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Biomedical subjects

B S Bloom

Publications and source records attributed to B S Bloom.

At least 37 records · Page 2Linked to original sources
PubMed1996

Predicting effects of minimal invasive therapy.

OBJECTIVE: To estimate expected effects of minimal invasive therapy (MIT). DESIGN: We developed a structured questionnaire and sent it to 35 mainly senior academic surgeons considered leaders in MIT in the UK, USA, and Canada. We asked their opinions on which specific operations would be done by minimal invasive technique and the effects of this change on hospitals over the next 5 years. We used these responses to predict effects on hospitals of MIT. We also compared predictions against published data 2 years later. RESULTS: Respondents predicted 34 specific operations would be performed using MIT, and that 53% of the patients undergoing these operations would receive MIT procedure. This transformation would lead, in their opinion, to a decline of 10 million inpatient hospital days, a 62% decline of average length of stay for operations predicted amenable to MIT, and a resultant savings of $4.5 billion in the U.S. Comparable effects could be expected to occur in other countries. CONCLUSION: Many of the trends predicted by respondents are being borne out. If these trends continue, MIT will have profound effects on patients (clinical, quality of life function), providers (hospital utilization and financing, physician training), and payers (expenditures) in all countries if respondents' predictions about MIT and its impact are even reasonable accurate. Attention should be directed first to the hospital sector, given expected effects of changes of clinical service mix, revenues, and the need for different, and differently trained, personnel.

Attitude of Health Personnel↗
PubMed1996

Evaluation of initial noninvasive therapy in pediatric patients presenting with suspected ulcer disease.

OBJECTIVE: To compare the clinical and economic effects of five likely treatment strategies in children with dyspepsia: initial diagnostic endoscopy (EGD) with biopsy for Helicobacter pylori infection; initial EGD without biopsy; H. pylori serology screening and treatment for H. pylori if positive; empiric treatment with antisecretory therapy; and empiric treatment for H. pylori with antibiotics and antisecretory therapy. METHODS: Our decision analysis model incorporated data from published literature on the incidence of duodenal ulcer disease and effect of H. pylori infection. Cost inputs were derived from payments made by third-party payers. For the three noninvasive strategies that did not include immediate endoscopy, endoscopy was performed on the first episode of symptom recurrence. RESULTS: The estimated costs per child evaluated for each strategy were: EGD with biopsy, $1458; EGD alone, $1248; H. pylori serology, $1224; antisecretory, $1160; and antisecretory-antibiotic, $1164. Results were sensitive to the costs of EGD and the likelihood of recurrent symptoms in children. When the cost of endoscopy fell below $950 or if over 65% of patients without ulcers eventually underwent endoscopy, there was no longer a cost advantage for initial noninvasive treatment when compared with EGD alone strategy. CONCLUSION: In a decision analysis model, empiric antisecretory treatment in children with dyspepsia was most cost-effective, eliminating 40% of endoscopies and leading to antibiotic use in only those patients with H. pylori (4%). Further studies to determine the actual recurrence rate of symptoms after empiric antisecretory treatment of children with dyspepsia are required.

Anti-Bacterial Agents↗
PubMed1996

Clinical and economic effects of mupirocin calcium on preventing Staphylococcus aureus infection in hemodialysis patients: a decision analysis.

This study was performed to determine the clinical and economic consequences of alternative strategies of preventing Staphylococcus aureus infection in chronic hemodialysis patients by use of intranasal mupirocin calcium to clear nasal carriage of S aureus. Decision analysis evaluated clinical outcomes and cost-effectiveness of three likely management strategies to address S aureus nasal carriage and prevent subsequent infection in chronic ambulatory hemodialysis patients: (1) screen for S aureus nasal carriage every 3 months and treat those with a positive test result with mupirocin calcium; (2) treat all patients weekly with mupirocin calcium; or (3) no prevention strategy, treat infection only. Rates of nasal carriage of S aureus, S aureus infection rates, proportion of infections attributable to nasal carriage, efficacy of mupirocin, natural history of infection, and patient management strategies were derived from the published literature and supplemented by a panel of experts. Actual payments for medical services were obtained from Medicare parts A and B. Incremental cost-effectiveness was calculated from the perspective of Medicare and subjected to sensitivity analyses. Assuming that 75% of S aureus infections are attributable to nasal carriage in hemodialysis patients, eliminating nasal carriage of S aureus with mupirocin calcium (with or without screening) markedly reduces the number of infections (45% to 55%) and also reduces health care expenditures relative to treating infections when they occur. Annual savings to Medicare are $784,000 to $1,117,000 per 1,000 hemodialysis patients, depending on the prevention strategy. Preventing S aureus infection by eradicating nasal carriage in chronic hemodialysis patients reduces morbidity while simultaneously reducing medical care costs. The decision to eliminate nasal carriage on a regular basis or use a screening test to guide antibiotic therapy is dependent on the tradeoff between improved short-term clinical and cost benefits and the potential for bacterial resistance that may arise from widespread use of mupirocin calcium.

Administration, Intranasal↗
PubMed1996

The tension between cost containment and the underutilization of effective health services.

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.

Cost Control↗
PubMed1995

Alternative management strategies for patients with suspected peptic ulcer disease.

OBJECTIVE: To estimate the clinical and economic effects of available invasive and noninvasive management strategies for peptic ulcer and Helicobacter pylori in persons with symptoms suggesting peptic ulcer disease. DESIGN: Cost-effectiveness analysis using a decision analytic model. INTERVENTION: 2 immediate endoscopy and 3 noninvasive diagnostic and treatment strategies were evaluated: 1) immediate endoscopy for peptic ulcer and biopsy for H. pylori; 2) immediate endoscopy without biopsy; 3) serologic test for H. pylori; 4) empiric treatment with antisecretory therapy; and 5) empiric treatment with antisecretory therapy and antibiotic agents to eradicate H. pylori. MEASUREMENTS: Cost per ulcer cured and cost per patient treated. RESULTS: The estimated costs per ulcer cured by strategy were as follows: 1) endoscopy and biopsy for H. pylori, $8045; 2) endoscopy without biopsy, $6984; 3) serologic test for H. pylori, $4541; 4) empiric antisecretory therapy, $4835; and 5) empiric antisecretory and antibiotic therapy, $4155. The predicted costs per patient treated were as follows: 1) endoscopy and biopsy for H. pylori, $1584; 2) endoscopy without biopsy, $1375; 3) serologic test for H. pylori, $894; 4) empiric antisecretory therapy, $952; and 5) empiric antisecretory and antibiotic therapy, $818. The cost-effectiveness advantage of the noninvasive strategies diminished as the cost of endoscopy decreased or as the probability of recurrent symptoms increased in patients initially managed without endoscopy. CONCLUSION: Endoscopy, although costly, precisely guided diagnosis and treatment and thus potentially reduced the number of patients inappropriately treated. However, the safety and effectiveness of less expensive, less invasive diagnostic and treatment strategies strongly support initial noninvasive care of symptomatic persons thought to have peptic ulcer disease.

Anti-Bacterial Agents↗
PubMed1995

Diffusion of laparoscopic cholecystectomy among general surgeons in the United States.

Introduced in 1989, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic gallstones. This study describes the diffusion of laparoscopic cholecystectomy among general surgeons; assesses the importance of various reasons for surgeons adopting the procedure; and examine the influence of surgeon, practice, and health care market characteristics on the timing of adoption. The data were obtained from a survey of a national sample of surgeons. Most surgeons (81%) adopted laparoscopic cholecystectomy by early 1992. More than three fourths of adopters identified the desire to keep up with the state-of-the-art and improved patient outcomes as very or extremely important reasons for adoption. Results of proportional hazards regression analysis indicate that individual surgeons' adoption behavior generally was consistent with expected utility maximization in an uncertain new technological environment. Of particular interest, fee-for-service payment and more competitive practice settings and markets were associated with earlier adoption. These findings suggest that the "technological imperative" and surgeons' perception of the relative clinical and financial advantages of laparoscopic cholecystectomy were important reasons for the rapid diffusion of laparoscopic cholecystectomy. Policies that accelerate current trends toward payment of physicians based on salary or capitation and promote the growth of multispecialty group practice could slow the diffusion of new physician-based product innovations in health care.

Adult↗
PubMed1995

Cost and quality effects of treating erosive oesophagitis. A re-evaluation.

The objective of this study was to re-evaluate the clinical and economic effects of common therapies for erosive oesophagitis in the light of a newly approved treatment regimen. A previously constructed 7-month community practice decision analytical model was revised to include the latest published data on efficacy and symptomatic outcomes. The original results of phase I therapy (antacids plus dietary, sleeping and lifestyle changes) alone or combined with ranitidine 150mg bid or omeprazole 20mg od were reassessed by adding new clinical data on the efficacy of and symptomatic response to ranitidine 150mg qid. The same payment data used in the first analysis were applied here as well, with the addition of the US price of ranitidine 150mg qid. The study perspective was that of the payer or insurer. Omeprazole-based therapy remained a dominant strategy for symptomatic care during the 7-month model. It was 14% less costly per patient, led to 23% fewer symptomatic months, and had 21% lower cost per symptom-free month than ranitidine 150mg qid, the next best alternative. Evolving treatment strategies necessitate rapid assessment and reassessment so that clinical practice can remain current, patients can be assured of the best quality, and insurers can be aware of treatment cost and budgetary impact given limited resources in all countries. Only by consistent and continuous re-evaluation of new or changing medical interventions can clinicians and insurers adapt patient management to new scientifically derived results. This is the best manner by which to meet patients' care needs and the clinical needs of practitioners, as well as the financial needs of payers.

Antacids↗
PubMed1995

Omeprazole or ranitidine plus metoclopramide for patients with severe erosive oesophagitis. A cost-effectiveness analysis.

The objective of this study was to evaluate the clinical and economic effects of 2 clinical strategies for treating severe (grade II and above) erosive oesophagitis or poorly responsive gastro-oesophageal reflux disease. A single-blind, randomised controlled trial of up to 8 weeks' duration was undertaken comparing omeprazole with ranitidine plus metoclopramide in patients with severe and symptomatic erosive oesophagitis (endoscopic grade II and above). Two cost-effectiveness ratios were calculated: cost per healed patient and cost per symptom-free day. The study perspective was that of the payer or insurer of medical care. Healing rates were significantly higher among omeprazole-treated patients than among those who received ranitidine/metoclopramide at 4 weeks (68.5% vs 30.4%; p < 0.01) and overall (81.5% vs 45.7%; p < 0.01). Overall, mean gastrointestinal-related direct medical costs per healed patient were lower for the omeprazole group ($US189.60) than for the ranitidine/metoclopramide group ($US319.28). The incremental cost of an additional cure with omeprazole compared with ranitidine/metoclopramide was $US24.05. The overall average cost per symptom-free day was lower in the omeprazole group ($US7.88) than in the ranitidine/metoclopramide group ($US10.81). The incremental cost to obtain an additional symptom-free day with omeprazole, compared with ranitidine/metoclopramide, was $US1.41. In conclusion, superior efficacy at comparable cost is achieved by omeprazole compared with ranitidine/metoclopramide in the treatment of patients with severe erosive oesophagitis.

Anti-Ulcer Agents↗
PubMed1994

Improved health benefits of increased use of thrombolytic therapy.

BACKGROUND: To quantify population health consequences of increased use of thrombolytic therapy for acute myocardial infarction in the United States. METHODS: A decision analytic model was constructed to evaluate treatment-related outcomes for two myocardial infarction treatment strategies: standard therapy and standard therapy plus combination aspirin-thrombolytic therapy. Patients were entered into the model by age, electrocardiographic presentation, and time to medical evaluation. Estimated mortality changes associated with increased use of thrombolytic therapy were calculated both for populations for which thrombolytic therapy is recommended and for specific patient populations for which thrombolytic therapy is not recommended under current guidelines. Sensitivity analyses tested the robustness of results when input variables were altered. RESULTS: If every patient with acute myocardial infarction for whom thrombolytic therapy is recommended under current guidelines were treated with aspirin and a thrombolytic agent, more than 4000 additional lives would be saved annually in the United States. The model projected that approximately 8000 additional lives could be saved if use of thrombolytic therapy were expanded to include the following patient groups: age greater than 75 years (approximately 4500 lives saved), left bundle-branch block on electrocardiogram (approximately 2500 lives saved), and presentation 6 to 12 hours after the onset of chest pain (approximately 2000 lives saved). Sensitivity analysis demonstrated a mortality advantage attributable to the use of thrombolytic therapy in each clinical scenario tested. CONCLUSIONS: Providing thrombolytic therapy more aggressively could prevent over 12,000 deaths from acute myocardial infarction each year in the United States.

Aged↗
PubMed1994

Government intervention in cardiovascular disease--help or hindrance? The US viewpoint.

Health and medical care services are not yet subject to the laws of supply and demand or the impersonal effects of the economic market. However, finite resources mean that governments and other payers are forced to make trade-offs. The United States, which has relied most heavily on market forces for its medical system, is now moving towards greater government responsibility for organization and financing, if not delivery, of services. President Clinton has proposed a national program of unified organization, service delivery, and financing so as to improve access to the US health care system and control cost. The proposed plan will enfranchise upwards of 50 million people who currently have no, or limited, access to medical care. Therefore, the initial effects will be more care of all kinds being provided by physicians. Such increases of services will increase expenditure, at least over the short-term.

Delivery of Health Care↗
PubMed1993

A reappraisal of hepatitis B virus vaccination strategies using cost-effectiveness analysis.

OBJECTIVE: To determine clinical and economic consequences of alternative vaccination strategies for preventing hepatitis B virus infection (HBV). METHODS: Decision analysis was used to evaluate costs, outcomes, and cost-effectiveness of three HBV management strategies ("no vaccination," "universal vaccination," and "screen and vaccinate") in four populations (newborns, 10-year-old adolescents, a high-risk adult population, and the general adult U.S. population). Information on HBV incidence and prevalence, clinical course, and management of acute illness and chronic sequelae was obtained from the literature and a panel of experts. Actual payments (costs) were obtained from Blue Cross/Blue Shield and local pharmacies. Incremental cost-effectiveness was calculated from the perspective of the payer of medical care and subjected to sensitivity analysis. RESULTS: Vaccination (with or without screening) prevents more disease at somewhat increased cost than no vaccination for the neonatal, adolescent, and adult populations. Vaccination (with or without screening) is a dominant strategy in adult high-risk populations (lower cost and greater benefit than no vaccination). Optimal cost-effectiveness, with nonmonetary benefits not discounted, results if all pregnant women are screened for active HBV infection, and HBV vaccine and hepatitis B immune globulin are administered to babies born to mothers with positive screening tests. Then HBV vaccine is administered to all children at age 10 and again 10 years later (incremental cost-per-year-of-life-saved relative to the "no vaccination" strategy is $375). A strategy of universal newborn vaccination alone leads to an incremental cost-per-year-of-life saved of $3332. If adolescents are vaccinated at age 10, incremental cost-per-year-of-life saved is $13,938; for the general adult population, the incremental cost-per-year-of-life saved of universal vaccination is $54,524. Discounting benefits will increase cost-per-year-of-life saved 7 to 12 times for all strategies. CONCLUSIONS: HBV vaccine is most cost-effective when a strategy of screening newborns is combined with routine administration to 10-year-old children. The means to achieve substantial improvements in the health of the public in a cost-effective fashion are now available and should be pursued aggressively.

Adolescent↗
PubMed1993

Time trends in peptic ulcer disease and in gastritis and duodenitis. Mortality, utilization, and disability in the United States.

This study compared the results of two analytic methods testing the effects of histamine H2 receptor antagonists on acid-related conditions. We examined the rates of peptic ulcer disease-related and of gastritis- and duodenitis-related mortality, hospitalizations, surgery, physician visits, work-loss, and disability retirements in the United States from 1970 to 1986. First, we performed a nonparametric epidemiologic analysis. For mortality, hospitalizations, and surgeries, age-specific rates continued their historic decline; there was an additional large one-time decline of operations in 1978. Trends were stronger for peptic ulcer than for gastritis and duodenitis. From pooled annual data, rates of physician visits and physician referral declined for peptic ulcer and for gastritis and duodenitis in the post-1977 period (p = 0.0001). Work-loss and other restrictions on normal daily activities also declined for persons with peptic ulcer and with gastritis and duodenitis (p = 0.0001). Second, we fit a parametric model by maximum likelihood to test specific population effects of H2 blockers. The model indicated that people > or = 65 years old had increasing peptic ulcer mortality rates after 1977 (p < 0.001), while people < 65 years old had a deceleration in rates of decline (p < 0.01). Hospitalization rates for peptic ulcer and for gastritis and duodenitis increased in the elderly after 1977 (p < 0.01) and decreased among those < 65 years old. Both age groups experienced similar declining trends of operations for peptic ulcer; these were not significantly different when pre- and post-1977 periods were compared. The rate of disability retirement declined sharply for workers > or = 50 years old (p < 0.01) and for those < 50 years of age (p < 0.001). The inconclusive results of the parametric analysis, plus only partial congruence between parametric and nonparametric analyses, emphasize the difficulty of relating diverse effects over time to a single, new, more effective treatment.

Activities of Daily Living↗
PubMed1992

Issues in the cross-national assessment of health technology.

With the growing international literature in economic evaluation and the rapid spread of new health technologies, there is a need to undertake, or at least interpret, economic evaluations on the international level. However, the ways in which cross-national differences affect the cost-effectiveness of health technologies or their evaluations have never been studied. This paper explores these issues by taking advantage of a unique situation in which the same economic evaluation of a new indication for a health technology was conducted simultaneously in four countries using an identical methodology. The study showed that if prior agreement on methods can be reached and local data applied, economic evaluations can be undertaken in a way that facilitates the extrapolation of results from country to country.

Cost-Benefit Analysis↗
PubMed1992

Cost, benefits and unintended gastrointestinal side effects of pharmaceutical therapy.

All healthcare services, however beneficial, carry inherent risks in addition to the costs of care, which may involve expenditures on unanticipated side effects. Substantial research over the past few decades has elucidated the full range of clinical and resource use effects of peptic ulcer medications, particularly for histamine H 2-receptor antagonists and nonsteroidal anti-inflammatory drug (NSAID)-related gastropathy. Less well known are some of the positive and negative side effects of many different types of pharmaceuticals on the gastrointestinal tract. This paper summarises information on unintended and unexpected positive and negative gastrointestinal side effects of medications administered to treat gastrointestinal and other diseases. It further analyses 2 drug classes and their effects on the gastrointestinal tract, histamine H 2-receptor antagonists, which have a positive impact on clinical effects and resource use, and NSAIDs, which have negative effects.

Anti-Inflammatory Agents, Non-Steroidal↗