psychiatric Care Settings:Hospitalization Versus Outpatient Care
Authors: Durham Mary L. , La Fond John Q.
Published: March 2009

This paper presents a discussion of the historical development of deinstitutionalization in the United States, including the political, ideological, and social origins of that policy. The outcomes of deinstitutionalization are considered, including the impact of the policy on the quality of life of people with severe mental disorders. The authors also provide a brief review of the literature on the efficacy and cost-effectiveness of hospitalization versus outpatient (community) care. Recent developments in the use of involuntary hospitalization are discussed, along with a number of important trends in the delivery and financing of services for persons with severe mental disorders.
Consumerism for Neurobiological Disorders:An Assessment
Authors: Peschel Richard E. , Peschel Enid
Published: March 2009

Consumerism is a growing phenomenon in U.S. health care, yet its exercise is still inhibited by powerful forces within the medical community. Despite the neuroscientific framework that stresses the commonalities between mental and physical illness, consumerism is even more problematic and difficult in mental health care than in other areas of health care. People with severe mental illness and their advocates must contend with limited public understanding of neurobiological disorders, poor definitions of effective treatment, and a paucity of outcome data, especially from prospective randomized and long-term studies. The only clear way for consumerism to grow in mental health care is for its advocates to align themselves with the neuroscientific revolution and to demand that effective and equitable treatment programs be created based on the documented evidence of the physical nature of neurobiological disorders.
The Public's Role in the Evaluation of Health Care Technology: The Conflict Over ECT
Authors: Heitman Elizabeth
Published: March 2009

The use of electroconvulsive therapy (ECT), controversial since its inception, offers an instructive case study on the challenge of addressing patients' perspectives in the evaluation of health care technology. Despite widespread professional acceptance of ECT, groups of former psychiatric patients have worked through the U.S. legal system to restrict and even ban ECT in the treatment of mental illness. This unusual lay participation in the regulation of health care illustrates how differing conceptions of evidence can affect the evaluation of technology. ECT provides a powerful example of the value of a more complex definition of the significant outcomes of treatment and the growing practice of outcomes assessment, especially as such research is used to shape health policy.
Use of Microbiological Diagnostics and Antibiotics in Danish General Practice
Authors: Sørensen Henrik Toft , Steffensen Flemming Hald , Schønheyder Henrik C. , Grøn Poul , Sabroe Svend
Published: March 2009

This article analyzes the use of antibiotics in Danish general practice. We observed considerable variation in the prescription of antibiotics among general practitioners (GPs). Internationally, Denmark has a low consumption of antibiotics. The use of antibiotics was closely associated with GPs' use of drugs, other than antibiotics, and to some extent with use of microbiological diagnostic tests. These findings provide evidence for the assumption that the consumption of antibiotics can be decreased further, which stresses the need for a restrictive policy concerning antibiotics.
The Growing Dependency in Health Care: Recent Changes in Medical Technology Imports and Exports in Turkey
Authors: Şemin Semih , Güldal Dilek
Published: March 2009

This study investigates recent changes related to the import and export of medical technology and their results in Turkey. Between 1980 and 1993 the number of medical technology imports in Turkey rose, and there was a parallel rise in its ratio to total imports and health expenditures. In contrast the ratio of medical technology exports to total exports decreased significantly in the same period. The liberalization of foreign trade and the changes of health services toward free market policy has caused growing import of medical technology in Turkey.
The Method of Information Synthesis and Its Use in the Assessment of Health Care Technology
Authors: Marcus Susan H. , Grover Prakash L. , Revicki Dennis A.
Published: March 2009

This paper compares information synthesis to literature review and meta-analysis as tools for the researcher trying to summarize published information and identify information gaps on emerging technologies. Because information synthesis is narrowly focused and addresses the question of what isnotknown, as well as whatisknown, it is a good precursor to a full-scale technology assessment. An example of information synthesis is given, comparing cost-effectiveness of extracorporeal shock wave lithotripsy to two other treatments for kidney stones.
Cost-Effectiveness Comparison of Estrogen Therapy and Orchidectomy in Patients With Prostatic Cancer
Authors: Henriksson Peter , Edhag Olaf
Published: March 2009

This study compares the cost of antitumor therapy and adverse cardiovascular effects during the first year of treatment with either exogenous estrogens or orchidectomy of patients with prostatic cancer. We found that the higher costs for the orchidectomy patients were partially outweighed by the costs of treating cardiovascular complications in the estrogen-treated patients; the net overcost of orchidectomy is balanced after two and a half years by the ongoing costs of estrogen treatment. The fact that 25% of the patients treated with estrogen suffered cardiovascular complications, but no difference in mortality rates between the two groups was observed, speaks in favor of orchidectomy as the preferred treatment for prostatic carcinoma.
Intensive Home Health Care in the United States
Authors: Fox Daniel M. , Andersen Kathleen S. , Benjamin A. E. , Dunatov Linda J.
Published: March 2009

This paper assesses the impact of mechanisms for financing intensive home health care services in the United States on their utilization. As lengths of stay have decreased in response to prospective payment methods for hospitals, demand has increased for intensive and complex services provided to patients in the home. Third-party payers, however, are willing to satisfy only some of this potential demand that their reimbursement policies have generated. It is the policies of payers rather than the safety and effectiveness of devices and procedures that are the major constraints on the expansion of intensive home health care. We describe the effects of these policies on who receives intensive home health care services, who provides them, what services are provided, how their quality is monitored, and what they cost.
Empirical Criteria for the Selection of Quality-of-Life Instruments for the Evaluation of Peripheral Blood Progenitor Cell Transplantation
Authors: Glick Henry A. , Shpall Elizabeth J. , LeMaistre C. F. , McCarron Thomas J. , Lu Z. John , Erder M. Haim , Glaspy John A.
Published: March 2009

We propose a method for selecting quality-of-life instruments for use in phase III trials using the convergent validity of patient responses collected in phase I and II clinical trials.Two generic and two disease-specific instruments were administered to patients with breast cancer undergoing peripheral blood progenitor cell mobilization and transplantation. They included the visual analog scale from the EuroQoL EQ5D instrument, the SF-36, the European Organization for Research and Treatment of Cancer (EORTC)-QLQ-C30, and the Functional Assessment of Cancer Therapy instrument. No single instrument was found to have superior convergent validity in all domains, but the EORTC-QLQ-C30 seemed to perform better than the SF-36.
The Effect of a Redistribution System for Health Care for the Elderly on the Financial Performance of Health Insurance Societies in Japan
Authors: Babazono Akira , Weiner Janet , Tsuda Toshihide , Mino Yoshio , Hillman Alan L.
Published: March 2009

Health care for the elderly in Japan is financed through a pool to which all insurers contribute. We analyzed insurers' financial data to evaluate this redistribution system. Cost sharing affected financial performance substantially. The current formula for cost-sharing redistributes elderly health care costs unequally and should be changed.
Cost-Effectiveness of Open Versus Laparoscopic Repair for Primary Inguinal Hernia
Authors: Dirksen Carmen D. , Ament André J. H. A. , Adang Eddy M. M. , Beets Geerard L. , Go Peter M. N. Y. H. , Baeten Cor G. M. I. , Kootstra Gauke
Published: March 2009

A cost-effectiveness (CE) analysis was performed of Bassini versus laparoscopic repair for primary inguinal hernia. Incremental costs per 1 -year recurrence-free patient were calculated for the societal and hospital perspective. From the hospital perspective, the incremental CE ratio of laparoscopic repair is 5.348 guilders. From the societal perspective, laparoscopic repair is both less costly and more effective than Bassini repair. Results were sensitive to assumptions about recurrence rates, laparoscopic operating time, and return to work. Laparoscopic repair should replace Bassini repair in order to benefit society. From the hospital perspective, the decision to accept laparoscopic repair depends on the willingness to pay.
Patient and Informal Caregiver Time in Cost-Effectiveness Analysis:A Response to the Recommendations of the Washington Panel
Authors: Brouwer Werner B. F. , Koopmanschap Marc A. , Rutten Frans F. H.
Published: March 2009

The time invested by patients and informal caregivers in treatment and rehabilitation should be valued in a cost-effectiveness analysis (CEA). The Washington Panel gives recommendations on incorporation of time costs that may misrepresent true societal costs. This article provides alternative recommendations for incorporating costs of time in CEA. Following an opportunity costs approach, time is separated into three parts, each with its own valuation methods: time spent on paid work, unpaid work, and leisure.
Routine Preoperative Investigation: Results of a Multicenter Survey in Italy
Authors: Ricciardi Gualtiero , Angelillo Italo F. , Prete Umberto Del , D'Errico Marcello M. , Grasso Guido M. , Gregorio Pasquale , Schioppa Francesco S. , Triassi Maria , Boccia Antonio
Published: March 2009

We conducted a study to acquire information on the current behavior of a sample of Italian surgeons and anesthesiologists about prescribing, interpreting, and using routine preoperative investigations. Consultants in surgery and anesthesiology in 60 hospitals in northern, central, and southern Italy were interviewed. Prescription of these procedures by doctors were driven more by personal experience than by updated scientific knowledge. This practice often led to ineffective and inefficient clinical practice, with healthy patients undergoing useless, time-consuming, costly, and sometimes harmful procedures.
Home Drug Infusion Therapy:A Literature Update
Authors: Balinsky Warren , Mollin Arthur
Published: March 2009

This paper is a literature review and update of home drug infusion therapy (HDIT) in the United States. It concentrates on cost-effectiveness studies of parenteral antibiotic therapy administered in an outpatient setting. This update is timely because Medicare and other payors are under the pressure of cost containment with respect to this modality. Additionally, managed care is redefining reimbursement programs, which will affect HDIT in the future.