Theory for all and rehabilitation for the few (with money): who does our theory serve?
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The case for treatment of dyspeptic patients infected with H. pylori.
H. pylori is probably the commonest bacterial infection worldwide and associated with a number of clinical outcomes including chronic active gastritis, peptic ulcer, gastric adenocarcinoma, gastric MALT lymphoma and possibly dyspepsia. Treatment to eradicate H. pylori infection has changed significantly the natural history of peptic ulcer disease and is now the recommended approach to patients with non-NSAID gastric and duodenal ulcers. Controversies remain as to whether H. pylori infection is a cause of dyspepsia and non-ulcer dyspepsia. However, results from several economic models evaluating a "test and treat" strategy have suggested that eradication of H. pylori infection as an initial choice is the most cost-effective approach and has a long-term benefit in a significant proportion of patients with dyspepsia. The conclusion of H. pylori as a group 1 human carcinogen by the IARC and the subsequent analyses have added further to the recommendation for eradication of the infection.
Dyspepsia↗
Cost-effectiveness analysis: application to endourology.
A literature review was conducted on the application of economic analysis to clinical medicine, particularly urology. The surgical management of urolithiasis and the treatment of ureteropelvic junction obstruction were used as specific disease examples to evaluate how cost-effectiveness analysis has been used to address the clinical concerns of practicing urologists. As the costs and outcomes of the treatment of kidney stone disease and ureteropelvic junction obstruction can be specifically defined, the application of cost-effectiveness analysis in these two areas meets most standards of economic analysis. Economic models that incorporate poor assumptions, incomplete data, or both are unlikely to have significant clinical utility. The most useful models are those that are structurally simple and evaluate healthcare program alternatives from the patient's, provider's, or society's perspective.
Cost-Benefit Analysis↗
Complete daVinci versus laparoscopic pyeloplasty: cost analysis.
BACKGROUND AND PURPOSE: Computer-assisted pyeloplasty with the daVinci system is an emerging technique to treat ureteropelvic junction (UPJ) obstruction. A relative cost analysis was performed assessing this technology in comparison with purely laparoscopic pyeloplasty. PATIENTS AND METHODS: Eight patients underwent computer-assisted (daVinci) dismembered pyeloplasty (CP) via a transperitoneal four-port approach. They were compared with 13 patients who underwent purely laparoscopic pyeloplasty (LP). All patients had a primary UPJ obstruction and were matched for age, sex, and body mass index. The cost of equipment and capital depreciation for both procedures, as well as assessment of room set-up time, takedown time, and personnel were analyzed. Surgeons and nursing staff for both groups were experienced in both laparoscopy and daVinci procedures. One- and two-way financial analysis was performed to assess relative costs. RESULTS: The mean set-up and takedown time was 71 minutes for CP and 49 minutes for LP. The mean length of stay was 2.3 days for CP and 2.5 days for LP. The mean operating room (OR) times for CP and LP were 176 and 210 minutes, respectively. There were no complications in either group. One-way cost analysis with an economic model showed that LP is more cost effective than CP at our hospital if LP OR time is <338 minutes. With adjustment to a volume of 500 daVinci cases/year, CP is still not as cost effective as LP. Two-way sensitivity analysis shows that in-room time must still be <130 minutes and yearly cases must be >500 to obtain cost equivalence for CP. CONCLUSIONS: Perioperative parameters for CP are encouraging. However, the costs are a clear disadvantage. In our hospital, it is more cost effective to teach and perform LP than to perform CP.
Adult↗
The role of single-agent gemcitabine in the treatment of non-small-cell lung cancer.
Gemcitabine is a novel antimetabolite which has shown anti-tumor activity against a variety of tumors including non-small-cell lung cancer (NSCLC). Phase I clinical trials with gemcitabine revealed it was well tolerated and several phase II trials were conducted. This report will summarize the data from 15 phase I-II trials conducted in both untreated and treated patients with advanced lung cancer. Overall, single-agent gemcitabine was active with response rates in untreated patients ranging from 14%-33% and 0%-25% in previously treated patients. Grade 4 toxicities were infrequent with neutropenia reported in 2%-6% of patients and grade 4 thrombocytopenia was rate (1%). One randomized phase III trial comparing the efficacy and safety of gemcitabine to best supportive care confirmed the role of gemcitabine as an active agent for the treatment of NSCLC. Furthermore, gemcitabine was shown in several economic models to be cost-effective. In summary single agent gemcitabine is active, minimally toxic, and cost-effective as a treatment regimen for patients with advanced lung cancer. Studies combining gemcitabine with other active agents are underway and have reported promising results. As monotherapy, gemcitabine may make a valuable contribution to those patients with a poor performance status or comorbid diseases desiring treatment studies in this setting should also be considered.
Antimetabolites, Antineoplastic↗
Economic benefits of an effective infection control program: case study and proposal.
An economic model of the 981 nosocomial infections that occurred in 1985 at the University of Virginia Medical Center was developed. It was determined that $2,401,709 in excess charges and $2,111,753 in excess variable costs were saved in 1985 as a result of having an effective infection control program in place. If a nominal per diem patient fee ($5) were billed to each patient or third-party carrier for preventive services rendered by the infection control team and channeled to infection control for the 196,141 patient-days in 1985, income of $980,705 would have been generated, leaving net income of $812,979 after the deduction of infection control operating costs. In addition, patients, third-party payers, and the hospital would have still saved $1,421,004 in excess charges, or $1,131,048 in excess variable costs, in prevented infections. Infection control programs are extremely cost effective, and if preventive care is to be encouraged, financial incentives for value received for infection control services are needed.
Costs and Cost Analysis↗
Expectations of nursing home use in the Health and Retirement Study: the role of gender, health, and family characteristics.
Economic models of life cycle behavior suggest that expectations about future events may affect savings, insurance, and retirement planning. This article uses data from the first wave of the Health and Retirement Survey (HRS) to examine how personal characteristics and health conditions influence expectations of nursing home use. Subjective expectations of nursing home use are quite close to known probabilities of lifetime use. There are marked differences in the determinants of expectations for women and men that also conform to actual behavior. There is strong evidence that women and men incorporate what is known about nursing home risk into their own expectations, even many years prior to the time when they are most likely to need long-term care.
Black or African American↗
Effects of arthritis on wage earnings.
Arthritis is the most frequently reported health condition in the working-age population, reported by nearly one quarter of the age 45 to 64 population in the 1978 Social Security Survey of disability and work. An economic model of earnings, which controls for differences in socioeconomic characteristics and other health conditions, indicates that arthritis is responsible for an annual loss of approximately $17 billion in wage earnings in the United States.
Adult↗
The life-cycle research productivity of mathematicians and scientists.
Declining research productivity with age is implied by economic models of life-cycle human capital investment but is denied by some recent empirical studies. The purpose of the present study is to provide new evidence on whether a scientist's output generally declines with advancing age. A longitudinal data set has been compiled for scientists and mathematicians at six major departments, including data on age, salaries, annual citations (stock of human capital), citations to current output (flow of human capital), and quantity of current output measured both in number of articles and in number of pages. Analysis of the data indicates that salaries peak from the early to mid-60s, whereas annual citations appear to peak from age 39 to 89 for different departments with a mean age of 59 for the 6 departments. The quantity and quality of current research output appear to decline continuously with age.
Adult↗
The real and the nominal? Making inflationary adjustments to cost and other economic data.
Given the scarcity of cost data for health interventions, there has been substantial use of a relatively small number of existing studies to underpin policy development formulation. Intervention-specific cost and cost-effectiveness data have been used to plan overall budgets, to assess the relative efficiency of different interventions and to consider the resource requirements for programme implementation at both the local and national levels. Cost and cost-effectiveness comparisons have been made between these studies and general sources such as the World Bank's World Development Report 1993. At the same time, information on key health sector variables, such as annual health expenditures, has been systematically compiled for more than two decades. The question of possible inflationary effects is becoming increasingly important as the original data on which these numbers are based ages. For example, cost figures from the mid-1980s require a 60% inflationary adjustment simply to maintain their real value in current dollars. This paper looks at methods to adjust cost data to account for inflation and discusses the difference between real or constant and nominal or current values. These methods are also used to make inflationary adjustments to other types of economic data such as income.
Cost-Benefit Analysis↗
Antimicrobial resistance: paradox, actions and economics.
The threat from antimicrobial-resistant organisms is accumulating and accelerating. One strand of the action that an adequate response to this threat demands is good clinical governance through management and audit of antimicrobial prescribing in hospitals. This is the subject of another article in this issue of the Journal, which describes the guidelines developed by the Scottish Medicines Consortium and Scottish Health Executive to tackle this problem. However, the problems posed by resistant organisms are wider still. In a period of increased threat, innovation (new drugs and technologies) seems to be in decline. There are grounds for serious concern that the current economic model is not capable of responding adequately. Governments need to acknowledge and address this fact. Patient outcomes will suffer increasingly if governments do not act to change the status quo.
Anti-Bacterial Agents↗
Breeding and genetics--historical perspective.
This paper is a review of selection methods that have been used in commercial breeding of table egg stocks, broilers, and turkeys, based on the author's experience. In addition, a number of historic developments that have shaped or influenced the selection process are listed and the significance of each is discussed. The merits of mass selection are noted and compared with the multiple forms of family selection, e.g., full or half sibs, progeny testing, and recurrent methods. Each of these methods is believed to have nearly universal application in applied breeding programs being practiced today. This review concludes that a combination of individual and family selection practices aimed at improving multiple traits simultaneously is required to remain a successful supplier of breeding stock to the current commercial industry.
Animal Husbandry↗
Forecasting requirements for physical therapists.
In response to the existing undersupply of physical therapists and the projected changes of the health care reform era, it is prudent for the profession to consider implementing a training strategy that would bring the supply of physical therapists in line with requirements. Before such a training strategy could be developed, however, the physical therapy community would need to produce a requirements forecast. This article compares the uses and limitations of the two major methods for generating health professions requirements--the "need-based" and "demand-based" approaches--and recommends a pragmatic, tailored approach to determining physical therapist requirements that uses easily obtainable data on staffing patterns of managed care plans. The proposed method draws from both need-based and demand-based models to produce complementary data on which to base policy formation.
Forecasting↗
HTA responses and the classic HTA report.
Reports produced in response to the need for health technology assessment (HTA) vary greatly in the methods they use, depending on the decision-maker's needs, the technology's characteristics and the resources available. HTA reports vary from the brief, such as 'vignettes' produced when a new technology emerges, to the exhaustive, such as 'Cochrane reviews' synthesising a mature evidence base. They may address a wide range of different questions. 'Classic HTAs', typically those reports prepared to support NICE appraisal decisions, seek to use scientifically rigorous methods to address a focused policy question. These are based on systematic reviews of the effectiveness evidence but this is often fed into economic models, in order to generate estimates of cost-effectiveness. Future developments in HTA responses will reflect both the embedding of systematic methods and a growing responsiveness to customer needs.
Cost-Benefit Analysis↗
Estimating the cost and health status consequences of treatment with TNF antagonists in patients with psoriatic arthritis.
OBJECTIVES: Tumour necrosis factor (TNF) has been shown to improve the outcomes in patients with psoriatic arthritis (PsA). We estimate the long-term impact on health status of prescribing the TNF antagonist etanercept, and evaluate the cost-effectiveness in a health economic model. METHODS: The relationship between disability (Health Assessment Questionnaire) and health state utility was explored to estimate the quality-adjusted life years (QALYs) gained from the TNF antagonist etanercept. A model was then used to compare sequences of treatments for PsA after failure of two conventional disease modifying anti-rheumatic drugs (DMARDs). One arm commences on etanercept therapy and this is compared with a strategy commencing with combination therapy of methotrexate and ciclosporin and another commencing with leflunomide. Individual patient data from Phase III etanercept trials is used to populate the model supported by published evidence from extensive literature searches. By incorporating a life table specific for a PsA population, and using a number of evidence- and expert opinion-based assumptions for disease progression, the model was extended beyond the trial duration to a 10-yr time horizon. Cost offsets were produced by avoiding surgery through delayed progression; drug and monitoring costs were also modelled. RESULTS: Over the 10 yrs, modelled etanercept treatment gave 0.82 more QALYs when compared with combination therapy with methotrexate and ciclosporin, and 0.65 more QALYs in comparison with leflunomide. This equates to a central estimate for the cost per QALY of pound28 189 and pound28 189 for ciclosporin and leflunomide, respectively. Sensitivity analyses demonstrated this could vary by as much as +/-28%. CONCLUSIONS: With limited data currently available, the potential cost-effectiveness of etanercept in DMARD failures for adults with PsA appears encouraging. The result for other TNF antagonists will depend on how their relative efficacy and drug price compares with etanercept. A number of limitations are described and priorities for further research suggested.
Adult↗
Individual fracture risk and the cost-effectiveness of bisphosphonates in patients using oral glucocorticoids.
OBJECTIVES: There are few data on the cost-effectiveness of bisphosphonates with oral glucocorticoids (GCs). An individual patient-based pharmaco-economic model was developed. METHODS: Data were obtained from a cohort of oral GC users aged 40+ (n = 190 000) in the UK General Practice Research Database. Individualized fracture and mortality risks were calculated specific for age, sex, daily and cumulative GC dose, indication and other clinical risk factors. UK costs of medication and direct costs of fracture were obtained from National Institute for Clinical Excellence and used to estimate costs per quality-adjusted life-year (QALY) gained and fracture prevented for bisphosphonates in patients treated for 5 yrs with GCs. RESULTS: With the use of 5 mg GCs daily, the cost per one QALY gained with bisphosphonates was 41k UK pounds (95% confidence intervals 22-72k) in women aged <60 [men 40k pounds (29-54k)], 17k pounds (13-24k) in women aged 60-79 [men 43k pounds (31-60k)], 5k pounds(3-6k) in women aged 80+ [men 35k pounds (25-46k)]. With 15 mg GC, these figures were 17k pounds (14-21k), 13k pounds (10-16k) and 15k pounds (9-26k) in women and 22k pounds (17-26k), 34 pounds (23-53k) and 33k pounds (27-42k) in men, respectively. When stratifying by overall fracture risk and life expectancy at the start of GC therapy, cost per QALY increased with decreasing life expectancy. Patients with rheumatoid arthritis had comparatively better cost-effectiveness, given higher fracture risk and better life expectancy. CONCLUSIONS: The cost-effectiveness of bisphosphonates varied substantially. Bisphosphonates can be considered cost-effective in patients with higher fracture risks, such as elderly patients (with a life expectancy over 5 yrs), and younger patients with a fracture history, low body mass index, rheumatoid arthritis or using high GC doses.
Adult↗
Mission aligned management and allocation: a successfully implemented model of mission-based budgeting.
In response to declining funding support and increasing competition, medical schools have developed financial management models to assure that resource allocation supports core mission-related activities. The authors describe the development and implementation of such a model at the University of Wisconsin Medical School. The development occurred in three phases and included consensus building on the need for mission-based budgeting, extensive faculty involvement to create a credible model, and decisions about basic principles for the model. While each school may encounter different constraints and opportunities, the authors outline a series of generic issues that any medical school is likely to face when implementing a mission-based budgeting model. These issues include decisions about the amounts and sources of funds to be used in the budgeting process, whether funds should be allocated at the department or individual faculty level, the specific metrics for measuring academic activities, the relative amounts for research and teaching activities, and how to use the budget process to support new initiatives and strategic priorities. The University of Wisconsin Medical School's Mission Aligned Management and Allocation (MAMA) model was implemented in 1999. The authors discuss implementation issues, including timetable, formulas used to cap budget changes among departments during phase-in, outcome measures used to monitor the effect of the new budget model, and a process for school-wide budget oversight. Finally, they discuss outcomes tracked during two years of full implementation to assess the success of the new MAMA budget process.
Budgets↗
Analysis of the nursing work force compared with national trends.
Nursing work force analysis gives crucial data for administrators, allowing them to anticipate employment opportunities and areas of limited growth. Using an economic model of supply and demand, this study examined the employment and educational needs for nurses. In many areas of data collection, the District of Columbia data paralleled national trends, indicating the nationwide relevance of the conclusions. Projected mismatches between the type of nurses (by educational preparation) entering the work force and the skills required for the job vacancies could lead to increased demand for nurses with certain credentials as well as shortages of nurses in certain types of facilities.
Ambulatory Care Facilities↗