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Biomedical subjects

A M Garber

Publications and source records attributed to A M Garber.

At least 19 recordsLinked to original sources
PubMed2002

Quality of life assessment software for computer-inexperienced older adults: multimedia utility elicitation for activities of daily living.

Functional status as measured by dependencies in the Activities of Daily Living (ADLs) is an important indicator of overall health for older adults. Methodologies for outcomes-based medical-decision-making for public policy, such as decision modeling and cost-effectiveness analysis, require utilities for outcome health states. Utilities have been reported for many disease states, but have not been indexed by functional status, which is a strong predictor of outcome in geriatrics. We describe here a utility elicitation program developed specifically for use with computer-inexperienced older adults: Functional Limitation And Independence Rating (FLAIR1). FLAIR1 design features address common physical problems of the aged and computer attitudes of inexperienced users that could impede computer acceptance. We interviewed 400 adults ages 65 years and older with FLAIR1. In exit interviews with 154 respondents, 118 (76%) found FLAIR1 easy to use. Design features in FLAIR1 can be applied to other software for older adults

Activities of Daily Living↗
PubMed2001

Cost-effectiveness of automated external defibrillators on airlines.

CONTEXT: Installation of automated external defibrillators (AEDs) on passenger aircraft has been shown to improve survival of cardiac arrest in that setting, but the cost-effectiveness of such measures has not been proven. OBJECTIVE: To examine the costs and effectiveness of several different options for AED deployment in the US commercial air transportation system. DESIGN, SETTING, AND SUBJECTS: Decision and cost-effectiveness analysis of a strategy of full deployment on all aircraft as well as several strategies of partial deployment only on larger aircraft, compared with a baseline strategy of no AEDs on aircraft (but training flight attendants in basic life support) for a hypothetical cohort of persons experiencing cardiac arrest aboard US commercial aircraft. Estimates for costs and outcomes were obtained from the medical literature, the Federal Aviation Administration, the Air Transport Association of America, a population-based cohort of Medicare patients, AED manufacturers, and the Bureau of Labor Statistics. MAIN OUTCOME MEASURES: Quality-adjusted survival after cardiac arrest; costs of AED deployment on aircraft and of medical care for cardiac arrest survivors. RESULTS: Adding AEDs on passenger aircraft with more than 200 passengers would cost $35 300 per quality-adjusted life-year (QALY) gained. Additional AEDs on aircraft with capacities between 100 and 200 persons would cost an additional $40 800 per added QALY compared with deployment on large-capacity aircraft only, and full deployment on all passenger aircraft would cost an additional $94 700 per QALY gained compared with limited deployment on aircraft with capacity greater than 100. Sensitivity analyses indicated that the quality of life, annual mortality rate, and the effectiveness of AEDs in improving survival were the most influential factors in the model. In 85% of Monte Carlo simulations, AED placement on large-capacity aircraft produced cost-effectiveness ratios of less than $50 000 per QALY. CONCLUSION: The cost-effectiveness of placing AEDs on commercial aircraft compares favorably with the cost-effectiveness of widely accepted medical interventions and health policy regulations, but is critically dependent on the passenger capacity of the aircraft. Placing AEDs on most US commercial aircraft would meet conventional standards of cost-effectiveness.

Aircraft↗
PubMed2000

Cost-effectiveness of androgen suppression therapies in advanced prostate cancer.

BACKGROUND: The costs and side effects of several antiandrogen therapies for advanced prostate cancer differ substantially. We estimated the cost-effectiveness of antiandrogen therapies for advanced prostate cancer. METHODS: We performed a cost-effectiveness analysis using a Markov model based on a formal meta-analysis and literature review. The base case was assumed to be a 65-year-old man with a clinically evident, local recurrence of prostate cancer. The model used a societal perspective and a time horizon of 20 years. Six androgen suppression strategies were evaluated: diethylstilbestrol (DES), orchiectomy, a nonsteroidal antiandrogen (NSAA), a luteinizing hormone-releasing hormone (LHRH) agonist, and combinations of an NSAA with an LHRH agonist or orchiectomy. Outcome measures were survival, quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios. RESULTS: DES, the least expensive therapy, had a discounted lifetime cost of $3600 and the lowest quality-adjusted survival, 4.6 QALYs. At a cost of $7000, orchiectomy was associated with 5.1 QALYs, resulting in an incremental cost-effectiveness ratio of $7500/QALY relative to DES. All other strategies-LHRH agonists, NSAA, and both combined androgen blockade strategies-had higher costs and lower quality-adjusted survival than orchiectomy. These results were sensitive to the quality of life associated with orchiectomy and the efficacy of combined androgen blockade, and they changed little when prostate-specific antigen results were used to guide therapy. Under a wide range of other assumptions, the cost-effectiveness of orchiectomy relative to DES was consistently less than $20 000/QALY. Androgen suppression therapies were most cost-effective if initiated after patients became symptomatic from prostate metastases. CONCLUSIONS: For men who accept it, orchiectomy is likely to be the most cost-effective androgen suppression strategy. Combined androgen blockade is the least economically attractive option, yielding small health benefits at high relative costs.

Aged↗
PubMed2000

A concise review of the cost-effectiveness of coronary heart disease prevention.

Coronary heart disease is one of the largest sources of morbidity, mortality, and health care expenditure in the United States. This article reviews a number of studies that estimate the cost per unit of health benefits associated with different primary and secondary prevention strategies for coronary heart disease. Although prevention does not provide a panacea for rising health care spending, many preventive strategies are cost-effective when compared to other common clinical interventions. Prevention should be incorporated into regular clinical practice.

Coronary Disease↗
PubMed1999

Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A cost-effectiveness analysis.

BACKGROUND: Low-molecular-weight heparins are effective for treating venous thrombosis, but their cost-effectiveness has not been rigorously assessed. OBJECTIVE: To evaluate the cost-effectiveness of low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. DESIGN: Decision model. DATA SOURCES: Probabilities for clinical outcomes were obtained from a meta-analysis of randomized trials. Cost estimates were derived from Medicare reimbursement and other sources. TARGET POPULATION: Two hypothetical cohorts of 60-year-old men with acute deep venous thrombosis. TIME HORIZON: Patient lifetime. PERSPECTIVE: Societal. INTERVENTION: Fixed-dose low-molecular-weight heparin or adjusted-dose unfractionated heparin. OUTCOME MEASURES: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. An in-patient hospital setting was used for the base-case analysis. Secondary analyses examined outpatient treatment with low-molecular-weight heparin. RESULTS OF BASE-CASE ANALYSIS: Total costs for inpatient treatment were $26,516 for low-molecular-weight heparin and $26,361 for unfractionated heparin. The cost of initial care was higher in patients who received low-molecular-weight heparin, but this was partly offset by reduced costs for early complications. Low-molecular-weight heparin treatment increased quality-adjusted life expectancy by approximately 0.02 years. The incremental cost-effectiveness of inpatient low-molecular-weight heparin treatment was $7820 per QALY gained. Treatment with low-molecular-weight heparin was cost saving when as few as 8% of patients were treated at home. RESULTS OF SENSITIVITY ANALYSIS: When late complications were assumed to occur 25% less frequently in patients who received unfractionated heparin, the incremental cost-effectiveness ratio increased to almost $75,000 per QALY gained. When late complications were assumed to occur 25% less frequently in patients who received low-molecular-weight heparin, this treatment resulted in a net cost savings. Inpatient low-molecular-weight heparin treatment became cost saving when its pharmacy cost was reduced by 31% or more, when it reduced the yearly incidence of late complications by at least 7%, when as few as 8% of patients were treated entirely as outpatients, or when at least 13% of patients were eligible for early discharge. CONCLUSIONS: Low-molecular-weight heparins are highly cost-effective for inpatient management of venous thrombosis. This treatment reduces costs when small numbers of patients are eligible for outpatient management.

Anticoagulants↗
PubMed1999

Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A meta-analysis of randomized, controlled trials.

BACKGROUND: Low-molecular-weight heparins may simplify the management of deep venous thrombosis. A critical clinical issue is whether this more convenient therapy is as safe and effective as treatment with unfractionated heparin. PURPOSE: To compare the safety and efficacy of low-molecular-weight heparins with those of unfractionated heparin for treatment of acute deep venous thrombosis. DATA SOURCES: Reviewers identified studies by searching MEDLINE, reviewing references from retrieved articles, scanning abstracts from conference proceedings, and contacting investigators and pharmaceutical companies. STUDY SELECTION: Randomized, controlled trials that compared a low-molecular-weight heparin preparation with unfractionated heparin for treatment of acute deep venous thrombosis. DATA EXTRACTION: Two reviewers extracted data independently. Reviewers evaluated study quality using a validated four-item instrument. DATA SYNTHESIS: Eleven of 37 studies met inclusion criteria for three major outcomes. Most studies used proper randomization procedures, but only one was double-blinded. Compared with unfractionated heparin, low-molecular-weight heparins reduced mortality rates over 3 to 6 months of patient follow-up (odds ratio, 0.71 [95% CI, 0.53 to 0.94]; P = 0.02). For major bleeding complications, the odds ratio favored low-molecular-weight heparins (0.57 [CI, 0.33 to 0.99]; P = 0.047), but the absolute risk reduction was small and not statistically significant (0.61% [CI, -0.04% to 1.26%]; P = 0.07). For preventing thromboembolic recurrences, low-molecular-weight heparins seemed as effective as unfractionated heparin (odds ratio, 0.85 [CI, 0.63 to 1.14]; P > 0.2). CONCLUSIONS: Low-molecular-weight heparin treatment reduces mortality rates after acute deep venous thrombosis. These drugs seem to be as safe as unfractionated heparin with respect to major bleeding complications and appear to be as effective in preventing thromboembolic recurrences.

Analysis of Variance↗
PubMed1999

Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease.

BACKGROUND: The appropriate roles for several diagnostic tests for coronary disease are uncertain. OBJECTIVE: To evaluate the cost-effectiveness of alternative approaches to diagnosis of coronary disease. DESIGN: Meta-analysis of the accuracy of alternative diagnostic tests plus decision analysis to assess the health outcomes and costs of alternative diagnostic strategies for patients at intermediate pretest risk for coronary disease. DATA SOURCES: Studies of test accuracy that met inclusion criteria; published information on treatment effectiveness and disease prevalence. TARGET POPULATION: Men and women 45, 55, and 65 years of age with a 25% to 75% pretest risk for coronary disease. TIME HORIZON: 30 years. PERSPECTIVE: Societal. INTERVENTIONS: Diagnostic strategies were initial angiography and initial testing with one of five noninvasive tests--exercise treadmill testing, planar thallium imaging, single-photon emission computed tomography (SPECT), stress echocardiography, and positron emission tomography (PET)--followed by coronary angiography if noninvasive test results were positive. Testing was followed by observation, medical treatment, or revascularization. OUTCOME MEASURES: Life-years, quality-adjusted life-years (QALYs), costs, and costs per QALY. RESULTS OF BASE-CASE ANALYSIS: Life expectancy varied little with the initial diagnostic test; for a 55-year-old man, the best-performing test increased life expectancy by 7 more days than the worst-performing test. More sensitive tests increased QALYs more. Echocardiography improved health outcomes and reduced costs relative to stress testing and planar thallium imaging. The incremental cost-effectiveness ratio was $75,000/QALY for SPECT relative to echocardiography and was greater than $640,000 for PET relative to SPECT. Compared with SPECT, immediate angiography had an incremental cost-effectiveness ratio of $94,000/QALY. RESULTS OF SENSITIVITY ANALYSIS: Qualitative findings varied little with age, sex, pretest probability of disease, or the test indeterminancy rate. Results varied most with sensitivity to severe coronary disease. CONCLUSIONS: Echocardiography, SPECT, and immediate angiography are cost-effective alternatives to PET and other diagnostic approaches. Test selection should reflect local variation in test accuracy.

Adult↗
PubMed1999

Cost-effectiveness of 3 methods to enhance the sensitivity of Papanicolaou testing.

CONTEXT: ThinPrep, AutoPap, and Papnet are 3 new technologies that increase the sensitivity and cost of cervical cancer screening. OBJECTIVE: To estimate the cost-effectiveness of these technological enhancements to Papanicolaou (Pap) tests. DESIGN: We estimated the increase in sensitivity from using these technologies by combining results of 8 studies meeting defined criteria. We used published literature and additional sources for cost estimates. To estimate overall cost-effectiveness, we applied a 9-state time-varying transition state model to these data and information about specific populations. SETTING: A hypothetical program serving a cohort of 20- to 65-year-old women who begin screening at the same age and are representative of the US population. RESULTS: The new technologies increased life expectancy by 5 hours to 1.6 days, varying with the technology and the frequency of screening. All 3 technologies also increased the cost per woman screened by $30 to $257 (1996 US dollars). AutoPap dominated ThinPrep in the base case. At each screening interval, AutoPap increased survival at the lowest cost. The cost per year of life saved rose from $7777 with quadrennial screening to $166000 with annual screening. Papnet produced more life-years at a higher cost per year of life saved. However, when used with triennial screening, each of them produced more life-years at lower cost than conventional Pap testing every 2 years. The cost-effectiveness ratio of each technology improved with increases in the prevalence of disease, decreases in the sensitivity of conventional Pap testing, and increases in the improvement in sensitivity produced by the technology. CONCLUSIONS: Technologies to increase the sensitivity of Pap testing are more cost-effective when incorporated into infrequent screening. Increases in sensitivity and decreases in cost may eventually make each technology more cost-effective.

Adult↗
PubMed1998

Cost effectiveness of coronary heart disease prevention strategies in adults.

Although risk-factor modification has gained wide acceptance as an effective approach to the prevention of coronary heart disease (CHD), health planners, physicians and patients confront considerable uncertainty over the most appropriate and efficient preventive strategies. Some preventive approaches are both inexpensive and effective; others are expensive while their effectiveness is slight or unproven. Effectiveness varies with an individual's age, gender and other risk factors. Information provided by a cost-effectiveness analysis can clarify the value of alternative strategies for CHD prevention in specific populations, thereby helping to choose among them. It does so by producing a standard measure of value--the cost per year of life saved (YLS) or cost per quality-adjusted life-year (QALY) saved--that reveals which of several alternative interventions provides the greatest health benefit from a given expenditure. This article summarises the extensive literature on the cost effectiveness of CHD prevention with an emphasis on primary prevention. Published work indicates that smoking-cessation programmes, particularly those that rely on counselling with or without nicotine supplements, are highly cost effective in many settings. Although the evidence is limited, exercise programmes also appear to be cost effective. The detection and treatment of hypertension is highly cost effective, particularly when inexpensive drugs with proven effectiveness, such as diuretics or beta-blockers, are used. Hormone-replacement therapy is a cost-effective approach to CHD prevention in most postmenopausal women, although direct clinical trial data are lacking and it is uncertain which hormone preparation is best. Cholesterol reduction is a cost-effective strategy for the prevention of CHD in individuals without other treatable risk factors who are at very high risk of developing CHD. For individuals with multiple CHD risk factors, the choice of risk-modification strategies is complex and depends upon the interactions of risk and the relative costs of treating each risk.

Antihypertensive Agents↗
PubMed1997

Cost-effectiveness of screening for carotid stenosis in asymptomatic persons.

BACKGROUND: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented. OBJECTIVE: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention. DESIGN: Cost-effectiveness analysis using published data from clinical trials. SETTING: General population of asymptomatic 65-year-old men. INTERVENTION: Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done. MEASUREMENTS: Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios. RESULTS: When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found). CONCLUSIONS: Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.

Aged↗
PubMed1997

Cholesterol screening should be targeted.

For primary prevention of coronary heart disease (CHD), the American College of Physicians (ACP) has recommended that initial cholesterol screening be targeted to people who have other risk factors in addition to elevated cholesterol. This would include those with symptoms of heart disease, asymptomatic men 35-65 years old and women 45-65 years old, or younger people who have > or = 2 risk factors or who might benefit from treatment for high blood cholesterol. After the age of 75, cholesterol is no longer a risk factor, so there is no rationale for testing. In primary prevention, lipoprotein fractionation should be performed in men and women who have been identified as having elevated blood cholesterol levels, not as part of initial testing. In secondary prevention, some studies indicate that cholesterol reduction may be beneficial after age 65. In asymptomatic younger people without other risk factors, the low prevalence of CHD and rapid response to cholesterol reduction once it is initiated suggest that early screening and treatment are unnecessary. Everyone should adopt the lifestyle modifications conducive to cardiovascular health, but the ACP believes that, for primary prevention, universal screening is neither cost effective nor the best use of the patient's and physician's time.

Adult↗
PubMed1997

Economic foundations of cost-effectiveness analysis.

To address controversies in the applications of cost-effectiveness analysis, we investigate the principles underlying the technique and discuss the implications for the evaluation of medical interventions. Using a standard von Neumann-Morgenstern utility framework, we show how a cost-effectiveness criterion can be derived to guide resource allocation decisions, and how it varies with age, gender, income level, and risk aversion. Although cost-effectiveness analysis can be a useful and powerful tool for resource allocation decisions, a uniform cost-effectiveness criterion that is applied to a heterogeneous population level is unlikely to yield Pareto-optimal resource allocations.

Cost-Benefit Analysis↗