Showing papers on "Cost effectiveness published in 2002"

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.

Abstract: Background Controversy exists about the best surgical treatment for esophageal carcinoma. Methods We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the distal esophagus either to transhiatal esophagectomy or to transthoracic esophagectomy with extended en bloc lymphadenectomy. Principal end points were overall survival and disease-free survival. Early morbidity and mortality, the number of quality-adjusted life-years gained, and cost effectiveness were also determined. Results A total of 106 patients were assigned to undergo transhiatal esophagectomy, and 114 to undergo transthoracic esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative morbidity was higher after transthoracic esophagectomy, but there was no significant difference in in-hospital mortality (P=0.45). After a median follow-up of 4.7 years, 142 patients had died — 74 (70 percent) after transh...

The Raw microprocessor: a computational fabric for software circuits and general-purpose programs

Abstract: Wire delay is emerging as the natural limiter to microprocessor scalability. A new architectural approach could solve this problem, as well as deliver unprecedented performance, energy efficiency and cost effectiveness. The Raw microprocessor research prototype uses a scalable instruction set architecture to attack the emerging wire-delay problem by providing a parallel, software interface to the gate, wire and pin resources of the chip. An architecture that has direct, first-class analogs to all of these physical resources will ultimately let programmers achieve the maximum amount of performance and energy efficiency in the face of wire delay.

Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain.

Abstract: Objective Chronic pain is a prevalent and costly problem. This review addresses the question of the clinical effectiveness and cost-effectiveness of the most common treatments for patients with chronic pain. Data sources Representative published studies that evaluate the clinical effectiveness of pharmacological treatments, conservative (standard) care, surgery, spinal cord stimulators, implantable drug delivery systems (IDDSs), and pain rehabilitation programs (PRPs) are examined and compared. The cost-effectiveness of these treatment approaches is also considered. Data synthesis Outcome criteria including pain reduction, medication use, health care consumption, functional activities, and closure of disability compensation cases are examined. In addition to clinical effectiveness, the cost-effectiveness of PRPs, conservative care, surgery, spinal cord stimulators, and IDDSs are compared using costs to return a treated patient to work to illustrate the relative expenses for each of these treatments. Conclusions There are limitations to the success of all the available treatments. The author urges caution in interpreting the results, particularly in comparisons between treatments and across studies, because there are broad differences in the pain syndromes and inclusion criteria used, the drug dosages, comparability of treatments, the definition of "chronic" used, the outcome criteria selected to determine success, and societal differences. None of the currently available treatments eliminates pain for the majority of patients. Pain rehabilitation programs provide comparable reduction in pain to alternative pain treatment modalities, but with significantly better outcomes for medication use, health care utilization, functional activities, return to work, closure of disability claims, and with substantially fewer iatrogenic consequences and adverse events. Surgery, spinal cord stimulators, and IDDSs appear to have substantial benefits on some outcome criteria for carefully selected patients. These modalities are, however, expensive. Pain rehabilitation programs are significantly more cost effective than implantation of spinal cord stimulators, IDDSs, conservative care, and surgery, even for selected patients. Research is needed to identify which patients are most likely to benefit from the available treatments and to study combinations of the available treatments since none of them appear capable of eliminating pain or significantly improving functional outcomes for all treated.

Randomised factorial trial of falls prevention among older people living in their own homes

Abstract: OBJECTIVE: To test the effectiveness of, and explore interactions between, three interventions to prevent falls among older people. DESIGN: A randomised controlled trial with a full factorial design. SETTING: Urban community in Melbourne, Australia. PARTICIPANTS: 1090 aged 70 years and over and living at home. Most were Australian born and rated their health as good to excellent; just over half lived alone. INTERVENTIONS: Three interventions (group based exercise, home hazard management, and vision improvement) delivered to eight groups defined by the presence or absence of each intervention. MAIN OUTCOME MEASURE: Time to first fall ascertained by an 18 month falls calendar and analysed with survival analysis techniques. Changes to targeted risk factors were assessed by using measures of quadriceps strength, balance, vision, and number of hazards in the home. RESULTS: The rate ratio for exercise was 0.82 (95% confidence interval 0.70 to 0.97, P=0.02), and a significant effect (P<0.05) was observed for the combinations of interventions that involved exercise. Balance measures improved significantly among the exercise group. Neither home hazard management nor treatment of poor vision showed a significant effect. The strongest effect was observed for all three interventions combined (rate ratio 0.67 (0.51 to 0.88, P=0.004)), producing an estimated 14.0% reduction in the annual fall rate. The number of people needed to be treated to prevent one fall a year ranged from 32 for home hazard management to 7 for all three interventions combined. CONCLUSIONS: Group based exercise was the most potent single intervention tested, and the reduction in falls among this group seems to have been associated with improved balance. Falls were further reduced by the addition of home hazard management or reduced vision management, or both of these. Cost effectiveness is yet to be examined. These findings are most applicable to Australian born adults aged 70-84 years living at home who rate their health as good.

Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data.

Abstract: OBJECTIVES: Our falls prevention research group has conducted four controlled trials of a home exercise program to prevent falls in older people. The objectives of this meta-analysis of these trials were to estimate the overall effect of the exercise program on the numbers of falls and fall-related injuries and to identify subgroups that would benefit most from the program. DESIGN: We pooled individual-level data from the four trials to investigate the effect of the program in those aged 80 and older, in those with a previous fall, and in men and women. SETTING: Nine cities and towns in New Zealand. PARTICIPANTS: One thousand sixteen community dwelling women and men aged 65 to 97. INTERVENTION: A program of muscle strengthening and balance retraining exercises designed specifically to prevent falls and individually prescribed and delivered at home by trained health professionals. MEASUREMENTS: Main outcomes were number of falls and number of injuries resulting from falls during the trials. RESULTS: The overall effect of the program was to reduce the number of falls and the number of fall-related injuries by 35% (incidence rate ratio (IRR) � 0.65, 95% confidence interval (CI) � 0.57‐0.75; and, respectively IRR � 0.65, 95% CI � 0.53‐0.81.) In injury prevention, participants aged 80 and older benefited significantly more from the program than those aged 65 to 79. The program was equally effective in reducing fall rates in those with and without a previous fall, but participants reporting a fall in the previous year had a higher fall rate (IRR � 2.34, 95% CI � 1.64‐3.34). The program was equally effective in men and women. CONCLUSION: This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall. J Am Geriatr Soc 50:905‐911, 2002.

Cost-effectiveness analyses of colorectal cancer screening: A systematic review for the U.S. Preventive Services Task Force

Abstract: Purpose To perform a systematic review of the cost-effectiveness of colorectal cancer screening for the U.S. Preventive Services Task Force. Data sources MEDLINE and the British National Health Service Economic Evaluation Database, January 1993 through September 2001. Study selection Original economic evaluations of colorectal cancer screening in average-risk patients were reviewed. The authors sought studies addressing the incremental cost-effectiveness of different screening strategies compared with no screening, of different screening strategies compared with one another, and of different ages of screening initiation and cessation. Two investigators independently reviewed each abstract, and potentially eligible articles were retrieved. A four-member working group reached consensus regarding final inclusion or exclusion of articles. Data extraction One reviewer extracted data into evidence tables. The results were checked by other members and discrepancies resolved by consensus. Data synthesis Among 180 potential articles identified, 7 were retained in the final analysis. Compared with no screening, cost-effectiveness ratios for screening with any of the commonly considered methods were generally between 10, 000 dollars and 25, 000 dollars per life-year saved. No one strategy was consistently found to be the most effective or to have the best incremental cost-effectiveness ratio. Currently available models provided insufficient evidence to determine optimal starting and stopping ages for screening. Conclusions Screening for colorectal cancer appears cost-effective compared with no screening, but a single optimal strategy cannot be determined from the currently available data. Additional data regarding adherence with screening over time, complication rates in real-world settings, and colorectal cancer biology are needed. Additional analyses are necessary to determine optimal ages of initiation and cessation.

Resolving Human-Wildlife Conflicts: The Science of Wildlife Damage Management

Abstract: Philosophy Definitions Philosophies of Wildlife Management What Positive Values Are Provided by Wildlife? What Is Wildlife Damage Management? Why Worry About Human-Wildlife Conflicts? Contributions of Wildlife Damage Management to the Larger Field of Wildlife Management Alternative Definitions for Wildlife Damage Management What Is In a Name? What Are the Necessary Ingredients for Damage by Wildlife? The Role of Government in Wildlife Management The Role of Government Wildlife Biologists History Prehistoric Wildlife Management Wildlife Damage Management in the Ancient World Wildlife Damage Management in Medieval Europe Wildlife Management in Colonial America from 1620 to 1776 Wildlife Management in the U.S. from 1776 to 1880 Why the Closing of the Frontier and the Industrial Revolution Sparked a New Philosophy of Wildlife Management Consequences of the World Wars and the Great Depression on Wildlife Management Wildlife Management in Modern America Wildlife Management in the 21st Century: What Now? Threats to Human Safety Why Do Animals Attack People? How Often Are Humans Injured or Killed by Wildlife? Snakebites Bear Attacks Shark Attacks Alligator Attacks Attacks by Wolves and Coyotes Cougar Attacks Attacks by Large Herbivores Why Has There Been a Recent Increase in Wildlife Attacks on Humans in North America? What Can Be Done to Reduce the Frequency of Wildlife Attacks on Humans? Human Injuries and Fatalities from Ungulate-Automobile Collisions Human Injuries and Fatalities from Bird-Aircraft Collisions Zoonoses Bacterial Diseases Viral Diseases Fungal Disease Economics Economic Analysis of Wildlife Values What Are the Sources of Economic Data about the Positive Values of Wildlife? Why Is It Important to Have Accurate Economic Data about Losses from Wildlife Damage? Measuring Wildlife Damage by Making a Direct Assessment of Losses Assessing the Extent of Wildlife Damage by Surveying People Lost Opportunity Costs Economic Assessment of Wildlife Damage in the U.S. and Worldwide Do High Levels of Wildlife Damage Mean that Wildlife Populations Are Too High? Wildlife Damage to Agricultural Production in Other Parts of the World Environmental Damage and Exotic Species What Is An Exotic Species? Impacts of Exotic Species on the Native Biota Hawaii Galapagos Islands Guam Australia North America Resolving Environmental Problems Caused by Exotic Animals Can We Predict when an Exotic Species Will Cause Environmental Damage? Which Sites Are Vulnerable to Exotic Species? Developing an Integrated Program to Stop the Spread of Exotics Lethal Control Intrinsic Growth Rates of Wildlife Populations What Effect Does Lethal Control have on a Wildlife Population's Birth and Mortality Rates? What Effect Does Lethal Control have on a Wildlife Population's Immigration Rate? Is There a Correlation between Wildlife Population Levels and Wildlife Damage? How Do Values Provided by Wildlife Change as Their Populations Increase? Should Lethal Techniques Be Directed at specific Individuals, Specific Subpopulations, or the Entire Population? Are Lethal Methods Legal? Are Lethal Methods Effective at Reducing Wildlife Damage? Should Lethal Methods Be Used Ahead of Time to Prevent Wildlife Damage or Only After Damage has Begun? Are Lethal Techniques Cost Effective? Do Lethal Techniques Pose a Risk to Nontarget Species? Are Lethal Techniques Humane and Socially Acceptable? Common Methods Used in Lethal Control Fertility Control Normal Reproductive Function Mechanical and Surgical Techniques to Reduce Fertility Reducing Fertility by Disrupting Endocrine Regulation Immunocontraception Administering Fertility Drugs to Animals Controlling the Release of an Antifertility Drug to the Body When Should We Use Contraception In Wildlife? Uses of Contraception in Wildlife Oiling, Addling, or Puncturing Eggs Efforts in Australia to Resolfe Human-Wildlife Conflicts Using Immunocontraceptives What are the Drawbacks to Wildlife Contraception? Public Perceptions of Wildlife Fertility Control Laws Governing the Use of Fertility Control to Manage Wildlife Wildlife Translocation Examples of the Use of Translocation to Resolve Wildlife Conflicts Do Translocated Animals Return to the Site where They Were Captured? Do New Animals Replace the Translocated Ones so that the Problem Persists? Do Translocated Animals Create the Same Problem Elsewhere? What Happens to Translocated Animals? What are the Consequences of Translocation on Resident Wildlife Populations? Is Translocation Cost-Effective? What are Governmental Policies Concerning the Translocation of Nuisance Animals? When Is Translocation Warranted? Fear-Provoking Stimuli Visula Stimuli Auditory Stimuli Olfactory Stimuli Chemical Stimuli The Problem of Habituation Can Habituation to Fear-Provoking Stimuli Be Delayed? Using Live Predators as Fear-Provoking Stimuli Using Guard Dogs as Fear-Provoking Stimuli Hazing or Harassment Chemical Repellants How Plants Use Chemicals to Defend Themselves from Herbivores Biological Basis of Food Preferences Types of Repellants Conditioned Food Aversions Based on Deception Similarities between Batesian Mimicry and DBFA Factors Influencing Repellant Effectiveness to Reduce Wildlife Damage Laws Governing the Use of Vertebrate Repellants Diversion Optimal Foraging Theory Large Group Formation as an Antipredator Behavior - A Natural Form of Diversion Examples of Diversion to Resolve Human-Wildlife Conflicts Creating a Food Diversion through Habitat Modification Response of Wildlife to Supplemental Food Response of Wildlife Diversion Cost Effectiveness What Type of Food or Crop Should Be Used in Diversion? Where Should a Feeder Station or Diversion Crop be Located? Can Wildlife Damage and the Effectiveness of Diversion Be Predicted? Which are Better, Diversionary Crops or Feeder Stations? Can Diversion Be Used with Other Techniques? Exclusion Factors Influencing the Cost Effectiveness of Fencing to Reduce Wildlife Damage Fences to Exclude Deer Using Fences to Reduce Predation on Livestock Using Exclusion to Reduce Predation on Nesting Birds Using Barriers to Protect Individual trees from Herbivores Exclusionary Devices to Prevent Beaver from Rebuilding Dams Using a Trap-Barrier System to Reduce Rat Damage in Rice Fields Using Exclusion to Solve Bird Damage Excluding Wildlife from Buildings Habitat Manipulation Reducing Human-Wildlife Conflicts by Modifying the Resource Reducing Human-Wildlife Conflicts by Modifying the Habitat around the Resource Reducing Human-Wildlife Conflicts at the Landscape Level Human Dimensions Societal Responses to Wildlife Damage Differences in Attitudes toward Wildlife Stakeholder Perceptions of Wildlife Damage Impact of Wildlife Damage on a Person's Attitudes toward Wildlife The Concept of Cultural Carrying Capacity Why is the Management of Human-Wildlife Conflicts So Controversial? Making Policy Decisions Regarding Wildlife Damage Management Forming Partnerships between Wildlife Agencies and People Suffering from Wildlife Damage Resolving Human-Wildlife Conflicts through the Human Dimension Are People's Perceptions about Wildlife Damage Accurate? Developing an Integrated Approach Reducing Blackbird Damage to Sunflowers Reducing Bird Predation at Fish Farms Protecting Ground-Nesting Birds from Mammalian Predators Appendix Latin Names for Species Mentioned in the Text All chapters include a Summary section and Literature Cited.

Systematic review of cost effectiveness studies of telemedicine interventions.

Abstract: Objectives: To systematically review cost benefit studies of telemedicine. Design: Systematic review of English language, peer reviewed journal articles. Data sources: Searches of Medline, Embase, ISI citation indexes, and database of Telemedicine Information Exchange. Studies selected: 55 of 612 identified articles that presented actual cost benefit data. Main outcome measures: Scientific quality of reports assessed by use of an established instrument for adjudicating on the quality of economic analyses. Results: 557 articles without cost data categorised by topic. 55 articles with data initially categorised by cost variables employed in the study and conclusions. Only 24/55 (44%) studies met quality criteria justifying inclusion in a quality review. 20/24 (83%) restricted to simple cost comparisons. No study used cost utility analysis, the conventional means of establishing the “value for money” that a therapeutic intervention represents. Only 7/24 (29%) studies attempted to explore the level of utilisation that would be needed for telemedicine services to compare favourably with traditionally organised health care. None addressed this question in sufficient detail to adequately answer it. 15/24 (62.5%) of articles reviewed here provided no details of sensitivity analysis, a method all economic analyses should incorporate. Conclusion: There is no good evidence that telemedicine is a cost effective means of delivering health care.

Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes

Abstract: CONTEXT Several treatment interventions can reduce complications of type 2 diabetes, but their relative cost-effectiveness is not known. OBJECTIVE To estimate the incremental cost-effectiveness of intensive glycemic control (relative to conventional control), intensified hypertension control, and reduction in serum cholesterol level for patients with type 2 diabetes. DESIGN, SETTING, AND PATIENTS Cost-effectiveness analysis of a hypothetical cohort of individuals living in the United States, aged 25 years or older, who were newly diagnosed as having type 2 diabetes. The results of the United Kingdom Prospective Diabetes Study (UKPDS) and other studies were used to create a model of disease progression and treatment patterns. Costs were based on those used in community practices in the United States. INTERVENTIONS Insulin or sulfonylurea therapy for intensive glycemic control; angiotensin-converting enzyme inhibitor or beta-blocker for intensified hypertension control; and pravastatin for reduction of serum cholesterol level. MAIN OUTCOME MEASURES Cost per quality-adjusted life-year (QALY) gained. Costs (in 1997 US dollars) and QALYs were discounted at a 3% annual rate. RESULTS The incremental cost-effectiveness ratio for intensive glycemic control is $41 384 per QALY; this ratio increased with age at diagnosis from $9614 per QALY for patients aged 25 to 34 years to $2.1 million for patients aged 85 to 94 years. For intensified hypertension control the cost-effectiveness ratio is -$1959 per QALY. The cost-effectiveness ratio for reduction in serum cholesterol level is $51 889 per QALY; this ratio varied by age at diagnosis and is lowest for patients diagnosed between the ages of 45 and 84 years. CONCLUSIONS Intensified hypertension control reduces costs and improves health outcomes relative to moderate hypertension control. Intensive glycemic control and reduction in serum cholesterol level increase costs and improve health outcomes. The cost-effectiveness ratios for these 2 interventions are comparable with those of several other frequently adopted health care interventions.

Probabilistic analysis of cost-effectiveness models: choosing between treatment strategies for gastroesophageal reflux disease.

Abstract: When choosing between mutually exclusive treatment options, it is common to construct a cost-effectiveness frontier on the cost-effectiveness plane that represents efficient points from among the treatment choices. Treatment options internal to the frontier are considered inefficient and are excluded either by strict dominance or by appealing to the principle of extended dominance. However, when uncertainty is considered, options excluded under the baseline analysis may form part of the cost-effectiveness frontier. By adopting a Bayesian approach, where distributions for model parameters are specified, uncertainty in the decision concerning which treatment option should be implemented is addressed directly. The approach is illustrated using an example from a recently published cost-effectiveness analysis of different possible treatment strategies for gastroesophageal reflux disease. It is argued that probabilistic analyses should be encouraged because they have potential to quantify the strength of evidence in favor of particular treatment choices.

The Cost-Effectiveness of Conservation Payments

Abstract: International donors invest billions of dollars to conserve ecosystems in low-income nations. The most common investments aim to encourage commercial activities, such as ecotourism, that indirectly generate ecosystem protection as a joint product. We demonstrate that paying for ecosystem protection directly can be far more cost-effective. Although direct-payment initiatives have imposing institutional requirements, we argue that all conservation initiatives face similar challenges. Thus conservation practitioners would be well advised to implement the first-best direct-payment approach, rather than a secondbest policy option. An empirical example illustrates the spectacular cost savings that can be realized by direct-payment initiatives.

Thinking Outside the Box: Recent Advances in the Analysis and Presentation of Uncertainty in Cost-Effectiveness Studies

Abstract: As many more clinical trials collect economic information within their study design, so health economics analysts are increasingly working with patient-level data on both costs and effects. In this paper, we review recent advances in the use of statistical methods for economic analysis of information collected alongside clinical trials. In particular, we focus on the handling and presentation of uncertainty, including the importance of estimation rather than hypothesis testing, the use of the net-benefit statistic, and the presentation of cost-effectiveness acceptability curves. We also discuss the appropriate sample size calculations for cost-effectiveness analysis at the design stage of a study. Finally, we outline some of the challenges for future research in this area-particularly in relation to the appropriate use of Bayesian methods and methods for analyzing costs that are typically skewed and often incomplete.

Guidelines for screening and surveillance of asymptomatic colorectal cancer in patients with inflammatory bowel disease

Abstract: Patients with ulcerative colitis (UC) are at increased risk of colorectal carcinoma.1,2 Many clinicians practice colonoscopic surveillance in these patients in the hope of detecting dysplasia or an early cancer at a surgically curable stage. However, a recent audit of gastroenterologists showed such surveillance to be disorganised and inconsistent.3 Much debate surrounds the efficacy and cost effectiveness of surveillance programmes in UC4–6 because they were introduced without benefit of randomised controlled trials. The following guidelines should bring uniformity to the process and be of help to both surgeons and physicians. The colorectal cancer risk in patients with colonic Crohn’s disease is similar to that in UC7,8 and thus the guidelines for UC should be equally applicable to such patients with Crohn’s disease. 1. Surveillance colonoscopies should be performed when the disease is in remission. (Recommendation Grade: C). 2. All patients should have a screening colonoscopy after 8–10 years that will also clarify disease extent. (Recommendation Grade: C). 3. Regular surveillance should begin after 8–10 years (from onset of symptoms) for pancolitis and after 15–20 years for left sided disease. (Recommendation Grade: C). 4. As the risk of cancer increases exponentially with time, there should be a decrease in the screening interval with increasing disease duration. For patients with pancolitis, in the second decade of disease a colonoscopy should be conducted every three years, every two years in the third decade, and yearly by the fourth decade of disease. (Recommendation Grade: C). 5. Two to four random biopsy specimens every 10 cm from the entire colon should be taken with additional samples of suspicious areas. (Recommendation Grade: C). Patients with primary sclerosing cholangitis (including those with an orthotopic liver transplant) represent a subgroup at higher risk of cancer and they should have annual colonoscopy. (Recommendation Grade: C). Although it …

Health economic evaluations: the special case of end-stage renal disease treatment.

Abstract: This article synthesizes the evidence on the cost-effectiveness of renal replacement therapy and discusses the findings in light of the frequent practice of using the cost-effectiveness of hemodialysis as a benchmark of societal willingness to pay. The authors conducted a meta-analytic review of the medical and economic literature for economic evaluations of hemodialysis, peritoneal dialysis, and kidney transplantation. Cost-effectiveness ratios were translated into 2000 U.S. dollars per life-year (LY) saved. Thirteen studies published between 1968 and 1998 provided such information. The cost effectiveness of center hemodialysis remained within a narrow range of $55,000 to $80,000/LY in most studies despite considerable variation in methodology and imputed costs. The cost-effectiveness of home hemodialysis was found to be between $33,000 and $50,000/LY. Kidney transplantation, however, has become more cost-effective over time, approaching $10,000/LY. Estimates of the cost per life-year gained from hemodialysis have been remarkably stable over the past 3 decades, after adjusting for price levels. Uses of the cost-effectiveness ratio of $55,000/LY for center hemodialysis as a lower boundary of society's willingness to pay for an additional life-year can be supported under certain assumptions.

Diagnostic value and cost-effectiveness of on-site evaluation of fine-needle aspiration specimens: review of 5,688 cases.

Abstract: Fine-needle aspiration (FNA) has proven to be a safe, economical, accurate, and rapid diagnostic technique. A successful FNA requires a specimen with adequate cellularity, high-quality preparation, an experienced aspirator, and cytopathologist. Up to 32% of FNAs in various organs (thyroid, breast, lung, etc.) may be nondiagnostic due to scant cellularity and poor preparation. On-site immediate evaluation of FNA specimens can be beneficial in determination of adequacy: triage for ancillary studies and provide a preliminary diagnosis of the specimen, which often facilitates rapid clinical decisions. In this study, we compared the on-site FNA interpretation with the final diagnosis and calculated its cost benefit. Reports of 5,688 on-site FNA cases from the files of the University of Pennsylvania Medical Center over a 5-yr period (1/1/96-12/31/00) were reviewed. Data of the immediate on-site interpretation and the final diagnosis in each case were compared to determine the diagnostic accuracy, clinical utility, and cost-effectiveness of on-site FNA evaluation. At our institution the average cost per FNA based on laboratory technical and professional fees (1,743 dollars) and the weighted average cost, based on utilization, of ancillary laboratory studies (328 dollars) and guidance procedures (1,025 dollars) is 3,096 dollars. An additional fee of 231 dollars per case is charged for on-site FNA evaluation by an attending cytopathologist. The average reported rate of nondiagnostic FNAs without on-site evaluation is 20%. Our own nondiagnostic rate for FNAs with on-site evaluation is 0.98%. If one assumes that patients will undergo a repeat FNA for each nondiagnostic specimen, the estimated additional cost in direct institutional charges is 2,022,626 dollars over 5 yr or 404,525 dollars per yr without on-site evaluation. This potential cost savings would be realized by utilizing on-site evaluation despite the additional fee due to a higher rate of specimen adequacy. Based on this study, on-site cytopathologic evaluation of FNA specimens is accurate, cost-effective, and has improved patient care at our institution.

A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women.

Abstract: Purpose To determine, from a societal perspective, the effectiveness and cost effectiveness of concentrated cranberry tablets, versus cranberry juice, versus placebo used as prophylaxis against lower urinary tract infection (UTI) in adult women. Materials and methods One hundred fifty sexually active women aged 21 through 72 years were randomized for one year to one of three groups of prophylaxis: placebo juice + placebo tablets versus placebo juice + cranberry tablets, versus cranberry juice + placebo tablets. Tablets were taken twice daily, juice 250 ml three times daily. Outcome measures were: (1) a >50% decrease in symptomatic UTI's per year (symptoms + >or= 100 000 single organisms/ml) and (2) a >50% decrease in annual antibiotic consumption. Cost effectiveness was calculated as dollar cost per urinary tract infection prevented. Stochastic tree decision analytic modeling was used to identify specific clinical scenarios for cost savings. Results Both cranberry juice and cranberry tablets statistically significantly decreased the number of patients experiencing at least 1 symptomatic UTI/year (to 20% and 18% respectively) compared with placebo (to 32%) (p 2 symptomatic UTI's per year (assuming 3 days antibiotic coverage) and had >2 days of missed work or required protective undergarments for urgency incontinence. Total antibiotic consumption was less annually in both treatment groups compared with placebo. Cost effectiveness ratios demonstrated cranberry tablets were twice as cost effective as organic juice for prevention. Conclusions Cranberry tablets provided the most cost-effective prevention for UTI.

Randomized controlled trial of internet-based cognitive behavior therapy for distress associated with tinnitus.

Abstract: Objective The aim of this study was to investigate if cognitive behavior therapy (CBT) provided via the Internet results in significant decreases of distress in individuals with tinnitus. Methods Participants were recruited through Web pages and newspaper articles and thereafter randomly allocated to a CBT self-help manual in six modules or to a waiting-list control group (WLC). All treatment and contact with participants were conducted via the Internet with Web pages and E-mail correspondence. Participants were 117 individuals with tinnitus of duration of more than 6 months. In the first randomized controlled phase of the study, 26 completed all stages of treatment (51% dropout), and 64 of the WLC group completed measures. At 1-year follow-up, all participants had been offered the program and 96 provided outcome measures (18% dropout rate from baseline). Tinnitus-related problems were assessed before and after treatment and at the 1-year follow-up. Daily diary ratings were included for 1 week before and 1 week following the treatment period. Results Tinnitus-related distress, depression, and diary ratings of annoyance decreased significantly. Immediately following the randomized controlled phase (with a WLC), significantly more participants in the treatment group showed an improvement of at least 50% on the Tinnitus Reaction Questionnaire. At the uncontrolled follow-up, 27 (31%) of all participants had achieved a clinically significant improvement. Conclusions CBT via the Internet can help individuals decrease annoyance associated with tinnitus. High dropout rates or delay in completing treatment can be a characteristic of treatment studies using the Internet but should be contrasted with the cost effectiveness and accessibility of the Internet.

An international survey of the health economics of IVF and ICSI

Abstract: The health economics of IVF and ICSI involve assessments of utilization, cost, cost-effectiveness and ability to pay. In 48 countries, utilization averaged 289 IVF/ICSI cycles per million of population per annum, ranging from two in Kazachstan, to 1657 in Israel. Higher national utilization of IVF/ICSI was associated with higher quality of health services, as indicated by lower infant mortality rates. IVF and ICSI are scientifically demanding and personnel-intensive, and are therefore expensive procedures. The average cost per IVF/ICSI cycle in 2002 would be US$9547 in the USA, and US$3518 in 25 other countries. Price elasticity estimates suggest that a 10% decrease in IVF/ICSI cost would generate a 30% increase in utilization. The average cost-effectiveness ratios in 2002 would be US$58,394 per live birth in the USA, and US$22,048 in other countries. In three randomized controlled trials, incremental costs per additional live birth with IVF compared with conventional therapy were US$ -26,586, $79,472 and $47,749. The national costs of IVF/ICSI treatment would be US$1.00 per capita in one current model, but the costs to individual couples range from 10% of annual household expenditures in European countries to 25% in Canada and the USA.

Pit and fissure sealant: review of the literature.

Abstract: For this literature review of pit and fissure sealant, 1,465 references were selected by a search for "sealants" on PubMed. References were limited to dental journals and papers in the English language. The search comprised papers from 1971 to October 2001. Additional papers of historical significance prior to 1971 were added from memory and from reference lists published in early papers. This paper reviewed the literature on pit and fissure sealants under the following subheadings: (1) laboratory studies, (2) clinical technique and tooth preparation, (3) etching time, (4) auxiliary application of pit and fissure sealant, (5) retention and caries prevention, (6) fluoride used with sealants and fluoride-containing sealant, (7) glass ionomer materials as sealants, (8) options in sealant: filled vs unfilled; colored vs clear; autocure vs light-initiated, (9) sealant placed over caries in a therapeutic manner, (10) cost effectiveness of sealant application, (11) underuse of pit and fissure sealant, (12) the estrogenicity issue, (13) use of an intermediate bonding layer to improve retention, (14) new developments and projections, and (15) summary and conclusions. From a careful and thorough review of peer-reviewed publications on pit and fissure sealant, it is clear that sealants are safe, effective and underused (at least underused in the United States). Pit and fissure sealant is best applied to high-risk populations by trained auxiliaries using sealant that incorporates the benefit of an intermediate bonding layer, applied under the rubber dam or with some alternative short-term, but effective, isolation technique, onto an enamel surface that has been cleaned with an air polishing technique and etched with 35% phosphoric acid for 15 seconds. The dental profession awaits with enthusiasm, and some impatience, the incorporation of dentin-bonding technology into the development of a modern, more durable, resin-based sealant.

The Future of Learning: From eLearning to mLearning.

Abstract: Die umfangreiche Darstellung der verschiedenen, mobilen Systeme und ihre didaktische Einordnung in den Zusammenhang von Fernstudium , dargestellt an unterschiedlichen Einsatzorten und -Verfahren zieht die Schlussfolgerung, dass es eine klare Linie vom Fernstudium alter Pragung uber das sog. elektronische Lernen zum mobilen Lerngeschehen gibt. Von daher sind die didaktischen Grundprinzipien des Fernstuiums immer noch aktuell. Der Vorteil dieser Studie ist die umfassende Darstellung der verschiedenen Projekte, Initiativen und Produkte des sogenannten M-learning.

Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease.

Abstract: Background Both aspirin and clopidogrel reduce the rate of cardiovascular events in patients with coronary heart disease. We estimated the cost effectiveness of the increased use of aspirin, clopidogrel, or both for secondary prevention in patients with coronary heart disease. Methods We used the Coronary Heart Disease Policy Model, a computer simulation of the U.S. population, to estimate the incremental cost effectiveness (in dollars per quality-adjusted years of life gained) of four strategies in patients over 35 years of age with coronary disease from 2003 to 2027: aspirin for all eligible patients (i.e., those who were not allergic to or intolerant of aspirin), aspirin for all eligible patients plus clopidogrel for patients who were ineligible for aspirin, clopidogrel for all patients, and the combination of aspirin for all eligible patients plus clopidogrel for all patients. Results The extension of aspirin therapy from the current levels of use to all eligible patients for 25 years would have an es...

Distance Learning: Promises, Problems, and Possibilities

Abstract: Distance learning and its relationship to emerging computer technologies have together offered many promises to the field of education. In practice however, the combination often falls short of what it attempts to accomplish. Some of the shortcomings are due to problems with the technology; others have more to do with administration, instructional methods, or students. Despite the problems, many users like technologies such as compressed video and see continued growth in the area. This paper will examine some of the current research and thought on the promises, problems, and the future possibilities in modern distance learning, particularly types that are delivered via electronic means.

Impact of Necrotizing Enterocolitis on Length of Stay and Hospital Charges in Very Low Birth Weight Infants

Abstract: Objective. To determine the impact of necrotizing enterocolitis (NEC) on length of stay and hospital charges. Design. Case-control study. Setting. Two neonatal intensive care units in an academic medical center. Patients. Infants born in 1992–1994 with birth weight Measurements and Main Results. We performed odds ratio and t testing. As with previous studies, there was no single factor that increased the risk for developing NEC. However, the diagnosis of NEC increased the risk for death, infection, and the need for central line placement. Infants with surgical NEC had lengths of stay that exceeded those of controls by 60 days, whereas lengths of stay among infants with medical NEC exceeded those of controls by 22 days. Based on length of stay, the estimated total hospital charges for infants with surgical NEC averaged $186 200 in excess of those for controls and $73 700 more for infants with medical NEC. The yearly additional hospital charges for NEC were $6.5 million or $216 666 per survivor. Conclusions. A diagnosis of NEC in the very low birth weight infant imposes a significant additional financial burden to the individual patient as well as the neonatal community as a whole. This expense justifies additional research into preventive measures and potentially costly therapies aimed at reducing the incidence of NEC. These data also provide an estimated cost to compare the cost effectiveness of new preventive measures for NEC.

Cost-effectiveness of alternative triage strategies for atypical squamous cells of undetermined significance.

Abstract: ContextEvery year approximately 2 million US women are diagnosed as having a cervical cytological result of atypical squamous cells of undetermined significance (ASC-US).ObjectiveTo determine the most efficient and cost-effective management strategy for women in the United States diagnosed as having ASC-US.Design and SettingCost-effectiveness analysis of data from clinical trials, prospective studies, and other published literature. A computer-based model was used to compare 4 management strategies for a cytological result of ASC-US: immediate colposcopy; human papillomavirus (HPV) triage, which includes colposcopy if high-risk HPV types are detected; repeat cytology, which includes follow-up cytology at 6 and 12 months and referral for colposcopy if a repeat abnormal result occurs; and reclassifying ASC-US as normal in which a cytological result of ASC-US is ignored. Reflex HPV DNA testing uses either residual liquid-based cytological specimens or samples co-collected at the time of the initial screening for conventional cytology. Another method, referred to as the 2-visit HPV DNA triage, requires a woman with an ASC-US result to return within 1 month to provide another speciman sample.Main Outcome MeasuresYears of life saved (YLS), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.ResultsThe least costly strategy for biennial screening was to reclassify ASC-US as normal, resulting in a reduction in total cancer incidence of 75% for conventional cytology and 84% for liquid-based cytology compared with no screening. The next least costly strategy was HPV DNA testing resulting in a reduction in total cancer incidence of 86% for conventional cytology and 90% for liquid-based cytology, followed by immediate colposcopy with a reduction of 87% and 91%, respectively. Compared with reflex HPV DNA testing, a strategy of repeat cervical cytology or delayed HPV testing costs more but is less effective. When all strategies were compared simultaneously, varying frequency and type of cytological test, biennial (vs every 3 years) liquid-based cytology with reflex HPV testing had a cost of $174 200 per YLS. In a similar comparison, liquid-based cytology with reflex HPV testing conducted every 3 years (vs every 5 years) had a cost of $59 600 per YLS and was more effective and less costly than a strategy of conventional cytology incorporating repeat cytology or immediate colposcopy conducted biennially.ConclusionReflex HPV DNA testing provides the same or greater life expectancy benefits and is more cost-effective than other management strategies for women diagnosed as having ASC-US.