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Biomedical subjects

M V Pauly

Publications and source records attributed to M V Pauly.

At least 37 records · Page 2Linked to original sources
PubMed1998

First-cycle blood counts and subsequent neutropenia, dose reduction, or delay in early-stage breast cancer therapy.

PURPOSE: If patients could be ranked according to their projected need for supportive care therapy, then more efficient and less costly treatment algorithms might be developed. This work reports on the construction of a model of neutropenia, dose reduction, or delay that rank-orders patients according to their need for costly supportive care such as granulocyte growth factors. PATIENTS AND METHODS: A case series and consecutive sample of patients treated for breast cancer were studied. Patients had received standard-dose adjuvant chemotherapy for early-stage nonmetastatic breast cancer and were treated by four medical oncologists. Using 95 patients and validated with 80 additional patients, development models were constructed to predict one or more of the following events: neutropenia (absolute neutrophil count [ANC] < or = 250/microL), dose reduction > or = 15% of that scheduled, or treatment delay > or = 7 days. Two approaches to modeling were attempted. The pretreatment approach used only pretreatment predictors such as chemotherapy regimen and radiation history; the conditional approach included, in addition, blood count information obtained in the first cycle of treatment. RESULTS: The pretreatment model was unsuccessful at predicting neutropenia, dose reduction, or delay (c-statistic = 0.63). Conditional models were good predictors of subsequent events after cycle 1 (c-statistic = 0.87 and 0.78 for development and validation samples, respectively). The depth of the first-cycle ANC was an excellent predictor of events in subsequent cycles (P = .0001 to .004). Chemotherapy plus radiation also increased the risk of subsequent events (P = .0011 to .0901). Decline in hemoglobin (HGB) level during the first cycle of therapy was a significant predictor of events in the development study (P = .0074 and .0015), and although the trend was similar in the validation study, HGB decline failed to reach statistical significance. CONCLUSION: It is possible to rank patients according to their need of supportive care based on blood counts observed in the first cycle of therapy. Such rankings may aid in the choice of appropriate supportive care for patients with early-stage breast cancer.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1998

Modeling the cost-effectiveness of granulocyte colony-stimulating factor use in early-stage breast cancer.

PURPOSE: To model the cost-effectiveness (CE) of granulocyte colony-stimulating factor (G-CSF) in early-stage breast cancer when its use is directed to those most in need of the medication. METHODS: A conditional CE model was developed for the use of G-CSF based on a ranking of patient need as determined by patient blood counts during the first cycle of chemotherapy. In the base case, no G-CSF was used. In the alternative case, G-CSF was used in the following manner. If the risk of a neutropenic event (as defined by a predictive model based on nadir absolute neutrophil count [ANC] and hemoglobin decrease in cycle 1) was equal to or exceeded a predetermined critical value "T," then patients would receive G-CSF in cycles 2 through 6 of chemotherapy. If the risk of an event was less than T, patients would not use G-CSF unless an event occurred, at which time G-CSF would be administered with every subsequent cycle. RESULTS: A decision rule (T) that would allow the most needy 50% of early-stage breast cancer patients to receive G-CSF after the first cycle of chemotherapy resulted in a CE ratio of $34,297 dollars per life-year saved (LYS). If only the most needy 10% of patients received G-CSF, then the associated CE ratio was $23,748/LYS; if 90% of patients could receive the medication, the CE ratio would be $76,487/LYS. These estimates were relatively insensitive to inpatient hospital cost estimates (inpatient costs for fever and neutropenia of $3,090 to $7,726 per admission produced dollar per LYS figures of $34,297 to $32,415, respectively). However, the model was sensitive to assumptions about the shape of the relationship between dose reduction and disease-free survival (DFS) at 3 years. CONCLUSION: Providing G-CSF to the neediest 50% of early-stage breast cancer patients (as defined by first-cycle blood counts) starting after the first cycle of chemotherapy is associated with a CE ratio of $34,297/LYS, which is well in the range of CE ratios for treatment of other common medical conditions. Furthermore, conditional CE studies, based on predictive models that incorporate individual patient risk, allow one to define populations for which therapy is, or is not, cost-effective. Limitations of our present understanding of the shape of the chemotherapy dose-response curve, especially at low levels of dose reductions, affect these results. Further work is required to define the shape of the dose-response curve in early-stage breast cancer.

Breast Neoplasms↗
PubMed1998

Managed care, market power, and monopsony.

OBJECTIVE: To examine the theoretical possibility of monopsony behavior under managed care insurance. STUDY DESIGN: Use of microeconomic theory to examine how managed care plans with market power would be expected to behave, and effects of that behavior on consumer and supplier welfare. PRINCIPAL FINDINGS: The article shows that, under managed care monopsony, the welfare of consumers may be increased but overall economic welfare will necessarily be reduced. It offers a test for whether the lower prices paid by managed care buyers with larger market share represent welfare-reducing monopsony or a welfare-increasing movement away from provider monopoly. The test says that, if the quantity of inputs (supplied under conditions of increasing long-run marginal cost) declines, monopsony is present. The article also argues that the translation of lower provider prices into lower premiums is consistent with welfare-reducing monopsony by nonprofit health plans. In contrast, for-profit health plans that obtain monopsony may reduce the welfare of consumers as well as that of input suppliers. These theoretical conclusions are shown to be consistent with recent empirical research indicating a negative relationship between buyer market power and cost per enrollee. CONCLUSIONS: Traditional antitrust policy has not been able to deal well with monopsony. The article concludes that health plans that use their market power to reduce medical spending may harm the well-being both of specialized medical workers and of consumers of medical care. Antitrust policy may need to be modified to deal with this situation.

Antitrust Laws↗
PubMed1997

The effects of health insurance on access to new medical technologies.

We examined the use of percutaneous transluminal coronary angioplasty, kidney stone lithotripsy, and bone marrow transplant among patients with different health insurance plans in California. HMO enrollees were less likely to receive these procedures compared with fee-for-service patients. Our results have implications for the inflationary effects of technology under managed care.

Angioplasty, Balloon, Coronary↗
PubMed1997

Structural incentives and adoption of medical technologies in HMO and fee-for-service health insurance plans.

Recent literature has argued that conventional fee-for-service (FFS) health insurance, as compared to managed care (HMO) insurance, may lead to the adoption of new technology that raises costs and reduces patient welfare. In this paper, we show that this result depends on an increasingly unrealistic key assumption-that FFS insurers cannot refuse to reimburse new technology. We also show that, when the assumption is changed, HMO insurers may adopt costly technologies that FFS insurers do not.

Decision Making, Organizational↗
PubMed1996

Effect of dialyzer reuse on survival of patients treated with hemodialysis.

OBJECTIVE: To evaluate the impact of dialyzer reuse on the survival of US hemodialysis patients. STUDY DESIGN AND PARTICIPANTS: Nonconcurrent cohort study of 27938 patients beginning hemodialysis in the United States in 1986 and 1987. MAIN OUTCOME MEASURE: Patient survival. RESULTS: Dialysis in freestanding facilities reprocessing dialyzers with the combination of peracetic and acetic acids was associated with greater mortality than treatment in facilities not reprocessing dialyzers (rate ratio [RR],1.10, 95% confidence interval [CI], 1.02-1.18; P=.02) In contrast, there was no significant difference between survival in freestanding facilities reprocessing dialyzers with either formaldehyde (RR,1.03, 95% CI, 0.96-1.10; P=.45) or glutaraldehyde (RR, 1.13, 95% CI, 0.95-1.35, P=.18) and survival in freestanding facilities not reprocessing dialyzers. Among freestanding facilities reprocessing dialyzers, use of peracetic/acetic acid was associated with a higher rate of death than use of formaldehyde (RR = 1.08, 95% CI, 1.01-1.14; P=.02). There was no statistical difference between survival in hospital-based facilities reprocessing dialyzers with either peracetic/acetic acid (RR=0.95, 95% CI, 0.85-1.06; P=.40), formaldehyde (RR=1.06, 95% CI, 0.98-1.15; P=.12), or glutaraldehyde (RR=1.09, 95% CI, 0.71-1.67; P=.70) and survival in hospital-based facilities not reprocessing dialyzers. In addition, choice of sterilant was not associated with a statistically significant difference in survival among hospital-based facilities reprocessing dialyzers. CONCLUSIONS: Dialysis in freestanding facilities reprocessing dialyzers with peracetic/acetic acid may be associated with worse survival than dialysis in free-standing facilities not reprocessing dialyzers or in those reprocessing with formaldehyde. We were unable to determine whether these relationships arose from greater comorbidity among patients treated in facilities using peracetic/acetic acid, poor quality of dialysis procedures in these facilities, or direct toxicity of peracetic/acetic acid. These findings raise important concerns about potentially avoidable mortality among US hemodialysis patients treated in dialysis facilities reprocessing hemodialyzers.

Adult↗
PubMed1996

Economics of multispecialty group practice.

The number of physicians organized in multispecialty group practices is growing. Research does not suggest that such practices will achieve economies of scope. Rather, the primary economic advantage to multispecialty group practice may be its ability to coordinate the process of care in a managed care setting, a process for which relatively large practices may be necessary.

Costs and Cost Analysis↗
PubMed1996

Comorbidity-adjusted complication risk: a new outcome quality measure.

The measurement of inpatient complications his received substantial attention in recent years because mortality rates and other outcome measures often appear unable to discriminate superior from inferior hospital care. Complication measurement holds out the promise of being more sensitive to variations in patient care because complications occur more frequently than do mortalities, and because complications are more direct consequences of the process of care. The authors developed a new measure of complications that seeks to give insight into the patient care given by different hospitals or physicians by using commonly available data. Specifically, this measure is based on a decision-theoretic model that estimates the probability of a complication for combinations of admitting and secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnoses. The measure can be evaluated at the patient level, or aggregated and risk-adjusted for the population of a given care provider (eg, physician or hospital). When applied to a set of patient-level UB- 82/92 data, this measure estimates the risk of complication for any member of a population, controlling for comorbidity, and hence is designated comorbidity-adjusted complication risk (CACR). The authors describe the development of CACR and its testing and validation using data acquired from the states of Pennsylvania, California, and Florida, as well as facility data obtained directly from hospitals. The data set includes 480,000 patients from 50 Pennsylvania hospitals, 300,000 patients from 33 Florida hospitals, 370,000 patients from 35 California hospitals, and 37,000 patients from six validation hospitals. Comorbidity-adjusted complication risk is constructed from widely available data common to most patient cases. Comorbidity-adjusted complication risk can be adjusted for its case mix, but such risk adjustment has much less effect on CACR than on other adverse outcomes such as mortality and morbidity. Comorbidity-adjusted complication risk varies widely across the hospitals in this sample, yet it is stable across time and is correlated with other known quality outcomes, including such accepted "gold standards" as hospital-documented adverse event rates and chart review determinations of complications.

Aged↗
PubMed1996

Measuring hospital outcomes from a buyer's perspective.

This study reports lessons learned from a project to develop a flexible, generalizable, and valid method for corporate buyers of hospital care that would permit them to use available secondary data to rate the outcomes quality of all hospitals in a local market area. As hospitalization insurance has moved from coverage that applied equally to all licensed hospitals to arrangements which selected a certain preferred hospital or hospitals and rejected others, the need to determine the quality of different hospitals (as well as what they would cost the insurer or buyer) has become apparent. The product of this project was the development and demonstration of a set of rating methods that build on the strengths available in large hospital discharge data bases, such as (but by no means limited to) that of the Pennsylvania Health Care Cost Containment Council (PHC4). These measures, or others developed using these methods, deal with uncertainty in the data--its diagnosis and treatment--in a conceptually valid and practically useful way, illustrate a process that might be used in the general development of quality measures, and provide a useful critique of some other measures.

Commerce↗
PubMed1996

Genetic screening for reproductive planning: methodological and conceptual issues in policy analysis.

OBJECTIVES: This paper explores several critical assumptions and methodological issues arising in cost-effectiveness analyses of genetic screening strategies in the reproductive setting. METHODS: Seven issues that arose in the development of a decision analysis of alternative strategies for cystic fibrosis carrier screening are discussed. Each of these issues required a choice in technique. RESULTS: The presentations of these analyses frequently mask underlying assumptions and methodological choices. Often there is no best choice. In the case of genetic screening in the reproductive setting, these underlying issues often touch on deeply felt human values. CONCLUSIONS: Space limitations for published papers often preclude explaining such choices in detail; yet these decisions determine the way the results should be interpreted. Those who develop these analyses need to make sure that the implications of important assumptions are understood by the clinicians who will use them. At the same time, clinicians need to enhance their understanding of what these models truly mean and how they address underlying clinical, ethical, and economic issues.

Cystic Fibrosis↗
PubMed1996

Health systems ownership: can regulation preserve community benefits?

This article addresses two questions. What determines the amount of community benefit a nonprofit firm will provide? What would be the expected effect of legal rules requiring nonprofit firms to provide more community benefit than they would otherwise have chosen? The amount of community benefit provided, it is argued, depends on the desires of the donors who endow the nonprofit firm with its equity capital and control its corporate board. The effect of a law requiring the provision of community benefit depends on the degree of competition in the local market. In competitive markets, such a rule is like a hidden tax. In markets in which nonprofit firms have market power, it may divert resources from types of benefit valued highly by the board toward activities valued highly by the political process. The definition of community benefit and the future of nonprofit hospitals are also discussed.

Community-Institutional Relations↗