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Biomedical subjects

B S Bloom

Publications and source records attributed to B S Bloom.

At least 55 records · Page 3Linked to original sources
PubMed1992

Cost and quality effects of alternative treatments for persistent gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease is commonly encountered by general internists and gastroenterologists. METHODS: We used decision analysis to assess the clinical and economic effects of three treatments--phase 1 therapy alone or combined with omeprazole or ranitidine hydrochloride therapy--for patients with persistent, symptomatic grade 2 or higher gastroesophageal reflux disease. To the maximum extent possible, data were obtained from the published literature. We convened an expert consensus panel to estimate specific data points when they were unavailable or contradictory in the literature, including estimates of optimal and actual clinical practice patterns. A 7-month model was used to correspond to the time frame of available clinical trial data. The perspective of the analysis was that of the payer. The costs of medical care for various clinical outcomes were based on actual mean payments made by Independence Blue Cross of Philadelphia and Pennsylvania Blue Shield. RESULTS: Although the retail payments for daily omeprazole therapy are the highest among the three interventions tested, it produced both the lowest expected overall payments for medical care and the most effective strategy for treating symptoms during the 7-month model. Omeprazole therapy was consistently approximately $1800 less costly than ranitidine therapy and $2700 less costly than phase 1 therapy alone during the period examined, regardless of whether empiric or nonempiric treatment strategies were used. Even when payments for major complications (the most important cost variable) were reduced by 80%, omeprazole therapy resulted in payments 17% and 22% lower than those associated with ranitidine therapy and phase 1 therapy alone, respectively. Omeprazole also produced the most symptom-free months during the 7-month follow-up period. The clinical and economic outcomes of performing an initial diagnostic workup, compared with treating patients empirically, were equal. CONCLUSIONS: We conclude that omeprazole therapy is the preferred initial therapeutic approach for patients with persistent, symptomatic gastroesophageal reflux disease in whom phase 1 therapy fails. Assessment of long-term approaches must await the results of extended clinical studies.

Adult↗
PubMed1991

Cross-national changes in the effects of peptic ulcer disease.

OBJECTIVE: To describe and to analyze the changing effects of peptic ulcer disease over time. DESIGN: Variables relating to peptic ulcer disease from 1970-1986 were compared. The variables included rates of mortality, hospitalizations, operations, physician visits, and endoscopies, and the amount of disability-related loss of work and early retirement in six countries (Belgium, England and Wales, the Federal Republic of Germany, The Netherlands, Sweden, and the United States). MEASUREMENTS: Nonparametric epidemiologic time-trend analysis. MAIN RESULTS: The historic, slow, declining trend in mortality and hospitalization rates continued. The rate of operations for peptic ulcer disease exhibited a large, one-time reduction, then returned to a parallel declining trend, but at a lower level. The rate of physician visits declined by 50%. The greatest changes were found in the rate of endoscopy use and in disability-related loss of work and early retirement, where increasing trends were quickly followed by decreasing trends. The elderly, especially women, generally did not share many of these benefits. CONCLUSIONS: The effects of new interventions can be understood more fully by examining several variables in many countries over a long time. Contrary to expectations, the effects of the widespread use of histamine H2 antagonists have been more indirect (affecting work loss and disability retirement more) than direct (affecting high-cost medical service use and mortality less).

Absenteeism↗
PubMed1991

Abruptly changing patterns of diffusion and use of extracorporeal shock-wave renal lithotripsy.

Early diffusion and use of extracorporeal shock-wave lithotripsy (ESWL) was found by a 1986 survey of the first 84 operational renal lithotripters in the United States to be similar to that of other equipment-embodied technologies. Resurvey in 1988 of this cohort of units found that clinical indications for ESWL treatment--stone size and location--expanded greatly. Professional fees for ESWL services remained essentially constant, while technical component charges increased 21.0%. Volume of procedures declined by 19.8% among the most productive units, and by 34.4% among the least productive study units; the previously noted approximate fourfold difference remained unchanged between most and least productive units. ESWL patterns of diffusion were comparable to other equipment-embodied diagnostic technology (magnetic resonance imaging [MRI] and computed tomography [CT]) during the first few years of clinical availability. ESWL growth slowed sooner than that of CT and MRI following their introduction into clinical practice, declining in the fourth to fifth year of use following rapid expansion in the first 2 years of availability. While clinical indications for both ESWL and imaging technologies expanded over time, CT and MRI experienced continued growth beyond that of ESWL at the same points of their respective life cycles. In the market areas of the 84 study units, the use of ESWL declined even with expanded indications for treatment, perhaps due to faster expansion of number of units than growth of clinical indications for treatment.

Diffusion of Innovation↗
PubMed1991

Impact of Phase I Pew National Dental education Program on U.S. schools of dental medicine.

This paper presents the results of four telephone surveys conducted by the Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, as part of its evaluation of the Pew National Dental Education Program (PNDEP), a five year, +4F8.7 million program established by The Pew Charitable Trusts to help dental schools respond to the changing health care environment. The four annual surveys were conducted between 1985 and 1988. The interviews were conducted with the deans from nearly all dental schools operating in the United States at the time of study or the principal investigators of the schools funded under Phase I and Phase II PNDEP grants. Their purpose was to determine the level of each school's involvement in PNDEP and in specific strategic planning activities, as well as to evaluate the impact of the Pew Program on both the individual schools and dental education nationwide. All systematic differences between schools funded (FD) PNDEP and those not funded (NFD) were examined. Overall, schools gained a better understanding of their environment. Schools also reported increased participation in and commitment to planning among their different constituencies (e.g., faculty, administration, students, alumni). By the end of Phase I, more PNDEP Phase I funded schools reported being involved in implementing strategic plans. Funded schools also were more likely to report PNDEP increased their understanding of strategic planning, improved communication, and helped encourage the emergence of new leaders.

Administrative Personnel↗
PubMed1990

Medical management and managing medical care: the dilemma of evaluating new technology.

A unique computer simulation model has been developed to investigate the broad clinical and economic effects of changing risk factors for cerebrovascular and cardiovascular disease. The model can be used in countries where good input data are available to provide valuable information to aid policy decisions on medical care. This article describes the computer model, the sources of population and cost data, and the assumptions that must be made when a model of this type is used. The Swedish and U.S. populations are compared, and the results are expressed in years of life saved. Cost-effectiveness of intervention is assessed by combining economic and clinical data, and the most favorable cost-effectiveness ratios are found in the elderly population with high levels of serum cholesterol and diastolic blood pressure. In contrast, the costs per year of life saved in the younger population at low risk are comparatively high.

Adult↗
PubMed1990

Changes in peptic ulcer and gastritis/duodenitis in Great Britain, 1970-1985.

The signal event of the 1970s in peptic ulcer disease was the introduction of H2 blockers. We examined changing direct and indirect effects of peptic ulcer and gastritis/duodenitis on the British population from 1970 to 1985. Death rates from gastric ulcer declined irregularly for all except women 65 years of age and older, in whom it increased, while for duodenal ulcer mortality declined only for men less than 65 years old and increased sharply for women 65 years and above. Mortality due to gastritis/duodenitis rose irregularly to 1980 and then fell inconsistently through 1985, and was but 1.0 to 1.5% that of peptic ulcer. Elderly women were disproportionately affected, much as with peptic ulcer. There was no significant change in essentially stable time trends for peptic ulcer perforation deaths. Hospitalizations for gastric and duodenal ulcer continued to fall through 1985 except for those age 65 years and above. Hospitalizations for peptic ulcer hemorrhage did not change overall, but the distribution favoring the elderly in the early 1970s reversed. Elderly men and women are now the most likely to bleed for both gastric and duodenal ulcer. Hospitalizations for gastritis/duodenitis increased for all populations. Peptic ulcer operations declined markedly for all groups, most for men and women less than 65 years old. Peptic ulcer as a cause of work loss declined sharply over time for men but was stable for women, while work loss due to gastritis/duodenitis plunged for both sexes beginning in 1979. Mean days off work per spell of absenteeism remained relatively constant: 35-45 days for peptic ulcer and 10-12 days for gastritis/duodenitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Absenteeism↗
PubMed1989

Transtracheal oxygen delivery and patients with chronic obstructive pulmonary disease.

A total of 43 severely ill COPD patients already on 24 h, or near 24 h, per day supplemental O2 were randomly assigned to transtracheal oxygen delivery (n = 22) or usual delivery of O2 by nasal cannula or face mask (n = 21). A few important changes were found in pulmonary function over time such as decreases of PEFR, FEF and MVV for both experimental and control groups, and FEV1% and FEV3% in experimental patients. At the same time, there was a significant decrease in both hematocrit and hemoglobin, and per cent shunting for the experimental group and a significant increase in per cent shunting in the control group. Physical, social and psychologic assessments showed significant improvement over time for experimental patients and declines for the control group. Lastly, medical costs were positively affected, as fewer days were spent in hospital post-study enrollment by experimental than control groups, and post-enrollment relative to pre-enrollment by experimental patients.

Activities of Daily Living↗
PubMed1989

The Swedish Council on Technology Assessment in Health Care.

During its first year of operation (1988) the Swedish Council on Technology Assessment in Health Care focused on nine areas. Additional activities will be added as need requires and resources permit. Also, preparations for 1989 projects have begun. The nine areas include: identification of technologies needing assessment, including international comparisons; review and synthesis of the value of preoperative routines; review and synthesis of the value of gastroscopy for diagnosing stomach pain; assessment of different treatment methods for back pain; assessment of the value of vascular surgery for vascular spasms in the legs; organization of a strategy conference concerning medical technology assessment in Sweden; creation of a strategy that addresses an international review of medical technology, future technologies in health care, waiting lists for medical care--the importance of medical technology, resource utilization and organizational and educational aspects of introducing new technology in health care, and costs and medical technology; translation of foreign assessment studies, with comments; national and international cooperation. SCTA has discussed the need for assessing specific technology such as bone marrow transplantation and surgical treatment of epilepsy. SCTA's Scientific Advisory Committee has additionally considered the following subjects for future projects: medical, social, and economic consequences of alternative technologies screening for prostate, colorectal, breast, and cervical cancer; costs, indications, and medical benefit of surgery for varicose vains; and modern urology technologies, particularly those related to prostate care.

Organizational Objectives↗
PubMed1989

Long-term technology assessment. Mortality, hospitalization, and work loss due to peptic ulcer and gastritis/duodenitis in the Federal Republic of Germany.

Once the effects of short-term data analysis of new medical technology appear clear, additional or long-term analyses are infrequently performed on subsequent information. This often leads to incomplete understanding of the technology's full medical, social, and economic effects. Available data for the Federal Republic of Germany on mortality, hospitalization, and work loss due to gastric and duodenal ulcer and gastritis/duodenitis allowed long-term analysis of direct and indirect impacts on the population from 1975 through 1984. Mortality rates declined for all ages (p less than 0.01) except for those age 75 and older, and nearly equally for all study diagnoses. Hospital discharge rates for all diagnoses rose slowly and steadily, while those for persons diagnosed with gastric ulcer, duodenal ulcer or gastritis/duodenitis declined sharply (p = 0.04). Declines of hospital discharges were greater for men than for women. The ongoing decline in rates of mortality and hospital discharges increased after 1977. Rates of work loss per 10,000 population-at-risk for study diagnoses were either stable or increasing until 1979, after which there was a marked decline (p = 0.03 for gastric ulcer, p = 0.02 for duodenal ulcer, p = 0.008 for gastritis/duodenitis). Work loss due to study diseases declined as a percentage of work loss for all diseases during the later study years. Only by examining many years' data could the accelerating declines be discerned, not only for mortality and hospitalizations, which have been examined before, but also for work loss, an infrequently analyzed effect of disease.

Absenteeism↗
PubMed1989

Patterns of care and expenditures by California Medicaid for peptic ulcer and other acid-related diseases.

We examined California Medicaid (Medi-Cal) service use and expenditures for peptic ulcer and other acid-related diseases during the 10-year period fiscal year (FY) 1976-1985. Between FY 1976 and FY 1980, hospitalizations rose irregularly, operations declined by 37%, endoscopies tripled, physician visits fluctuated from year to year, antacid prescriptions increased by 36%, and anticholinergic medication use was stable. From FY 1981 to FY 1985, hospitalizations declined by 52%, operations by 91%, endoscopies by 45%, physician visits by 30%, antacid use by 12%, and anticholinergic medication use by 48%. H2 antagonists were allowed onto Medi-Cal formulary near the end of FY 1980, and use rose sharply through 1985. Similar results were found across specific gastrointestinal (GI) diagnoses. Total payments for acid-related conditions were essentially stable during FY 1976-1980 period, although, for individual services, utilization and expenditures did not always move in the same direction. For example, declining operations rates and stable expenditures were found. However, during FY 1981-85, changes in rates of service use were generally matched by similar changes in total expenses for that service. For example, the 40% reduction in rate of endoscopies was accompanied by a near 50% decline in payments. Overall expenditures for all acid-related diagnoses fell by nearly 28% between 1981 and 1985. We concluded that the introduction of H2 antagonists had important positive clinical effects on all studied acid-related GI diagnoses.

California↗
PubMed1989

Economic effects of prophylactic use of misoprostol to prevent gastric ulcer in patients taking nonsteroidal anti-inflammatory drugs.

Prophylactic use of misoprostol has been found to cause a 15-fold reduction in the rate of gastric ulcer among symptomatic nonsteroidal anti-inflammatory drug users with osteoarthritis. Using data from a variety of sources, we performed a decision analytic-based evaluation of direct medical costs in these patients to determine whether routine prophylactic use of this medication is a preferred strategy over no prophylaxis. The base-case analysis revealed that misoprostol is cost-reducing for the initial 3 months of prophylaxis when the compliance rate is 60%, the silent ulcer rate is 40%, and the medication is priced below $1.74/d (expected costs per patient of approximately $300). The model is highly sensitive to changes in these parameters. Changing the rates of hospitalization and operation have less effect. Reliable estimates of misoprostol's economic impact after the initial 3 months of treatment are impossible to develop with current data. Nonmedical direct costs, patients' out-of-pocket costs, and indirect economic effects, such as work loss, were not considered in the model. All would enhance the economic benefit of the medication. Health care policy makers and payers must consider trade-offs between the clinical and economic implications of preventive medical interventions, such as misoprostol, especially as the call intensifies for more efficient allocation of health care resources.

Adult↗
PubMed1989

Risk and cost of gastrointestinal side effects associated with nonsteroidal anti-inflammatory drugs.

A retrospective cohort study determined the risk and cost of gastrointestinal side effects associated with the use of nonsteroidal anti-inflammatory drugs for an at-risk period from January 1, 1985, through March 31, 1985. Overall relative risk, adjusted for sex and race, was 2.52 (95% confidence interval, 2.25 to 2.82) and varied from 1.64 (95% confidence interval, 0.92 to 2.91) for duodenal ulcer to 3.27 (95% confidence interval, 1.40 to 7.66) for gastrointestinal bleeding. After deleting cases with a history of steroid or anticoagulant use or an alcohol-related diagnosis, adjusted relative risk was 2.58 (95% confidence interval, 2.29 to 2.90) and varied from 1.45 (95% confidence interval, 0.73 to 2.89) for all other cases of peptic ulcer to 2.37 (95% confidence interval, 1.26 to 4.46) for disorders of stomach function. There was a bimodal distribution of expenditures of Medicaid-paid gastrointestinal side effects. Most patients had low hospitalization costs, but an important minority had high hospitalization costs. Median ambulatory treatment costs during the 3-month study period for persons with gastrointestinal side effects was $27 and varied from $14 for those diagnosed as having nausea, vomiting, or heartburn to $393 for those diagnosed as having gastrointestinal bleeding. Median inpatient costs were $2006 and ranged from $1487 for persons with nausea, vomiting, or heartburn to $2486 for those with duodenal ulcer. For patients who had undergone an inpatient surgical procedure other than endoscopy alone, median hospital costs were $7209. An approximately twofold increase in payment for the same services would be expected if private third-party payers were responsible for the bill.

Adult↗
PubMed1988

Direct medical costs of disease and gastrointestinal side effects during treatment for arthritis.

We conducted a study to determine the costs of caring for patients with arthritis. Data were obtained from the Medicaid Management Information System (MMIS) of Washington, DC. A retrospective analysis was undertaken of all direct medical costs related to individual Medicaid recipients who obtained treatment for arthritis. First, all data were adjusted for patient compliance with nonsteroidal anti-inflammatory drugs (NSAIDs). Second, we determined the actual expenditure of treating arthritis. Last, the medical costs of treating adverse gastrointestinal side effects were examined. There was a linear relationship between compliance and pharmaceutical dose schedule per diem. Treatment costs per quarter were $145; 54 percent of the cost was for NSAIDs with the remainder equally divided between physician and hospital costs. Approximately 25 percent of the population experienced NSAID-related gastrointestinal side effects that required further medical care. The per-quarter mean cost of treating these adverse gastrointestinal drug reactions was $66 per person, which added nearly 46 percent to the per-quarter mean cost of treatment. The total cost of treating patients with arthritis therefore averaged $211 per quarter. Nearly one third of overall cost went to provide medical care to the 25 percent of the population who experienced adverse reactions, and slightly more than two thirds went towards treating the disease itself. Overall costs of treating adverse drug reactions were accounted for by pharmaceuticals (about 42 percent), usually the histamine (H2)-receptor antagonist cimetidine, rare but expensive inpatient hospital care (about 38 percent) and physician visits (about 20 percent).

Aged↗