While reversible cases of dementia are rare once detected, the patient may benefit from treatment. This paper examines the cost-effectiveness of computerized tomography (CT) scanning as a screening test for potentially reversible dementia. A systematic review was carried out to identify the proportion of patients with dementia above and below the age of 65 years with a theoretically treatable condition and the proportion of these patients who would benefit from neurosurgery. Information was combined with epidemiological and financial data relating to Scotland to model the costs and benefits of implementing a national screening program. Subdural hematoma, normal pressure hydrocephalus, and brain tumours are rare conditions treatable by neurosurgery. A scanning and treatment program for Scotland would cost £4.6 million per annum. Of 531 reversible cases detected, 136 would benefit from neurosurgery, 369 would not benefit, and 26 would die as a result of surgery. Treating normal pressure hydrocephalus reduces overall quality-adjusted survival. The most cost effective screening strategy is to scan all patients but treat only subdural hematomas, gaining 178 quality-adjusted life-years (QALYs) at a cost of £14,171 per QALY for patients aged 65 at the time of the scan. The corresponding figures for patients above and below 65 years are £9,000 and £23,000, respectively. CT scanning appears cost-effective in dementia patients under 65 years. It should be undertaken selectively in more elderly patients. Surgical treatment of normal pressure hydrocephalus may reduce quality adjusted survival and should only be undertaken within clinical trials.

Objectives: Knowledge of resource use and costs can be useful when evaluating existing services or planning new services. This study investigates the use of health care and social services during the first year after a stroke. Total costs are calculated, costs are compared across subgroups of patients, and resource items of major importance for the total costs are identified.

Methods: The study is based on a database comprising data on all stroke patients admitted to a university hospital in Copenhagen, Denmark, over a 1-year period, 1994–95. Patients were followed for 1 year after the stroke, and data on resource use during and after hospitalization were collected prospectively at interviews. This paper focuses on a subset of 385 patients who were admitted because of cerebral infarct or unspecified stroke.

Results: The mean cost, based on all patients, of health care and social services during the first year was 142,900 DKK (US $25,500). The hospital care until the first discharge, including acute care and rehabilitation, cost 101,600 Danish krones (DKK) (US $18,100), i.e., 71% of the total cost. Major resource items after discharge were nursing homes, readmissions, outpatient rehabilitation, and home help. The cost during the first year varied with a number of factors, with the most important being survival and degree of disability. Patients who survived the acute phase and who had severe disability (Barthel Activities of Daily Living [ADL] Index: 0–9) 7–10 days after admission had a total cost during the first year that was five times as high as patients with no disability (Barthel ADL Index: 20).

Conclusion: Costs of health care and social services during the first year after a stroke vary considerably. Disability as measured with the Barthel ADL Index is a stronger predictor of costs than Scandinavian Stroke Scale scores and other clinical and demographic variables.

Objectives: Due to the discovery in the 1980s that blood transfusion can transmit HIV, there has been increased interest in technologies that reduce the amount of allogeneic blood used during and after surgery. These technologies include drugs (aprotinin, tranexamic acid, epsilon-aminocaproic acid, erythropoietin), devices (cell salvage), and techniques (acute hemodilution, predeposited autologous donation). The purpose of this study was to ascertain the degree of practice variation, if any, that exists for eight technologies in nine countries in orthopedic and cardiac surgery.

Methods: In each country, either all hospitals or a random sample of hospitals with medical/surgical beds were surveyed between 1995 and 1997. Two instruments were used. The first instrument was a postcard that asked recipients whether the technologies were currently being used in their hospital for orthopedic and/or cardiac surgery to reduce perioperative allogeneic transfusion. The second questionnaire elicited information regarding the degree of use both in qualitative and quantitative terms. Data were collected, entered, and analyzed in each country, with summary results submitted to the Canadian coordinating center on a standardized data collection form.

Results: Pharmaceuticals were generally used in a much smaller proportion of hospitals in orthopedic than in cardiac surgery. Aprotinin and tranexamic acid were the drugs most frequently used in cardiac surgery. Nonpharmacological technologies were used to a greater degree than drugs in orthopedic surgery, although there was wide variation among technologies and countries. Acute hemodilution and cell salvage were used in a greater proportion of hospitals for cardiac surgery than orthopedic surgery.

Conclusions: The results of this survey indicate that there is considerable practice variation in the use of technologies to minimize exposure to perioperative allogeneic transfusion within and between countries.

This paper tests the null hypothesis of a zero effect of cesarean section rate on health outcome against the alternative of a positive effect. Using data from 59 hospitals in Sweden from 1988–92, we specify two separate linear regression models for health outcome, one with perinatal mortality, and the other with rate of asphyxia, as dependent variable. We estimate the models by single-year cross-section regressions and as pooled data systems. The null hypothesis cannot be rejected, i.e., we do not find any significant positive effect of cesarean section rate on health outcome. Thus, we conclude that an increase in cesarean section rate does not imply lower perinatal mortality or lower rate of asphyxia. This in turn indicates that the minimum cesarean section rate is optimal.

Objective: To analyze the nature and presentation of print media messages regarding cholesterol and heart disease in women. The hypothesis is that print media messages about cholesterol and heart disease may encourage and perpetuate the use of cholesterol-lowering drugs in women.

Methods: A hand-search of the "seven sisters" of American women's magazines and of two Canadian women's magazines. All print material related to cholesterol and heart disease in women was photocopied and the content analyzed qualitatively. The print media content was divided into two categories: magazine articles and drug industry–sponsored advertisements. Themes were identified and were analyzed for the messages they contained about heart disease, cholesterol, and the use of cholesterol-lowering drugs in women.

Results: From the magazine articles, three main messages were identified. First, heart disease is the number one killer of women. Second, women must demand recognition of their high risk of heart disease and demand equal access to prevention and treatment services for heart disease. Third, lifestyles changes are not enough. Cholesterol-lowering drugs should be considered. Drug advertisements also emphasize that postmenopausal women are at high risk of heart disease and that lifestyle changes are inadequate or insufficient to lower this risk. In both cases, high blood cholesterol is considered not as a risk factor for heart disease but as the disease itself.

Conclusions: Magazine articles and drug advertisements act synergistically and may encourage and promote the use of cholesterol-lowering drugs in women. Postmenopausal women not on hormone therapy are particularly targeted.

We conducted a retrospective cohort study based on a case note review to determine whether there are differences in the treatment pathways followed for men and women admitted with acute myocardial ischemia and infarction after adjusting for differences in case mix. Women were as likely as men to receive thrombolysis, but were less likely subsequently to undergo exercise testing (adjusted odds ratio, 0.58; 95% CI, 0.40–0.84) or angiography (adjusted odds ratio, 0.62; 95% CI, 0.39–0.99). Coronary anatomy was the strongest predictor of revascularization regardless of sex. Women with diagnosed cardiac pain are less likely than men to be placed on the investigative pathways that lead to revascularization. Those women who are investigated are as likely as men to undergo revascularization. These findings are independent of the effects of age, angina grade, comorbidity, or cardiac risk factors. Clinicians' and patients' beliefs and preferences about treatment require investigation.

Recombinant human erythropoietin (Epo) use represents a substantial pharmaceutical expense for UHC hospital members. In 1997 it ranked second to filgrastim (G-CSF), with UHC member annual purchases totaling more than $23 million.

This paper examines the rationality of the concepts underlying evidence—based medicineand health technology assessment (HTA), which are part of a new current aimed at promoting the use of the results of scientific studies for decision making in health care. It describes the different approaches and purposes of this worldwide movement, in relation to clinical decision making, through a summarized set of specific HTA case studies from Catalonia, Spain. The examples illustrate how the systematic process of HTA can help in several types of uncertainties related to clinical decision making.

This qualitative review describes the current molecular basis of breast and prostate cancer, assesses the clinical relevance of genetic susceptibility, addresses nondirective counseling, and explores the ethical, psychosocial, and policy implications associated with genetic testing.

This article dicusses the individual's choice to engage in informal care as an issue for economic evaluation. Traditional methods used in economic evaluation studies for valuing time spent on informal care are discussed and an alternative method is put forward that incorporates the quality of life of caregivers as an outcome measure to represent the effects on caregivers. The methodological issues concerning the valuation of informal caregivers' time are becoming more important as new drugs and other health care technologies are introduced for patients with diseases that are typically associated with informal care.

Objectives: Decision-makers and the general public are often reluctant to adopt policy recommendations based exclusively upon cost–utility analyses. One possible reason explored here is that patients' previous health state before experiencing the onset of an acute life-threatening illness may influence the value of saving those patients' lives.

Methods: We surveyed members of the general public to see the relative importance of saving patients' lives when some patients could be returned to perfect health and others would live the remainder of their years with paraplegia. Among this latter group, some were described as having pre-existing paraplegia. Others were described as having the onset of paraplegia. The relative importance of saving each of these lives was measured using the person trade-off method.

Results: Six hundred five subjects completed questionnaires, and 250 met pre-established consistency criteria and were included in the final analysis. Overall, subjects placed equal importance on saving the lives of people with pre-existing paraplegia versus those who could be returned to perfect health because they did not have pre-existing paraplegia. In contrast, respondents gave lower priority to patients who would experience the onset of paraplegia after having their lives saved, especially if their paraplegia was avoidable with an alternative treatment.

Conclusion: People do not think that all quality-adjusted life-years are created equal. Instead, the value that people place on treatment programs depends on patients' state of health before developing life-threatening illnesses, and on whether alternative treatments are available that provide better health outcomes for the patients. These results may explain, in part, public discomfort over basing health care priorities on cost–utility analysis.

In this paper, we discuss the complex relationship between health technology assessment (HTA) and the regulation of medical devices and procedures. The relationship is first examined through a conceptual framework describing the itinerary from research to three levels of policy making: micro (standards of medical practice), meso (institutional rules), and macro (health policies). Four reports from the Quebec Health Technology Assessment Council (CÉTS) are used to illustrate how HTA activities can influence the regulatory mechanisms operating at each decision-making level. We then discuss the skillful balancing act required from HTA agencies to constantly negotiate the right distance from the regulatory process at which to operate. We propose that HTA agencies should not be incorporated into any regulatory, auditing, or monitoring process. Finally, the relationship between health technology assessment and health care reform is discussed. It is suggested that HTA activities will contribute most during the data-driven preparation and consolidation phases of a reform process. The fast pace of events and the political turmoil characteristic of the implementation phase provide a less receptive environment for HTA contributions.

Objective: To determine which of three approaches to care produces the lowest incidence of pressure ulcers, promotes the most effective care of sores that develop, and leads to the fewest hospitalizations in newly injured patients with spinal cord injury after discharge.

Methods: Spinal cord injury patients (n = 12) were recruited for a telehealth intervention after initial injury, and matched cases were recruited for telephone counseling and standard care groups. Patients were monitored for 6–8 months after discharge.

Results: The video group had the greatest number of reported and identified pressure ulcers. Differences in health care utilization between the video and telephone telehealth groups were small. The standard care group reported the lowest number of pressure ulcers and lowest frequency of health care utilization. Substantial differences existed in employment rates before and after injury. The video group had the lowest pre-injury rate of employment and the highest post-injury rate of employment.

Conclusions: Tracking pressure ulcer incidence, particularly stage I sores, is difficult. Self-report is likely to lead to substantial underreporting. Similarly, self-report on health care utilization over extended periods may lead to undercounting of encounters. Telehealth interventions appear to improve ulcer tracking and management of all ulcer occurrences. Video interventions may affect outcomes, such as employment rates, which are not conventionally measured.

Using the example of substitution of peripheral blood stem cell (PBSC) collection to bone marrow harvest for autologous transplantation in cancer patients, our study attempts to illustrate how economic assessment, starting at an early stage of medical innovation, can influence the development and diffusion process of a new technological procedure whose optimal design has not yet been established. Two cost minimization studies comparing costs for obtaining a clinically reinfusable graft using bone marrow harvest or alternatively various protocols of PBSC collection contributed to a change in the French clinical standard for this procedure.

Objective: To assess the impact of guidelines on drug use issued by a consensus conference on polycythemia vera held in Paris in June 1993. 32Phosphorus (32P) was recommended for patients over 70 and/or at risk, whereas pipobroman and hydroxyurea were recommended for patients under 70.

Methods: A questionnaire was sent to all 119 departments of nuclear medicine in France 1 year after the conference to find out whether and how often they measured plasma volume and red cell mass (the recommended diagnostic tests for polycythemia vera). Time-series analyses were performed on sales of 32P, pipobroman (both virtually exclusively prescribed for polycythemia), and hydroxyurea over a 4-year span (January 1992–December 1995).

Results: The average number of plasma volume determinations per year did not change significantly after the conference (22 ± 26 before vs 21 ± 25 after). 32P and pipobroman sales were stable until July 1993, when 32P sales decreased while pipobroman sales rose steadily. Hydroxyurea sales increased over the whole period with no change in trend after the guidelines were published.

Conclusions: The guidelines apparently influenced clinical practice since sales of drugs that are specifically used to treat polycythemia vera showed clear changes in trend after publication of the guidelines. This type of study seems to be an effective way of assessing the impact of consensus conferences.

Ultrasound examination in conjunction with pregnancy was introduced nearly 25 years ago. At the outset, this technology was used mainly in cases of suspected morbidity or fetal malformation. As ultrasound technology has advanced, the indications for this type of examination have also expanded, and all pregnant women in Sweden are now offered an ultrasound examination at least once during their pregnancy. In Sweden an average of slightly more than two ultrasound examinations are performed per pregnant woman, including examinations performed for medical indications. More than 95% of women who deliver have undergone routine ultrasound examination.

The differential staining cytotoxicity (DiSC) assay involves in vitro drug panel testing against patient tumor cells to identify optimal therapy. This observational study investigated whether DiSC assay guided treatment could improve outcome in patients with chronic lymphocytic leukemia. A cohort of 178 patients were categorized either as sensitive to drugs in vitro and receiving a sensitive drug in vivo, sensitive in vitro but not treated with a sensitive drug, or having disease resistant to all drugs tested in vitro. Response and survival for these patient categories were compared using multivariate regression techniques. Patients receiving a sensitive drug, compared with those who though having sensitivity did not, had a higher remission rate (odds ratio, 6.5; 95% CI, 2.91–14.53) and reduced death rate (hazard ratio, 0.29; 95% CI, 0.16–0.53). Having adjusted for all known confounding factors, the results suggest that in vitro drug sensitivity is an important independent prognostic variable to include in future trials, and that the DiSC assay may be a cost-effective use of health resources: the estimated incremental cost-effectiveness was £1,470 per life-year gained. A randomized controlled trial is required to confirm the benefit and estimate reliably the potential impact of assay-guided choice of therapy.

Objective: To compare different methods to estimate the confidence interval of the incremental cost-effectiveness ratio (ICER).

Methods: The adequacy of Fieller intervals and three methods for calculating bootstrap intervals are compared based on a simulation of 10,000 trials, using data from one trial.

Results: Both Fieller and bootstrap methods lead to unsatisfactory results when the difference in effectiveness is approximately zero. Where this difference is significant, the four methods for calculating confidence intervals for ICER do not give very different results, but Fieller's interval performs best.

Conclusions: Since Fieller's confidence limits are relatively easy to compute compared with bootstrap simulations, we recommend using this method.

Objective: To describe the diffusion of cardiac catheterization technologies and time trends of their use according to setting and geographic region in Germany during a 13-year period. It is hypothesized that the cardiac catheterization technology has matured from an experimental state to a broadly accepted technology.

Methods: Data come from the annual survey of the German Society for Cardiovascular Research. All German cardiac catheterization units are requested to provide data on volume and type of catheterization procedures. Data are available from 1984 to 1996. Number and type of procedure, type of unit, diagnoses, and complications are all recorded. The overall response rate is 90%, on average.

Results: The total number of catheterization units was 324 in 1996, or an average of 3.69 units per 1 million population. In 1996, all of the East German Länder and districts were below average. Utilization of cardiac catheterization procedures increased exponentially during the study period. The number of angiographies rose from about 45,000 in 1984 to more than 450,000 in 1996; the number of angioplasties increased almost by a factor of 50 to 125,000 procedures in 1996. Inverse correlations between the rates per million population of either coronary angiographies or PTCAs and mortality rates from ischemic heart disease were observed at the level of the German Länder.

Conclusion: Further studies taking patient characteristics, long-term outcomes, and other factors in account are necessary to clarify the large geographic variations and the negative relationship between utilization rates and coronary heart disease mortality found in this study.

Recently, the advent and extension of vancomycin-resistant enterococci (VRE) has raised the awareness of the professional community, given that this antimicrobial is used as first-choice therapy for multiresistant gram-positive bacteria. The objectives are: