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C L Bennett

Publications and source records attributed to C L Bennett.

At least 127 records · Page 7Linked to original sources
PubMed1996

A review of the costs, cost-effectiveness and third-party charges of bone marrow transplantation.

In an era of health care reform, costs, cost-effectiveness and charges for health care are taking on a larger role in the decision to adopt a new therapy. Hospitals, health maintenance organizations, third-party payers, doctors and patients all have an interest in the economic factors of health care; however, not all new therapies or medications have been analyzed. Bone marrow transplantation is one of the most expensive cancer treatments, costing an average of +193,000 per patient; therefore, many economic studies have focused on the costs of the therapy. However, it is important to note that these findings are not necessarily applicable to other diseases. Cost data are not static and even small changes in protocol can make a large difference in costs. Also, cost data from outside the United States is not always applicable to the United States system due to differences such as socialized medicine, workers' wages and pharmaceutical costs. Many economic analyses focus on the hospitals' charges and extrapolate cost-effectiveness from these figures, yet the amount hospitals charge for services and products is not always relative to the costs. Therefore, third-party payer costs are also important in analyzing the cost-effectiveness of a procedure. This article will review five signature papers which illustrate important issues to consider when trying to determine the costs and cost-effectiveness of bone marrow transplants.

Bone Marrow Transplantation↗
PubMed1996

A program for eradication of hepatitis B from Taiwan by a 10-year, four-dose vaccination program.

Approximately 15 percent of the Taiwanese population are chronic carriers of hepatitis B virus (HBV), among the highest rates in Asia. In July 1984, the Taiwanese government initiated a nationwide HBV-vaccination program. The program began with educational efforts and voluntary prenatal screening for HBsAg. Infants of HBsAg-carrier mothers received a four-dose regimen of hepatitis B vaccine. Those born to highly infectious mothers also received a dose of hepatitis-B immune globulin within 24 hours after birth. Seroepidemiologic studies were conducted using a random sample of infants. Serum samples were collected at 18, 24, 36, and 48 months and analyzed via radioimmunoassay for HBsAg, anti-HBs, and anti-HBc. Infants of highly infectious mothers had HBsAg positivity rates of 14.2 percent (vaccine plus HBIG) and 19.7 percent (vaccine only) when on schedule, and 17.0 percent when off schedule. Infants of moderately infectious mothers had an HBsAg positivity rate of 3.0 percent when on schedule and 6.4 percent when off schedule. These low positivity rates persisted throughout the 48-month follow-up period. This represents a dramatic improvement upon the 40 to 96 percent vertical transmission rate seen before the program implementation. This program demonstrates that mass immunoprophylaxis for HBV is feasible, and provides practical strategies for other Asian countries.

Adolescent↗
PubMed1996

Self-perceived unmet health care needs of persons enrolled in HIV care.

We examined the prevalence of, and factors associated with unmet health service needs among persons with HIV disease. Data were examined from 1,851 participants in the U.S. AIDS Cost and Service Utilization Study, drawn from 26 medical care providers in 10 cities. Geographic areas with large numbers of AIDS cases, and health care providers within them were chosen as study sites. After completing a screener questionnaire, potential participants at each site were stratifed by illness stage, HIV exposure route, and insurance status; a systematic random sample within those strata were selected for the study. Participants completed a comprehensive survey of HIV-related service use and costs, which also asked them to identify unmet health service needs. Analyses identified the relationship between unmet needs and: stage of illness, type of insurance, source of care, living arrangement, and AIDS prevalence of respondents' geographic region. At least one unmet need was reported by 20% of the sample. Needs for non-institutional services, e.g, dental care, mental health, and medications were more likely to be unmet than need for emergency room and hospital care. While most factors significantly affected the odds of having an unmet need, the greatest effects were found for private insurance and HIV asymptomatic status, both of which decreased the odds of unmet needs by approximately 50%. These findings suggest that insurance coverage for services required during the chronic phase of HIV illness is inadequate and should be augmented.

Acquired Immunodeficiency Syndrome↗
PubMed1996

AIDS-related Pneumocystis carinii pneumonia in older patients.

MAIN RESULTS: Compared with younger patients, patients aged 50 years or older were less likely to have acquired HIV via intravenous drug use or homosexual contact (p = .0001). Older patients were more likely to have comorbid diseases (12% vs 4%; p = .0001), had more frequent neurologic findings on admission (19% vs 9%; p = .0001), and scored higher on a PCP-specific severity-of-illness scale indicating more severe disease (p = .0001). Older patients had more intensive care unit admissions and intubations (p = .0001). Patients aged 50 years or older were less likely to have a diagnosis of HIV mentioned in their progress notes during the first 2 days of admission (75% vs 85%; p = .0001), less likely to receive PCP-specific therapy within the first 2 hospital days (58% vs 76%; p = .0001), and more likely to receive steroids (32% vs 22%; p = .0001). Older patients had a greater in-hospital mortality (32% vs 18%; p = .0001). However, in logistic regression analysis with mortality as the outcome, the effect of older age was diminished when adjustments were made for insurance status, severity of illness, comorbidity, timely PCP therapy, and inpatient use of steroids. CONCLUSIONS: Age differences in mortality for AIDS-related PCP may be explained by increased severity of presenting illness, underrecognition of HIV, and delay in initiation of PCP-specific therapy. Physicians may need to consider HIV-related infections for persons aged 50 years or older at risk of HIV infection.

AIDS-Related Opportunistic Infections↗
PubMed1996

Performance measurement in prostate cancer care: beyond report cards.

OBJECTIVES: Review and analyze various approaches to performance measurement in health care, demonstrating the value of provider-initiated performance measurement in which ongoing monitoring of both processes and outcomes of care coupled with the use of clinical guidelines enhances performance improvement efforts. Describe some of the issues and findings associated with the use of such a methodology in prostate cancer care. METHODS: Literature review and case study. RESULTS: There are a number of significant limitations in the use of a "report card" methodology to improve quality and efficiency in health care. The complementary approach of combining "instrument panels" and clinical guidelines within an overall continuous quality improvement framework appears to have resulted in improved clinical outcomes and reduced costs in a six-physician urology group located in a heavily managed-care penetrated market. CONCLUSIONS: Performance measurement tools are integral to efforts to improve outcomes and efficiency in health care. Providers of care might consider adapting the kind of performance improvement methodology described in this article. Practice benefits including improved clinical and economic outcomes are likely to follow.

Forecasting↗
PubMed1996

Use of hematopoietic colony-stimulating factors: the American Society of Clinical Oncology survey. The Health Services Research Committee of the American Society of Clinical Oncology.

PURPOSE: Dissemination of use of the hematopoietic colony-stimulating factors (CSFs) is unprecedented in oncology, with almost all physicians having experience with granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) shortly after the drugs received Food and Drug Administration (FDA) approval in 1991. The American Society of Clinical Oncology (ASCO) Health Services Research Committee sought to assess patterns of use of CSFs before dissemination of its first-ever publication of ASCO guidelines. METHODS: A questionnaire describing clinical scenarios was mailed to American oncologists and hematologists who practice medical oncology. In each scenario, the physician was asked whether he would prefer to use a CSF to prevent or treat neutropenia. RESULTS: The response rate to the mailed survey was 49% (N = 475). Most physicians preferred to use CSFs for secondary prophylaxis in patients receiving chemotherapy at rates of 44% to 85%, rather than reduce doses. Patterns of use did not differ for palliative, curative, or adjuvant chemotherapy. While the majority of CSF patterns of care were similar to those recommended in the ASCO guidelines, more than half of the physicians chose to use CSFs in the treatment of febrile neutropenia, an area not supported in the subsequent guidelines. In general, physicians at academic medical centers and in Health Maintenance Organization (HMO) practices were more likely to prefer dose-reduction strategies over addition of CSFs, while fee-for-service physicians preferred the opposite strategies. CONCLUSION: Variations in CSF preferences for use were related to differences in clinical characteristics (history of afebrile v febrile neutropenia), drug characteristics (G-CSF or GM-CSF), and physician practice characteristics (HMO or fee-for-service setting). However, before dissemination of the guidelines, the majority of American oncologists preferred strategies that were subsequently included in the ASCO CSF guidelines. CSF guidelines would be most likely to reduce CSF use for treatment of afebrile and uncomplicated febrile neutropenia.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1996

The impact of housing status on health care utilization among persons with HIV disease.

This study sought to identify the prevalence of unstable housing situations, and for whom they occurred, and to examine differences in health care utilization by housing status. Housing status and inpatient and outpatient health care utilization of 1,851 HIV-infected individuals was ascertained through interviews. Nine percent of respondents were in unstable housing situations. Unstable housing was associated with significantly lower functional status. The unstably housed were more likely to visit an emergency room (p < 0.05) and had fewer ambulatory visits than persons with stable housing (p < 0.03). They incurred nearly five more hospital days and their average hospitalization was approximately 1.5 days longer than the stably housed, although these differences were not significant. Utilization of ambulatory care is lower among unstably housed persons with HIV disease, which may have led to their increased reliance upon emergency rooms and hospitals. Helping HIV-infected individuals maintain adequate housing could reverse this pattern.

Adult↗
PubMed1996

Estimating the cost effectiveness of atovaquone versus intravenous pentamidine in the treatment of mild-to-moderate Pneumocystis carinii pneumonia.

Pneumocystis carinii pneumonia (PCP) is the most common severe opportunistic infection, and one of the most costly, among people with AIDS. Over 50% of patients experience toxic effects of the major anti-PCP medications- cotrimoxazole (trimethoprim-sulfamethoxazole) and pentamidine. Recently, the US Food and Drug Administration approved a new oral drug therapy, atovaquone, as an alternative to pentamidine for the treatment of people with mild-to-moderate PCP who are intolerant of cotrimoxazole. We developed a decision tree model to estimate the costs and cost effectiveness of atovaquone therapy compared with intravenous pentamidine therapy for cotrimoxazole-intolerant patients with mild-to-moderate PCP. Clinical outcomes were based on data from a phase III trial comparing the 2 medications. Our economic outcomes were based on treatment algorithms derived from discharge data, published reports and the clinical judgement of the co-authors. We estimate the total expected cost of treating a patient for an episode of PCP with atovaquone to be $US3990 compared with $US6545 for pentamidine under our baseline scenario (1995 dollars). Our decision model also provides insight into the large cost-savings benefits of treating mild-to-moderate PCP on an outpatient basis.

Antifungal Agents↗
PubMed1995

The learning curve for AIDS-related Pneumocystis carinii pneumonia: experience from 3,981 cases in Veterans Affairs Hospitals 1987-1991.

Previous studies have found lower mortality rates for AIDS-related Pneumocystis carinii pneumonia (PCP) in hospitals with higher levels of experience with PCP. It is not known if patients are selectively referred to better hospitals or if there is a learning curve whereby outcomes improve as physicians gain experience in treating PCP. We assessed cases of PCP at 140 Veterans Administration (VA) Medical Centers in the United States. During 1987-1991, 3,981 patients were hospitalized with first-episode AIDS-related PCP. Mortality at 30 days after admission. For these 3,981 hospitalizations at the 140 study hospitals, the 30-day mortality was 19%. Logistic regression models indicate that older age, race, geographic area, earlier year of treatment, hospitalization in the previous 12 months, and lower levels of hospital experience with AIDS were significant predictors of mortality at 30 days after admission. Compared with hospitals that had treated three cases or fewer of first-episode PCP, the odds of mortality at 30 days at hospitals that treated > 50 cases of first-episode PCP were 0.73 (95% confidence interval 0.58-0.91), after controlling for differences in characteristics of the patients, year, and region. Mortality of patients with AIDS-related PCP decreases as VA hospitals gain experience. Longitudinal analyses over a 5-year period suggest that a learning curve best explains this finding.

AIDS-Related Opportunistic Infections↗
PubMed1995

Granulocyte-macrophage colony-stimulating factor as adjunct therapy in relapsed lymphoid malignancy: implications for economic analyses of phase III clinical trials.

With the increasing concern over the high cost of health care, policy makers have incorporated economic analyses into phase III clinical trials as the randomized clinical trials can provide important information on the efficacy and potential cost-effectiveness of new pharmaceutical agents. Economic analyses of single-hospital experience during phase III trials of granulocyte-macrophage colony-stimulating factor (GM-CSF) as adjunct therapy for high dose chemotherapy with autologous stem cell support found significant shortening of neutropenia with GM-CSF at each hospital, but shortened hospitalization (and lower costs) at only two of three hospitals. In this study, we added data from three additional hospitals and found that the 103 patients who received GM-CSF had, on average, 5.7 days shorter durations of severe neutropenia than the 95 patients who received placebo (p < 0.0001) and 3.4 days shorter in hospitalization (p = 0.06). However, the duration of hospitalization, the primary determinant of health care costs, was shorter for GM-CSF patients in only four of the six centers and the duration of hospitalization of placebo patients was shorter at the other two centers. Careful analyses must be carried out when phase III clinical trial results are used to derive estimates of cost-effectiveness of new pharmaceutical agents. The interpretation of economic analyses of phase III clinical trials raises issues related to the perspective of the investigators, study design, collection of data on resource utilization, learning curve effects and generalizability of the results to other settings.

Antineoplastic Agents↗
PubMed1995

The learning curve for laparoscopic cholecystectomy. The Southern Surgeons Club.

BACKGROUND: The use of laparoscopic surgical procedures without previous training has grown rapidly. At the same time, there have been allegations of increased complications among less experienced surgeons. METHODS: Using multivariate regression analyses, we evaluated the relationship between bile duct injury rate and experience with laparoscopic cholecystectomy for surgeons in the Southern Surgeons Club. RESULTS: Fifty-five surgeons performed 8,839 procedures. Fifteen bile duct injuries (by 13 surgeons) resulted with 90% of the injuries occurring within the first 30 cases performed by an individual surgeon. Multivariate analyses indicated that the only significant factor associated with an adverse outcome was the surgeon's experience with the procedure. A regression model predicted that a surgeon had a 1.7% chance of a bile duct injury occurring in the first case and a 0.17% chance of a bile duct injury at the 50th case. CONCLUSIONS: While surgeons appear to learn this procedure rapidly, institutions might consider requiring surgeons to move beyond the initial learning curve before awarding privileges.

Bile Ducts↗
PubMed1995

Estimating the cost effectiveness of total androgen blockade with flutamide in M1 prostate cancer.

OBJECTIVES: Although combined androgen blockade with flutamide plus medical or surgical castration is effective in metastatic prostate cancer, debate exists over whether it is cost effective. METHODS: Decision analysis model of hypothetical cohorts of 70-year-old men presenting with metastatic prostate cancer, using a societal perspective, calculated anticipated survival and incremental cost per life-year gained. Time to progression and survival rate were from the Intergroup 0036 trial. Costs were based on Medicare data and wholesale drug pricing. Flutamide was estimated to reduce the relative risk of progressive disease by 25% (range, 0 to 50%). Costs and survival benefits were discounted at a 5% annual rate. RESULTS: In our model for minimal disease, median survival increased from 42.3 to 49.4 months with flutamide and average survival by 5.2 months at an incremental cost of $25,300 per life-year gained. If the efficacy were as high as 50%, the benefit would be 12 months at a cost of $13,700 per life-year gained. At a 10% efficacy, the benefit would be 1.9 months at a cost of $60,900 per life-year gained. For severe disease, the model estimated the median survival increased from 29.5 to 34.3 months with flutamide and average survival by 4.0 months at an incremental cost of $20,000 per life-year gained. At worst-case 10% efficacy, the benefit decreased to 1.5 months at an incremental cost of $47,500 per life-year gained. Total costs for patients treated with an orchiectomy and flutamide compared to leuprolide alone were similar if severe disease was present and actually lowered costs if there was minimal disease. CONCLUSIONS: Flutamide has an incremental cost effectiveness more favorable than most accepted therapies. If drug costs are covered under health care reform, flutamide should be initiated and covered for all good performance status patients.

Aged↗
PubMed1995

Patterns of care for and outcomes of Pneumocystis carinii pneumonia among persons with transfusion-acquired AIDS.

BACKGROUND: The most common human immunodeficiency virus (HIV)-related cause of death in persons with transfusion-acquired (TA) AIDS has been Pneumocystis carinii pneumonia (PCP). While better treatment for PCP accounts for improved survival among HIV-infected homosexual or bisexual men, the extent to which others have benefitted from these developments is unknown. STUDY DESIGN AND METHODS: Patterns of PCP care among persons with TA-AIDS, intravenous drug users, and homosexual or bisexual men are compared. RESULTS: TA-AIDS patients were older (mean, 46 years vs. < 40 for others, p < 0.05), more severely ill (59% had an alveolar-arterial oxygen gradient > 48.5 torr vs. 41% of others, p < 0.05), and less likely to have received PCP prophylaxis (16% of TA-AIDS patients versus 24-41% of others, p < 0.05). PCP care and outcomes also differed: TA-AIDS patients were less than half as likely to have early use of PCP medications (relative odds ratio = 0.45; 95% CI, 70% vs. > 80% for others, p < 0.05), more likely to be intubated (22% vs. 9-13% of others, p < 0.05), and more likely to die in-hospital (26% vs. 13-22% of others, p < 0.05). After controlling for differences in severity of illness, insurance, age, and hospital characteristics, TA-AIDS patients were 45 percent as likely to have early PCP therapy (95% CI, 22%, 91%) as were persons in high-risk groups. CONCLUSION: For persons whose only risk factor was transfusion, recognition of the HIV infection and its complications appears to be problematic, which may help explain poorer outcomes in persons with HIV-related PCP.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Costs of terminal care for people with AIDS.

Despite the numerous studies on the costs of AIDS, little has been reported on the economic costs for terminal care. This study reports on the average monthly costs of care used in the last 6 months of life by a group of people with AIDS between 1984 and 1990. Hospital and outpatient visits, laboratory results, and medications were evaluated for all subjects. Standard costs (1990 dollars) were applied to all services. The 81 subjects received care in a large private medical practice located in northern California. The group was primarily male (98 percent), white (87 percent), and gay or bisexual (89 percent). Mean age at diagnosis of AIDS was 40.8 (SE = 1.1). Patients averaged a total of 2.9 (SE = 0.2) opportunistic infections (OIs) from the diagnosis of AIDS to death. Median survival was 13.2 months. The primary outcome measures were the components of the costs of terminal care: inpatient visits and outpatient costs. Covariates include location of death, year of death, and OIs. Average monthly terminal care resources included 8.3 days of in-hospital care, $8258 in costs for inpatients care, $840 in outpatient costs, and $9098 in total costs. Death at home increased in frequency (from 20 percent for 1984-1987 to 37 percent for 1987-1990). However, costs in the last 6 months of life did not change significantly as costs for patients who died in the hospital decreased and costs for patients who died at home increased over time. Policies that promote dying at home, while likely to affect patient quality of life, may not lower health care costs.

AIDS-Related Opportunistic Infections↗
PubMed1995

Empirically treated Pneumocystis carinii pneumonia in Los Angeles, Chicago, and Miami: 1987-1990.

Many patients infected with the human immunodeficiency virus (HIV) with symptoms suggestive of pneumonia are treated empirically for Pneumocystis carinii pneumonia (PCP), although other bacterial infections (e.g., tuberculosis) and pulmonary Kaposi's sarcoma may cause identical symptoms. Empiric treatment for PCP may result in misdiagnosis and mistreatment. When the outcomes of cytologically confirmed versus empirically treated PCP cases were evaluated, the most important predictors of in-hospital mortality were severity of illness and use of bronchoscopy. Persons who did not undergo bronchoscopy had higher mortality rates than patients negative by bronchoscopy or cytologically confirmed as positive for PCP (22% vs. 11% vs. 14%, P < .01), although severity of illness and timing of anti-PCP medications did not differ significantly. Compared with cytologically confirmed cases, persons who did not have bronchoscopy were more likely to die than were bronchoscopy-negative patients (P < .05), after adjusting for severity of illness. Bronchoscopy use may have contributed to better outcomes for persons treated for HIV-related PCP.

AIDS-Related Opportunistic Infections↗
PubMed1995

Relationship between procedures and health insurance for critically ill patients with Pneumocystis carinii pneumonia.

The objective of the present study was to assess the association between type of health insurance coverage and use of diagnostic tests and therapies among patients with AIDS-related Pneumocystis carinii pneumonia (PCP). Fifty-six private, public, and community hospitals in Chicago, Los Angeles, and Miami were selected for the study, and the charts of 890 patients with empirically treated or cytologically confirmed PCP, hospitalized during 1987 to 1990 were retrospectively reviewed. Patients were classified by insurance status: self-pay (n = 56), Medicaid (n = 254), or private insurance, including health maintenance organizations and Medicare (n = 580). Primary outcomes were the use and timing of bronchoscopy, the type and timing of PCP therapy, and in-hospital mortality. The results indicate that Medicaid patients were less likely than privately insured patients to undergo bronchoscopy (relative odds = 0.61; 95% CI = 0.40, 0.93; p = 0.02) or to have their diagnosis of PCP confirmed (relative odds = 0.51; 95% CI = 0.33, 0.77), after adjusting for patient, severity of illness, and hospital characteristics. Medicaid patients were approximately three-fourths more likely than privately insured patients (relative odds = 1.73; 95% CI = 1.01, 2.96; p = 0.04) to die in-hospital, after adjusting for patient, severity of illness, and hospital characteristics. However, with further adjustment for confirmation of PCP, Medicaid patients no longer had a significantly higher likelihood of dying in-hospital. We conclude that Medicaid patients are less likely to receive diagnostic bronchoscopy than privately insured or self-insured patients, more likely to be empirically treated for PCP, and more likely to die in-hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Opportunistic Infections↗
PubMed1995

Costs of care and outcomes for high-dose therapy and autologous transplantation for lymphoid malignancies: results from the University of Nebraska 1987 through 1991.

PURPOSE AND METHODS: High-dose therapy with autologous stem-cell support has become common treatment for relapsed or refractory lymphomas. We conducted a study of 178 patients with Hodgkin's disease and 149 patients with non-Hodgkin's lymphoma who received high-dose therapy with stem-cell support. We evaluated the following: (1) whether improvements in outcomes over time found for surgical procedures were also true for a new nonsurgical procedure, autologous bone marrow and peripheral stem-cell transplantation; and (2) whether such a relationship, if it existed, applied to both clinical and economic outcomes. RESULTS: Mortality rates for patients with Hodgkin's disease decreased from 20% in 1987 to 0% in 1991. For non-Hodgkin's lymphoma, the mortality rate decreased from 29% in 1987 to 4% in 1991. Multivariate analyses indicated that the number of previous transplants was the most important factor associated with survival and low-cost care. After controlling for differences in clinical factors, a logistic regression model predicted that patients with Hodgkin's disease had a 20% chance of dying after 30 cases and a 5% chance after 178 cases; patients with non-Hodgkin's disease had a 33% chance of dying after 14 cases and a 5% chance after 149 cases. For patients with Hodgkin's disease, the cost decreased at a rate of 10% per year from 1987 to 1991 (P = .001), while for patients with non-Hodgkin's lymphoma, the cost of transplants decreased at a rate of 8% per year. CONCLUSION: Survival rates improved and costs of care decreased over time for patients who received high-dose therapy with stem-cell support. These changes are most likely related to improvements in supportive care technologies, better patient selection, and experience of the transplant team.

Antineoplastic Combined Chemotherapy Protocols↗