bluuebunny/crossref_metadata_2025 huggingface dataset:
EQUALITY, BENEVOLENCE, AND RESPONSIVENESS TO AGENT-RELATIVE VALUE
Authors: Mack Eric
Published: December 2002

Do differences in income or wealth matter, morally speaking?
This essay addresses a broader issue than this question
seems to pose. But this broader issue is, I believe,
the salient philosophical issue which this question
actually poses. Let me explain. Narrowly read, the
question at hand is concerned only with inequality of income
or wealth. It asks us to consider whether inequality of income
or wealth as such is morally problematic. On this
construal, the question invites us to consider whether the bare
fact that Joshua has a greater income or net worth than Rebekah
is a morally defective social state of affairs. Is there at
least a significant moral presumption on behalf of equality
of income or wealth such that, if an inequality of income or
wealth obtains vis-à-vis Joshua and Rebekah, that inequality
ought to be nullified unless some impressive positive justification
for the inequality can be provided? On this narrow reading,
the salient issue is whether there exists in particular
an egalitarian presumption with respect to income or wealth.
But I believe that the genuinely salient issue here is whether
there exists in general an egalitarian presumption
with respect to whatever factual condition of individuals
one is supposed to attend to when assessing social states of
affairs. The crucial question is not whether income or wealth or
utility or well-being is the condition the unequal distribution of
which is as such morally problematic.
BIOETHICS AND THE PROBLEM OF PLURALISM
Authors: Ainslie Donald C.
Published: December 2002

The state that we inhabit plays a significant role in shaping
our lives. For not only do its institutions constrain the kinds
of lives we can lead, but it also claims the right to punish
us if our choices take us beyond what it deems to be appropriate
limits. Political philosophers have traditionally tried to justify
the state's power by appealing to their preferred theories
of justice, as articulated in complex and wide-ranging moral
theories—utilitarianism, Kantianism, and the like. One
of John Rawls's greatest contributions to political philosophy
has been his recognition that this is the wrong way for this
field to approach its task. He points to what he calls “the
fact of reasonable pluralism,” which is the incontestable
fact that in a free society people striving to lead their lives
ethically will subscribe to conflicting moral and religious
doctrines, many of which will be “reasonable” in
the special sense of leaving their adherents willing to cooperate
with those with whom they have moral disagreements. And this means
that political philosophers can no longer rely on any particular
“comprehensive” doctrine in their attempts to justify
the state. For doing so would be unfair to those who subscribe
to a conflicting reasonable doctrine; it would mean that the
coercive power of the state would not be justified to them
in terms they can accept, even while they were forced
to abide by its terms.
PRAGMATISM IN BIOETHICS: BEEN THERE, DONE THAT
Authors: Arras John D.
Published: December 2002

It has often been remarked that bioethics is a quintessentially
American phenomenon. Broadly speaking, bioethics as a field
has tended to enshrine the value of autonomy, it places individual
rights above communal well-being, and it has adopted a largely
permissive and optimistic view of emerging biotechnologies.
In contrast to much European thinking at the intersection of
ethics and medicine, American-style bioethics has been resolutely
middlebrow, eschewing grand philosophical schemes in favor of
pragmatic policy-making and democratic consensus. It was, then,
perhaps only a matter of time before various theorists began
proposing a marriage between bioethics and pragmatism, which
is the homegrown American philosophy.
INFORMATION(AL) MATTERS: BIOETHICS AND THE BOUNDARIES OF
THE PUBLIC AND THE PRIVATE
Authors: Parker Lisa S.
Published: December 2002

In this essay, I argue that the way American bioethics has
traditionally conceived of the distinction between public and
private has given rise to some ethically problematic blind spots
in its analyses to date. Furthermore, I argue that bioethics's
view of the public and private spheres has reinforced a shortsighted
view of bioethics's analytical sphere of influence. In particular,
it has led bioethics to conceptualize issues largely from the
perspective of health professionals, eschewing analyses of the
problems of health and health information that patients and
their intimates face outside of professional relationships and
traditional health-care settings. It has also led some bioethical
analyses to reflect, and to some degree reinforce, relationships
of power that they might instead challenge.
BIOETHICS AS SOCIAL PHILOSOPHY
Authors: Wildes Kevin Wm.
Published: December 2002

When many people think of bioethics, they think of gripping
issues in clinical medicine such as end-of-life decision-making,
controversies in biomedical research such as that over work
with stem cells, or issues in allocating scarce health-care
resources such as organs or money. The term “bioethics”
may evoke images of moral controversies being discussed on news
programs and talk shows. But this “controversy of the
day” focus often treats ethical issues in medicine
superficially, for it addresses them as if they could be examined
and discussed in isolation from the context in which they are
situated. Such a focus on the latest controversies fails to
take into account that medicine is a social institution and
that the controversies in bioethics often reflect deeper social
and moral issues that transcend the boundaries of medicine and
ethics. If one moves beyond the issue-of-the-day approach to
bioethics, one can see that the field must address these deeper
issues.
SOCIAL MORAL EPISTEMOLOGY
Authors: Buchanan Allen
Published: December 2002

The distinctive aim of applied ethics is to provide guidance
as to how we ought to act, as individuals and as shapers of
social policies. In this essay, I argue that applied ethics as
currently practiced is inadequate and ought to be transformed to
incorporate what I shall call social moral epistemology. This is a
branch of social epistemology, the study of the social practices and
institutions that promote (or impede) the formation, preservation,
and transmission of true beliefs. For example, social
epistemologists critically evaluate the comparative advantages
of adversarial versus inquisitorial criminal proceedings as
mechanisms for the discovery of truth.
WHY HEALTH IS NOT SPECIAL: ERRORS IN EVOLVED BIOETHICS INTUITIONS
Authors: Hanson Robin
Published: December 2002

There is a widespread feeling that health is special; the rules
that are usually used in other policy areas are not applied
in health policy. Health economists, for example, tend to be
reluctant to offer economists' usual prescription of
competition and consumer choice, even though they have largely
failed to justify this reluctance by showing that health economics
involves special features such as public goods, externalities,
adverse selection, poor consumer information, or unusually severe
consequences.
POWER, INTEGRITY, AND TRUST IN THE MANAGED PRACTICE OF MEDICINE:
LESSONS FROM THE HISTORY OF MEDICAL ETHICS
Authors: McCullough Laurence B.
Published: December 2002

Bioethics as a field began some years before it was finally
named in the early 1970s. In many ways, bioethics originated in
response to urgent matters of the moment, including the controversy
over disconnecting Karen Quinlan's respirator, the egregious
paternalism of Donald Cowart's doctors in the famous “Dax”
case, the abuse of research subjects in the notorious Tuskegee
Syphilis Study, and the need to devise an intellectual framework
for the development of federal regulations to protect human
subjects of research. The phrase “new and unprecedented”
became a common description of the topics and issues to which people
who later came to be called “bioethicists” responded. It
should come as no surprise that bioethics and its practitioners soon
came to the self-understanding that their work was new and
unprecedented, much as the innovations of biomedical science
and their clinical applications were thought to be.
THE DISTRIBUTION OF LIFE-SAVING MEDICAL RESOURCES: EQUALITY,
LIFE EXPECTANCY, AND CHOICE BEHIND THE VEIL
Authors: Stein Mark S.
Published: December 2002

In this essay, I survey egalitarian and utilitarian approaches
to the distribution of scarce life-saving medical resources.
In my view, the major criterion for the distribution of scarce
life-saving medical resources (hereinafter sometimes the
“distribution of life”) should be life expectancy:
we should distribute life so as to maximize life-years. In Section
II, I discuss the life-year maximization approach and situate
it within utilitarian theory.
PHARMACOGENETIC INTERVENTIONS, ORPHAN DRUGS, AND DISTRIBUTIVE
JUSTICE: THE ROLE OF COST-BENEFIT ANALYSIS
Authors: Rai Arti K.
Published: December 2002

With the human genome mapped, and with the mapping of more
than one hundred animal genomes in progress, the amount of genetic
data available is increasing exponentially. This exponential
increase in data is having an immediate impact on the process of
drug development. By using techniques of information technology to
manipulate data regarding the genes, proteins, and biochemical
pathways associated with various diseases, scientists are beginning
to be able to design drugs in a systematic fashion. In the context
of any given disease, scientists look to see whether a gene, a protein
for which the gene codes, or another protein in the relevant biochemical
pathway could be the “target” biological molecule, the
“knocking out” of which would halt or slow the
disease's progression. Once a target molecule has been
identified and characterized structurally, drug therapies that
would be likely to knock out this target can be identified and
tested systematically. The merger of information technology
and genetic technology has changed the process of pharmaceutical
development so much that a new term—bioinformatics—has
been coined to describe this new approach to such development.
THE UBIQUITY AND UTILITY OF THE THERAPEUTIC MISCONCEPTION
Authors: Dresser Rebecca
Published: December 2002

The term “therapeutic misconception” was coined
in 1982 by Paul Appelbaum, Loren Roth, and Charles Lidz. Appelbaum
and his colleagues interviewed participants in several psychiatric
studies, including a drug trial with a placebo control arm.
Appelbaum's group found that many people were unaware of
the differences between participating in a study and receiving
treatment in the clinical setting. Rather than understanding
these differences, study participants tended to believe that
therapy and research were governed by the same primary goal:
to advance the individual patient's best interests.
Appelbaum's group labeled this mistaken belief the therapeutic
misconception.
INDIFFERENCE OF SUBJECTS: AN ALTERNATIVE TO EQUIPOISE IN
RANDOMIZED CLINICAL TRIALS
Authors: Veatch Robert M.
Published: December 2002

The physician who upholds the Hippocratic oath is supposed
to be loyal to his or her patients. This requires choosing only
the therapy that the physician believes is best for the patient.
However, knowing what is best requires randomized clinical trials.
Thus, clinicians must be willing to recruit their patients to
be assigned at random to one of two therapies (or perhaps to
a therapy or a placebo) in order to determine which is best
based on the highest standards of pharmacological science.
THE BIOPHILOSOPHICAL BASIS OF WHOLE-BRAIN DEATH
Authors: Bernat James L.
Published: December 2002

Notwithstanding these wise pronouncements, my project here
is to characterize the biological phenomenon of death of the
higher animal species, such as vertebrates. My claim is that
the formulation of “whole-brain death” provides
the most congruent map for our correct understanding of the
concept of death. This essay builds upon the foundation my
colleagues and I have laid since 1981 to characterize the concept
of death and refine when this event occurs. Although our society's
well-accepted program of multiple organ procurement for
transplantation requires the organ donor first to be dead, the
concept of brain death is not merely a social contrivance to
permit us to obtain the benefits of organ procurement. Rather,
the concept of whole-brain death stands independently as the most
accurate biological representation of the demise of the human organism.
FREEDOM AND RESPONSIBILITY IN GENETIC TESTING
Authors: Brody Baruch A.
Published: December 2002

Public statements by various international groups emphasize
that decisions to undergo genetic screening, either for
disease-carrier status or for predisposition-to-disease status,
and decisions about the use of the resulting information should
be made voluntarily by the party to be screened. For example,
the World Medical Association, in its Declaration on the Human
Genome Project, says, “One should respect the will of
persons screened and their right to decide about participation
and about the use of the information obtained.” Giving
this principle a name, “voluntarism,” the Council for
International Organizations of Medical Sciences, in its Declaration
of Inuyama (the host city for the conference), announced that
“voluntarism should be the guiding principle in the provision
of genetic services.
FALSE-NEGATIVE RESULTS IN SCREENING PROGRAMS
Authors: Petticrew Mark , Sowden Amanda , Lister-Sharp Deborah
Published: December 2002

Objectives: Assessment of the appropriateness of screening programs involves consideration of the harms as well as the benefits. These harms include the risk of false-negative results, the consequences of which have remained underinvestigated. This paper reports the results of a systematic literature review that aimed to assess the medical psychological, economic, and legal consequences of false-negative results in national screening programs.

Methods: The review included a comprehensive literature search and contact with experts to identify relevant literature. Most studies that were identified presented only anecdotal evidence. However, thirteen studies presented quantitative information on medical consequences of false negatives, eight studies presented information on psychological consequences, and two studies presented information on economic consequences.

Results: The strength of evidence from most of the primary studies was low. There is some evidence, however, that false-negative results may have a large legal impact. There is also a consensus in the literature that false negatives may have a negative impact on public confidence on screening; evidence is however limited.

Conclusions: False negatives are evident even in high-quality screening programs. They may have the potential to delay the detection of breast and cervical cancer, but there is little evidence to help in assessing their psychological consequences. They also may lead to legal action being taken by those affected and may reduce public confidence in screening. Their impact may be reduced by provision of full information to participants about the benefits and limitations of screening programs and by increasing public education on these issues.
DIALYSIS FOR END-STAGE RENAL DISEASE
Authors: Kirby Liz , Vale Luke
Published: December 2002

Objective: Renal replacement therapy (RRT) is essential for maintenance of life for those with end-stage renal disease. However, there remain many areas of uncertainty about which method of RRT should be chosen. This paper reports an economic model based on a systematic review that attempts to determine which method of dialysis, continuous ambulatory peritoneal dialysis (CAPD) or hemodialysis, a patient should have as the initial method of RRT.

Methods: A systematic review and a costing exercise carried out in a Scottish hospital were used to populate a Markov model. Scenario analysis was used to model plausible variations in variables included in the model.

Results: In 8 of the 16 scenarios developed hemodialysis dominated CAPD. In a further eight scenarios, the cost per life-year displayed considerable variability, ranging from between £5,000 to £51,000. The higher costs per life-year were associated with minimum estimates of additional survival for a patient starting RRT on hospital hemodialysis.

Conclusion: It may be more cost-effective to manage patients starting on RRT with hospital hemodialysis than CAPD. This has particular implications for the United Kingdom, given that up to 50% of new patients receive CAPD.
SCREENING AND CLINICAL MANAGEMENT OF PROSTATE CANCER
Authors: Peters Saskia M.A.B. , Jovell Albert J. , García-Altes Anna , Serra-Prat Mateu
Published: December 2002

Objectives: The objectives of the study were to identify the current standards of clinical practice regarding prostate cancer screening in western Europe, Canada, and the United States, and to highlight major characteristics of current prostate cancer screening programs or patterns of practice.

Methods: We performed a semi-structured interview by means of a self-administered questionnaire sent by fax to 26 institutes pertaining to the International Network of Agencies for Health Technology Assessment.

Results: None of the countries surveyed had a formal national screening policy. Despite that, all the countries answering the questionnaire had discretionary, public-financed screening practices. Moreover, some scientific and professional organizations recommended population screening for prostate cancer, and few of the surveyed countries offered it as experimental practice within a randomized controlled trial. Survey results showed variation regarding screening policies, in particular test of choice, age cut-off points, and treatment prescribed for positive test results.

Conclusions: Despite the lack of conclusive evidence on the benefits of prostate cancer screening, the availability of simple and easy-to-administer tests has lead to an enormous variation on screening policies around the world. Practice variations also affect prostate cancer therapy.
THE PRACTICE OF DISCOUNTING IN ECONOMIC EVALUATIONS OF HEALTHCARE INTERVENTIONS
Authors: Smith David H. , Gravelle Hugh
Published: December 2002

Objectives: Discounting of costs in health-related economic evaluation is generally regarded as uncontroversial, but there is disagreement about discounting health benefits. We sought to explore the current recommendations and practice in health economic evaluations with regard to discounting of costs and benefits.

Methods: Recommendations for best practice on discounting for health effects as set out by government agencies, regulatory bodies, learned journals, and leading health economics texts were surveyed. A review of a sample of primary literature on health economic evaluations was undertaken to ascertain the actual current practice on discounting health effects and costs.

Results: All of the official sources recommended a positive discount rate for both health effects and costs, and most recommended a specific rate (range, 1% to 8%). The most frequently specified rates were 3% and 5%.

A total of 147 studies were reviewed; most of these used a discount rate for health of either 0% (n = 50) or 5% (n = 67). Over 90% of studies used the same discount rate for both health and cost. While 28% used a zero rate for both health and cost, in 64% a nonzero rate was used for both. Studies where the health measure was in natural clinical units (direct) were significantly more likely to have a zero discount rate.

Conclusion: The finding that 28% of studies did not discount costs or benefits is surprising and concerning. A lower likelihood of discounting for benefits when they are in natural units may indicate confusion regarding the rationale for discounting health effects.
A LOGIT MODEL FOR THE EFFECT OF TELECARDIOLOGY ON ACUTE NEWBORN TRANSFERS
Authors: Rendina Mark C. , Carrasco Noel , Wood Brian , Cameron Andrew , Bose Carl
Published: December 2002

The deregionalization of neonatal intensive care in the United States has shifted the site of care for many newborn infants away from academic medical centers where subspecialty support is available.

Objective: To investigate the effect of immediate echocardiogram interpretation via telemedicine on rates of neonatal transfer to academic medical centers.

Methods: A logit model was developed to predict the probability of transfer from two regional level 3 neonatal intensive care units to academic medical centers. One of these units implemented a telecardiology program and the other acted as a comparison institution with on-site cardiology expertise. The telecardiology intervention began 18 months into the 36-month study period.

Subjects: Infants (n = 2,142) admitted to neonatal intensive care at either of the two institutions during calendar years 1994 through 1996.

Results: A statistically significant reduction in the rate of transfer to academic medical centers was observed. Telecardiology was associated with a 58% reduction of such transfers (p = .001, 95% CI = 30%, 75%). No such reduction was noted at the comparison institution. It is estimated that approximately 30 transfers were eliminated during the study period, resulting in the elimination of approximately $150,000 in hospital charges. In addition, the infants that were transferred after the adoption of telemedicine were more often transferred to their telemedicine partner institution (p < .02).
INTRODUCTION
Authors: Luce Bryan R. , Shih Ya-Chen Tina , Claxton Karl
Published: December 2002

Until the mid-1980s, most economic analyses of healthcare technologies were based on decision theory and used decision-analytic models. The goal was to synthesize all relevant clinical and economic evidence for the purpose of assisting decision makers to efficiently allocate society's scarce resources. This was true of virtually all the early cost-effectiveness evaluations sponsored and/or published by the U.S. Congressional Office of Technology Assessment (OTA) (15), Centers of Disease Control and Prevention (CDC), the National Cancer Institute, other elements of the U.S. Public Health Service, and of healthcare technology assessors in Europe and elsewhere around the world. Methodologists routinely espoused, or at minimum assumed, that these economic analyses were based on decision theory (8;24;25). Since decision theory is rooted in—in fact, an informal application of—Bayesian statistical theory, these analysts were conducting studies to assist healthcare decision making by appealing to a Bayesian rather than a classical, or frequentist, inference approach. But their efforts were not so labeled. Oddly, the statistical training of these decision analysts was invariably classical, not Bayesian. Many were not—and still are not—conversant with Bayesian statistical approaches.
INTRODUCTION TO BAYESIAN REASONING
Authors: Hornberger John
Published: December 2002

Interest in Bayesian analyses has increased recently, in part as a response to policy makers wanting sound scientific bases for health technology assessments, and associated healthcare funding decisions. This paper provides a brief and simplified description of Bayesian reasoning. Bayes is illustrated in a clinical setting of an expert helping a woman understand the potential risk of passing on an inheritable disease (hemophilia) to her next child, based on disease occurrence in two living children. The illustration describes fundamental concepts and derivations, such as Bayes theorem, likelihood functions, prior probability, and posterior probability. A second illustration shows the use of Bayes for interpreting clinical trial results. The uncertainty in the clinical effect before and after the trial analyses has been completed is characterized by the Bayes prior and posterior probabilities, respectively. Techniques are also shown for estimating the potential loss (e.g., in lives lost) for making the wrong decision with and without knowledge of the trial results, an estimation that cannot be carried out using techniques of hypotheses testing associated with the frequentist school of statistics. Information from Bayes analysis then may be used to help policy makers decide, or justify, whether the analyses provides a sufficient basis for making a treatment recommendation, or whether there remains a need to request more information. Subsequent papers in this volume offer additional examples and clarification of the use of Bayes in clinical practice and in interpretation of clinical studies.
ESTIMATING THE BAYESIAN LOSS FUNCTION
Authors: Bala Mohan V. , Mauskopf Josephine
Published: December 2002

Current health economic literature does not provide clear guidelines on how uncertainty around cost-effectiveness estimates should be incorporated into economic decision models. Bayesian analysis is a promising alternative to classical statistics for incorporating uncertainty in economic analysis. Estimating a loss function that relates outcomes to societal welfare is a key component of Bayesian decision analysis. Health economists commonly compute the loss function based on the quality-adjusted life-years associated with each outcome. However, if welfare economics is adopted as the theoretical foundation of the analysis, a loss function based in cost-benefit analysis (CBA) may be more appropriate. CBA has not found wide use in health economics due to practical issues associated with estimating such a loss function. In this paper, we present a method based in conjoint analysis for estimating the CBA loss function that can be applied in practice. We illustrate the use of the methodology using data from a pilot study.
BAYESIAN VALUE-OF-INFORMATION ANALYSIS
Authors: Claxton Karl , Neumann Peter J. , Araki Sally , Weinstein Milton C.
Published: December 2002

A framework is presented that distinguishes the conceptually separate decisions of which treatment strategy is optimal from the question of whether more information is required to inform this choice in the future. The authors argue that the choice of treatment strategy should be based on expected utility, and the only valid reason to characterize the uncertainty surrounding outcomes of interest is to establish the value of acquiring additional information. A Bayesian decision theoretic approach is demonstrated through a probabilistic analysis of a published policy model of Alzheimer's disease. The expected value of perfect information is estimated for the decision to adopt a new pharmaceutical for the population of patients with Alzheimer's disease in the United States. This provides an upper bound on the value of additional research. The value of information is also estimated for each of the model inputs. This analysis can focus future research by identifying those parameters where more precise estimates would be most valuable and indicating whether an experimental design would be required. We also discuss how this type of analysis can also be used to design experimental research efficiently (identifying optimal sample size and optimal sample allocation) based on the marginal cost and marginal benefit of sample information. Value-of-information analysis can provide a measure of the expected payoff from proposed research, which can be used to set priorities in research and development. It can also inform an efficient regulatory framework for new healthcare technologies: an analysis of the value of information would define when a claim for a new technology should be deemed substantiated and when evidence should be considered competent and reliable when it is not cost-effective to gather any more information.
A BAYESIAN APPROACH TO STOCHASTIC COST-EFFECTIVENESS ANALYSIS
Authors: Briggs Andrew H.
Published: December 2002

The aim of this paper is to discuss the use of Bayesian methods in cost-effectiveness analysis (CEA) and the common ground between Bayesian and traditional frequentist approaches. A further aim is to explore the use of the net benefit statistic and its advantages over the incremental cost-effectiveness ratio (ICER) statistic. In particular, the use of cost-effectiveness acceptability curves is examined as a device for presenting the implications of uncertainty in a CEA to decision makers. Although it is argued that the interpretation of such curves as the probability that an intervention is cost-effective given the data requires a Bayesian approach, this should generate no misgivings for the frequentist. Furthermore, cost-effectiveness acceptability curves estimated using the net benefit statistic are exactly equivalent to those estimated from an appropriate analysis of ICERs on the cost-effectiveness plane. The principles examined in this paper are illustrated by application to the cost-effectiveness of blood pressure control in the U.K. Prospective Diabetes Study (UKPDS 40). Due to a lack of good-quality prior information on the cost and effectiveness of blood pressure control in diabetes, a Bayesian analysis assuming an uninformative prior is argued to be most appropriate. This generates exactly the same cost-effectiveness results as a standard frequentist analysis.
BAYESIAN COST-EFFECTIVENESS ANALYSIS
Authors: Fryback Dennis G. , Chinnis James O. , Ulvila Jacob W.
Published: December 2002

A desirable element of cost-effectiveness analysis (CEA) modeling is a systematic way to relate uncertainty about input parameters to uncertainty in the computational results of the CEA model. Use of Bayesian statistical estimation and Monte Carlo simulation provides a natural way to compute a posterior probability distribution for each CEA result. We demonstrate this approach by reanalyzing a previously published CEA evaluating the incremental cost-effectiveness of tissue plasminogen activator compared to streptokinase for thrombolysis in acute myocardial infarction patients using data from the GUSTO trial and other auxiliary data sources. We illustrate Bayesian estimation for proportions, mean costs, and mean quality-of-life weights. The computations are performed using the Bayesian analysis software WinBUGS, distributed by the MRC Biostatistics Unit, Cambridge, England.
AN ELEMENTARY INTRODUCTION TO BAYESIAN COMPUTING USING WINBUGS
Authors: Fryback Dennis G. , Stout Natasha K. , Rosenberg Marjorie A.
Published: December 2002

Bayesian statistics provide effective techniques for analyzing data and translating the results to inform decision making. This paper provides an elementary tutorial overview of the WinBUGS software for performing Bayesian statistical analysis. Background information on the computational methods used by the software is provided. Two examples drawn from the field of medical decision making are presented to illustrate the features and functionality of the software.
CAN BAYESIAN METHODS MAKE DATA AND ANALYSES MORE RELEVANT TO DECISION MAKERS?
Authors: Sheingold Steven H.
Published: December 2002

Decision making in health care has become increasingly reliant on information technology, evidence-based processes, and performance measurement. It is therefore a time at which it is of critical importance to make data and analyses more relevant to decision makers. Those who support Bayesian approaches contend that their analyses provide more relevant information for decision making than do classical or “frequentist” methods, and that a paradigm shift to the former is long overdue. While formal Bayesian analyses may eventually play an important role in decision making, there are several obstacles to overcome if these methods are to gain acceptance in an environment dominated by frequentist approaches. Supporters of Bayesian statistics must find more accommodating approaches to making their case, especially in finding ways to make these methods more transparent and accessible. Moreover, they must better understand the decision-making environment they hope to influence. This paper discusses these issues and provides some suggestions for overcoming some of these barriers to greater acceptance.
USING DATA TO ENHANCE THE EXPERT PANEL PROCESS
Authors: Oishi Sabine M. , Morton Sally C. , Moore Alison A. , Beck John C. , Hays Ron D. , Spritzer Karen L. , Partridge Jennifer M. , Fink Arlene
Published: December 2002

Objective: To enhance the validity of a well-known expert panel process, we used data from patient surveys to identify and correct rating errors.

Methods: We used the two-round RAND/UCLA panel method to rate indications of harmful (presence of problems), hazardous (at risk for problems), and nonhazardous (no known risks) drinking in older adults. Results from the panel provided guidelines for classifying older individuals as harmful, hazardous, or nonhazardous drinkers, using a survey. The classifications yielded unexpectedly high numbers of harmful and hazardous drinkers. We hypothesized possible misclassifications of drinking risks and used the survey data to identify indications that may have led to invalid ratings. We modified problematic indications and asked three clinician panelists to evaluate the clinical usefulness of the modifications in a third panel round. We revised the indications based on panelist response and reexamined drinking classifications.

Results: Using the original indications, 48% of drinkers in the sample were classified as harmful, 31% as hazardous, and 21% as nonhazardous. A review of the indications revealed framing bias in the original rating task and vague definitions of certain symptoms and conditions. The modified indications resulted in classifications of 22% harmful, 47% hazardous, and 31% nonhazardous drinkers.

Conclusions: Analysis of survey data led to identification and correction of specific errors occurring during the panel-rating process. The validity of the RAND/UCLA method can be enhanced using data-driven modifications.
PROVIDING HEALTH INFORMATION TO WOMEN
Authors: Moyer Cheryl A. , Vishnu Leilanya O. , Sonnad Seema S.
Published: December 2002

Objectives: We were interested in health coverage in women's magazines in the United States and how it compared with articles in medical journals, women's health interests, and women's greatest health risks.

Methods: We examined 12 issues of Good Housekeeping (GH) and Woman's Day (WD) and 63 issues of the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA). We tallied the most common health questions of women presenting to the University of Michigan's Women's Health Resource Center (WHRC) during the same period.

Results: Less than a fifth of the magazine articles dealt with health-related topics. Of those, a third dealt with diet, with the majority emphasizing weight loss rather than eating for optimal health. Few of the articles cited research studies, and even fewer included the name of the journal in which the study was published. In JAMA and NEJM, less than one-fifth of original research studies dealt with women's health topics, most commonly pregnancy-related issues, hormone replacement therapy, breast and ovarian cancer, and birth defects. At the same time, the most common requests for information at the WHRC related to pregnancy, fertility, reproductive health, and cancer.

Conclusion: The topics addressed in women's magazines do not appear to coincide with the topics addressed in leading medical journals, nor with women's primary health concerns or greatest health risks. Information from women's magazines may be leading women to focus on aspects of health and health care that will not optimize risk reduction.
TIME COSTS ASSOCIATED WITH CERVICAL CANCER SCREENING
Authors: Shireman Theresa I. , Tsevat Joel , Goldie Sue J.
Published: December 2002

Objectives: Time costs borne by women when undergoing cervical cancer screening have rarely been elucidated, although such costs may pose substantial barriers to care. The purpose of this project was to quantify the opportunity costs associated with cervical cancer screening in young women attending Planned Parenthood Clinics.

Methods: We conducted a self-report survey of 105 women from six clinics to measure travel, waiting, and exam times associated with cervical cancer screening. Respondents recorded their time of arrival and departure, length of time in the waiting room, age, income level, and hours per week they worked outside of the home. Time costs were valued three ways: through self-reported hourly wage, age- and gender-adjusted minimum earnings, and national age- and gender-adjusted hourly wages.

Results: Respondents were on average 24 years old, worked 29 hours per week outside the home, and earned less than $20,000 per year. Mean time for one-way travel was 18.7 minutes; waiting room time was 16.9 minutes; and exam time was 50.8 minutes. Time costs were estimated to be $14.08 per visit based upon the self-reported hourly wage; $16.46 per visit based upon age- and gender-adjusted minimum earnings; and $19.63 per visit based upon age- and gender-adjusted national wage rates.

Conclusions: Time costs associated with cervical cancer screening represent an important opportunity cost and should be considered in studies attempting to identify barriers to screening adherence. Our results indicate that time costs accounted for up to 25% of cervical cancer screening costs. Time costs should be identified, measured, valued, and included in cost-effectiveness analyses of cervical cancer screening.
THE ACCURACY AND EFFECTIVENESS OF ROUTINE POPULATION SCREENING WITH MAMMOGRAPHY, PROSTATE-SPECIFIC ANTIGEN, AND PRENATAL ULTRASOUND
Authors: Woolf Steven H.
Published: December 2002

Objective: To review published data regarding the accuracy and effectiveness of three screening tests: mammography, prostate-specific antigen (PSA), and prenatal ultrasound.

Methods: Published evidence regarding the accuracy and effectiveness of the three tests was collected by computerized literature search and supplemented by manual review of relevant bibliographies.

Results: Screening mammograms lower breast cancer mortality by about 20%. Most data come from women aged 50–64 years; women aged 40–49 years may also benefit, but the absolute risk reduction is lower. Up to 1,500 to 2,500 women must undergo screening to prevent one death from breast cancer. Mammograms miss approximately 12% to 37% of cancers, generate false-positive results, and cause anxiety while abnormal results are evaluated. PSA screening can detect 80% to 85% of prostate cancers but has a high false-positive rate. There is little direct evidence that early detection reduces morbidity or mortality. Indirect evidence includes a trend toward earlier stage tumors and steadily declining mortality rates in geographic areas where PSA screening has become common. Potential harms include the morbidity associated with evaluating abnormal results, and complications from treatment (e.g., impotence, incontinence). The overall balance of benefits and harms remains uncertain in the absence of better evidence. Prenatal ultrasound may reduce perinatal mortality, primarily through elective abortions for congenital anomalies, but does not appear to lower live birth rates. Although ultrasound has no proven effect on neonatal morbidity, it provides more accurate estimates of gestational age that prevent unnecessary inductions for post-term pregnancy. Screening detects multiple gestations, congenital anomalies, and intrauterine growth retardation, but direct health benefits from having this knowledge are unproved. Ultrasound has both positive and negative psychological effects on parents. The scans do not appear to harm childhood development.

Conclusions: Even for the most established screening tests, the appropriateness of routine testing depends on subjective value judgments about the quality of supporting evidence and about the trade-offs between benefits and harms. Individuals, clinicians, policy makers, and governments must weigh the evidence in light of these values and the constraints imposed by available resources.
SCREENING IN AUSTRIA
Authors: Wild Claudia
Published: December 2002

Objective: To study cases of screening in Austria to learn about national strategies to handle the health policy challenge of early detection of widespread diseases and about the outcome of those strategies. The article describes three healthcare interventions (mammography, PSA testing, and routine use of ultrasound in pregnancy) and the instruments of Austrian health policy that are used—with or without explicit intention—to enforce or to control the widespread use of (early) diagnoses.

Methods: Data and information collection on healthcare services, their accessibility, rate of use, expert consensus, and official regulations. For all three case studies, expert interviews were carried out with main actors.

Results: Risk-group screening is not a priority in Austrian federal health policy. Although health promotion and prevention is a national task, examinations for early detection of specific diseases (i.e., carcinoma) are left to the health insurance funds, which delegate the decision to offer early diagnoses to their contracted physicians. In this opportunistic screening, general practitioners or specialists are encouraged by their health insurance funds or motivated by professional guidelines to offer certain examinations.

Conclusions: Screening is a coordinated effort to acquire a grasp of a common disease at an early stage in a specified population. To achieve this objective, a culture of coordination and centralization has to be implemented. The collection of data is an essential element in coordination of decentralized medical interventions as much as quality control is an essential task in looking at and comparing the outcome of interventions. In the three case studies, neither of these two essential criteria were met. Evaluations and scientific evidence on the effectiveness of interventions were not used.
IMPACT OF HEALTH TECHNOLOGY ASSESSMENT ON PREVENTIVE SCREENING IN BELGIUM
Authors: Vermeulen Veerle , Coppens Katja , Kesteloot Katrien
Published: December 2002

Objective: To describe how scientific evidence has influenced healthcare policy making in Belgium in the field of sickness prevention for mammography, PSA testing in prostate cancer screening, and use of ultrasound in pregnancy.

Methods: Review of published and gray literature and interviews with stakeholders and experts.

Results: At the end of 1999, a systematic national/regional screening program had not yet been implemented for any of the three screening strategies. A systematic breast cancer screening program is being prepared for implementation only in Flanders. This limited impact can be attributed to the fragmentation in healthcare policy, the different options among the different regions, fragmentation in healthcare practice, the strong impact of healthcare stakeholders (provider groups and sickness funds) on decision making, and limited attention to scientific evidence in health policy and technology assessment.

Conclusions: Health technology assessment has had very little impact on policy and practice in use of mammography, PSA testing, and ultrasound in pregnancy in Belgium.
EVALUATION OF PREVENTIVE TECHNOLOGIES IN GERMANY
Authors: Perleth Matthias , Busse Reinhard , Gibis Bernhard , Brand Angela
Published: December 2002

Objective: In this article, three preventive strategies—mammography screening for breast cancer, PSA screening for prostate cancer, and routine ultrasound in normal pregnancy—are discussed in the context of German health care.

Methods: Epidemiologic data and German studies evaluating different aspects of these preventive measures were identified and analyzed.

Results: Only a few studies could be identified that investigate these preventive measures. Despite sufficient evidence, in part derived from a German study, there is not yet a mammography screening program. In contrast, ultrasound in pregnancy is offered routinely, although there are controversies regarding the benefit of this practice. PSA screening is not offered as part of the screening program for prostate cancer. However, PSA tests as well as mammographies are done in large numbers in German ambulatory care—a practice that could be considered wild or opportunistic screening.

Conclusions: These case studies show that preventive programs and practices in Germany are not sufficiently based on sound evidence. The paucity of evaluation activities related to prevention in Germany is probably due to the low threshold to introduce new preventive programs into the German healthcare system in the past.
MAMMOGRAPHY, ROUTINE ULTRASONOGRAPHY IN PREGNANCY, AND PSA SCREENINGS IN ITALY
Authors: Favaretti Carlo , De Pieri Paolo
Published: December 2002

Objective: To present current scientific statements and practice on mammography, ultrasonography in pregnancy, and PSA within the Italian National Health Service (NHS).

Methods: Information on the three screenings was found in several position papers prepared by working groups at national and regional levels.

Results: For mammography the adjusted mortality rate for breast cancer increased in the last four decades and decreased in the last few years. Only 4.9% of women aged 50–70 years are covered by screening. In 1996 a consensus paper stated that biennial examination for women aged 50–69 years should be offered to reduce breast cancer mortality. A national program for breast cancer screening was launched under the responsibility of regional governments, but data about its implementation are not yet available. Regarding PSA screening, the results show that prostate cancer is the fourth most frequent neoplasm in males. A formal evaluation of prostate cancer screening was done in 1995 by the National Research Council and the Italian Association for Cancer Research; they did not recommend the NHS implement this service. In the National Health Plan 1998–2000, prostate cancer screening is not mentioned. So far, an organized and standardized screening program, based on routine PSA testing, does not exist in Italy. Nevertheless, a lot of PSA tests are performed at the clinical level to detect early prostate cancers. The results with regard to routine ultrasonography in pregnancy show that in 1996 the birth rate was 9.30 per 1,000 inhabitants, with 536,740 live births. In the period from 1992–94, the percentage of babies with a birth weight less than 2,500 gm and less than 1,500 gm were 5.85% and 0.91%, respectively. A formal screening program for detecting fetal growth retardation, based on the routine ultrasonography in the third trimester of the normal pregnancy, doesn't exist in Italy, but this test is widely performed. It is paid for under NHS coverage.

Conclusion: In 1998 the National Health Plan 1998–2000 stated that the NHS should offer only evidence-based preventive and diagnostic interventions and stressed the importance of appropriate use of health technology.