Showing papers by "Alessandro Liberati published in 1995"

Benefits and Costs of Screening and Treatment for Early Breast Cancer: Development of a Basic Benefit Package

Abstract: Objective. —To develop a basic benefit package for detection and treatment of early breast cancer by evaluating the effectiveness and costs for screening mammography, primary surgery, adjuvant therapy, and follow-up care. Data Sources. —Published articles were retrieved through MEDLINE; additional articles were obtained through searches of their bibliographies. Cancer statistics were taken from Surveillance, Epidemiology, and End Results (SEER) Program data, population statistics were taken from US Census data, and charges from 1993 Southern California Medicare fees were used to represent costs. Study Selection. —Studies were selected on the basis of their design. Preference, in decreasing order, was given to meta-analyses of randomized trials, individual randomized clinical trials, prospective cohort studies, retrospective cohort studies, and case series. Data Extraction. —Studies were examined for the effect of the intervention on overall survival, disease-free survival, and health-related quality of life. We evaluated effects on survival in terms of number of lives saved at 10 years and average years of life saved. Costs were related to the benefits observed and modeled onto a hypothetical health care organization of 500 000 lives. Results. —Based on this analysis, we recommend a basic benefit plan for the detection and treatment of early breast cancer that would include the following: (1) screening mammography only for women aged 50 to 69 years; (2) choice of mastectomy or breast-conserving surgery with radiation therapy for all women with early breast cancer; (3) adjuvant therapy for all women at risk of recurrence; and (4) only clinical follow-up without routine testing for metastatic disease. Conclusions. —By choosing which services they provide to specific groups of patients, providers can substantially reduce their expenses and still provide quality health benefits. (JAMA. 1995;273:142-148)

Appropriateness of hospital use: an overview of Italian studies.

Abstract: This paper reports on the general features and findings of 11 studies conducted in Italy on appropriateness of hospital admission and days of stay using the Appropriateness Evaluation Protocol (AEP). Studies have been grouped for presentation in two categories. The first comprises six heterogeneous studies illustrating different ways of targeting the use of the AEP: two used it to assess appropriateness of admission in an emergency room setting, two measured appropriateness of days of stay in patients with AIDS and nosocomial infections and finally two others evaluated hospital days in a group of elderly patients and “before and after” the institution of a domiciliary nursing service, respectively. The second group comprises five more homogeneous utilization review studies aimed at assessing inappropriateness of admissions and days of stay in medical/surgical departments of large hospitals in northern Italy. Besides detecting a substantial amount of inappropriateness in admission (range = 25–38%) and days of stay (range = 28–49%) this latter group of studies suggests that delays in execution and reporting of laboratory investigations, unavailability of operating rooms and delays due to difficulties in transferring patients to long-term care facilities are the most common causes of inappropriate days of stay. Despite the differences in their objectives, design and methods of sampling, these studies indicate that an explicit, diagnosis-independent and standardized instrument such as the AEP can help to uncover a substantial amount of the potentially avoidable use of hospital resources in the Italian context.

A European Project assessing the appropriateness of hospital utilization: Background, objectives and preliminary results

Abstract: This paper presents the background, objectives and preliminary results of a coordinated European Project involving researchers in seven countries aimed at harmonizing methods to assess inappropriate use of hospital care and qualifying its determinants. After briefly reviewing the philosophy of the European Union “Concerted Action” program in the context of current attempts at reforming the way health care is financed and delivered in several member states, the paper presents results obtained so far. Besides a method workshop where the approaches and methodologies used were compared, during the first year the following tasks have been undertaken: (a) identification and appraisal of a few dozen empirical studies conducted in various countries; (b) qualitative comparison of the instruments used to assess appropriateness; (c) initial development of a common list of reasons for inappropriate hospital use of potential relevance in European health care systems. While the project has already undoubtedly indicated the great potential of European collaboration in health services research, the large number of unpublished studies traced indicates—among other things—the need to create channels through which results of this type of research can be disseminated.

The efficacy of mammography and screening for breast cancer. author's reply

Abstract: To the Editor. —The article by Dr Kattlove and colleagues 1 presents a basic benefit package for detection and treatment of early breast cancer. I believe this concept has many flaws. Implementation of this package takes the diagnosis and treatment of breast cancer out of the hands of the patient and her physician and transfers it into the hands of third-party payers. I cannot agree with the authors' denying screening mammography for women younger than 49 years. Early-age screening mammography detects breast tumors that are small. This leads to a more favorable prognosis for the breast cancer patient. Breast-conserving surgery for early cancer of the breast requires adjunct radiotherapy. Friedman 2 concluded from studying pathological tissues from 100 women who received radiation therapy that carcinoma of the breast cannot be considered a radiosensitive tumor. Radiation therapy produces initial fibrosis, loss of elasticity, fat necrosis, telangiectasia, lymphopenia, and obliterative arteritis. Tissue