OBJECTIVE To determine whether published cost-effectiveness and cost-benefit analyses have adhered to basic analytic principles. DESIGN Structured methodologic review of published articles. STUDY SAMPLE Seventy-seven articles published either from 1978 to 1980 or from 1985 to 1987 in general medical, general surgical, and medical subspecialty journals. MAIN OUTCOME MEASUREMENTS Articles were reviewed to assess the use and reporting of six fundamental principles of analysis. These principles were derived by reviewing widely cited textbooks and articles describing the methods for performing economic analyses and by selecting the methods universally recommended. MAIN RESULTS Overall performance was only fair. Three articles adhered to all six principles, and the median number of principles to which articles adhered was three. Among the problems noted were failure to make underlying assumptions explicit and, therefore, verifiable, and failure to test assumptions with sensitivity analyses. No improvement in performance was observed between 1978 and 1987. Articles in general medical journals, however, were more likely to use analytic methods appropriately than articles in the general surgical or medical subspecialty literature. CONCLUSIONS Greater attention should be devoted to ensuring the appropriate use of analytic methods for economic analyses, and readers should make note of the methods used when interpreting the results of economic analyses.

Cost-effectiveness and cost-benefit analyses in the medical literature. Are the methods being used correctly?

We prospectively studied the evaluation of dementia in 107 unselected outpatients; 83 had so-called "irreversible" dementias, including 74 who had an Alzheimer-type dementia. Fifteen patients had potentially reversible dementias, of which hypothyroidism and drug toxicity were the commonest causes. Distinguishing features of reversible dementia were shorter duration, use of more prescription drugs, and less severe dementia. Almost half of the patients had other previously unrecognized treatable medical diseases. Most diagnoses were made from patient history and physical and mental status examination. Patients with reversible dementia improved but rarely reverted to normal. Objective improvement occurred in 25 patients after treating unrecognized coexistent medical and psychiatric diseases, or stopping unnecessary medication. Careful clinical observation is the most useful part of the evaluation and extensive testing may not be required for all patients. Overemphasis on distinguishing reversible from irreversible forms of dementia may detract from recognition of commoner, treatable causes of dysfunction and suffering.

Dementia in elderly outpatients: a prospective study.

Most new diagnostic technologies have not been adequately assessed to determine whether their application improves health. Comprehensive evaluation of diagnostic technologies includes establishing technologic capability and determining the range of possible uses, diagnostic accuracy, impact on the health care provider, therapeutic impact and impact on patient outcome. Guidelines to determine whether each of these criteria have been met adequately are presented. Diagnostic technologies should be disseminated only if they are less expensive, produce fewer untoward effects and are at least as accurate as existing methods, if they eliminate the need for other investigations without loss of accuracy, or if they lead to institution of effective therapy. Establishing patient benefit often requires a randomized controlled trial in which patients receive the new test or an alternative diagnostic strategy. Other study designs are logistically less difficult but may not provide accurate assessment of benefit. Rigorous assessment of diagnostic technologies is needed for efficient use of health care resources.

A framework for clinical evaluation of diagnostic technologies

Background: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. Objective: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. Design: Case-control, consecutive sample. Setting: Major metropolitan trauma center emergency department. Patients and Materials: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. Data Analysis: Nonparametric statistical analysis. Results: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or non-focal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. Conclusions: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomgraphic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.

Predictors of Intracranial Pathologic Findings in Patients Who Seek Emergency Care Because of Headache

Publisher Summary This chapter discusses that the consideration of the status of chemotherapy of cancer in man today is based upon the actual achievement of objective effects against several forms of disseminated cancer by the action of chemical substances. A review of the advances in cancer chemotherapy in small number of institutions, which have pioneered in this field, leaves no question concerning the value of these directions of research. The chapter explores that the panels are accelerating progress in the areas of organic chemistry, screening, pharmacology, biochemistry, and clinical investigation. Synthesis of new chemical compounds is proceeding in a number of directions, although most of the workers are making nucleic acid inhibitors and cytotoxic agents. The pharmaceutical industry and the university laboratories are furnishing thousands of chemical compounds for biological studies from their stock sources. The chapter concludes that the costly lag between discovery in the laboratory or in the clinic and application to the patient with cancer should be abolished or greatly shortened.

Advances in chemotherapy of cancer in man.

One hundred sixty-one highly selected patients with headache were studied to assess the impact of computerized tomography (CT) on diagnostic evaluation and to determine cost-effectiveness of neurodiagnostic evaluation of headache. Fewer nuclide brain scans were performed after availability of CT, but diagnostic charges stayed about the same. A careful history and physical and neurological examinations were adequate screens to detect intracranial mass lesions or systemic disease associated with headache. In patients with normal findings from neurological examination, no clinically important abnormalities were detected by CT, skull roentgenogram, angiography, or nuclide brain scan. The cost of finding a case of brain tumor was estimated to be at least $1,265 for patients with abnormalities on neurological examination and $11,901 for patients with normal findings on neurological examination. Neurodiagnostic evaluation of headache patients with normal findings from neurological examination is expensive and was clinically unrewarding in this series.

Diagnostic Evaluation of Headache: Impact of Computerized Tomography and Cost-effectiveness

To the Editor:— Since the report by Edith Paterson and her co-workers (Lancet1:677 [May 11] 1946) on the remarkable effect of urethane in the treatment of leukemia, the validity of this observation has been confirmed by a number of workers in this country (personal communications) and in our own clinic. The British investigators noted, however, that other forms of malignant neoplasia were not appreciably affected by the drug. In 3 of 13 cases of advanced carcinoma of the breast and in 4 of 11 other forms of malignant disease the tumor masses underwent only temporary diminution in size. We have recently observed a man aged 44 who in June 1946 observed the generalized appearance of multiple skin tumors which in the next three months increased rapidly in size and number. When he first came under our observation he was covered with hard tender skin nodules which varied in

Urethane in leukemia

The remarkable advance of medicine has brought immense benefits to man. At the same time it has created problems, strange and uncomfortable dimensions, in the spiritual, moral, ethical, and economic aspects of the care of the dying. We can restore life to some whose hearts have stopped. It is possible to resist the advance of certain fatal diseases for long periods. Malfunctioning organs are replaced with those that function, or devices are available to assist or take over their function. Drugs and mechanical devices can prolong the life of a dying person for long periods.Many live and are active after having literally been brought from the dead by our resuscitative skills. Others live comfortably with artificial heart valves or implanted cardiac pacemakers. The artificial kidney, immunosuppressive agents, steroids, and cancer chemotherapeutic drugs, and a host of other agents are important and relatively new means of prolonging life and avoiding

Machine Medicine and Its Relation to the Fatally Ill

• Constant efforts must be made to integrate the basic medical sciences with clinical teaching. They should begin in medical school but should continue, under the leadership of the clinical teachers, during internship and residency years. Two procedures that aid this integration are here described: the teaching round and the therapeutic pathology conference. The teaching rounds are held twice a week and attended only by residents, interns, and the clinician. They are devoted to the exploration of the basic biological and clinical aspects of the conditions of selected patients. The therapeutic pathology conferences are held weekly and attended by the residents, the pathologists, and representatives of the departments of medicine and radiology. They are devoted to a scrutiny of the results of diagnostic and therapeutic efforts in the light of the findings of the pathologist and the radiologist. If there is a free interchange of ideas, opinions, and facts, these sessions bring out the basic science aspects of medicine and help to produce well-motivated, well-rounded physicians.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=318075&pdfFileName=jama_161_1_008.pdf

Integration of basic science with clinical training

The swirling progress of 20th century medicine has left us all a little breathless and has created problems that seem to multiply faster than we can solve them. Not the least of these has been the structure of our system of medical education that, one would judge, has opened its seams a bit and is beginning to take water. There is abroad in our land, indeed the whole medical world, a feeling that something should be done about something; but if I sense the situation correctly, we have not yet clearly defined that "something." This medical ferment is inescapably intertwined with the training of our future physicians. It is about this and the connotations it has for the future of internal medicine that I wish to discuss here. I can probably do little to dispel the fog in which we find ourselves afloat, but I hope I can point out

Howard P. Lewis

Papers

Diagnostic Evaluation of Headache: Impact of Computerized Tomography and Cost-effectiveness

Urethane in leukemia

Machine Medicine and Its Relation to the Fatally Ill

Integration of basic science with clinical training

A look at the future of internal medicine.