bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessment of Rehabilitation Technologies in Stroke:Outcomes and Costs
Authors: Hass Ursula , Persson Jan , Brodin Håkan , Fredén-Karlsson Ingrid , Olsson Jan-Edvin , Berg Inger
Published: March 2009

Abstarct

Initial functional ability (Barthel Index, mean 57) was found to be an important predictor of functional ability 1 year after stroke (mean 80) and for costs during the period. On average the total cost for a stroke patient was about SEK 200,000; the main expense, accommodation, averaged about SEK 140,000, while assistive devices amounted to SEK 2,600. Those who use assistive devices, although having achieved a high functional ability, perceive and rate their life situation (Nottingham Health Profile) considerably more impaired than those without assistive devices.
The Development of Health Care Technology Assessment:An International Perspective
Authors: Battista Renaldo N. , Hodge Matthew J.
Published: March 2009

Abstarct

We consider the nature of technology assessment and then briefly summarize technology assessment activities in five countries: Canada, France, the Netherlands, the United Kingdom, and the United States. Drawing from these examples, we then identify determinants of the emergence and impact of technology assessment.
Declining Cost-Effectiveness of Screening for Disease: The Case of Gastric Cancer in Japan
Authors: Babazono Akira , Hillman Alan L.
Published: March 2009

Abstarct

We examined the cost-effectiveness of screening for gastric cancer in hypothetical cohorts of asymptomatic Japanese ages 40, 50, 60, and 70, followed for 10 years. Current screening recommendations in Japan are not optimal. Although indirect x-ray is the correct method, screening for gastric cancer may not be cost-effective for Japanese under the age of 50. Policymakers worldwide should monitor the changing incidence of disease as they consider and recommend screening policies.
Preventing and Managing Prematurity
Authors: Lumley Judith
Published: March 2009

In the past decade the prevention and management of prematurity have begun to be addressed with more appropriate designs. A few strategies—very few—can now be recommended. A few, some widely implemented, can be abandoned. The risks and benefits of most interventions still require clarification.
Do Doctors and Patients Agree?: Views of the Outcome of Transurethral Resection of the Prostate
Authors: Black Nick , Petticrew Mark , Ginzler Maria , Flood Ann , Smith Joe , Williams Grant , Davies Jane , Doll Helen , Mcpherson Klim
Published: March 2009

In an attempt to establish the extent to which patients and doctors agree on the outcome of health care, the pre- and postoperative states of health of 388 men undergoing transurethral resection of the prostate for benign disease were studied. Generally, high levels of concordance (>70%) were obtained. The strongest agreement was for clearly defined events, such as episodes of acute retention (95%); the weakest agreement occurred over the most subjective symptoms, prognostic expectations, and ambiguous terms (around 60%). The level of agreement was not associated with any characteristics of the patient, surgeon, or treatment.
Informing the Mammography Coverage Debate: Results of Meta-analysis, Computer Modeling, and Issue Analysis
Authors: Simpson Kit N. , Snyder Lyle B.
Published: March 2009

Methods of meta-analysis, computer modeling, and issue analysis are used to answer four key questions related to efficacy, cost, and political feasibility of legislating insurance coverage for mammography. The findings are presented, and the strengths and weaknesses of the combined use of these methods to inform policy debate at the regional level are discussed.
Expensive Medical and Surgical Technology
Authors: Black Douglas
Published: March 2009

The very title - “Expensive Medical and Surgical Technology” - expresses in coded form a myth that is widely prevalent among those who consider the political and economic aspects of health care. Strangely, it is a myth that finds favor mainly at the extreme ends of the range of attitudes toward health care. Monetarists see it as an incentive toward increasing private provision of health care, while extreme egalitarians see it as another example of unjust privilege. The content of the myth is that there is a definable group of costly procedures, which can somehow be isolated from the general practice of medicine and surgery, after which such procedures can either be made the subject of special private provision or, alternatively, discarded from a rationed system of health care.
Comparison of Adjuvant Therapies Using Quality-Of-Life Considerations
Authors: Gelber Richard D. , Goldhirsch A.
Published: March 2009

The benefit for patients with operable breast cancer treated with adjuvant systemic therapy is small, if reduction of early mortality within the context of randomized control trials is used for treatment comparison. One might consider that the 75%–85% of patients who die despite treatment are overtreated, as are patients who remain alive even without therapy within a given time frame. Larger treatment benefits in terms of avoided or delayed breast cancer relapse have been demonstrated even at early phases of follow-up in the vast majority of adjuvant trials. Exposure of all patients to adjuvant therapy at a time at which no symptoms of disease are present is detrimental in terms of quality of life.

Based on our assumption that the quality of life of the patient is typically altered both by subjective toxic effects of adjuvant treatment and by the appearance of relapse, we developed a method of comparing treatment effects in terms of time without symptoms of disease and toxicity of treatment (TWiST). Because the impact of treatment on relapse rates appears earlier than survival effects in all adjuvant therapy trials, and because the value of time without relapse in terms of the quality of life of the patients is as yet poorly defined, we have generalized our method of comparing treatment attitudes to include individual qualitative judgment values. The experience gained from integrating quality-of-life issues into clinical trials for breast cancer might also be applied to other diseases characterized by a chronic course, toxic treatments, and gains in periods of relative or absolute freedom from toxic effects and progressive disease.
Evaluating New Treatments and Diagnostic Technologies in Obstetrics: Practical Problems, Ethics, and Solutions
Authors: Lilford Richard J.
Published: March 2009

This article develops arguments for the use of decision theory, rather than intuition, to determine the size of trials. It is wrong to expect doctors to ignore personal preferences in favor of clinical experiments unless the trial is capable of showing differences in treatment effect that would influence clinical practice substantially.
It follows from our analysis that if delta (the treatment effect that the trial is designed to detect) is sufficient to alter clinical practice, then the alpha and beta errors of a trial should be equal. This applies even if a new treatment is to be compared with conventional therapy or if a treatment with high “costs” is compared with a less invasive or more inexpensive method.
A Call for Randomized Controlled Cost-Effectiveness Analysis of Percutaneous Transluminal Coronary Angioplasty
Authors: Holly Norman
Published: March 2009

A rapidly evolving technology, percutaneous transluminal coronary angioplasty, is increasingly favored over bypass surgery for treating some types of coronary stenosis because of its less traumatic invasion, better recovery response, and lower initial cost. However, substantially higher failure rates in initial procedures offset PTCA's savings to an unknown extent and cloud analysis of its overall impact. Lack of randomized clinical data precludes valid cost-effectiveness comparison of the technologies at this time. Criteria for establishing valid data and evaluations of currently available data are described in this paper.
Transferability of Health Technology Assessment with Particular Emphasis on Developing Coutries
Authors: Attinger Ernst O. , Panerai Ronney B.
Published: March 2009

The importance of health technology assessment for developing countries is unquestionable. Although these countries are still plagues by tropical diseases and primary health problems, they have been forced to import modern medical technologies because of internal and international pressures. Recognition of the potentoial of health technology assessment for improving the management of technology and health care delivery in developing countries leads to the critical question of how to promote the development of assessment activities there. But as technology assessment is itself also a technology, it can be assuned that its direct transfer to developing countries in the form that it has unfolded in the richer nations is doomed to failure. How successful transfer of health technology assessment can be achieved is outlined.
The Diffusion of Two Diagnostic Technologies among Hospitals in New York State
Authors: Haddock Cynthia Carter , Begun James W.
Published: March 2009

Using combined data from an independent survey by the American Hospital Association and the State of New York, the diffusion of two diagnostic technologies–the automated chemistry analyzer and the computed tomography (CT) scanner–among hospitals in New York State was analyzed. A linearized form of the logistic function was estimated using cumulative diffusion data for each. Diffusion patterns of both technologies fit the logistic curve well, with the coefficient of diffusion for the CT scanner being greater than that for the automated analyzer. Further analysis examined characteristics of early adopters of each technology. Similar hospital characteristics (e.g., high volume of admissions and medical school affiliation) were important in explaining early adoption of both technologies.
The Clinical Use of Nuclear Exercise Tests
Authors: Steingart Richard M. , Wassertheil-Smoller Sylvia , Budner Nancy , Tobin Jonathan , Wachspress Joseph , Lense Lloyd , Wexler John P. , Slagle Susan
Published: March 2009

In the mid-1970s, after decades of clinical use, the utility of electrocardiographic exercise testing for the evaluation of patients with suspected ischemic heart disease was critically examined and questioned. Concurrent with this critique, two sophisticated, more expensive and powerful “nuclear” exercise tests were introduced sequentially for clinical use: myocardial perfusion imaging with thallium-201 and radionuclide ventriculography with technetium 99m. The published indications for the two tests are similar, and both have been shown to offer advantages over ECG stress testing in selected populations. However, few data are available regarding the comparative utility of thallium versus ventriculographic imaging. As part of a prospective study to assess the efficacy of cardiovascular nuclear medicine studies, we undertook the present analysis to assess the clinical evolution of these tests and to elucidate factors responsible for clinicians' choice for the often competing examinations. The study examined 213 consecutive patient referrals for thallium scintigraphy and 183 referrals for ventriculography, ranging from patients with no symptoms or highly non-specific chest pain syndromes (21% of referrals) to patients with proven coronary disease (28% of the referrals). Twenty-one percent of patients were referred to confirm the clinical impression that the patient did not have coronary disease, 40% to confirm its presence, and 37% to determine its severity.

Analyses were undertaken to determine the factors that dictated a preference for thallium scintigraphy rather than ventriculography; only the physician's intent in testing and level of training were significant predictors for a particular nuclear test.
Healthy Children: Investing in the Future Office of Technology Assessment
Authors: Perry Seymour , Blanpain Jan , Hanft Ruth , Hutton John , Tanneberger Stephan
Published: March 2009

Despite many gains, the United States could do better in preventing health problems in infants and young children, says the congressional Office of Technology Assessment (OTA) in its new report, Healthy Children: Investing in the Future.

Rep. Henry Waxman (D-Calif.), Chairman, Subcommittee on Health and the Environment, Committee on Energy and Commerce, released the report at a hearing.
Increased Availability of Human Growth Hormone: A Challenge for Health Economics
Authors: Albertsson-Wikland Kerstin , Larsson Agne
Published: March 2009

Human growth hormone (GH) has until recently been prepared commercially from pituitary glands collected at autopsy. Availability has been limited and cost high, so the indications for GH treatment have had to be “tight.” Owing to recent development in hybrid DNA technology, the availability of GH has increased dramatically. At the same time, the manufacturers have maintained constant prices, so that treatment costs continue to influence decision making about its use. This rapid transition has generated an interesting change of strategy, which is outlined in this review.
Correlates of Physician Utilization of Physical Therapy
Authors: Anderson Judith , Campbell Suzann K. , Gardner H. Garry
Published: March 2009

A survey of 200 physicians explored the relationship between their beliefs in the efficacy of physical therapy (PT) and their use of PT for their patients with cerebral palsy (CP). Results show that utilization of PT is related to physicians' use of PT in general and is inversely related to the percentage of CP in physicians' patient loads, but is not related to their opinions of the value of PT services.
Benesh Movement Notation: A Tool to Record Observational Assessment
Authors: Harrison Marilyn A. , Atkinson Helen , De Weerdt Willy
Published: March 2009

This article describes the introduction into physiotherapy practice of Benesh Movement Notation, a method for recording observations of patients’ posture and movement sequences. Assessments of the technique show it to be a reliable and practical tool for clinical use.
Hospital Care Versus Home Care for Rehabilitation After Hip Replacement
Authors: Möller Gudrun , Goldie Ian , Jonsson Egon
Published: March 2009

A pilot study was done to assess the feasibility of reducing the hospital stays of patients with total hip replacement (THR). The length of hospital stay for these patients depends largely on how rehabilitation, mostly physical therapy, is organized. This study shows that not more than a half hour per postoperative day was devoted to care services and rehabilitation activities. It is feasible and less expensive to reduce substantially hospital stay by planned physical therapy in the patient's home. These results have prompted a randomized controlled clinical trial to assess hospital versus home rehabilitation.
Medical Equipment in the People's Republic of China: A Survey of Medical Equipment Procurement, Utilization, and Maintenance in University-Affiliated Hospitals between 1976 and 1987
Authors: Peabody John W. , Schmitt Joseph M.
Published: March 2009

We report results of a survey of medical equipment purchasing, utilization, and maintenance practices in 12 Chinese tertiary-care hospitals. A dramatic increase in expenditures on medical equipment was found to have occurred after 1979, mainly resulting from purchases of imported equipment. Based on survey results and on personal observations, recommendations are given for reducing equipment-related costs through the development of clinical engineering services.
The Potential for Medical Informatics in the Eastern Mediterranean Region
Authors: Al-hashimi Mukhtar S. A. , Pryor T. Allan
Published: March 2009

This article assesses the potential value of an integrated medical/hospital information system (IMIS) for the members of the Eastern Mediterranean Region of the World Health Organization, and describes the preliminary results of a feasibility study questionnaire done in December 1989 at Salmaniya Medical Center (SMC) in the state of Bahrain.
DNA Technology and Vaccines
Authors: Brown Fred
Published: March 2009

It has been 20 years since the concepts that are now embraced in the term recombinant DNA technology were first described. The technology has been used to design new vaccines, and one product — that for hepatitis B — has been in widespread use for almost a decade. Several other engineered vaccines have shown considerable promise in laboratory trials. Nevertheless, the potential of the approach is still to be realized. This article describes the principles that are involved in the design of these new vaccines, focusing on those for hepatitis B and rabies.
Gene Therapy: Molecular Medicine of the 1990s
Authors: Wivel Nelson A.
Published: March 2009

In less than four years, the techniques of gene transfer have been taken from the laboratory and translated into numerous clinical trials. Although gene therapy was initially designed for the molecular repair of monogenic deficiency diseases, most of the current studies of gene therapy are targeting cancer.
The Economic Costs of Acute Myeloid Leukemia in Sweden
Authors: Tennvall Gunnel Ragnarson , Persson Ulf , Nilsson Bo
Published: March 2009

The direct and indirect costs of acute myeloid leukemia were estimated for Sweden in 1989. The calculated total cost was SEK 460 million. Nearly half of the costs, or 1.7 million per patient diagnosed, were indirect costs due to premature mortality. Direct costs of relapses and indirect costs of mortality represent costs due to the absence of completely curable therapy. They also represent potential cost savings that could be ootained after introduction of new treatment options in the future.
Synergism in Technology Assessment
Authors: Tyson Ted R.
Published: March 2009

In 1899, Charles H. Duell, Commissioner of the U.S. Office of Patents, urged President McKinley to abolish the Patent Office by saying, “Everything that can be invented has been invented.” Fortunately for the health care industry, there have been more significant “medical inventions” in the 89 years following Duell's utterance than in all of recorded history preceding it.

There is now a crisis in medical technology, and it has not been caused by a lack of ideas from innovative clinicians, inventors, and scientists. Instead, it is a result of sincere, but often spasmodic, efforts to control health care costs, which in the minds of many observers threaten the national economy, if not the country's survival.
Selecting Technologies for Assessment
Authors: Eddy David M.
Published: March 2009

This article describes criteria used by several organizations to select technologies for assessment and the factors that are common to most lists of criteria. It presents a framework or model (called TAPSS) that relates the most important factors. The model can be used to estimate the expected impact of an assessment on health and economic outcomes for a population. It incorporates information on such factors as the health and economic importance of the disease addressed by the technology, the expected impact of the technology on health and economic outcomes, variations in the technology's current use, and factors affecting the production and reception of an assessment. The article includes an example of an application of the method—screening for maple syrup urine disease.
Eliciting and Combining Subjective Judgments About Uncertainty
Authors: Wolpert Robert L.
Published: March 2009

Frequently, health care decisions must be made before compelling and unequivocal evidence is available about the benefits, risks, and costs of a proposed new health technology. It is common for decision makers to seek the advice and opinions of experts to supplement the available evidence. This article reviews some of the methods used or recommended for eliciting the opinions of experts about uncertain events and for combining these opinions with those of others and with available empirical evidence.
Advances in Prenatal Diagnosis Social–Psychological and Policy Issues
Authors: Kolker Aliza
Published: March 2009

Chorionic villus sampling (CVS), a new technique for prenatally diagnosing chromosomal and genetic disorders, may soon replace amniocentesis. This procedure, performed by inserting a catheter through the pregnant woman's cervix or through the abdomen and removing cells from the placenta, has the advantages of being available earlier in the pregnancy than amniocentesis (at 9 to 11 weeks gestational age) and of yielding results in a shorter time. Although the medical aspects of the procedure are being investigated, its psychosocial and policy implications have not been studied systematically. These issues include the subjective assessment of risk that prompts women to choose or to reject CVS, the implications of earlier diagnosis for feelings about abortion, the potential of negative findings (i.e., the absence of the designated disorder) for well-being during the remainder of the pregnancy, the ramifications of first trimester identification of fetal sex, equity of access to prenatal diagnosis, and the possible over- utilization of these procedures. Drawing on previous research regarding amniocentesis and more recent research concerning CVS, this article discusses the potential implications of CVS.
Test of a Noninvasive Instrument for Measuring Hemoglobin Concentration
Authors: Sanchez-Carrillo Constanza I. , de Jesus Ramirez-Sanchez Teresita , Zambrana-Castañeda- Marcela , Selwyn Beatrice J.
Published: March 2009

A colorimetric instrument for the noninvasive quantification of hemoglobin, designed using color shades resembling those observed in the conjunctiva, was tested. The instrument's colors are contrasted against the color of the conjunctiva to measure hemoglobin content. Sensitivity, specificity, negative predictive value, and false-negative value were estimated to test the instrument's accuracy; kappa coefficients were used to estimate inter- and intraobserver variability. Physician field evaluations of conjunctiva color for the screening of anemia, reported in the literature, have had sensitivities and specificities as high as 70%. Readings with the instrument demonstrated a 63% sensitivity, 72% specificity, and 38% false negatives for screening hemoglobin values of less than or equal to 13 g/dl. The interobserver kappa coefficients for three pairs of readers were good to excellent for the same hemoglobin screening value. Statistically significant differences were noted, however, between observers during the reliability test. The instrument can be used by unskilled personnel to improve their decision-making about whom to send for futher care or for supplementation with iron.
The Rational Use of Medicines
Authors: Werkö Lars
Published: March 2009

A short description is given of the interplay between the pharmaceutical industry and its critics regarding the rational use of medicines since the 1960s. This was especially vigorous in the developing countries but also had ramifications in the industrialized world. The initiatives taken by the World Health Organization in starting a dialogue between the industry representatives in the International Federation of Pharmaceutical Manufacturers Associations and the critical voices of Health Action International are specially emphasized. The recent developments in the therapy of primary hypertension and peptic ulcer are discussed briefly as examples of the rapid changes in what should be rational in pharmacologic treatment of disease.
Patient Decision Making: The Missing Ingredient in Compliance Research
Authors: Donovan Jenny L.
Published: March 2009

Medical noncompliance has been identified as a major public health problem that imposes a considerable financial burden upon modern health care systems. There is a large research record focusing on the understanding, measurement, and resolution of noncompliance, but it is consistently found that between one third and one half of patients fail to comply with medical advice and prescriptions. Critically absent from this research record has been the patient's role in medical decision making. For patients, particularly those with chronic illnesses, compliance is not an issue: they make their own reasoned decisions about treatments based on their own beliefs, personal circumstances, and the information available to them. The traditional concept of compliance is thus outmoded in modern health care systems, where chronic illness and questioning patients predominate.
Pharmacists as Agents of Change for Rational Drug Therapy
Authors: Lipton Helene Levens , Byrns Patricia J. , Soumerai Stephen B. , Chrischilles Elizabeth A.
Published: March 2009

We analyze what is known and unknown about the contribution of the pharmacist as patient educator, physician consultant, and agent to affect patient outcomes in ambulatory settings. The need for pharmacist services is discussed, as are the theoretical underpinnings and quality of the scientific evidence to support their efficacy. The analysis is conducted in the context of a shift in pharmacists' roles from product to patient orientation as well as recent U.S. legislation mandating enhanced pharmacists' roles via drug utilization review for all Medicaid patients. We conclude with a research and action agenda, calling for stronger research designs in evaluating pharmacists' interventions. The shifting paradigm in the pharmacy profession, coupled with the implementation of the Omnibus Budget Reconciliation Act of 1990, provide unique opportunities for rigorous evaluations of pharmacists as agents of change for rational drug therapy.
Cost-Effectiveness Studies of Renal Transplantation
Authors: Karlberg Ingvar , Nyberg Gudrun
Published: March 2009

This study analyzes opportunity costs for the treatment of end-stage renal disease. Kidney transplantation remains the most cost-effective treatment for uremia and is one of the most cost-effective technologies in health care. Improved survival of grafts and increased numbers of transplants have the potential to reduce costs for dialysis programs. To support organ donation activities, the public and concerned health professionals should be informed about the opportunity cost of “unnecessary” dialysis. These resources could be reallocated from dialysis to other programs. Among patients in dialysis, a more common use of chronic ambulatory peritoneal dialysis instead of institution-based hemodialysis would greatly increase cost-utility and further reduce the program costs of renal replacement therapy.
Allocating Resources
Authors: Drummond Michael F.
Published: March 2009

This article reviews the methods of economic evaluation of health technology. The different forms of evaluation are outlined and the importance of assessing costs and benefits at the margin stressed. The approaches used by economists to analyze priorities for health technologies are discussed and a number of key managerial and policy issues identified. It is concluded that, while further methodological improvements can be made, a clear methodology for economic evaluation of health technologies has been established. However, attention needs to be paid to the timeliness and relevance of economic evaluation in order to ensure its maximum impact
Cost-Effectiveness Analysis of the Treatment of End-Stage Renal Disease in Brazil
Authors: Sesso Ricardo , Eisenberg John M. , Stabile Carlos , Draibe Sergio , Ajzen Horacio , Ramos Oswaldo
Published: March 2009

Cost-effectiveness analysis compared four treatments of end-stage renal disease in Brazil: continuous ambulatory peritoneal dialysis (CAPD), in-center hemodialysis (HD), cadaver donor transplantation (CD-Tx), and living related donor transplantation (LR-Tx). After 2 years, the costs per year of survival were CAPD, $12,134; HO, $10,065; CO-Tx, $6,978; and LR-Tx, $3,022. The HD cost was lower than CAPO partially because of the reuse of hemodialyzers in Brazil. Although less cost-effective, both dialysis treatments yielded more years of survival after 2 years. This analysis reveals a trade-off between cost per year of survival and years of survival.
Technology Assessment:Old, New, and Needs-based
Authors: Tugwell Peter , Sitthi-amorn Chitr , O'connor Annette , Hatcher-roberts Janet , Bergevin Yves , Wolfson Michael
Published: March 2009

Recent health reports, including the 1993 World Development Report, have emphasized the importance of integrating the needs of the population into technology assessment. This paper reviews previous approaches to technology assessment and identifies the missing link between technology and its impact on the physical, emotional, and social needs of the community, namely needs-based technology assessment. It stresses the key role played by issues of equity and community values in making technology decisions. A number of models for needs-based technology assessment are described.
Case Study: Needs-Based Technology Assessment and Essential National Health Research: Experience in the Philippines
Authors: Tan-Torres Tessa L.
Published: March 2009

Essential national health research (ENHR) ensures that health research will be undertaken in priority areas defined by the people and will be used in decision making. Needs-based technology assessment (NBTA) is anchored on the ENHR philosophy. Two case studies are presented, one illustrating a successful application of NBTA and the other a failed approach. Reasons for the difference in success are examined.
Variation in Use of Breast-Conserving Surgery in Lombardia, Italy
Authors: Grilli Roberto , Repetto Francesca
Published: March 2009

The extent of variation in the use of breast-conserving surgery was analyzed using the 1990 and 1991 hospital discharge data of Lombardia, Italy. The proportion of patients undergoing breast-conserving surgery for unilateral breast cancer was estimated for each of the 10 geographic areas (9 provinces plus metropolitan Milano) in which the region is divided. Overall, the rate of use was 41% of 3,225 patients in 1990, and 45% of 3,736 patients in 1991. In both study years, patient age was strongly correlated with the likelihood of undergoing conservative surgery, with younger women more frequently treated with this approach. In each province, patients treated at centers located in the main city had a greater probability (OR, 1.54; 95% Cl, 1.37–1.69) of having conservative surgery. This procedure was also more often used in private hospitals (OR, 1.59; 95% Cl, 1.20–2.08) where care is paid at the point of consumption by patients, directly or through their private insurance. The observed variation in the use of the conservative procedure across the 10 regional areas was greater than that expected by chance alone (p <.0001), with rates ranging from 29% to 60%. This pattern persisted even after adjusting for the relevant patient and hospital characteristics. Despite the relatively large body of scientific evidence, it appears that the surgical management of breast cancer is more dependent on physicians' attitudes in each geographic area than on individual patients' characteristics.
Perioperative Use of Total Parenteral Nutrition: Variations in Guidelines and Practice in Three Norwegian Hospitals
Authors: Mjaaland Marianne , Revhaug Arthur , Førde Olav Helge
Published: March 2009

In a cross-sectional, retrospective study of 604 cases, variations among three Norwegian hospitals in use of perioperative parenteral nutrition (TPN) after gastrointestinal surgery was determined. Postoperative TPN rates were 25%, 34% (p =.05) and 56% (p <.0001). respectively. However, a substantial part of the variation was explained by differences in patient characteristics.
Assisted Conception Techniques: On What Basis Do Health Technologies Become Routinely Available When They Have Been Assessed As Effective?
Authors: Freemantle Nick , Watt Ian
Published: March 2009

The possibility of restoring fertility among some infertile couples through assisted reproductive technology has led to questions about the terms under which such treatments should be made available. Although there is now evidence on their effectiveness, there is considerable variation in the availability of these treatments under the U.K. National Health Service.
The Tension Between Cost Containment and the Underutilization of Effective Health Services
Authors: Bloom Bernard S. , Mark Fendrick A.
Published: March 2009

One of the common ingredients in all attempts to slow escalating health care costs is to control the utilization of services that provide little or uncertain benefit. To reform existing delivery systems, the organization, provision, and financing of health care need to be evaluated critically. Successful reform requires that more rational methods be used to determine which services to provide. The preferences of physicians, patients, and payers of care do not appear optimal from a societal perspective in choosing health care services. While reducing the use of interventions of little or unknown benefit should save money, a policy to restrict the use of medical services may lead to an unwanted result: the underutilization of interventions of proven clinical benefit. Through the determination of the value—by rigorous assessment of both costs and benefits of available alternatives—in a context sensitive to the unique cultural, political, and economic characteristics of individual nations, the health of the population should be improved and growth of health expenditures constrained. This is the first step in health care reform.
A Cost-Utility Analysis of Laser-Assisted Angioplasty for Peripheral Arterial Occlusions
Authors: Sculpher Mark , Michaels Jonathan , Mckenna Mike , Minor Julia
Published: March 2009

Despite the perception of many people that lasers represent the cutting edge of high-technology medicine, this form of medical technology has been subject to relatively little rigorous evaluation. This dearth of research relates particularly to economic evaluation, where there have been few attempts to justify the high cost of laser equipment. This paper details an economic evaluation of the use of laser technology as a secondary adjunct to angioplasty to treat peripheral arterial occlusions. Using data from a range of sources, including a published randomized trial, a cost-utility model is developed to estimate the costs and benefits of the laser, relative to standard angioplasty. The best available data indicate a cost-effective role for the laser, but important areas of uncertainty exist, including the laser's secondary recanalization rate, which has been estimated on the basis of limited numbers of patients. This uncertainty suggests that further research is required before widespread diffusion of the laser for use in this clinical context.
A Risk Assessment and Control Model for the Failing Björk-Shiley Convexo-Concave Heart Valve
Authors: Koornneef Floor , van Gaalen Geerda L. , de Mol Bas A. J. M.
Published: March 2009

For risk assessment and control of the failing Björk-Shiley convexo-concave heart valve, we present a life cycle-based complex system model and a risk intensity assessment model, allowing consistent analysis of this complex medical problem and identification of all pertinent aspects of product-related risks to patients.
The Measurement of Utility in Multiphase Health States
Authors: Richardson Jeffrey , Hall Jane , Salkeld Glen
Published: March 2009

To examine the validity of the additive quality-adjusted lite year model used to evaluate a multiphase health state, data from a pilot study of mammography were used to determine whether the values assigned to a multiphase postmastectomy health state could be estimated from a combination of the independently rated constituent health state values. The results suggest that they cannot.
Making Choices in Hospital Resources Allocation: The Use of an Assessment Tool to Decide Which New Projects Are Financed
Authors: Durand-Zaleski Isabelle , Leclerq Roland , Bagot Martine , Lemaire François , Revuz Jean , Spetebroodt Yvon , Zafrani Elie-Serge , Rochant Henri
Published: March 2009

We designed a scoring system to rank acute care hospital projects and allocate resources between them. The evaluation tool assessed projects on an ordinal scale; the criteria scored were medical interest, feasibility, interest for teaching and research, and compatibility with the hospital's strategy. Clinical and technical projects were ranked separately. In 1994, 25 new projects, representing a total cost of $1.4 million, were reviewed by two independent reviewers. The scores ranged from 30 to 18 over 36. Projects presented by clinical departments scored higher than projects presented by medicotechnical departments.
Beware of Surrogate Outcome Measures
Authors: Gøtzsche Peter C. , Liberati Alessandro , Torri Valter , Rossetti Luca
Published: March 2009

Surrogate outcome measures may speed up clinical research if they can be measured earlier in a study than the primary outcome of interest. We review the justification for their use and conclude that reliance on them may be harmful. Results obtained with surrogates should therefore be regarded as preliminary. Large, definitive trials with clinically relevant outcomes should always be performed before new interventions are accepted.
Using the Evidence: A Need for Quantity, Not Quality?
Authors: Hyde C. J.
Published: March 2009

The use of research evidence depends on more than its quality. If one considers other factors that influence the use of evidence, the quantity of accessible evidence and initiatives ensuring a wider understanding of it must be equally important. In consequence, improving the quality of research evidence alone will not necessarily lead to its greater use.
Transcutaneous Electrical Nerve Stimulation (TENS): A Technology Assessment
Authors: Reeve Janis , Menon Devidas , Corabian Paula
Published: March 2009

The scientific evidence for clinical effectiveness of transcutaneous electrical nerve stimulation (TENS) for treatment of acute, chronic, and labor and delivery pain is assessed in this paper, and it is concluded that there is little evidence for other than a limited use of TENS. The utilization of TENS in Canadian hospitals and payments for TENS services are addressed. Some practicalities regarding the use and assessment of health technologies are discussed.
Hospital-and Patient-Related Characteristics Determining Length of Hospital Stay for Hip and Knee Replacements
Authors: Rissanen Pekka , Aro Seppo , Paavolainen Pekka
Published: March 2009

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most prestigious health care technologies. Their popularity has grown rapidly, and an increasing proportion of health care resources is allocated to them. We studied patient- and hospital-related factors that cause variation in a major determinant of hospital costs, the length of hospital stay (LOS) for THA and TKA. We gathered data on 10,288 hip and 5,173 knee patients with primary or secondary arthrosis from the Finnish Arthroplasty Register, which we linked with the Finnish Hospital Discharge Register. Patientand hospital-related variations in LOS were explained using regression models. Of the patient-related factors, complications caused the greatest prolongation of hospital stay, but patient's age, gender, and charge category also influenced LOS. Hospital-related factors were major causes of LOS variation. In the hospitals the average case-mix-adjusted LOS ranged from less than a week to 3 weeks. The number of arthroplasties performed in hospital was inversely related to LOS. The within-hospital LOS figures for THA and TKA were strikingly similar and persistent.
Economic Evaluation of HIV Testing Among Intravenous Drug Users: An Analytic Framework and Its Application to Italy
Authors: Villari Paolo , Fattore Giovanni , Siegel Joanna E. , Paltiel A. David , Weinstein Milton C.
Published: March 2009

We performed an economic evaluation of HIV testing among intravenous drug users (IVDUs) in Italy using the analytical framework of cost-effectiveness analysis. A semi-Markov model was developed to calculate costs and life expectancy of a cohort of IVDUs with and without an annual HIV testing program. We also investigated the incremental cost-effectiveness of a hypothetical early treatment to prolong the life expectancy of HIV-infected asymptomatic subjects by 1 year. The testing program is cost saving in the low prevalence scenario (0.05), and costs L 14,000,000 (US $8,400) and L 55,800,000 (US $33,500) per year of life saved in areas of medium (0.3) and high (0.6) prevalence, respectively. The incremental cost-effectiveness of the hypothetical early treatment may compare favorably with other health care interventions. The program may be considered a cost-effective procedure in low and medium prevalence areas. Where prevalence is high, more evidence about the magnitude of the behavior change is needed. In these areas, the availability of an effective early treatment may become the economic rationale for implementing such a program.
Low-Cost Diagnostic Technologies and Clinical Outcomes:The Impact of Inappropriate Utilization
Authors: Lewis Steven , Foreman Jeanette
Published: March 2009

Commodification of low-cost diagnostic technologies (LCDTs) carries the risk of an unintended and potentially worrisome shift in how we conceive of health assessment. Optimizing practice requires a balanced understanding of both the beneficial and harmful impact of the use of LCDTs and the development of system incentives for appropriate use.
Medical and Surgical Supply Costs: Case Study of a Costly Low-Cost Technology
Authors: Thamer Mae , Fitzpatrick Kevin J. , Perry Seymour
Published: March 2009

There is a paucity of research regarding the contribution of “low-cost” technologies to the escalation of medical costs in the United States. We examined total charges for medical and surgical supplies (MSS) among all hospitalized Medicare beneficiaries in 1994; a total of US $16.8 billion was spent on MSS, or $1,397 per hospitalization. For selected surgical procedures, both the proportion of total hospital charges attributed to MSS and the mean charge per hospitalization were considerably higher. Concerns regarding excessive payments for MSS and the lack of accountability by the Medicare program are discussed. Itemization of MSS supplies may serve to eliminate wasteful use and lead to decreased costs.
Costs and Cost-Effectiveness in Hip and Knee Replacements:A Prospective Study
Authors: Rissanen Pekka , Aro Seppo , Sintonen Harri , Asikainen Kimmo , Slätis Pär , Paavolainen Pekka
Published: March 2009

The extensive benefits of the total hip (THA) and knee (TKA) replacements are well documented, but surprisingly little is known about their economics. We assessed costs, cost-effectiveness (C/E), and patient-related C/E variances in THA and TKA from data on 276 THA and 176 TKA patients. Patients with primary arthrosis, primary operation, and total joint replacement were recruited from seven hospitals between March 1991 and June 1992. Their use of health and other welfare services together with health-related quality of life (HRQoL) were measured before the surgery and at 6, 12, and 24 months postoperatively. HRQoL was assessed by the 15D, a 15-dimensional HRQoL instrument, and the Nottingham Health Profile. Costs were assessed from questionnaire responses, the Finnish Hospital Discharge Register, and Finnish Arthroplasty Register. Total hospital costs per patient were 45,000 FIM (US $10,500) for THA and 49,600 FIM (US $11,500) for TKA. Prosthesis costs comprised 21 % of these costs in THA and 24% in TKA. On average, hip patients gained more in terms of HRQoL, and the operations were more cost-effective. The C/E ratio for younger (« 60 years) knee patients did not differ from those in all age groups of hip patients, whereas TKAs in those over 60 years had a worse C/E ratio compared with all other patient subgroups. It was concluded that allocation efficiency can be improved by considering not only the intervention but also patient characteristics such as age. Indeed, the C/E ratio varied more across age groups of knee patients than between average THA and TKA patients.
Total Hip Replacement:The Preoperative Health Status of Patients in Japan Compared with England and the United States
Authors: Imamura Kyoko , Black Nick A.
Published: March 2009

To explore the contribution of health care to the excellent health status enjoyed by the Japanese compared with other industrialized populations, the preoperative health status of a retrospective cohort of 256 patients who underwent total hip replacement in Japan was compared with 301 patients in England (and published data from the United States). Patients in Japan had less severe hip disease, less comorbidity (in particular, less cardiovascular disease), and were in better general health. This finding suggests that health care contributes little to explaining the better health of people in Japan compared with England and the United States.
The Economic Impact of Technical Change in the Local Treatment of Breast Cancer
Authors: Kurdas Chidem
Published: March 2009

Some studies suggest that breast-conserving treatment increases the cost of breast cancer. Estimates from a social perspective show that incremental cost depends on the proportion of lumpectomies done in outpatient facilities and on the demand for reconstructive surgery. Conservative treatment reduces spending within a reasonable range of values.
Healthy Years Equivalents Versus Time Trade-off: Ambiguity on Certainty and Uncertainty
Authors: Rittenhouse Brian E.
Published: March 2009

Preference assessment literature has debated the equivalence of the healthy years equivalents (HYE) and time trade-off (TTO) methods. The central issue is whether the HYE measures preferences under uncertainty. This work shows that the two stages of the HYE first add and then remove the element of uncertainty so that ultimately the technique does not measure preferences under uncertainty. This makes the HYE, at best, a cumbersome equivalent of the TTO.
The Effects of Health Insurance on Access to New Medical Technologies
Authors: Ramsey Scott D. , Hillman Alan L. , Pauly Mark V.
Published: March 2009

We examined the use of percutaneous transluminal coronary angioplasty, kidney stone lithotripsy, and bone marrow transplant among patients with different health insurance plans in California. HMO enrollees were less likely to receive these procedures compared with fee-for-service patients. Our results have implications for the inflationary effects of technology under managed care.
The Patient's Perspective
Authors: Calnan Michael W.
Published: March 2009

The paper outlines the context in which patient's views have been emphasized and the evidence from survey research about the criteria users employ to evaluate health care. Evidence from qualitative research shows that users are ambivalent about modern medicine and are particularly sceptical about the value of drugs and medicine.
Empowering Individuals in the Prevention of Genetic Disease
Authors: Pauker Susan P.
Published: March 2009

As the International Human Genome Project nears the term of a long gestation, the ethical and social implications of complex new genetic technologies will require a new breed of clinicians for a safe delivery. Clinical genetic care has been time intensive as performed by medical specialists. Empowering individuals to take advantage of new opportunities for genetic testing to prevent disease will require clinician education and decision support in the context of individual values.