Despite the perception of many people that lasers represent the cutting edge of high-technology medicine, this form of medical technology has been subject to relatively little rigorous evaluation. This dearth of research relates particularly to economic evaluation, where there have been few attempts to justify the high cost of laser equipment. This paper details an economic evaluation of the use of laser technology as a secondary adjunct to angioplasty to treat peripheral arterial occlusions. Using data from a range of sources, including a published randomized trial, a cost-utility model is developed to estimate the costs and benefits of the laser, relative to standard angioplasty. The best available data indicate a cost-effective role for the laser, but important areas of uncertainty exist, including the laser's secondary recanalization rate, which has been estimated on the basis of limited numbers of patients. This uncertainty suggests that further research is required before widespread diffusion of the laser for use in this clinical context.

Clnical trial randomization schemes to control patient characteristics that can influence clinical response are not sufficient to control for their effects on operational efficiency and cost within the provider institution. This variation can result in biased economic findings when patients are allowed to select a provider themselves.

The scientific evidence for clinical effectiveness of transcutaneous electrical nerve stimulation (TENS) for treatment of acute, chronic, and labor and delivery pain is assessed in this paper, and it is concluded that there is little evidence for other than a limited use of TENS. The utilization of TENS in Canadian hospitals and payments for TENS services are addressed. Some practicalities regarding the use and assessment of health technologies are discussed.

The use of cardiac catheterization procedures and the number of hemodynamic laboratories in Italy increased steadily from 1983 through 1993, sometimes with no planning or modern technology assessment. It is recommended that in the future funds be assigned to improve underused laboratories rather than to build new facilities.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most prestigious health care technologies. Their popularity has grown rapidly, and an increasing proportion of health care resources is allocated to them. We studied patient- and hospital-related factors that cause variation in a major determinant of hospital costs, the length of hospital stay (LOS) for THA and TKA. We gathered data on 10,288 hip and 5,173 knee patients with primary or secondary arthrosis from the Finnish Arthroplasty Register, which we linked with the Finnish Hospital Discharge Register. Patientand hospital-related variations in LOS were explained using regression models. Of the patient-related factors, complications caused the greatest prolongation of hospital stay, but patient's age, gender, and charge category also influenced LOS. Hospital-related factors were major causes of LOS variation. In the hospitals the average case-mix-adjusted LOS ranged from less than a week to 3 weeks. The number of arthroplasties performed in hospital was inversely related to LOS. The within-hospital LOS figures for THA and TKA were strikingly similar and persistent.

We present the prospective economic evaluation that served as a secondary endpoint for the FIRST study, a randomized international multicenter trial of patients with severe congestive heart failure. Although the clinical results of this study were disappointing, we demonstrated the feasibility of incorporating prospective economic evaluation in phase III clinical trials.

Agreement between two expert panels in assessing gain in life expectancy and quality of life from unselected stays in a department of internal medicine was investigated. Weighted kappa statistics of 0.45 for gain in life expectancy and 0.63 for gain in quality of life were found.

We performed an economic evaluation of HIV testing among intravenous drug users (IVDUs) in Italy using the analytical framework of cost-effectiveness analysis. A semi-Markov model was developed to calculate costs and life expectancy of a cohort of IVDUs with and without an annual HIV testing program. We also investigated the incremental cost-effectiveness of a hypothetical early treatment to prolong the life expectancy of HIV-infected asymptomatic subjects by 1 year. The testing program is cost saving in the low prevalence scenario (0.05), and costs L 14,000,000 (US $8,400) and L 55,800,000 (US $33,500) per year of life saved in areas of medium (0.3) and high (0.6) prevalence, respectively. The incremental cost-effectiveness of the hypothetical early treatment may compare favorably with other health care interventions. The program may be considered a cost-effective procedure in low and medium prevalence areas. Where prevalence is high, more evidence about the magnitude of the behavior change is needed. In these areas, the availability of an effective early treatment may become the economic rationale for implementing such a program.

To increase access to care for cataract patients in Sweden, it was decided, starting in 1992, that all cataract patients listed for surgery and with priority should have their cataract extraction performed within three months. To evaluate the effect of this waiting time guarantee, a National Cataract Register (NCR) was initiated in late 1991. In 1992, 81% of all cataract extractions performed in Sweden were reported to the NCR; in 1993 this figure was 92%. Reasons for this high participation ratio are discussed. In 1993, 74.4% (range between different clinics, 40–99%) of the patients with priority had their operation performed within three months. Great variation in visual acuity and age was found in patients with priority among the different surgical units.

The ability to extract information on resource use from randomized controlled trials can provide the groundwork for systematically compiling health economic reviews of health interventions. A review of the brief smoking interventions in general practice demonstrates that not all the necessary information can be extrapolated from these trials, and cost data will have to be supplemented from other sources.

Proliferation of acute health care technology creates problems and benefits for nurses and patients. In this paper the impact of technology on the nursing work role is reviewed through the international literature. The thrust of the nursing literature has, not surprisingly, matured over time as the use of technology has become well established in the acute care environment, and three themes can be identified. The implications for acute care nurse specialists, including their educational needs, are set in context of the Australian health care system, with particular reference to the cardiac care environments.

For risk assessment and control of the failing Björk-Shiley convexo-concave heart valve, we present a life cycle-based complex system model and a risk intensity assessment model, allowing consistent analysis of this complex medical problem and identification of all pertinent aspects of product-related risks to patients.

We reviewed the Canadian literature on cost-effectiveness from 1980–1995 with regard to costing methodologies. We abstracted each study using a list of data elements that describe costing methodology, and evaluated costing methodologies in the light of biases in costing methods, site, and case-mix selection.

In the last several years, the development of an effective breast cancer screening procedure has increased the possibility of the early detection of this cancer. We investigated the cost-effectiveness of a breast cancer screening program to screen 100,000 women 50–64 years of age in Catalonia (Spain). The cost-effectiveness ratio was measured in terms of the cost per cancer detected comparing program costs to the estimated number of cancers detected. We assumed a participation rate, sensitivity, and specificity of 70%, 92%, and 94%, respectively, and that 0.36 breast cancers could be detected per 100 women screened. We estimated a total cost of $2.1 million with $1.4 million for the mammographic stage and $0.7 million for the detection of the true positive mammographic results. The cost per woman screened was $30. We estimated that 252 cases of breast cancer could be detected with the program. The cost-effectiveness ratio obtained in this study was $8,424 per cancer detected. Sensitivity analysis has shown that cost-effectiveness results are sensitive to the variations in the following variables: specificity, cancer detection rate, and screening costs. In planning preventive programs, breast cancer screening should be considered one of the priorities.

We studied the role of economic incentives for private providers in explaining Spain's disproportionately large number of extracorporeal shock wave lithotripters (ESWLs) and low number of linear accelerators (linacs) per million population (pmp) in comparison to other countries of the Organization for Economic Cooperation and Development (OECD). We found that the reimbursement policy for 1990 allowed an average profit per private ESWL of $732,000, but no profit for linacs. Regional per-capita income was positively correlated with ESWLs pmp in Spain (R2 = 0.49; p =.001), but not with linacs. Sixty-nine percent of ESWLs were privately held versus only 16% of linacs. To avoid these types of distortions, financial incentives should be based on a reasonable relationship between cost and charges and should be associated with the appropriateness of medical care.

In a national survey of medical directors at 231 U.S. private health care plans that cover over two thirds of the privately insured population, we studied whether medical directors are aware when a new technology, such as laser therapy, is being used in procedures for which claims are submitted, the factors alerting them to such use, and the factors prompting them to make a specific coverage decision for the technology. We also examined possible associations between health plans' characteristics (HMO versus indemnity, size, profit status, and time in operation) and their medical directors' awareness of the use of technologies, factors alerting medical directors to their use, and factors prompting specific coverage decisions. The majority of plans were generally not aware that laser technology was being used when it was billed under a general billing code, raising the possibility that less effective or less safe technologies could be introduced rapidly into the treatment of insured populations. Nonprofit and older plans were less likely to be aware that lasers were used in some procedures than for-profit and younger plans.