Methods of evaluating socioeconomic relationships have evolved over many years, and a number of specific approaches have been developed. Among the techniques available, cost-effectiveness analysis (CEA) has emerged as the most widely used and accepted method. Yet, despite considerable effort by the analytical community to refine this technique into one more useful for making health policy decisions, much debate and confusion still persist among analysts, readers, and policy-makers concerning methods standards and the overall usefulness of CEA in resource allocation decision making. Thus the purpose of this paper is to summarize, critically examine, and comment on existing recommended methods for socioeconomic evaluation of health care interventions. In particular, we examine an exhaustive set of component methods within the general area of cost-effectiveness and comment on areas of apparent consensus and debate. Our review reveals many areas of agreement and many yet to be resolved. Analysts generally agree on the components of the overall framework for an analysis; basic methodologic principles; the general treatment of costs; the principle of marginal analysis; the need for and general approach to discounting; the use of sensitivity analysis; the extent to which ethical issues can be incorporated; and the importance of choosing appropriate alternatives for comparison. The principal areas in which disagreement still persists are choice of study design, measurement and valuation of health outcomes including conversion of health outcomes to economic values, transformation of efficacy results into effectiveness outcomes, and the empirical measurement of costs.

Cost-Benefit Analysis↗

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Mivacurium infusion during nitrous oxide-isoflurane anesthesia: a comparison with nitrous oxide-opioid anesthesia.

STUDY OBJECTIVE: To determine the potentiation of the neuromuscular blockade induced by a titrated infusion of mivacurium in the presence of isoflurane versus a nitrous oxide (N2O)-opioid anesthesia. DESIGN: An open-label, controlled study. SETTING: The inpatient anesthesia service of two university medical centers. PATIENTS: Thirty adults divided into two groups. INTERVENTION: An intravenous infusion of mivacurium during anesthesia with N2O-opioid or N2O-isoflurane. MEASUREMENTS AND MAIN RESULTS: A neuromuscular blockade was monitored by recording the electromyographic activity of the adductor pollicis muscle resulting from supramaximal stimulation at the ulnar nerve at 2 Hz for 2 seconds at 10-second intervals. The mivacurium infusion rate was significantly less in the presence of isoflurane [4.0 +/- 0.8 micrograms/kg/min (mean +/- SEM)] than during N2O-opioid anesthesia (6.4 +/- 0.6 micrograms/kg/min). The recovery rates did not differ between anesthetic groups. After the termination of the infusion, spontaneous recovery to T4/T1 of at least 0.75 occurred in an average of 17.9 +/- 1.5 minutes, with a mean recovery index (T25-75) of 6.0 +/- 0.7 minutes. CONCLUSION: Isoflurane anesthesia reduces the infusion rate of mivacurium required to produce about 95% depression of neuromuscular function.

Adult↗

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Gastric mucosal bleeding time in cirrhosis.

Gastric mucosal bleeding time was measured prospectively in 25 patients with cirrhosis and portal hypertension undergoing routine sclerotherapy. Age and sex-matched controls without liver disease were also studied. Correlations were sought between gastric mucosal bleeding time and age, platelet count, prothrombin time, skin bleeding time, Child-Pugh score, variceal size before sclerotherapy, and degree of portal hypertensive gastropathy. Gastric bleeding time was prolonged in 12% of the patients with cirrhosis (mean, 3.24 minutes; SEM, 0.476) and in none of the controls (mean, 3.0; SEM, 0.171). No correlation was noted between gastric bleeding time and any of the above variables. The results of this study indicate that gastric mucosal bleeding time is prolonged in cirrhosis but is an independent physiologic parameter unrelated to any of the above-mentioned variables.

Bleeding Time↗

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The Eighteenth John Snow Memorial Lecture. The anaesthetist and the law.

The nature of the possible litigation, in which anaesthetists may be involved and the nature and manner of the preparation, which are necessary if he should be required to appear in court, are discussed.

Anesthesiology↗