Objective: The objective was to compare and evaluate assistive technology given to patients treated in a stroke unit and patients treated in a general medical ward.

Method: Use and cost of assistive technology was evaluated in a randomized study comprising 249 patients during a 12-month period.

Result: Acute stroke unit care was associated with a higher prescription of assistive devices during the first 3 months. There was no difference in use and total mean cost per patient of assistive technology during the first year after stroke.

Conclusion: There was no difference in use or cost of assistive technology during the first year, but a beneficial effect was found on supplementary prescription of assistive devices during the first 3 months. The cost during the first year after stroke was a small fraction of the total costs for care and rehabilitation. It is a not expensive for the community to equip these patients and their caregivers with assistive technology, and economic resources should be available to this vulnerable group of elderly patients.

Objective: To characterize the net cost and quality of life effects associated with hip protector use among the elderly relative to no intervention.

Methods: We developed two deterministic hypothetical cohorts of 500,000 65-year-old women or men and followed them over the remainder of their lifetimes. Data inputs were collected from secondary sources. Net costs are expressed in 1999 U.S. dollars, whereas net effectiveness is expressed in lives saved and in quality-adjusted life-years (QALYs) gained.

Results: Hip protector use results in net cost savings for both elderly women and men. Women over age 65 and men over age 85 also gain QALYs through hip protector use.

Conclusions: Using the estimates available in the literature, our analysis indicates that use of hip protectors among women is associated with large cost savings and QALY gains even when accounting for the inconvenience of using the protectors. Among men, hip protectors are also associated with cost savings (although of smaller magnitude), but there are net losses of QALYs because of the inconveniences associated with the protectors.

Governments may perform health technology assessment (HTA) in their roles as a regulator in the public interest, as a source of information for decision makers in the public and private sectors, and/or as a purchaser or provider of healthcare services. The U.S. government's roles in the health sector as a regulator, source of information, and purchaser and provider of services are influenced both by characteristics of that sector and by its stakeholders' effectiveness in influencing national health policy debates.

Objective: To identify training programs and educational resources in health technology assessment (HTA) in Europe.

Methods: A postal survey among potential informants in European countries and Israel, expanding on surveys among ISTAHC and INAHTA members. Informants were identified either using HTA networks or by means of Internet sources.

Results: The combined results of the three surveys show that in the European Union (EU), including Norway and Switzerland, 13 of 17 countries (76%) provide either university level courses or continuing education HTA courses. In the candidate EU countries, 4 of 10 countries (40%) provide HTA courses. In the remainder of countries, only Israel provides HTA courses. Ten different types of courses were identified, mainly applying traditional teaching methods. A substantial number of the courses were first organized in recent years. Many countries in central and eastern Europe expressed the wish to become more involved in HTA.

Conclusion: There is a rapid increase in the number and diversity of courses in HTA in Europe. In particular, countries in the EU are well represented. Education and training in HTA is scarce in EU candidate membership countries, and virtually absent in the remainder of countries. In general, HTA as a field is in the process of becoming established and institutionalized both in individual countries and internationally. To stimulate this development in the area of education and training, both bilateral cooperation and an EU-wide coordinated effort are recommended.

The Canadian Coordinating Office for Health Technology Assessment (CCOHTA) was established by the Federal, Provincial, and Territorial Ministers of Health in 1989 for a 3-year trial period. In 1993 CCOHTA was made a permanent organization and in 1999 the Deputy Ministers of Health renewed CCOHTA's mandate and increased its funding. CCOHTA's role is to coordinate health technology assessment (HTA) priorities across jurisdictions, foster and undertake assessment activity, and function as a clearinghouse for technology assessment results while increasing healthcare system stakeholder awareness of HTA findings. The coordinated and collaborated approach adopted by CCOHTA minimizes duplication with other national and provincial organizations and contributes to the ability of the Canadian healthcare system to continue to deliver high-quality health care to its constituents.

Objectives: The objective was to develop the Audiological Disabilities Preference Index (ADPI), a measure to determine health state preferences associated with audiological disabilities. The ADPI consists of a hearing-related health state description, hearing-related health state valuation, and transformation of the latter to the overall health scale. Research questions were: a) to determine the feasibility of ADPI in an older hearing-impaired population; b) to assess gain in health state preference after hearing aid fitting; c) to evaluate the reliability of ADPI using hypothetical health states; and d) to compare the results of ADPI with the EuroQol.

Methods: The ADPI, the marker states, and the EuroQol were administered to 78 first-time hearing aid users before and 12 and 25 weeks after hearing aid fitting.

Results: The ADPI was feasible in an older hearing-impaired population (mean age, 69.1 years). After hearing aid fitting, all dimensions of audiological disability improved (p < .001). Change in hearing-specific health state and the latter framed in overall health were 0.27 and 0.12, respectively (p < .001). The mean values of the marker states were stable, but the intraclass correlation coefficients were low. Correlations between ADPI and hearing loss and the EuroQol, respectively, were low, while moderate with hearing aid satisfaction. There was a slight change on the EuroQol visual analog scale, with only an improvement in the feeling dimension (p < .05).

Conclusions: The ADPI provides a practical and useful method to assess hearing-related health state preferences needed for clinical decision making and cost-effectiveness analysis.

Objectives: To describe the number of trials and participants in a typical systematic review from The Cochrane Database of Systematic Reviews.

Methods: The number of trials in 1,000 Cochrane systematic reviews in issue 1, 2001 of The Cochrane Database of Systematic Reviews was counted for three categories of trial: included trials, ongoing trials, and trials awaiting assessment for inclusion. (The term trial is used in this paper, although a small number of Cochrane reviews include studies that are not trials.) The total number of participants in included trials was extracted from a sample of reviews.

Results: A total of 9,778 trials were included in the Cochrane reviews. There were a further 356 ongoing trials and 1,138 trials awaiting assessment for inclusion. A typical review contained six included trials. Forty percent of the reviews listed ongoing trials and/or trials awaiting assessment for inclusion. Based on a sample of 258 reviews, the median number of participants per review was 945 (interquartile range, 313 to 2,511) per review and 118 (interquartile range, 60 to 241) per trial.

Conclusion: This report is a descriptive study of the number of trials and participants in a typical Cochrane review from The Cochrane Library, issue 1, 2001.

Objective: Familial adenomatous polyposis (FAP) is a well-known hereditary colorectal cancer-predisposing syndrome. Genetic testing for colorectal cancer risk is now part of standard medical practice, but very little is known about the economic impact of this technology. The aim of this study was to assess, from a healthcare system perspective, the direct costs of two strategies for screening at-risk relatives of FAP patients: clinical screening versus genetic testing for FAP.

Methods: A systematic review of the literature was carried out. Additional information was gathered from experts in research and clinical laboratories and in hospital departments. A decision tree was constructed to compare per-person and per-family costs of the two strategies for screening at-risk relatives of FAP patients. Sensitivity analysis was performed to assess the stability of the model across the full range of plausible values for all key parameters.

Results: According to the decision analysis, with FAP screening starting at puberty, the average screening costs are $3,181 and $2,259 (Canadian dollars), respectively, for the clinical screening and the genetic testing strategies. Genetic screening is cost saving up to a first screening age of 36. Sensitivity analysis shows that the results of the baseline analysis hold across a variety of assumptions concerning the parameter values.

Conclusions: The genetic testing strategy is cost saving relative to the clinical screening alternative. Apart from its lower costs, it is associated with many other benefits. Accordingly, under predefined conditions, predictive genetic testing seems to be the optimal screening strategy for FAP.

Objectives: To evaluate the cost-effectiveness of reusing hemodialyzers for patients with kidney failure on dialysis employing either a heated citric acid or formaldehyde sterilization method, in comparison to the standard practice of single-use dialysis.

Methods: A meta-analysis of all relevant studies was performed to determine whether hemodialyzer reuse was associated with an increased relative risk of mortality or hospitalization. A decision tree was constructed to model the effect of three different dialysis strategies (single-use dialysis, heated citric acid, and formaldehyde dialyzer reuse) on the costs and quality-adjusted life expectancy of “typical” hemodialysis patients. The cost of heated citric acid reuse was estimated from a center experienced with the technique. The cost of end-stage renal disease (ESRD) care, survival data, and patient utilities were estimated from published sources.

Results: There was evidence of a higher relative risk of hospitalization (but not mortality) for hemodialyzer reuse compared with single-use dialysis. Depending on the assumptions used, the cost savings that could be expected by switching from single-use dialysis to heated citric acid reuse were small, ranging from CAN $0–739 per patient per year.

Conclusions: ESRD programs can incorporate the results of this study based on their individual situations to determine whether hemodialyzer reuse is appropriate in their setting.

Objectives: This study was designed to estimate the effects of treatment with linezolid as compared with vancomycin, on the distribution of length of stay (LOS) for hospitalized patients with methicillin-resistant staphylococcal infections. Treatment with intravenous–oral linezolid may allow some patients to be discharged earlier than would treatment with intravenous vancomycin.

Methods: The analysis is based on the intention-to-treat sample from a randomized multinational phase 3 clinical trial of 460 patients showing that the treatments had equal efficacy. Given the nature of the LOS data, some censoring, and some imbalances between treatment groups, multivariate survival analysis was indicated. Cox proportional hazards assumptions were tested and failed, and accelerated failure time models were tested for best fit. The log-logistic model was selected and used as the basis for estimating the overall treatment effect on LOS. Two methods for multivariate corrections to the survivorship functions allowed more thorough description of the treatment effect on the distribution of LOS, including multivariate-adjusted Kaplan-Meier curves.

Results: The average reduction in LOS associated with linezolid treatment, based on the log-logistic model after correction for covariate effects, was 18.1\% (p = .041) or 2.53 days at the median. This was consistent with differences at the medians of the adjusted survivorship functions, which were 2 or 3 days depending on the method used. Treatment-based differences exist at each decile of LOS and consistently favor linezolid. Estimated mean reduction in LOS due to linezolid was 1.62 days in both methods.

Conclusions: In this study sample, linezolid treatment resulted in statistically significantly shorter hospital LOS as compared with vancomycin treatment. Appropriate use of multivariate survival analysis allows better examination of the nature of the treatment effect on LOS, which may be important for economic analysis.

Objective: A recurring question is whether evidence from systematic reviews has any impact on medical practice. We have studied this question in relation to some conclusions in seven reports, where relatively simple means to monitor trends could be used.

Results: As recommended, in the report preoperative routines the number of preoperative examinations diminished at six hospitals, during around 3,000 operations studied, a savings of SEK 130 million. After the report on moderately elevated blood pressure sales of the preferred drugs, diuretics and beta-blockers, stopped falling while calcium blockers and ACE inhibitors stopped rising. As concluded in the report, general prostate cancer screening has not been introduced, but tests as a sign of opportunistic screening have increased. Bone density measurements were not recommended for screening, and sales of equipment have declined after the report. The use of neuroleptics as unspecific calming therapy for old persons was discouraged due to the serious side effects. The frequency of patients given this medication diminished from 34% to 28% at nursing homes after 1 year. For smoking cessation, the use of nicotine substitution medications has increased, which is in line with suggestions presented in the report. For stomach pain proton pump inhibitors given for functional dyspepsia have diminished in a region of the country after special efforts to disseminate the message.

Conclusions: It appears to be possible to monitor changes in practice corresponding to selected conclusions in systematic reviews. After rather extensive disseminating efforts, some results look encouraging.

More than 10 years ago, the Australian government took the bold and unprecedented step of announcing that it would request evidence on comparative cost-effectiveness of new pharmaceutical products, assess this evidence, and then use it to guide systematically the decisions as to whether to subsidize these new products. This paper summarizes the Australian drug subsidy scheme and the activities involved in making this announcement work in practice, assesses the impact these activities have had on broader policy actions, and examines whether these have resulted in any worthwhile achievements.

Objectives: Considering the previously published incidences of heparin-induced thrombocytopenia (HIT) in patients receiving a thromboprophylactic therapy, the role of the hemostasis laboratory is essential in making a clinical decision. The purpose of this project was to compare the strategies of diagnosis and associated care of patients with suspected HIT after elective hip replacement using platelet aggregation assay, carbon 14-serotonin release, and “doing nothing.”

Methods: The authors used an incremental cost-effectiveness analysis based on data extracted from the literature. The effectiveness of the strategies was represented by the number of deep venous thromboses prevented. Cost data were collected from the observation of biological and medical practice at Edouard Herriot University Hospital, Lyon, France, in 1999.

Results: In comparison with the strategies of doing nothing using no biological test for diagnosis, and clinical care of HIT-suspected patients, the strategy using platelet aggregation test was more expensive and less effective. With respect to the strategy using carbon 14-serotonin release assay, the incremental cost-effectiveness ratio, expressed as U.S. dollars per deep venous thrombosis prevented, reached $200,000, with a marginal effectiveness of eight deep venous thromboses prevented for 10,000 HIT-suspected patients.

Conclusion: This study suggests that clinical hemostasis laboratories might consider replacing the platelet aggregation test with the carbon 14-serotonin release assay or should use another functional assay such as the flow cytometric assay for the diagnosis and care of patients with suspected HIT.

Somewhat over 1 million people in Sweden suffer from asthma or chronic obstructive pulmonary disease (COPD). These two diseases greatly reduce the quality of life, and together they account for approximately 2,300 deaths annually in Sweden.

Health technology is an indispensable part of any nation's healthcare system. During the past 50 years, all member states that comprise the European Union have increased their technological base for health care, both in terms of knowledge and by investments in equipment, devices, and pharmaceuticals. Generally, this process has gone well. However, several problems have emerged related to the acquisition, diffusion, and use of modern health technology. Concerns have been also raised about the effectiveness and efficiency of already established procedures in health care.

Objectives: Decision analytic modeling allows a rational, feasible, scientific, and timely approach to measure the efficiency of new medical technologies in health care by using the best available evidence of different sources to produce detailed estimates of the clinical and economic consequences of different healthcare interventions. The aim of this article has been twofold: first, to state the benefit, usefulness, and limitations of decision analytic modeling; and second, to propose a list of steps that should be considered when carrying out this sort of analysis in order to increase its credibility and validity for medical decision making.

Methods: After having read the published literature about decision analytic models, a checklist was created, listing the paramount items and points that should always be followed when carrying out disease modeling.

Results: A checklist with 13 items and steps to be taken was drawn up to ensure that all important methodologic aspects are considered when performing and assessing decision analytic modeling, thereby constituting a standard guide to good modeling practices. In addition, a set of limitations inherent to the use of decision analytic models is also contemplated, along with a list of recommendations increasing their validity and utility.

Conclusions: Health economic assessments will continue to be an important tool for the correct allocation of resources, and disease analytic modeling will be a potentially invaluable tool in assisting decision makers in this task.

Background: Between 1986 and 1996, the overall mean overnight length of stay for all diagnoses in Sweden decreased from 20.8 to 7.1 days.

Objectives: The study describes changes in surgical technique, from mastectomy to breast-conserving surgery, in treatment of female breast cancer and the parallel change in average length of hospital stay, and discusses the possible link between the trends.

Research Design: The study was performed as a descriptive register study on hospital admission data from the Swedish Hospital Discharge Register over a 16-year period (1980–95).

Results: During the study period, the mean length of stay for surgical curative breast cancer treatment in Sweden decreased by 56%. In 1980, the proportion of women receiving conservative surgery was 7%. At the end of the period, this share had increased to 51%. Breast-conserving surgery had an approximately 30% shorter mean length of stay compared with mastectomy. The gap was remarkably stable during the study period. The shift from mastectomy to breast-conserving surgery had a limited effect on the share of patients that went through lymph node dissection. Neither age nor the number of operations per woman could, to any significant extent, explain the decrease in mean length of stay. Approximately 14% of the overall decline can be attributed to the changes in technique.

Conclusions: Clinical practice style, in this case the surgical technique, has had an effect on length of stay, but the surgical technique can only to some extent explain the trend.

Interest is growing in the application of standard statistical inferential techniques to the calculation of cost-effectiveness ratios (CER), but individual level data will not be available in many cases because it is very difficult to undertake prospective controlled trials of many public health interventions. We propose the application of probabilistic uncertainty analysis using Monte Carlo simulations, in combination with nonparametric bootstrapping techniques where appropriate. This paper also discusses how decision makers should interpret the CER of interventions where uncertainty intervals overlap. We show how the incorporation of uncertainty around costs and effects of interventions into a stochastic league table provides additional information to decision makers for priority setting. Stochastic league tables inform decision makers about the probability that a specific intervention would be included in the optimal mix of interventions for different resource levels, given the uncertainty surrounding the interventions.

The 30th annual meeting of the International Society for the Study of the Lumbar Spine will be held in Vancouver, Canada, May 13–17, 2003. If you are interested in attending the meeting as a nonmember, you must have a paper on the program or be invited by a member. Please contact the Secretary, Dr. Scott Boden, at Sunnybrook and Women's Health Science Center, Room MG 323, 2075 Bayview Avenue, Toronto M4N 3M5, Canada.

Health technology assessment (HTA) seeks to inform health policy makers by using the best scientific evidence on the medical, social, economic, and ethical implications of investments in health care. Technology is broadly defined to include the drugs, devices, medical, and surgical procedures used in health care, as well as measures for prevention and rehabilitation of disease, and the organizational and support systems in which health care is provided.