Background: Healthcare use and costs are about 81% higher for morbidly obese individuals compared to non-obese persons, and 47% higher compared to the non-morbidly obese population. The benefits of bariatric surgery for health are well established, but its mid-term impact on healthcare use and costs remains controversial.

Methods: This study examines the trends in healthcare use and costs in a Brazilian cohort during a 4-year period before and after surgery. Healthcare use and direct costs related to inpatients and outpatients were retrieved from a healthcare insurance company database from which all cohort members were selected.

Results: Between 2004 and 2010, 4,006 individuals underwent bariatric surgery. Most patients were female (80%) with a mean age of 36.2 years and a mean body mass index of 42.8 kg/m2. Elevated blood pressure was present in 38% of cases and diabetes was found in 12.5% of subjects. Hospital admissions increased consistently after surgery, even after excluding hospitalizations for esthetic surgery and pregnancy-related care. The most prevalent conditions in this group were gastrointestinal diseases. Emergency department visits increased after bariatric procedures, in particular for genitourinary and hematologic problems. Adjusted costs were higher after surgery as assessed during a 4-year follow-up period.

Conclusion: Results indicate that costs and hospital admissions after bariatric surgery increase following this procedure, even when elective interventions are excluded. Healthcare providers and policy makers need to be aware that a decrease in obesity-related diseases following bariatric surgery does not reduce healthcare use and costs.

Priority setting for the evaluation of health technologies in the Netherlands is exclusively based on the scientific merits of individual research proposals. This process has not resulted in satisfactory allocation of resources. Therefore, societal criteria for setting priorities for health technology assessment have been proposed as an adjunct to scientific criteria. These societal criteria include the burden of disease, uncertainty about the (cost-)effectiveness of the intervention at issue, the potential benefits of the research project, and its potential impact on health care. To realize the full potential of this model for priority setting, a number of methodological issues need to be addressed. Joint efforts of researchers and policy makers in this field are necessary for future progress.

Using a case study methodology, we examined the implementation of a nursing flow sheet system in the trauma center of a large, not-for-profit, teaching hospital. Findings add new insights to the existing body of knowledge in the information technology and medical informatics fields. First, results reveal that the success of clinical information systems requires a proactive stance where key actors anticipate and address the challenges ahead and capitalize on opportunities. Second, empirical evidence indicates that project outcomes ultimately depend on how the implementation process is managed and what the organization and its members do with the system once it is introduced. Finally, the case at hand shows that the nature and overall quality of the implementation strategy can be largely predicted by the key actors involved in the project, given their own background, skills, interest, and level of motivation.

The extent of variation in the use of breast-conserving surgery was analyzed using the 1990 and 1991 hospital discharge data of Lombardia, Italy. The proportion of patients undergoing breast-conserving surgery for unilateral breast cancer was estimated for each of the 10 geographic areas (9 provinces plus metropolitan Milano) in which the region is divided. Overall, the rate of use was 41% of 3,225 patients in 1990, and 45% of 3,736 patients in 1991. In both study years, patient age was strongly correlated with the likelihood of undergoing conservative surgery, with younger women more frequently treated with this approach. In each province, patients treated at centers located in the main city had a greater probability (OR, 1.54; 95% Cl, 1.37–1.69) of having conservative surgery. This procedure was also more often used in private hospitals (OR, 1.59; 95% Cl, 1.20–2.08) where care is paid at the point of consumption by patients, directly or through their private insurance. The observed variation in the use of the conservative procedure across the 10 regional areas was greater than that expected by chance alone (p <.0001), with rates ranging from 29% to 60%. This pattern persisted even after adjusting for the relevant patient and hospital characteristics. Despite the relatively large body of scientific evidence, it appears that the surgical management of breast cancer is more dependent on physicians' attitudes in each geographic area than on individual patients' characteristics.

The International Society for Technology Assessment in Health Care (ISTAHC) was formed in 1985. It grew out of the increasing awareness of the international dimensions of health technology assessment (HTA) and the need for new communication methods at the international level. The main function of ISTAHC was to present an annual conference, which gradually grew in size, and also to generally improve in quality from to year. ISTAHC overextended itself financially early in the first decade of the 2000s and had to cease its existence. A new society, Health Technology Assessment international (HTAi), based on many of the same ideas and people, grew up beginning in the year 2003. The two societies have played a large role in making the field of HTA visible to people around the world and providing a forum for discussion on the methods and role of HTA.

Objectives: To explore one aspect of the external validity of the randomized controlled trial (RCT), specifically how being selected for inclusion in a trial and having participated has influenced the use and cost of asthma-related health services.

Methods: Services used by asthmatic users of inhaled corticosteroids (iCSTs) having previously participated in an RCT (TS, n = 46) were compared with individuals who had never participated (NS, n = 51).

Results: TS were more likely to use higher (≥400 μg) daily doses of iCSTs than NS (OR, 3.3; 95% CI, 1.1–8.3) but less likely to visit emergency departments (OR, 0.3; 95% CI, 0.1–0.7). Total asthma-related costs did not differ significantly.

Conclusions: Subject differences may impede generalizing from RCTs to real life.

Objectives: Assess the degree to which research project findings were published and explore factors that influenced publication.

Methods: Questionnaire to project leaders. Classification of publications and findings. Chi-squared; univariate and multivariate Cox regression analyses.

Results: Forty percent of projects published in peer-reviewed journal; highly statistically significant relationships between publication in peer-reviewed journals and (1) projects in Responsive/Fellowships streams (p=.045); and (2) projects awarded >£22,713 (p=.02); influence of study findings not statistically significant.

Conclusions: Funders should consider the significant number of studies that did not result in publication and the higher rate of publication in peer-reviewed journals from some programs.

Objectives: We describe, in general, the principles used in priority setting and, in particular, policy processes and decision making in Norway.

Methods: A newly established council for setting priorities in health care is presented to illustrate how health technology assessments (HTAs) can support national advisors in complex priority-setting processes.

Results and Conclusions: Setting priorities in health care is a complex task. Careful thinking is, therefore, required in determining the components of a system for priority-setting. Based on recent Norwegian experiences, we believe that the following generic parts may provide some of the solution: a common set of values; an organizational structure made up of key stakeholders; supporting mechanisms in the form of HTA organizations and documented best evidence; and loyalty to decisions by stakeholders responsible for implementing national policies.

Background: Availability of real-time electronic healthcare data provides new opportunities for rapid-cycle evaluation (RCE) of health technologies, including healthcare delivery and payment programs. We aim to align decision-making processes with stages of RCE to optimize the usefulness and impact of rapid results. Rational decisions about program adoption depend on program effect size in relation to externalities, including implementation cost, sustainability, and likelihood of broad adoption.

Methods: Drawing on case studies and experience from drug safety monitoring, we examine how decision makers have used scientific evidence on complex interventions in the past. We clarify how RCE alters the nature of policy decisions; develop the RAPID framework for synchronizing decision-maker activities with stages of RCE; and provide guidelines on evidence thresholds for incremental decision-making.

Results: In contrast to traditional evaluations, RCE provides early evidence on effectiveness and facilitates a stepped approach to decision making in expectation of future regularly updated evidence. RCE allows for identification of trends in adjusted effect size. It supports adapting a program in midstream in response to interim findings, or adapting the evaluation strategy to identify true improvements earlier. The 5-step RAPID approach that utilizes the cumulating evidence of program effectiveness over time could increase policy-makers' confidence in expediting decisions.

Conclusions: RCE enables a step-wise approach to HTA decision-making, based on gradually emerging evidence, reducing delays in decision-making processes after traditional one-time evaluations.

This article describes the use of research synthesis procedures (e.g., meta-analysis) in evaluating medical technologies. The synthesis process involves retrieval, extraction, and analysis of pertinent information from a set of research studies. There are several advantages of research synthesis: determining overall effectiveness, explaining seemingly contradictory findings, providing a standard measure of effect, and increasing statistical power. In addition, such syntheses provide timely results that can assist various policy decisions such as initiating clinical trials at NIH, reimbursement at HCFA, and answering NIH consensus conference questions. The authors' synthesis of the research literature on coronary artery bypass graft surgery (CABGS) illustrates how this method can address the various elements of a technology assessment such as safety, efficacy, and cost-effectiveness. The paper concludes by noting how research synthesis can be particularly advantageous in assessing technologies that are rapidly evolving (e.g., lytic agents for acute myocardial infarction).

We aimed to establish a 1996 baseline of new health care technologies that are predicted to have an impact on the United Kingdom's National Health Service in the next five years. One thousand and ninty-nine health care technologies were identified from a variety of sources. Further work will attempt to determine the most efficient method of identifying and monitoring new health care technologies.

The results of a field study of three sites that used video to link primary care medical centers to hospitals are reported. The analysis was concerned with identifying the people involved, the tasks carried out in collaboration at each end of the link, and how the different communications facilities helped or hindered. The results are summarized as six task characteristics and their design implications for this model of telemedical consultation are discussed.

Objectives: This study was undertaken to understand how women view characteristics of tests for cervical dysplasia, because these characteristics can affect patient decision-making about screening and follow-up.

Methods: We recruited women who participated in a clinical trial of optical spectroscopy for the diagnosis of cervical dysplasia and used conjoint analysis to assess the women's preferences concerning test attributes. One group of women had a history of an abnormal Papanicolaou smear (diagnostic sample), while the other group did not (screening sample). Participants rated pairs of test scenarios that varied on characteristics such as test sensitivity and painfulness. Based on their responses, the relative importance of test sensitivity, specificity, timing of results feedback and treatment, and pain were calculated, and a cluster analysis was done to identify subgroups of participants with different preference patterns.

Results: In the overall sample, sensitivity was the most important attribute, followed by timing, specificity, and pain. Cluster analysis revealed four distinct groups who placed varying importance on each characteristic. The participants in the cluster for which pain was the most important attribute were more likely to be diagnostic patients, non-white, and have low education levels. They also reported more anxiety and pain during the examination than participants in other clusters.

Conclusions: To continue to reduce morbidity and mortality from cervical cancer, developers of new testing procedures should take into account test attributes such as these, which may affect adherence to screening and diagnostic follow-up to further minimize morbidity and mortality from cervical cancer.

Objectives: To estimate the potential for cost reduction in the acute care setting and the required investment in the home care setting of implementing an outpatient/early discharge strategy for operable (stages I and II) breast cancer in Canada.

Methods: Data from a community hospital were augmented by expert knowledge and incorporated into the breast cancer submodel of Statistics Canada's Population Health Model. For the estimated 90% of patients for whom this approach was assumed to be appropriate, the resource utilization for outpatient breast-conserving surgery and 2 days of hospitalization for those women undergoing mastectomy was quantified and costed, as were the appropriate home care services. A 5% readmission rate for complications was assumed. Cost per case, total cost burden, investment in home care, savings in acute care, and net savings were calculated. Sensitivity analyses were performed around readmission rates and home care/surgical follow-up costs. All costs were determined in 1995 Canadian dollars.

Results: The cost of initial treatment for the 15,399 women diagnosed with stages I and II breast cancer in 1995 in Canada was estimated to be $127.6 million. Hospitalization made up 53% of these costs. Under the outpatient/early discharge strategy, the acute care cost of initial breast cancer management could be reduced by $47.2 million, with an investment in home care of $14.5 million ($453 per patient), resulting in an overall net saving of $33 million. Under this strategy, hospitalization would contribute only 21% to the total care cost.

Conclusions: If Canadian surgeons and healthcare administrators were to work together to put in place processes to support ambulatory breast cancer surgery and if resources were redirected to the provision of home-based post-operative care, there would be potential for a large net healthcare saving and preservation of high-quality patient care.

Objectives: It is generally accepted that home peak flow monitoring increases patients' self-management and could lead to cost savings. The aim of this review was to analyze costs and the cost-effectiveness of self-management based on peak flow monitoring interventions in asthma.

Methods: Twenty-one studies were included in this review. Data were extracted, and methodological and economic quality were assessed. These studies presented economic information regarding self-management interventions based on peak flow monitoring in asthmatics. The mean methodological quality was 4.6 (maximum 8), and the mean economic quality was 12.0 (maximum 15).

Results: In eighteen studies, the interventions led to net savings compared with usual care or less intensive intervention. Only three studies found the total costs to be higher in the intervention group. In thirteen of the seventeen studies that analyzed health outcomes, at least one of the reported health outcomes improved statistically significantly after the intervention. However, the methods of economic evaluation differed among the studies and were not always in line with the standard methodology.

Conclusions: The interventions, costs, and outcomes were very diverse. The results emphasize the need for guidelines to increase the comparability of cost-effectiveness evaluations relating to asthma. Only then will it be possible to conclude whether interventions for asthmatics, such as self-management based on peak flow monitoring interventions, are cost-effective.

Objectives: The aim of this study was to systematically review economic analyses comparing drug-eluting stents (DES) to bare metal stents (BMS) in patients who undergo percutaneous coronary intervention to form an overall view about cost-effectiveness of DES and to construct a simple decision analysis model to evaluate the cost–utility of DES.

Methods: Electronic databases searched from January 2004 to January 2006 were Cochrane Database of Systematic Reviews; DARE, HTA, EED (NHS CRD); MEDLINE(R) In-Process, Other Non-Indexed Citations, MEDLINE(R). References of the papers identified were checked. We included randomized controlled trials (RCT) or model-based cost-effectiveness analyses comparing DES to BMS in patients with coronary artery disease. The methodological quality of the papers was assessed by Drummond's criteria. Baseline characteristics and results of the studies were extracted and data synthesized descriptively. A decision tree model was constructed to evaluate the cost–utility of DES in comparison to BMS, where health-related quality of life was measured by the 15D.

Results: We identified thirteen good-quality economic evaluations. In two of these based on RCTs, DES was found cost-effective. In six studies, it was concluded that DES might probably be a cost-effective strategy in some circumstances, but not as a single strategy, and four studies concluded that DES is not cost-effective. One study did not draw a clear conclusion. In our analysis, the overall incremental cost-effectiveness ratio was €98,827 per quality-adjusted life-years gained. Avoiding one revascularization with DES would cost €4,794, when revascularization with BMS costs €3,260.

Conclusions: The evidence is inconsistent of whether DES would be a cost-effective treatment compared with BMS in any healthcare system where evaluated. A marked restenosis risk reduction should be achieved before use of DES is justifiable at present prices. When considering adoption of a new health technology with a high incremental cost within a fixed budget, opportunity cost in terms of untreated patients should be seriously considered as a question of collective ethics.

Objectives: Positron emission tomography (PET) is an innovative imaging tool. Associated with computed tomography (CT), it allows a better definition for the tumor volume for radiotherapy, compared with CT only. The aim of this study was to assess the effects of PET on resource allocation (costs and savings) and on the choice of the following treatment in radiotherapy.

Methods: In 2004 and 2005, 209 patients were enrolled (97 patients with Hodgkin's disease and 112 with non-small cell lung cancer) in a national study conducted in eight hospitals. Two treatment decisions made on the basis of CT only or CT associated with PET, were compared in a prospective study where each subject was his/her own control. The direct medical cost of using PET was assessed by microcosting, using data collected from specific questionnaires. The costs of new tests and the costs and savings associated with changes in the chosen treatment were calculated on the basis of reimbursement rates.

Results: The mean cost of using PET was approximately €800 per patient (50 percent for the radionuclide 18F-FDG [2-[18F]fluoro-2-deoxy-D-glucose]). Radiotherapy treatments were modified for 10 percent of patients with Hodgkin's disease versus 40 percent of patients with lung cancer. Overall, the use of PET induced both increases and decreases in the mean cost per patient: the net effect was a €425 and €931 cost increase in lung cancer and Hodgkin's disease, respectively.

Conclusions: The use of PET for radiotherapy decision making seems more valuable for lung cancer than for Hodgkin's disease, both in terms of costs and changes in radiotherapy treatment. This result might help policy makers for prioritization.