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M C Weinstein

Publications and source records attributed to M C Weinstein.

At least 109 records · Page 6Linked to original sources
PubMed1988

Costs and effectiveness of routine therapy with long-term beta-adrenergic antagonists after acute myocardial infarction.

We analyzed the costs and effectiveness of routine therapy with beta-adrenergic antagonists in patients who survived an acute myocardial infarction. On the basis of data pooled from the literature, this form of therapy resulted in a 25 percent relative reduction annually in the mortality rate for years 1 to 3 and a 7 percent relative reduction for years 4 to 6 after a myocardial infarction. The estimated cost of six years of routine beta-adrenergic-antagonist therapy to save an additional year of life was $23,400 in low-risk patients, $5,900 in medium-risk patients, and $3,600 in high-risk patients, assuming that the entire benefit of earlier treatment is lost immediately after six years. Under a more likely assumption--that the benefit of six years of treatment wears off gradually over the subsequent nine years--the estimated cost of therapy per year of life saved would be $13,000 in low-risk patients, $3,600 in medium-risk patients, and $2,400 in high-risk patients. As compared with coronary-artery bypass grafting and the medical treatment of hypertension, routine beta-adrenergic-antagonist therapy has a relatively favorable cost-effectiveness ratio.

Adrenergic beta-Agonists↗
PubMed1988

A cost-effectiveness analysis of exercise as a health promotion activity.

We used cost-effectiveness analysis to estimate the health and economic implications of exercise in preventing coronary heart disease (CHD). We assumed that nonexercisers have a relative risk of 2.0 for a CHD event. Two hypothetical cohorts (one with exercise and the other without exercise) of 1,000 35-year-old men were followed for 30 years to observe differences in the number of CHD events, life expectancy, and quality-adjusted life expectancy. We used jogging as an example to calculate cost, injury rates, adherence, and the value of time spent. Both direct and indirect costs associated with exercise, injury, and treating CHD were considered. We estimate that exercising regularly results in 78.1 fewer CHD events and 1,138.3 Quality Adjusted Life Years (QALYs) gained over the 30-year study period. Under our base case assumptions, which include indirect costs such as time spent in exercise, exercise does not produce economic savings. However, the cost per QALY gained of $11,313 is favorable when compared with other preventive or therapeutic interventions for CHD. The value of time spent is a crucial factor, influencing whether exercise is a cost-saving activity. In an alternative model, where all members of the cohort exercise for one year, and then only those who like it or are neutral continue, exercise produces net economic savings as well as reducing morbidity.

Adult↗
PubMed1987

Performance of screening and diagnostic tests. Application of receiver operating characteristic analysis.

Evaluation of psychiatric screening and diagnostic tests has benefited from the application of sensitivity, specificity, the kappa-statistic, and predictive values. These measures derive their meaning from a single criterion threshold. Receiver operating characteristic (ROC) analysis extends assessment of test performance by providing information about all possible pairs of achievable sensitivity and specificity values. The ROC analysis offers a comprehensive means for comparing different tests or different scoring procedures for one test. As a demonstration we used the ROC analysis to evaluate three types of scoring rules for one psychiatric test, the Health Opinion Survey. The demonstration indicated that ROC analysis can profitably take a place among the standard methods for test evaluation in psychiatric research. In addition, ROC analysis can assist clinicians in selecting appropriate test procedures for particular patient populations.

Borderline Personality Disorder↗
PubMed1987

Cost-effectiveness analysis of periodontal disease control.

Cost-effectiveness analysis was used to evaluate alternative methods of periodontal disease control. The alternatives considered included non-surgical and surgical procedures as well as the use of antimicrobial agents. Data on costs were obtained from American Dental Association publications of average charges for periodontal services. The concept of quality-adjusted tooth-years (QATYs) was developed to provide an outcome measure which could be compared across treatments. The conclusions of this analysis are as follows: (1) Conservative non-surgical treatments for periodontal disease control not only have costs lower than surgical alternatives, as would be expected, but also maximize expected quality-adjusted tooth-years over a wide range of estimates; (2) antimicrobial therapy used as an adjunct to non-surgical treatment is likely to be both effective and cost-effective; and (3) quality of tooth-years is a critical consideration in the determination of outcome of periodontal treatment. For example, when tooth-years are not adjusted for quality, differences between treatments are diminished, and surgical treatment becomes as good as or better than more conservative treatments for some levels of disease severity.

Alveoloplasty↗
PubMed1987

Forecasting coronary heart disease incidence, mortality, and cost: the Coronary Heart Disease Policy Model.

A computer simulation model was developed to project the future mortality, morbidity, and cost of coronary heart disease (CHD) in the United States population. The model contains a demographic-epidemiologic (DE) submodel, which stimulates the distribution of coronary risk factors and the conditional incidence of CHD in a demographically evolving population; a "bridge" submodel, which determines the outcome of the initial CHD event; and a disease history (DH) submodel, which simulates subsequent events in persons with a previous CHD event. The user of the model may simulate the effects of interventions, either preventive (i.e., risk factor modification) or therapeutic, upon mortality, morbidity, and cost for up to a 30-year period. If there were no future changes in risk factors or the efficacy of therapies after 1980, baseline projections indicate that the aging of the population, and especially the maturation of the post-World War II baby-boom generation, would increase CHD prevalence and annual incidence, mortality, and costs by about 40-50 per cent by the year 2010. Unprecedented reductions in risk factors would be required to offset these demographic effects on the absolute incidence of CHD. The specific forecasts could be inaccurate, however, as a consequence of erroneous assumptions or misestimated baseline data, and the model awaits validation based on actual future data.

Adult↗
PubMed1987

Application of decision analysis to drug selection for formulary addition.

Decision analysis (DA) is a quantitative method for making decisions, incorporating both probabilistic data and value judgments, and clinical and economic outcomes. The P & T Committee at the Mary Hitchcock Memorial Hospital used this technique to aid in selection of a third-generation cephalosporin for formulary addition. Cost-specific data from this hospital, together with clinical data derived from the medical literature, and a panel of infectious disease specialists were used to compare costs associated with antibiotic regimens of three infections. Results show that ceftizoxime is the least costly treatment for hospital-acquired pneumonia and sepsis of unknown origin, whereas metronidazole plus gentamicin is the least costly regimen for intra-abdominal infections. This demonstrates that drugs with higher acquisition costs can, in some cases, be less expensive than drugs with lower acquisition costs when the total cost of drug therapy is considered.

Cephalosporins↗
PubMed1986

Risk reduction for nonmelanoma skin cancer with childhood sunscreen use.

Exposure to ultraviolet radiation is the principle cause of basal and squamous cell carcinomas of the skin, which are the most frequent tumors occurring in white residents of the United States. Using a mathematical model based on epidemiologic data, we quantified the potential benefits of using a sunscreen with a sun protective factor of 15 and estimate that regular use of such a sunscreen during the first 18 years of life would reduce the lifetime incidence of these tumors by 78%. Additional benefits of sunscreen use during childhood include reduced risk of sunburn, retarding the pace of skin aging, and possible reduction in melanoma risk. We recommend that pediatricians encourage sunscreen use and sun avoidance as a regular part of pediatric preventive health care.

Adolescent↗
PubMed1985

Will disease prevention spare the medical commons?

Everywhere the disparity grows between what modern medicine can achieve, on the one hand, and what society can afford, on the other. In industrialized nations health resource allocation questions now focus primarily on diagnostic, therapeutic and rehabilitative medical programmes. With increases both in our capabilities in preventive medicine and in public awareness of those capabilities, soon that realm is likely to be demanding more resources from the health budget. These considerations and others make urgent the development of better methods for setting priorities for the allocation of health resources. A common thread in the consideration of competing programmes will be issues of trade-offs. Beneficial programmes that save more health resources than they consume are much to be desired, but resource saving should not be regarded as a necessary condition for giving high priority to a programme. Cost-effectiveness ratios provide one approach to measuring the ability of competing programmes to use health-care resources to produce health benefits. Application of cost-effectiveness principles suggests that prevention programmes merit a greater share of resources, even though such programmes generally consume more health resources than they save. For the process of priority-setting to be equitable and rational, more and better data will be required on programmatic costs and benefits. Furthermore, the process should be flexible, allowing priorities to differ from one geographic area to another, and from time to time within the same area. Finally, the process must be understood by a majority of the population, and perceived as fair.

Adolescent↗
PubMed1985

Probabilistic sensitivity analysis using Monte Carlo simulation. A practical approach.

The data for medical decision analyses are often unreliable. Traditional sensitivity analysis--varying one or more probability or utility estimates from baseline values to see if the optimal strategy changes--is cumbersome if more than two values are allowed to vary concurrently. This paper describes a practical method for probabilistic sensitivity analysis, in which uncertainties in all values are considered simultaneously. The uncertainty in each probability and utility is assumed to possess a probability distribution. For ease of application we have used a parametric model that permits each distribution to be specified by two values: the baseline estimate and a bound (upper or lower) of the 95 percent confidence interval. Following multiple simulations of the decision tree in which each probability and utility is randomly assigned a value within its distribution, the following results are recorded: (a) the mean and standard deviation of the expected utility of each strategy; (b) the frequency with which each strategy is optimal; (c) the frequency with which each strategy "buys" or "costs" a specified amount of utility relative to the remaining strategies. As illustrated by an application to a previously published decision analysis, this technique is easy to use and can be a valuable addition to the armamentarium of the decision analyst.

Decision Making↗
PubMed1985

The decision concerning coronary angiography in patients with chest pain. A cost-effectiveness analysis.

We examined the decision whether to perform coronary angiography (followed by bypass surgery if appropriate findings are present) in middle-aged men who have chest pain and have undergone exercise tolerance testing (ETT). We developed a model of this decision that combines data from a variety of sources and selects the optimal strategy based on health outcome and, if desired, monetary cost. The analysis supports the following conclusions: for patients with nonspecific chest pain or atypical angina, the ETT provides useful information concerning the decision; furthermore, the number of millimeters of ST-segment depression above which angiography should be performed depends on coronary risk factors and pain severity. A normal ETT is insufficient evidence to exclude coronary angiography for patients with typical angina, provided that one is willing to expand resources for health benefits at levels comparable to those for other accepted medical practices. If monetary considerations are excluded, the preceding statement concerning ETT and angiography also holds for patients with atypical angina and for those with nonspecific pain and advanced risk factors. These last two conclusions suggest that ETT is not useful in guiding management decisions concerning coronary angiography in patients at high enough risk of coronary artery disease on the basis of symptoms and risk profile.

Angina Pectoris↗
PubMed1985

What do patients value? Willingness to pay for ultrasound in normal pregnancy.

Evaluations of diagnostic tests have focused primarily on their value in clinical decisions. Patients may attach value to 1) information that has little or no medical significance, and 2) information (medical or nonmedical) that has no bearing on decisions to be made by the doctor or the patient. Ultrasound in pregnancy, which provides a great deal of information to both doctor and patient, was chosen as the example with which to explore these hypotheses. Sixty-two women with current or recent normal pregnancies were given a structured interview to elicit their willingness to pay for ultrasound information. Among these women, 26% of the value attached to the test related to information having no decisional significance, and 37% of the value related to information of use to the patient, but not the doctor. Overall, 44% of the value of the test, from the patients' point of view, pertained to uses outside the realm of medical decisions. On the average, interviewees alleged that they would pay +706 for the information contained in an ultrasound test in an uncomplicated pregnancy. Decision analyses and cost-effectiveness analyses that take note only of the medical, decisional uses of test information may overlook a high proportion of the value patients attach to the information.

Decision Theory↗
PubMed1985

Elective hysterectomy. Benefits, risks, and costs.

This study evaluated the effect of hysterectomy or hysterectomy and bilateral salpingo-oophorectomy (hysterectomy and oophorectomy) versus alternative medical management on life expectancy, quality of life, and direct medical costs. Using techniques of decision analysis and available data on sequelae, it was found that gains in life expectancy and quality of life can be expected when women ages 30-60 undergo hysterectomy for benign neoplasm, disorders of menstruation, acquired abnormal anatomy, cervical disease, or endometriosis, owing primarily to prevention of reproductive tract cancers, which outweighs the impact of operative mortality. However, women who have relatively high operative risk or low expected cancer risks, beyond thresholds estimated in sensitivity analyses, suffer losses in life expectancy. Women younger than 35 not treated with replacement estrogens following hysterectomy and oophorectomy can expect net losses in life expectancy with surgical intervention due to increased risks of heart disease and osteoporosis. For women in the reproductive years who wish to preserve their potential to bear children, sterilization may be an unacceptable consequence of elective hysterectomy in the quality of life.

Adult↗
PubMed1984

Cost-effectiveness of lowering the aflatoxin tolerance level.

The cost-effectiveness of adopting aflatoxin tolerance levels of 15, 10 and 5 ppb for peanuts and peanut products was assessed. Estimates of the annual cost to manufacturers of monitoring and controlling peanut aflatoxin levels at the current 20-ppb action level, and estimates of the projected increase in costs of establishing lower tolerances were elicited from producers by questionnaire. Exposures to peanut products were derived from the HANES I survey and from peanut production statistics. The risk of liver cancer at each tolerance level was estimated using both epidemiological and extrapolated experimental data assuming that exposure would be reduced in direct proportion to the decrease in the tolerance. It was found that the 15-ppb tolerance would cost $60,000 per cancer death averted (range $20,000-$1,700,000) and is therefore relatively cost-effective. The marginal costs per life saved for both the 10-ppb and 5-ppb levels were found to be $1.7 million (range $0.6 million-$11.4 million) and $1.6 million (range +0.6 million-$31.1 million), respectively. Conclusions on the optimal regulatory approach should be guided by comparisons of these figures with corresponding cost-effectiveness ratios for alternative regulatory uses of national resources in the interests of public health.

Arachis↗
PubMed1984

Preferences for health outcomes. Comparison of assessment methods.

This study compared standard gamble (SG), time trade-off (TTO), and category scaling (CS) methods for assessing preferences among hypothetical outcomes of coronary artery bypass surgery. High correlations among assessment methods, as found in some previous studies, do not assure the absence of systematic differences in rating obtained by different methods. This study used analysis of variance to test for differences among the three assessment methods. Questionnaire responses were obtained from 67 of 109 physicians participating in a postgraduate course on clinical decision making, following a lecture and workshop on utility theory. SG and CS were used to rate multivariate combinations of angina (none, moderate, and severe) and survival (0, 5, and 10 years); and SG, TTO, and CS were used to rate univariate outcomes with angina (none, moderate, and severe) for the remainder of their life expectancy. SG ratings were higher than TTO ratings, which were higher than CS ratings (p less than 0.001 for all comparisons). Multivariate responses revealed a significant interaction between angina and survival dimensions using CS, but not using SG. We conclude that these methods are not interchangeable and that differences between SG and CS require a more complex explanation than differences in attitude toward risk.

Angina Pectoris↗