While subcutaneous heparin is a standard prophylaxis for death from pulmonary embolism following general surgery, it has been suggested that adding the vasoconstricting drug dihydroergotamine would improve survival compared to heparin alone. Dihydroergotamine may be associated with rare but life-threatening side effects; thus, reduced mortality from pulmonary embolism could be offset by increased mortality from other causes. Because a clinical trial to examine this possibility would be impractical, we performed a cost-effectiveness analysis to evaluate the effects of prophylactic dihydroergotamine on mortality. Based on published data, despite its favorable effects on the prevention of deep vein thrombosis, the addition of dihydroergotamine did not appear to save lives when added to heparin as prophylaxis. Probabilistic sensitivity analysis demonstrated that even if published risk estimates are in error, substantial changes would still not support the conclusion that dihydroergotamine is lifesaving. In the absence of clear potential for improved survival, the increased costs associated with dihydroergotamine provide reason to question its routine prophylactic use in general surgery.

Diagnostic information within administrative data bases is generally in the form of lnternational Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. The purpose of this article is to introduce ICD-9-CM, to review its strengths and limitations, and to suggest ways that it can be used through administrative files for assessing the quality of hospital care.

The objective of this study was to test whether the relatively new, noninvasive technique of extracorporeal shock-wave lithotripsy (ESWL) for renal stones resulted in a measurably better outcome from the patients' point of view than percutaneous surgery. The claimed superiority of ESWL was not demonstrated with the data available.

Evince-I is a desktop expert system for the differential diagnosis of dementia, implemented on a personal computer. It is intended to assess the effectiveness of this new technology in modeling a psychiatrist who uses international guidelines for diagnosing dementia. EVINCE-I was tested in diagnosing 19 patients with varying stages of dementia and 10 patients showing other disorders except dementia. EVINCE-I and the human expert were in perfect agreement on the diagnosis of dementia and correlated highly on the diagnosis of dementia of the Alzheimer type and multiple infarct dementia. EVINCE-I thus offers important possibilities as a tool in investigating the data and procedures used by the human expert.

This article examines the potential impact of recently developed nonsurgical treatments for gallstones on patient care and resource utilization. Using epidemiological and efficacy data from the literature and current patient selection criteria, the authors evaluate UDCA, extracorporeal shock-wave lithotripsy, and direct instillation of methyltertbutyl ether in terms of short-term clinical results, health policy, and economic implications.

The National Institutes of Health (NIH) is periodically asked to conduct assessments of new medical technologies to assist in coverage decisions made at the Office of Health Technology Assessment (OHTA) for the Health Care Financing Administration coverage policy. Analysis of NIH assessments indicates that even though most NIH assessments rely only on expert opinion, OHTA agreed with NIH recommendaations in over 90%.

Despite their potential utility, clinicians are skeptical about claims data as a substrate for clinical research. Clinicians' concerns are centered on two issues—the quality of the data and the fairness of comparisons that are made. To increase the impact of claims data research on clinical practice, several strategies should be pursued.

Our present-day health sectors are increasingly characterized by both rapid technological change and growing visibility of its considerable consequences in terms of the quality and costs of health care. Improved health care decision-making in such an environment requires adequate and timely information on the benefits, risks, and costs of health care technology. Whereas traditionally, technology assessment focused predominantly on evaluating efficacy and (short-term) safety in a more or less “controlled” environment, an interesting shift in emphasis is now occurring. There is a growing recognition that improved information is also needed on the health and economic outcomes of technology as used in everyday clinical practice, i.e., on its effectiveness, cost-effectiveness, and long-term safety in normal “uncontrolled” daily medical life. Moreover, because the treatment of particular clinical conditions (such as stable angina, gallstones, or prostatism) increasingly involves choices among alternative diagnostic and therapeutic options, these assessments should ideally provide effectiveness and cost-effectiveness information for all the various technological alternatives involved.

During the past 5 years, hospitals in several countries have experienced a significant increase in the use of platelet concentrates. In the Netherlands, e.g., the number of donor units of platelet concentrates rose from 59,000 in 1981 to almost 97,000 in 1984 at a cost of 5 million guilders (US $2,800,000) annually. This increased utilization has been attributed to such factors as chemo- and radiotherapy, major surgery, severe trauma, and bone marrow transplantation.

However, there was concern that in a significant number of patients, platelet concentrates are administered for no good reason, that the effect of platelet transfusions is often not adequately controlled, that insufficient care is taken to prevent side effects (notably alloimmunization), and that the quality control applied to platelet suspension is not optimal.

The implications of effectiveness research are far-reaching. Thus, the specification of a broad research agenda and the soundness of the underlying research methodologies and data bases are critical. This article discusses the quality of administrative data and the infrastructure supporting an ongoing effectiveness research effort.

The discussion of the effectiveness of the use of large bases for technology and quality assessments in health care is important to policy makers because of their increasing concern about the value of the dollars spent on health care. The focus on value is particularly acute for those policy makers having responsibility for the Medicare program. Recognizing that knowledge regarding medical outcomes will be imperfact, nevertheless, they have put the wheels in motion to empand research in this area beyond clinical trials.

As prefigured in the Greek tragedy Antigone, one of the primary conflicts in contemporary health care is that between humane concern for the individual and concern for society at large and administrative rules. The computerization of the health care system and development of large data bases will create new forms of this conflict that will challenge the self-definition of health care and health care professionals.