Showing papers on "Cost effectiveness published in 1998"

Primary total hip replacement surgery: a systematic review of outcomes and modelling of cost-effectiveness associated with different prostheses.

Abstract: Objectives- T identify the literature on primary total hip replacement(THR) surgery that is relevant to the question of whether prostheses differ in their medium to longer term outcomes, and to synthesise this evidence. To use evidence regarding both costs and outcomes of primary THR to model how much more effective newer prostheses must be to justify higher costs

Investing in Our Children: What We Know and Don't Know About the Costs and Benefits of Early Childhood Interventions

Abstract: The authors find that well-targeted early intervention programs for at-risk children, such as nurse home visits to first-time mothers and high-quality pre-school education, can yield substantial advantages to participants in terms of emotional and cognitive development, education, economic well-being and health.

Fighting poverty with microcredit : experience in Bangladesh

Abstract: Providing microcredit to the poor has become an important antipoverty scheme in many countries. Microcredit helps the poor become self-employed and thus generates income and reduces poverty. In Bangladesh, these programs reach about 5 million poor households. This books attempts to find out whether these programs cost-effective, drawing on the experiences of the well-known microcredit programs of Bangladesh's Grameen Bank, the Rural Development-12 projects, and the Bangladesh Rural Advancement Committee. It examines the cost-effectiveness of microcredit programs vis-�vis other antipoverty programs, such as Food-for-Work. Moreover, the book uses extensive household survey data to address how the gender of participants affects the impact of microcredit programs.

Understanding controlled trials: Why are randomised controlled trials important?

Abstract: Randomised controlled trials are the most rigorous way of determining whether a cause-effect relation exists between treatment and outcome and for assessing the cost effectiveness of a treatment. They have several important features: Other study designs, including non-randomised controlled …

The Cost-Effectiveness of Alternative Instruments for Environmental Protection in a Second-Best Setting

Abstract: This paper employs analytical and numerical general equilibrium models to examine the costs of achieving pollution reductions under a range of environmental policy instruments in a second-best setting with pre-existing factor taxes. We compare the costs and overall efficiency impacts of emissions taxes, emissions quotas, fuels taxes, performance standards, and mandated technologies, and explore how costs change with the magnitude of pre-existing taxes and the extent of pollution abatement. We find that the presence of distortionary taxes raises the costs of pollution abatement under each instrument relative to its costs in a first-best world. This extra cost is an increasing function of the magnitude of pre-existing tax rates. For plausible values of pre-existing tax rates and other parameters, the cost increase for all policies is substantial (35 percent or more). The impact of pre-existing taxes is particularly large for non-auctioned emissions quotas: here the cost increase can be several hundred percent. Earlier work on instrument choice has emphasized the potential reduction in compliance cost achievable by converting fixed emissions quotas into tradable emissions permits. Our results indicate that the regulator's decision whether to auction or grandfather emissions rights can have equally important cost impacts. Similarly, the choice as to how to recycle revenues from environmentally motivated taxes (whether to return the revenues in lump-sum fashion or via cuts in marginal tax rates) can be as important to cost as the decision whether the tax takes the form of an emissions tax or fuel tax, particularly when modest emissions reductions are involved. In both first- and second-best settings, the cost differences across instruments depend importantly on the extent of pollution abatement under consideration. Total abatement costs differ markedly at low levels of abatement. Strikingly, for all instruments except the fuel tax these costs converge to the same value as abatement levels approach 100 percent.

Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials

Abstract: Objective: To determine whether intranasal corticosteroids are superior to oral H 1 receptor antagonists (antihistamines) in the treatment of allergic rhinitis. Design: Meta-analysis of randomised controlled trials comparing intranasal corticosteroids with oral antihistamines. Setting: Randomised controlled trials conducted worldwide and published between 1966 and 1997. Subjects: 2267 subjects with allergic rhinitis in 16 randomised controlled trials. Main outcome measures: Nasal blockage, nasal discharge, sneezing, nasal itch, postnasal drip, nasal discomfort, total nasal symptoms, nasal resistance, and eye symptoms and global ratings. Outcomes measured on different scales were combined to determine pooled odds ratios (categorical outcomes) or standardised mean differences (continuous outcomes). Assessment of heterogeneity between studies, and subgroup analyses of eye symptoms, were undertaken. Results: Intranasal corticosteroids produced significantly greater relief than oral antihistamines of nasal blockage (standardised mean difference −0.63, 95% confidence interval −0.73 to −0.53), nasal discharge (−0.5, −0.6 to −0.4), sneezing (−0.49, −0.59 to −0.39), nasal itch (−0.38, −0.49 to −0.21), postnasal drip (−0.24, −0.42 to −0.06), and total nasal symptoms (−0.42, −0.53 to −0.32), and global ratings gave an odds ratio for deterioration of symptoms of 0.26 (0.08 to 0.8). There were no significant differences between treatments for nasal discomfort, nasal resistance, or eye symptoms. The effects on sneezing, total nasal symptoms, and eye symptoms were significantly heterogeneous between studies. Other combined outcomes were homogeneous between studies. Subgroup analysis of the outcome of eye symptoms suggested that the duration of assessment (averaged mean score over the study period versus mean score at end of study period) might have accounted for the heterogeneity. Conclusion: The results of this systematic review, together with data on safety and cost effectiveness, support the use of intranasal corticosteroids over oral antihistamines as first line treatment for allergic rhinitis.

Impact of renal cadaveric transplantation on survival in end-stage renal failure: evidence for reduced mortality risk compared with hemodialysis during long-term follow-up.

Abstract: Despite a superior quality of life and a favorable cost effectiveness, it has not been well established thus far whether renal cadaveric transplantation contributes to superior survival probability of end-stage renal disease patients in Europe, because the mortality rate on dialysis is lower compared with the United States. This analysis was undertaken to compare the mortality of wait-listed patients and transplant recipients during long-term follow-up, including the possibility of a retransplant in a single-center study. The study cohort included 309 consecutive patients, ages 17 to 72 yr, being registered on the waiting list of the Renal Transplantation Center of Mannheim since the initiation of the transplantation program on June 3, 1989. Follow-up was terminated on September 30, 1997, with a mean of 4.15 yr. A total of 144 renal cadaveric transplants (four retransplants) was performed during the follow-up period. A Cox regression model considering the time-dependent exposure to the different therapy modalities was applied for statistical analysis. Patients being removed from the waiting list or coming back to dialysis after transplantation were censored at time of withdrawal or graft failure. Transplantation resulted in a lower hazard ratio, which was 0.36 (95% confidence interval, 0.15 to 0.87) when the hazard of the wait-listed group was taken as 1.00. The underlying incidence rate of death was 0.026 per patient-year (0.032 on dialysis versus 0.016 with functioning graft). Performing the evaluation on an intention-to-treat basis without censoring the lower risk of the transplanted group was still pronounced according to a hazard ratio of 0.44 (95% confidence interval, 0.22 to 0.89). Thus, patients receiving a renal cadaveric transplantation have a substantial survival advantage over corresponding end-stage renal disease patients on the waiting list even in the setting of a single transplantation center where mortality on regular dialysis therapy was comparatively low.

Confidence intervals or surfaces? Uncertainty on the cost-effectiveness plane.

Abstract: Although cost-effectiveness analysis is not new, it is only recently that economic analysis has been conducted alongside clinical trials. Whereas in the past economic analysts most often used sensitivity analysis to examine the implications of uncertainty for their results, the existence of patient-level data on costs and effects opens up the possibility of statistical analysis of uncertainty. Unfortunately, ratio statistics can cause problems for standard statistical methods of confidence interval estimation. The recent health economics literature contains a number of suggestions for estimating confidence limits for ratios. In this paper, we begin by reviewing the different methods of confidence interval estimation with a view to providing guidance concerning the most appropriate method. We go on to argue that the focus on confidence interval estimation for cost-effectiveness ratios in the recent literature has been concerned more with problems of estimation than with problems of decision-making. We argue that decision-makers are most likely to be interested in one-sided tests of hypothesis and that confidence surfaces are better suited to such tests than confidence intervals. This approach is consistent with decision-making on the cost-effectiveness plane and with the cost-effectiveness acceptability curve approach to presenting uncertainty due to sampling variation in stochastic cost-effectiveness analyses. Copyright © 1998 John Wiley & Sons, Ltd.

Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke

Abstract: Tissue plasminogen activator (tPA) has been shown to improve 3-month outcome in stroke patients treated within 3 hours of symptom onset. The costs associated with this new treatment will be a factor in determining the extent of its utilization. Data from the NINDS rt-PA Stroke Trial and the medical literature were used to estimate the health and economic outcomes associated with using tPA in acute stroke patients. A Markov model was developed to estimate the costs per 1,000 patients eligible for treatment with tPA compared with the costs per 1,000 untreated patients. One-way and multiway sensitivity analyses (using Monte Carlo simulation) were performed to estimate the overall uncertainty of the model results. In the NINDS rt-PA Stroke Trial, the average length of stay was significantly shorter in tPA-treated patients than in placebo-treated patients (10.9 versus 12.4 days; p = 0.02) and more tPA patients were discharged to home than to inpatient rehabilitation or a nursing home (48% versus 36%; p = 0.002). The Markov model estimated an increase in hospitalization costs of $1.7 million and a decrease in rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per 1,000 eligible treated patients for a health care system that includes acute through long-term care facilities. Multiway sensitivity analysis revealed a greater than 90% probability of cost savings. The estimated impact on long-term health outcomes was 564 (3 to 850) quality-adjusted life-years saved over 30 years of the model per 1,000 patients. Treating acute ischemic stroke patients with tPA within 3 hours of symptom onset improves functional outcome at 3 months and is likely to result in a net cost savings to the health care system.

Cost-effectiveness Analysis of a Rotavirus Immunization Program for the United States

Abstract: Context.—Rotavirus is the most common cause of severe diarrhea in children, and a live, oral vaccine may soon be licensed for prevention.Objective.—To estimate the economic impact of a national rotavirus immunization program in the United States.Design.—Cost-effectiveness was analyzed from the perspectives of the health care system and society. A decision tree used estimates of disease burden, costs, vaccine coverage, efficacy, and price obtained from published and unpublished sources.Intervention.—The proposed vaccine would be administered to infants at ages 2, 4, and 6 months as part of the routine schedule of childhood immunizations.Main Outcome Measures.—Total costs, outcomes prevented, and incremental cost-effectiveness.Results.—A routine, universal rotavirus immunization program would prevent 1.08 million cases of diarrhea, avoiding 34000 hospitalizations, 95000 emergency department visits, and 227000 physician visits in the first 5 years of life. At $20 per dose, the program would cost $289 million and realize a net loss of $107 million to the health care system—$103 per case prevented. The program would provide a net savings of $296 million to society. Threshold analysis identified a break-even price per dose of $9 for the health care system and $51 for the societal perspective. Greater disease burden and greater vaccine efficacy and lower vaccine price increased cost-effectiveness.Conclusions.—A US rotavirus immunization program would be cost-effective from the perspectives of society and the health care system, although the cost of the immunization program would not be fully offset by the reduction in health care cost of rotavirus diarrhea unless the price fell to $9 per dose.

Blue Water Crime: Deterrence, Legitimacy, and Compliance in Fisheries

Abstract: This study adds to the limited body of empirical evidence on the effect that legitimacy and deterrence have on compliance behavior. The theoretical models of compliance behavior tested include the basic deterrence model, which focuses on the certainty and severity of sanctions as key determinants of compliance, and models which integrate economic theory with theories from social psychology to account for legitimacy, deterrence, and other motivations expected to influence indiv duals' decisions whether to comply. Probit and Tobit econometric estimators are used to examine the compliance behavior of 318 Peninsular Malaysian fishermen who face a regulation banning them from fishing in a zone along the coast. The results of the empirical analysis provide additional evidence on the relationship of deterrence and legitimacy to compliance. The findings are also used to draw implications for compliance policy for regulated fisheries. According to normative compliance theory, people tend to obey laws made and implemented by authorities perceived to be legitimate. A key determinant of perceived legitimacy, according to the procedural justice literature, is the fairness built into the procedures used to develop and implement laws and regulations.l Paternoster et al. (1997) note that while there are numerous theoretical perspectives suggesting that legitimacy is an important determinant of compliance, the empirical evidence making that connection is meager.2 Our study adds to this limited body of empirical evidence. The subjects of our study are fishermen. Fishermen are excellent subjects for the study of compliance. They are subject to numerous regulations that constrain their opportunities to earn income, and temptations and opportunities for offending repeatedly occur.3 Passion, inadvertence, and accident rarely cause a fishery violation; most are the result of deliberate choice. The behavior of fishermen offers good evidence on which to test the role deterrence, legitimacy, and other factors play in explaining compliance. Studying the compliance behavior of such regulated economic agents as fishermen is important for other reasons. Achieving compliance in regulated industries is both costly and difficult. Expenditures on enforcement commonly constitute the largest cost element in governmental regulatory programs. The viability of environmental protection and resource management programs is often threatened by low rates of compliance and high enforcement costs. This raises questions whether there are ways to improve the cost effectiveness of traditional enforcement and whether there are ways to secure compliance without heavy reliance on costly enforcement. Central to improving the cost effectiveness of enforcement and compliance programs is understanding the compliance behavior of the economic agents subject to regulations. To this end, we present tests of alternative models of compliance behavior. The models tested include the basic deterrence model, which focuses on the certainty and severity of sanctions as key determinants of compliance, and models which integrate economic theory with theories from social psychology to account for both intrinsic and extrinsic motivations influencing individuals' decisions whether to comply.4 The tests are conducted on data from interviews with fishermen in Peninsular Malaysia (selfreports of violations). Becker (1968) was the first to develop a formal theoretical framework for explaining criminal activity. Following Smith (1966 [1759], 1985 [1776]) and Bentham (1967 [1789]), Becker assumes that criminals behave basically like other individuals in that they attempt to maximize utility subject to a budget constraint. In Becker's model, an individual commits a crime if the expected utility from committing the crime exceeds the utility from engaging in legitimate activity.5 The basic deterrence framework used in these studies assumes that the threat of sanctions is the only policy mechanism available to improve compliance with regulations. …

Carrier screening for cystic fibrosis: costs and clinical outcomes.

Abstract: Objectives. To evaluate the costs and clinical effects of 16 alternative strategies for cystic fibrosis (CF) carrier screening in the reproductive setting; and to test the sensitivity of the results to assumptions about cost and detection rate, stakeholder perspective, DNA test specificity, chance of nonpaternity, and couples' reproductive plans. Method. Cost-effectiveness analysis. Results. A sequential screening strategy had the lowest cost per CF birth avoided. In this strategy, the first partner was screened with a standard test that identifies 85% of carriers. The second partner was screened with an expanded test if the first partner's screen was positive. This strategy identified 75% of anticipated CF births at a cost of $367,000 each. This figure does not include the lifetime medical costs of caring for a patient with CF, and it assumes that couples who identify a pregnancy at risk will choose to have prenatal diagnosis and termination of affected pregnancies. The cost per CF birth identified is ap...

Smoking cessation guidelines for health professionals - A guide to effective smoking cessation interventions for the health care system

Abstract: These guidelines have been written in parallel with guidance on the cost effectiveness of smoking cessation interventions, produced by the Centre for Health Economics at the University of York. The cost effectiveness guidance underpins these clinical guidelines and provides the economic justification for them. It is published as the second part of this Thorax supplement. These smoking cessation clinical guidelines are also published in a shorter version as a journal article ( BMJ 1999; 318 : in press). The clinical guidelines have been submitted to many professions for their official endorsement and support. This was not a passive process and their suggestions are reflected in this final version. The guidelines were commissioned by the Health Education Authority (HEA), which is responsible for health education in England. They are written for the English health care system but may prove relevant and adaptable to other countries and health care systems. Comments and questions about these guidelines can be addressed to Dr Ann McNeill at Health Education Authority, Trevelyan House, 30 Great Peter Street, London SW1P 2HW. #### Professional endorsement At the time of going to press the following organisations have endorsed these guidelines: Royal College of Physicians (London), Royal College of General Practitioners, British Medical Association, Royal College of Nursing, Royal College of Midwives, Community Practitioners’ and Health Visitors’ Association, British Thoracic Society, British Lung Foundation, National Asthma Campaign, National Primary Care Facilitators Programme, National Heart Forum, British Dental Association, British Dental Hygienists Association, National Pharmaceutical Association, Royal Pharmaceutical Society of Great Britain, Action on Smoking and Health, ASH Scotland, Quit, Association for Public Health, Imperial Cancer Research Fund, Cancer Research Campaign. #### Acknowledgements This project has depended especially on the goodwill and hard work of the peer reviewers and we would like to thank them for their contribution in reviewing the draft guidelines. We also thank Jacqueline …

Evaluation of antismoking advertising campaigns.

Abstract: Context.—Active and passive smoking are the first and third leading preventable causes of death. Many states are running or initiating antitobacco media campaigns.Objective.—To review research on the effectiveness of different antismoking messages and published evidence of the effectiveness of paid antismoking advertising.Data Sources.—Focus group studies conducted by professional advertising agencies that contract with California, Massachusetts, and Michigan to run their antismoking advertising campaigns, the Centers for Disease Control and Prevention's Media Campaign Resource Book, and copies of the advertisements. In total, we reviewed the results of 186 focus groups involving more than 1500 children and adults dealing with 118 advertisements that had actually been aired and additional concept advertisements that were not produced. Published literature was located using MEDLINE and standard bibliographic sources on the effectiveness of large, paid antitobacco media campaigns. We also reviewed reports and studies conducted by, or for, the California and Massachusetts health departments on program effectiveness, and conducted our own comparison of California vs Massachusetts using cigarette consumption data from the Tobacco Institute.Study Selection.—All available studies.Data Synthesis.—Eight advertising strategies to prevent people from starting to smoke and persuading them to stop were reviewed: industry manipulation, secondhand smoke, addiction, cessation, youth access, short-term effects, long-term health effects, and romantic rejection. These focus groups identified strategies that would be expected to be effective and ineffective. Regression analysis was used to compare the cost-effectiveness of the California and Massachusetts programs.Conclusions.—Focus group participants indicated that industry manipulation and secondhand smoke are the most effective strategies for denormalizing smoking and reducing cigarette consumption. Addiction and cessation can be effective when used in conjunction with the industry manipulation and secondhand smoke strategies. Youth access, short-term effects, long-term health effects, and romantic rejection are not effective strategies. More aggressive advertising strategies appear to be more effective at reducing tobacco consumption.

Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40

Abstract: Objectives: To estimate the economic efficiency of tight blood pressure control, with angiotensin converting enzyme inhibitors or beta blockers, compared with less tight control in hypertensive patients with type 2 diabetes. Design: Cost effectiveness analysis incorporating within trial analysis and estimation of impact on life expectancy through use of the within trial hazards of reaching a defined clinical end point Use of resources driven by trial protocol and use of resources in standard clinical practice were both considered. Setting: 20 hospital based clinics in England, Scotland, and Northern Ireland. Subjects: 1148 hypertensive patients with type 2 diabetes from UK prospective diabetes study randomised to tight control of blood pressure (n = 758) or less tight control (n = 390). Main outcome measure: Cost effectiveness ratios based on (a) use of healthcare resources associated with tight control and less tight control and treatment of complications and (b) within trial time free from diabetes related end points, and life years gained. Results: Based an use of resources driven by trial protocol, the incremental cost effectiveness of tight control compared with less tight control was cost saving. Based on use of resources in standard clinical practice, incremental cost per extra year free from end points amounted to pound 1049 (costs and effects discounted at 6'% per year) and pound 434 (costs discounted at 6%, per year and effects not discounted). The incremental cost per life year gained was pound 720 (costs and effects discounted at 6% per year) and pound 291 (costs discounted at 6% per year and effects not discounted). Conclusions: Tight control of blood pressure in hypertensive patients with type 2 diabetes substantially reduced the cost of complications, increased the interval without complications and survival, and had a cost effectiveness ratio that compares favourably with many accepted healthcare programmes.

Cost-effectiveness of treatments for major depression in primary care practice.

Abstract: Background This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians. Methods A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed. Results In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510. Conclusions Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.

US-guided core breast biopsy: use and cost-effectiveness.

Abstract: PURPOSE: To determine the frequency with which ultrasonographically (US) guided core biopsy obviated diagnostic surgical biopsy of nonpalpable breast masses, to calculate the cost savings of diagnosis attributable to US-guided core biopsy, and to compare the costs of US-guided versus stereotactically guided core biopsy. MATERIALS AND METHODS: US-guided core biopsy was performed in 151 consecutive solitary, nonpalpable breast masses in 151 women (age range, 23-80 years) by using a 14-gauge automated gun and needle. Clinical follow-up data were obtained. Cost savings were assessed by using national Medicare reimbursement costs of +385 for US-guided core biopsy, +610 for stereotactic core biopsy, and +1,332 for needle localization and surgical biopsy. RESULTS: US-guided core biopsy obviated a surgical procedure in 128 (85%) of 151 women. The mean adjusted direct cost saving per US-guided core biopsy was +744 per case. Use of US-guided biopsy decreased the cost of diagnosis by 56% (+744/+1,332) over the cost ...

Use and Cost Effectiveness of Smoking-Cessation Services under Four Insurance Plans in a Health Maintenance Organization

Abstract: Background Lack of information about the effect of insurance coverage on the demand for and use of smoking-cessation services has prevented widescale adoption of coverage for such services. Methods In a longitudinal, natural experiment, we compared the use and cost effectiveness of three forms of coverage with those of a standard form of coverage for smoking-cessation services that included a behavioral program and nicotine-replacement therapy. The study involved seven employers and a total of 90,005 adult enrollees. The standard plan offered 50 percent coverage of the behavioral program and full coverage of nicotine-replacement therapy. The other plans offered 50 percent coverage of both the behavioral program and nicotine-replacement therapy (reduced coverage), full coverage of the behavioral program and 50 percent coverage of nicotine-replacement therapy (flipped coverage), or full coverage of both the behavioral program and nicotine-replacement therapy. Results Estimated annual rates of use of smoking...

Using the WinWin Spiral Model: A Case Study Fifteen teams used the WinWin spiral model to prototype, plan, specify, and build multimedia applications for USC's Integrated Library System. The authors report lessons learned from this case study and how they extended the model's utility and cost-effectiveness in a second round of projects.

Abstract: Fifteen teams used the WinWin spiral model to prototype, plan, specify, and build multimedia applications for USC's Integrated Library System. The authors report lessons learned from this case study and how they extended the model's utility and cost-effectiveness in a second round of projects.

Interpretation of cost-effectiveness analyses.

Abstract: Dr. Owens is supported by a Career Development Award from the VA Health Services Research and Development Program.

Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression

Abstract: Objective This report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care. Study Design Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trial (N = 217), consulting psychiatrists provided enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153), Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologists provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. Results Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression, Collaborative Care was more costly and not more cost-effective than Usual Care. Conclusions Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.

Male circumcision: assessment of health benefits and risks.

Abstract: OBJECTIVES: Globally approximately 25% of men are circumcised for religious, cultural, medical, or parental choice reasons However, controversy surrounds the procedure, and its benefits and risks to health We review current knowledge of the health benefits and risks associated with male circumcision METHODS: We have used, where available, previously conducted reviews of the relation between male circumcision and specific outcomes as "benchmarks", and updated them by searching the Medline database for more recent information RESULTS: There is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases We could find little scientific evidence of adverse effects on sexual, psychological, or emotional health Surgical risks associated with circumcision, particularly bleeding, penile injury, and local infection, as well as the consequences of the pain experienced with neonatal circumcision, are valid concerns that require appropriate responses CONCLUSION: Further analyses of the utility and cost effectiveness of male circumcision as a preventive health measure should, in the light of this information, be research and policy priorities A decision as to whether to recommend male circumcision in a given society should be based upon an assessment of the risk for and occurrence of the diseases which are associated with the presence of the foreskin, versus the risk of the complications of the procedure In order for individuals and their families to make an informed decision, they should be provided with the best available evidence regarding the known benefits and risks

Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime.

Abstract: OBJECTIVE: Quadriceps sensorimotor dysfunction may be important in the pathogenesis of knee osteoarthritis (OA) and a determinant of disability. Exercise regimes can increase quadriceps strength, but whether this improves proprioception and reduces disability is uncertain. Moreover, research regimes involve protracted treatment which is clinically impracticable. METHODS: We compared quadriceps sensorimotor function and disability in 60 patients with knee OA, before and after an exercise regime, with a control group (n = 37) who did not exercise. RESULTS: Exercise improved quadriceps strength (mean change, 95% CI; 73 N, 26-19 N), voluntary activation (14%, 5-20%), knee joint position sense (0.6 degrees, 0.1-1.8 degrees), and reduced the Lequesne Index (3.5, 0.5-4) and aggregate time of four activities of daily living (8.4 s, 0.2-16.7 s). At 6 month follow-up, these improvements were maintained. The parameters of the control group were unchanged. CONCLUSIONS: These results substantiate the association between quadriceps sensorimotor dysfunction and disability, emphasizing the importance of quadriceps exercise in the management of knee OA. The regimen is relatively brief and clinically practicable, but could be adapted to make it more cost effective.

Cost-effectiveness of preoperative sestamibi scan for primary hyperparathyroidism is dependent solely upon the surgeon's choice of operative procedure.

Abstract: Background: In 1991, a National Institutes of Health Consensus Panel stated that preoperative localization for primary hyperparathyroidism is not cost effective Since then, the sestamibi scan has been applied to parathyroid disease with excellent results, even allowing unilateral exploration under local anesthesia Study Design: A metaanalysis of the English literature over the past 10 years was performed to determine the collective sensitivity and specificity of sestamibi scanning to establish its utility in directing a unilateral procedure The cost effectiveness of scanning all patients with sporadic primary hyperparathyroidism was examined by determining the costs of seven operative technique–dependent variables that could be reduced with a limited procedure Results: The average sensitivity and specificity of sestamibi were 907% and 988%, respectively, indicating its ability to guide an accurate unilateral exploration The analysis of 6,331 patients showed that 87% had solitary adenomas An average cost savings of $650 was demonstrated for a unilateral operation, which could be realized in as many as 90% (sestamibi sensitivity) of those with solitary adenomas Conclusions: A preoperative sestamibi scan is specific enough in identifying solitary adenomas to allow unilateral exploration with a

The Cost-effectiveness of Automatic Implantable Cardiac Defibrillators: Results From MADIT

Abstract: Background—The recently reported Multicenter Automatic Defibrillator Implantation Trial (MADIT) showed improved survival in selected asymptomatic patients with coronary disease and nonsustained ventricular tachycardia. The economic consequences of defibrillator management in this patient population are unknown. Methods and Results—Patients were followed up to quantify their use of healthcare services, including hospitalizations, physician visits, medications, laboratory tests, and procedures, during the trial. The costs of these services, including the costs of the defibrillator, were determined in patients randomized to defibrillator and nondefibrillator therapy. Incremental cost-effectiveness ratios were calculated by relating these costs to the increased survival associated with the use of the defibrillator. The average survival for the defibrillator group over a 4-year period was 3.66 years compared with 2.80 years for conventionally treated patients. Accumulated net costs were $97 560 for the defibri...

Evaluating information technology in health care: barriers and challenges

Abstract: There is strong push for clinical leadership in the development and procurement of information technology in health care.1 The lack of clinical input to date has been cited as a major factor in the failure of information technology in health services2 and has prompted many clinicians to become involved in such endeavours. Furthermore, there are various clinical decision support systems available, the merits of which clinicians are expected to judge (such as Prodigy3 and Capsule4). It is essential that clinicians have a knowledge of evaluation issues in order that they can assess the strengths and weaknesses of evaluation studies and thus interpret their results meaningfully, and also contribute to the design and implementation of such studies to provide them with useful information. #### Summary points Clinicians are becoming increasingly involved in the development and procurement of information technology in health care, yet evaluation studies have provided little useful information to assist them Evaluations by means of randomised controlled trials have not yet provided any major indication of improved patient outcomes or cost effectiveness, are difficult to generalise, and do not provide the scope or detail necessary to inform decision making Clinical information systems are a different kind of intervention from drugs, and techniques used to evaluate drugs (particularly randomised controlled trials) are not always appropriate The challenge for clinical informatics is to develop multi-perspective evaluations that integrate quantitative and qualitative methods Evaluation is not just for accountability but to improve our understanding of the role of information technology in health care and our ability to deliver systems that offer a wide range of clinical and economic benefits Decision makers may be …