Objectives: Health technology reassessment and disinvestment can be difficult due to uncertainties regarding available evidence. Pathology testing to investigate cobalamin (vitamin B12) deficiency is a strong case in point. We conducted a 3-month economic evaluation of five strategies for diagnosing and treating cobalamin deficiency in adult patients hypothetically presenting with new unexplained fatigue in the primary care setting. The first consultation per patient was considered. Screening tests other than serum cobalamin were not included.

Methods: A cost-effectiveness analysis was undertaken using a decision tree to represent the diagnostic / treatment pathways, with relevant cost and utility scores assigned to different stages in the evaluation process. Input parameter values were estimated from published evidence, supplemented by expert opinion, with sensitivity analysis undertaken to represent parameter uncertainty.

Results: Ordering serum vitamin B12 to assess cobalamin deficiency among patients with unexplained fatigue was not cost-effective in any patient population, irrespective of pretest prevalence of this deficiency. For patients with a pretest prevalence above 1 percent, treating all with oral vitamin B12 supplements without testing was most cost-effective, whereas watchful waiting with symptoms monitoring was most cost-effective for patients with lower pretest prevalence probabilities.

Conclusions: Substantial evidence gaps exist for parameter estimation: questionable cobalamin deficiency levels in the fatigued; debatable treatment methods; unknown natural history of the condition. Despite this, we reveal a robust path for disinvestment decision making in the face of a paradox between the evidence required to inform disinvestment compared with its paucity in informing initial funding decisions.

Objectives: The aims of this study were to assess the 1-year cost-effectiveness of a new combined immunosuppressive and anti-infectious regimen in kidney transplantation to prevent both rejection and infectious complications.

Methods: Patients (pts) transplanted from January 2000 to March 2003 (Group A) and treated with a conventional protocol were compared with pts submitted to a combined regimen including universal cytomegalovirus (CMV) prophylaxis between April 2003 and July 2005 (Group B). Costs were computed from the hospital accounting system for hospital stays, and official tariffs for outpatient visits. Patients with incomplete costs data were excluded from analysis.

Results: Fifty-three patients were analyzed in Group A, and 60 in Group B. Baseline characteristics including CMV serostatus were not significantly different between the two groups. Over 12 months after transplantation, acute rejections decreased from 41.5 percent in Group A to 6.7 percent in Group B (p < .001), and CMV infections from 47 percent to 15 percent (p < .001). Overall, readmissions decreased from 68 percent to 55 percent (p = .160), and average hospital days from 28 ± 19 to 20 ± 11 days (p < .007). The average number of outpatient visits decreased from 49 ± 10 to 39 ± 8 (p < .001). Average 1-year immunosuppressive and CMV prophylaxis costs (per patient) increased from CHF20,402 ± 7,273 to 27,375 ± 6,063 (p < .001), graft rejection costs decreased from CHF4,595 ± 10,182 to 650 ± 3,167 (p = .005), CMV treatment costs from CHF2,270 ± 6,161 to 101 ± 326 (p = .008), and outpatient visits costs from CHF8,466 ± 1’721 to 6,749 ± 1,159 (p < .001). Altogether, 1-year treatment costs decreased from CHF39’957 ± 16,573 to 36,204 ± 6,901 (p = .115).

Conclusions: The new combined regimen administered in Group B was significantly more effective, and its additional costs were more than offset by savings associated with complications avoidance.

Despite the need for more safe and effective contraceptive drugs and devices, enormous barriers to contraceptive research and development have been raised in the United States. The designation of contraceptives as orphan drugs, with concomitant incentives, may be warranted to encourage private manufacturers to reenter the field.

The two components of low birth weight — preterm delivery and fetal growth retardation — lead singly or in combination to a heavy burden of mortality, short- and long-term morbidity, and high medical and social costs. Although different types of long-term morbidity are still being identified, the primary focus of concern has been neurodevelopmental disability resulting from the cerebral palsies, hydrocephalus, and visual and auditory deficits among survivors of very low birth weight. Additional special risks in such infants include chronic lung disease, acute lower respiratory infections, and rehospitalization in infancy and early childhood.

French drug policy is closely controlled by the government to achieve two main purposes: to ensure therapeutic efficacy and safety, and to control pricing. Manufacturers usually price new drugs at the amount the French Sécurité Sociale (Social Security) agrees to reimburse the consumer. The specific steps a new ethical drug must go through in order to be released on the French market, and the process of negotiation between the government and the manufacturer are discussed in this paper.

Standardized conditions for blood pressure measurements and strict definitions of systolic and diastolic blood pressure are essential for a consequent management of hypertension during pregnancy. In Sweden, it has been agreed to measure blood pressure with the pregnant women sitting in upright position. Home-monitoring of blood pressure is recommended in women at risk of preeclampsia.

Drs. Weinstein and Wulff (in issue 1:3) have raised legitimate and important concerns about the ethical acceptability and feasibility of randomized control trials (RCTs) of diagnostic technologies. Their criticisms are all the more compelling in light of their strong advocacy of rigorous evaluation, and their insights into the advantages of RCTs and potential problems with alternative approaches as outlined with great clarity in Dr. Weinstein's paper. We shall not attempt a point by point rebuttal (partly because we are in full or partial agreement with most of their comments) but instead will highlight several issues which we believe merit further discussion.

The French health system is a complex organization that has developed since 1945 as the result of a subtle combination of two fundamental principles: liberal medicine — the freedom of both the consumers and the producers of care, and solidarity — universal access to health care — embodied in a quasi-generalized system of health insurance (4).

Today, this balance, to which the French are uncontestably dedicated, appears to be precarious. It has gradually become apparent that the financing system—80% of which is based on mandatory deductions and is intended to guarantee the balance between freedom of choice and universal access — is not consistent with the dynamic of health expenditures. The growing costs of care, as witnessed by the increase of health expenses as a percentage of total household expenses from 4.5% in 1950 to 13.3 in 1985, has led to increased state control over the health care system since 1975.

Statistical analyses that involve regression methods often encounter data in which some observations have substantial influence. This article presents a nontechnical discussion of influence and of two techniques, based on leaving out each individual observation in turn, for diagnosing influential data. An example illustrates the techniques in an analysis of recurrence rates in endoscopic treatment of bleeding peptic ulcers.

This study assesses the nature, use, and quality of large administrative data bases available in different countries for technology assessment in health care. Using postal questionnaires, data were collected describing 91 data bases from 15 countries. Current uses are promising, but more efforts are needed if the full potential of administrative data files is to be tapped.

Many factors, including cultural, economic, technical, and regulatory influences, affect how different technologies come together for today's medical diagnostic products. An analysis of the development of automated immunoassay systems reveals that companies used a variety of approaches to access needed technologies, that mature technologies play an important role in the development of new products, and that implementation seemed more important in these companies than strategy.

Since the National Institutes of Health (NIH) Consensus Development Conference (1983) concluded that liver transplantation was a procedure deserving of wider application to the treatment of end-stage liver disease, there has been a very considerable increase in the number of centers performing liver transplantation, in Europe as well as in the United States. The number of operations performed has increased logarithmically (Figure 1, in Höckerstedt and Kankaanpää, p. 453). With the detailed overall assessment of liver transplantation in Europe by Höckerstedt and Kankaanpää, we will take the opportunity to review the position in Great Britain from a physician's, i.e., non-surgeon's, viewpoint as seen from one of the two centers (Cambridge/King's College and Birmingham) currently recognized in this country. This is based on an experience of 255 cases dating from the first liver transplant performed in Great Britain by Professor Roy Y. Calne in May 1968.

The use of computers in primary care in the United Kingdom has developed without coordination. The present situation is described. The proposal is that policies for improving primary care will be enhanced by appropriate application of information technology. Benefits and obstacles are identified; practical proposals for effective development are listed.