Objective: To explore whether more could be done to increase the implementation of health technology assessment (HTA) findings.

Methods: A literature review was undertaken to identify the main barriers to implementation, the mechanisms that influence the diffusion and use of health technologies, and evidence of the successful implementation of findings.

Results: Numerous barriers to the implementation of HTA findings exist at the public policy, health- care professional, and general public levels. Several mechanisms for influencing the use of health technologies exist, and there are some examples of findings being implemented through these mechanisms. However, there are also concerns about the aggressive implementation of findings. A balanced approach to the implementation of HTAs is required.

Conclusion: The main elements of a successful implementation strategy are: a) defining a clear policy question; b) defining a clear research question; c) making recommendations commensurate with the evidence; d) identifying the implementation mechanism; e) paying attention to incentives and disincentives; and f) clarifying the roles and responsibilities of the various parties. Further research is also required into several aspects of implementation.

Objectives: Use of complementary and alternative medicine (CAM) is growing in all Western countries. The goal of this study was to evaluate quality of randomized controlled trials (RCTs) of CAM interventions for specific diagnoses to inform clinical decision making.

Methods: MEDLINE and related databases were searched for CAM RCTs. Visual review was done of bibliographies, meta-analyses, and CAM journals. Inclusion criteria for review and scoring were blinded RCT, specified diagnosis and intervention, complete study published between January 1, 1966 and July 31, 1998 in an English-language, peer-reviewed journal. Two reviewers independently scored each study.

Results: More than 5,000 trials were found, but only 258 met all study inclusion criteria. The main cause for rejection (> 90%) was that the study was not an RCT or had no blinding. Mean score across 95 diagnosis/intervention categories was 44.7 (S.D. ± 14.3) on a 100-point scale. Ordinary least-squares regression found date of publication, biostatistician as author or consultant, published in one of five widely read English-language medical journals and diagnosis/intervention category of hypertension/relaxation as significant predictors of higher scores.

Conclusions: The overall quality of evidence for CAM RCTs is poor but improving slowly over time, about the same as that of biomedicine. Thus, most services are provided without good evidence of benefit.

Objectives: This article reports a cost-effectiveness analysis of targeted screening for abdominal aortic aneurysm (AAA). A major emphasis was on the estimation of distributions of costs and effectiveness.

Methods: We performed a Monte Carlo simulation using C programming language in a PC environment. Data on survival and costs, and a majority of screening probabilities, were from our own empirical studies. Natural history data were based on the literature.

Results: Each screened male gained 0.07 life-years at an incremental cost of FIM 3,300. The expected values differed from zero very significantly. For females, expected gains were 0.02 life-years at an incremental cost of FIM 1,100, which was not statistically significant. Cost-effectiveness ratios and their 95% confidence intervals were FIM 48,000 (27,000–121,000) and 54,000 (22,000–∞) for males and females, respectively. Sensitivity analysis revealed that the results for males were stable. Individual variation in life-year gains was high.

Conclusions: Males seemed to benefit from targeted AAA screening, and the results were stable. As far as the cost-effectiveness ratio is considered acceptable, screening for males seemed to be justified. However, our assumptions about growth and rupture behavior of AAAs might be improved with further clinical and epidemiological studies. As a point estimate, females benefited in a similar manner, but the results were not statistically significant. The evidence of this study did not justify screening of females.

Little is known about the value patients, physicians, and payers place on intangible attributes of care. Differences in valuations among these groups and misperceptions of value of intangible attributes to other groups can contribute to conflicts about treatment recommendations or coverage decisions. We surveyed patients, physicians, and managed care executives to assess their willingness to pay (WTP) for diagnostic certainty for peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). To determine if patients, physicians, and payers accurately perceive each other's valuations of diagnostic certainty, participants were also asked to estimate the WTP of each of the other types of respondents. Patients were most likely, and executives least likely, to value diagnostic certainty. For PUD, 84% of patients, 61% of physicians, and 43% of executives expressed a positive WTP. Median WTP was low for all three groups ($1–9 for patients and physicians; $0 for payers). Physicians and executives both correctly predicted patient WTP. For GERD, 87% of patients, 52% of physicians, and 29% of executives expressed a positive WTP. Executives underestimated patient WTP. For both diseases, physicians' WTP was overestimated by patients and underestimated by executives. The inconsistency in the value that patients, physicians, and managed care executives place on diagnostic certainty indicates the potential for conflict over practice guidelines or access to services. WTP surveys can provide information to aid in anticipating and addressing areas of disagreement.

Objectives: To estimate willingness to pay (WTP) for effective treatment in a sample of obese individuals and to examine whether WTP is associated with factors reflecting the severity of obesity as well as a number of other variables such as age, sex, education, and income.

Methods: WTP and data on the severity of obesity were collected from the study, Swedish Obese Subjects. Associations between WTP, income, and obesity-related factors were analyzed by linear regression.

Results: The mean age was 47 years (range, 37 through 59 years) and the mean body mass index (BMI) was 39.6 kg/m2 (n = 3,549). Average personal monthly income was SEK 13,000 (≈ US $1,585), average WTP was SEK 26,900 (≈ US $3,280) and the median value was SEK 10,900 (≈ US $1,330). A high WTP was associated with high personal and household income, high weight, high education, female sex, poor perceived health, low current age, and low age at onset of obesity. Over 50% of the patients deemed it necessary to borrow money to cover their WTP. When adding a loan to the regression analysis, the associations between WTP and perceived health, age, and gender disappeared.

Conclusion: Obese patients are willing to pay approximately twice their monthly salary for effective treatment and a higher WTP is associated with higher weight and poorer perceived health.

Objective: To compare two methods of measuring willingness to pay (WTP): closed-ended questions with and without follow-up.

Methods: A measurement experiment based on dichotomous choice contingent valuation survey data is reported. Marginal WTP estimates for alleviation of rheumatoid arthritis symptoms resulting from treatment with a novel anti-rheumatic agent, cA2 (TNF-α blockade), were calculated. Monte Carlo simulations were undertaken to evaluate the methods with respect to their statistical power.

Results: The estimated marginal WTP values using closed-ended questions with and without follow-up were DKK 637 (US $91) and DKK 1,268 (US $181), respectively. A Wilcoxon's signed-rank test showed that the difference of DKK 631 was significant. Moreover, including a follow-up question increases the precision of the result. Monte Carlo simulations showed that trade-offs between power (i.e., the probability of a correct rejection of a false null hypothesis), efficiency, and size may exist in the two models.

Conclusions: There was a significant difference between the WTP estimates when using closed-ended questions with and without follow-up. When choosing between the models, however, power, efficiency, and size could be used as selection criteria.

Objective: The objective was to develop an economic prioritization model to assist those involved in the selection and prioritization of health technology assessment topics and commissioning of HTA projects.

Methods: The model used decision analytic techniques to estimate the expected costs and benefits of the health care interventions that were the focus of the HTA question(s) considered by the NHS Health Technology Assessment Programme in England. Initial estimation of the value for money of HTA was conducted for several topics considered in 1997 and 1998.

Results: The results indicate that, using information routinely available in the literature and from the vignettes, it was not possible to estimate the absolute value of HTA with any certainty for this stage of the prioritization process. Overall, the results were uncertain for 65% of the HTA questions or topics analyzed. The relative costs of the interventions or technologies compared to existing costs of care and likely levels of utilization were critical factors in most of the analyses. The probability that the technology was effective with the HTA and the impact of the HTA on utilization rates were also key determinants of expected costs and benefits.

Conclusions: The main conclusion was that it is feasible to conduct ex ante assessments of the value for money of HTA for specific topics. However, substantial work is required to ensure that the methods used are valid, reliable, consistent, and an efficient use of valuable research time.

Objectives: To investigate doctors' and nurses' attitudes toward 14 potential prioritization criteria.

Methods: This study was performed by using the random paired scenario method. The respondents received a questionnaire with 12 pairs of scenarios, imaginary patient cases, each of which contained two to three different prioritization criteria (e.g., child, old patient, poor patient). Respondents were asked which one of each scenario pair they would choose if only one patient could be treated. The scenarios were randomly put into 30 different questionnaire sets. There was a random selection of 241 doctors and 151 nurses in Finland, with response rates of 60.3% and 50.3%, respectively.

Results: Doctors prioritized young patients, severe disease, expensive treatments and posteriorized (negatively prioritized) demented or institutionalized patients, and patients having a self-caused disease. Children were strongly prioritized, even over serious diseases. Expensive treatments appeared to be favored by doctors, and this result cannot be explained by severity of disease. Nurses' attitudes were similar to those of doctors.

Conclusions: Children were strongly prioritized. Elderly persons were posteriorized if they had dementia or were living in institutions. Patients having a self-caused disease are posteriorized, more often by nurses than by doctors.

Objectives: To test the feasibility of obtaining a baseline level of quality of reporting for cost-utility analysis (CUA) studies using the British Medical Journal economic submissions checklist, test interrater reliability of this tool, and discuss its longer term implications.

Methods: CUA studies in peer-reviewed English language journals in 1996, assessed using the British Medical Journal checklist, a quality index, and interrater reliability correlations.

Results: Forty-three CUA studies were assessed, with 23 checklist items acceptable and 10 items inadequate. Lowest quality scores were reported in specialist medical journals. Proportional agreement between assessors was over 80%.

Conclusions: The British Medical Journal checklist is a feasible tool to collect baseline information on the quality of reporting in journals other than the British Medical Journal. Editors of specialist medical journals are in greatest need of economic guidance. If handled carefully, they might consider adopting the British Medical Journal checklist.

Objectives: Although cost-utility analysis (CUA) has been recommended by some experts as the preferred technique for economic evaluation, there is controversy regarding what costs should be included and how they should be measured. The purpose of this study was to: a) identify the cost components that have been included in published CUAs; b) catalogue the sources of valuation used; c) examine the methods employed for estimating costs; and d) explore whether methods have changed over time.

Methods: We conducted a comprehensive search of the published literature and systematically collected data on the cost estimation of CUAs. We audited the cost estimates in 228 CUAs.

Results: In most studies (99%), analysts included some direct healthcare costs. However, the inclusion of direct non-healthcare and time costs (17%) was generally lacking, as was productivity costs (8%). Only 6% of studies considered future costs in added life-years. In general, we found little evidence of change in methods over time. The most frequently used source for valuation of healthcare services was published estimates (73%). Few studies obtained utilization data from RCTs (10%) or relied on other primary data (23%). About two-thirds of studies conducted sensitivity analyses on cost estimates.

Conclusions: We found wide variations in the estimation of costs in published CUAs. The study underscores the need for more uniformity and transparency in the field, and continued vigilance over cost estimates in CUAs on the part of analysts, reviewers, and journal editors.

Objectives: Calculations of healthcare costs rarely disclose the specific approach used to allocate the cost of hospitalizations by diagnosis. However, the type of approach used can have a major impact on the findings in the case of significant comorbidities. The present analyses compared three approaches for attributing Medicare DRG reimbursements (which were used as surrogates for average costs) for hospitalization by diagnosis.

Methods: Medical resource utilization data from the National Hospital Discharge Survey were analyzed using each of three allocation approaches: a) attributing 100% of the cost of hospitalization to the disease when it was the first-listed diagnosis; b) attributing a portion of the cost of hospitalization to the disease, depending on its position in the list of diagnoses and the relevance of any comorbidities; and c) an incremental analysis of cost based upon the hospitalization experiences of an age and gender matched cohort. These three approaches were applied to the cost of hospitalization for chronic obstructive pulmonary disease (COPD).

Results: The first approach projected 206,098 hospitalizations at $3,449 per hospitalization for a projected U.S. annual total of $711 million. The second approach projected 681,547 hospitalizations at $3,205 per hospitalization for a projected U.S. annual total of $2.2 billion. The third approach also projected 681,547 hospitalizations, but at $2,361 per hospitalization, for a projected U.S. annual total of $1.6 billion.

Conclusions: Expanding from the example on COPD, the limitations of each approach are described and their applications to other conditions are presented.

Objective: To adjust patients' time trade-off (TTO) scores using information on their utility functions for survival time to derive a measure of health state utility equivalent to the standard gamble (SG).

Methods: A sample of 199 cardiovascular patients were asked three TTO and SG questions (to assess their own health state), and three certainty equivalent questions (to assess their utility function for survival time) in an interview.

Results: Patients' utility functions for time were increasingly concave, but being unable to model this successfully, a constant function with an averaged level of concavity was used. The raw TTO scores were significantly higher than SG scores, while the adjusted TTO scores were equivalent to the SG.

Conclusions: Raw time trade-off scores will give biased estimates of health state utility when patients' utility functions for time are not linear, but these can be adjusted to yield true utilities. The constant proportional risk-posture assumption of the conventional QALY model, on which previous attempts to adjust time trade-offs have been based, was not supported by the data.

Objective: An economic evaluation of the resources used for mechanically ventilated patients using various measures for the benefits of extending life.

Methods: Regression analysis is applied to New York State discharge data for patients under DRG 475 during 1992–96 to predict age-specific survival rates and payments per life saved. Sensitivity analysis is used to compare benefits of extending life associated with different economic values of life with the payments per life saved at each age.

Results: Payments per life saved decreased over time, primarily due to reduced reimbursements. Payments exceeded the age-adjusted and the quality-of-life and age-adjusted benefits for all economic values of life at ages 90 and older.

Conclusions: Since the benefits of extending life associated with DRG 475 exceed the payments per life saved at most ages, economic evaluations may be best applied with psychosocial evaluations to allocate resources more ethically.

Objective: To evaluate the appropriateness of the use of hip joint replacements (HJRs) using explicit criteria developed by an expert panel.

Methods: Observational study. Nine hundred ninety-seven patients from five hospitals with a diagnosis of osteoarthritis, avascular necrosis, hip fracture, or revision who were undergoing HJR were consecutively included in the study during a 1-year period. The appropriateness of the indication was judged by explicit criteria. Complications were recorded at the time of the intervention and 3 months postoperatively.

Results: Of the 1,030 interventions, 604 were for osteoarthritis, 31 avascular necrosis, 191 fractures, and 204 revisions. No differences were found among the hospitals for the main clinical and patient variables. Indications for surgery were considered appropriate in 59% of cases, uncertain in 32%, and inappropriate in 8%, mainly in the osteoarthritis group. Differences were found in the rates of appropriateness among some centers. The complication rate did not differ among the groups based on the level of appropriateness of the procedure.

Conclusions: The appropriate use of HJR, as measured by the criteria established by the panel, identified a moderate percentage of inappropriate indications. Those equivocal and inappropriate cases demand further studies to identify patients with an adequate risk-to-benefit ratio from this procedure.

Objective: To examine the relative importance of factors influencing health insurers' coverage of new genetic technologies.

Methods: A national survey in which the decision makers for private health insurers were asked whether they would cover cystic fibrosis (CF) carrier screening, testing for genetic susceptibility to breast cancer (BRCA test), and medical costs of a clinical trial of gene therapy for CF under a variety of conditions.

Results: Respondents' coverage of the two tests and of medical costs of clinical trials was low at the time of the study (4%–15.5% of insurers.) Their coverage of CF carrier screening and BRCA testing would be increased significantly if the group tested was restricted to those at high risk, if detection rates were higher and costs lower, and if testing was endorsed by a national professional group or consensus conference. Coverage of the medical costs of a trial of CF gene therapy would be significantly more likely if the trial was restricted to children or adults with severe CF, safety and effectiveness was proven, and therapy could be administered in a regional hospital or an outpatient setting rather than in a research hospital.

Conclusions: Health insurers play a critical role in the diffusion of new genetic technologies. The validity of genetic tests and the safety and effectiveness of new therapies are primary factors influencing health insurers' coverage. Lower costs and approval of professional groups are other factors associated with increased coverage.

Objective: To assess the influence of physician specialty and the way in which patient data are presented in the treatment recommended for patients with coronary artery disease.

Methods: In a prospective study, 3,628 patients with significant coronary artery disease who had been referred to 1 of 10 heart centers in the Netherlands as possible candidates for either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) were recruited. Within each center, the recommended treatment is determined by a team consisting of cardiologists only, cardiovascular surgeons only, or cardiologists and cardiovascular surgeons (i.e., composite teams). The main outcome measures are the proportions of patients for whom PTCA, CABG, or noninvasive (medical) therapy was recommended.

Results: Composite teams made 71% of recommendations, surgeon-only teams, 12%, and cardiologist-only teams, 17%. Cardiologist-only teams primarily recommended patients to PTCA, surgeon-only teams to CABG, while combined teams made more evenly distributed recommendations (p < .001). Although the patients discussed by the three types of teams were clinically different, the recommendation patterns remained significant after adjusting for these differences (p < .001). For patients with recent myocardial infarction, direct presentation of the case to the team by the referring cardiologist reduced the likelihood that CABG would be recommended.

Conclusions: The treatment recommended to patients with coronary artery disease is affected by the composition of the team providing the recommendation. These findings have important implications for clinical decision making for patients with cardiovascular disease.

Objective: Extracorporeal shock wave therapy (ESWT) as an emerging technology in orthopedics has been assessed in Austria with the objective to establish a scientific basis for pending and pressing health policy decisions. Despite encouraging results within some indications and the promising prospect of a noninvasive treatment for some orthopedic diseases, it seemed crucial to assess this new field of application in the light of evidence-based standards, without forgetting the reality of healthcare decisions. This article presents the results of the abovementioned assessment in the context of the policy-making process in Germany, Austria, and Switzerland.

Methods: The study is based on an overview of the already existing reviews on the effectiveness of ESWT as carried out by different actors (health insurances and orthopedists), and on an overview of additional literature covering all relevant aspects (mode of action, recommendations, economic estimates). Orthopedic societies, several institutions involved in health technology assessment, and health insurance agencies were contacted in search of further relevant literature, ongoing studies, and assessments.

Results: Until now, clear evidence has not been available on the effectiveness of ESWT in four currently recommended indications (tendinosis calcarea of the shoulder, epicondylopathia humeri radialis, calcaneal spur, and pseudarthrosis), although a substantial body of literature has been produced. Despite encouraging results in some indications, the lack of coherent therapy schemes and the poor quality in the design of clinical studies has been serious enough to hinder the drawing of reasonable conclusions.

Conclusions: Due to the rapid diffusion of ESWT and the pressure on reimbursement agencies to prove the ineffectiveness of ESWT, the policy option of a pragmatic approach is recommended to controll the diffusion of an uncertain health technology, alongside active research that would allow a more comprehensive appraisal of this potentially interesting treatment strategy in orthopedics.

Objectives: To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention.

Methods: Randomized study with health center as unit. General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group. Main outcome measures were group differences in fractions of patients without registrations (process evaluation) and mean group differences for the same variables (patient outcome evaluation).

Results: Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking (intervention group, 82.6%; control group 94.5%), body mass index (78.2% vs. 93.0%), and sufficient registrations for calculation of risk score for myocardial infarction (91.1% vs. 98.3%); all during 18 months. Large center variations were shown for all variables. The only statistically significant group difference was −2.3 mm Hg (95% CI, −3.8, −0.8) in diastolic blood pressure in favor of the intervention group. Statistically insignificant differences in favor of the intervention group were HbA1c, −0.1% (95% CI, −0.4, 0.1), systolic blood pressure, −1.2 mm Hg (95% CI, −4.4, 2.0). Statistically insignificant differences in favor of the control group were fractions of smokers, +3.0% (95% CI, −4.0, 10.0), body mass index, +0.3 kg/m2 (95% CI, −0.8, 1.4), risk score in female +0.1 (95% CI, −5.1, 5.2), and risk score in male +2.6 (95% CI, −14.2, 19.5).

Conclusions: Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.

Background: Despite the growing medical and public interest in reducing exposure to allogeneic blood, little is known about the use of alternatives to allogeneic transfusion. This study was conducted to determine the availability of these technologies in Canadian hospitals and was undertaken under the auspices of the International Study of Peri-Operative Transfusion (ISPOT), a 10-country study of the effectiveness of, attitudes toward, and practices related to the use of alternatives to allogeneic transfusion.

Methods: A cross-sectional national mail survey of Canadian hospitals with greater than 50 medical/surgical beds. Chiefs of anesthesia, surgery, and the divisions of cardiac, orthopedic, vascular, and urology were initially mailed a brief postcard asking which of seven technologies were used in their center. This was then followed up with a one-page questionnaire asking how frequently the technologies were used, their thoughts on the appropriateness of the use of the technologies, barriers to their greater use, and reasons for nonuse of the technologies.

Results: Response rates to the postcard survey ranged from 70%–98%, depending on the technology and type of surgery, and ranged from 27%–53% for the follow-up questionnaire. All technologies were used most frequently in cardiac surgery. Aprotinin, tranexamic acid, aminocaproic acid, desmopressin, and cell salvage were reported used in over 70% of cardiac surgery centers. Of these, tranexamic acid and cell salvage were the only ones used routinely in some centers. Acute normovolemic hemodilution and erythropoietin were used in 45% and 20% of cardiac centers, respectively. The drugs were used in less than 15% of orthopedic, vascular, and urologic divisions, with the exception of desmopressin in urologic and vascular surgery and aminocaproic acid in urologic surgery. The techniques of cell salvage and acute normovolemic hemodilution were used in 30%–45% of these divisions, with the exception of cell salvage, which was used in less than 15% of urology units. In more than 60% of cases, the technologies were considered to be used “about right,” although an important minority felt that they were underused.

Conclusions: In general, alternatives to perioperative allogeneic transfusion were rarely used except in cardiac surgery.

Objectives: As health care budgets continue to face close scrutiny, any new acquisition must be evaluated for both costs and outcomes. This study was undertaken to demonstrate the application of an economic framework for the evaluation of a multileaf collimator as an example of a new technology that can have both quantifiable and nonquantifiable benefits for patients, staff, and cancer care institutions.

Methods: Using financial data from the Northeastern Ontario Regional Cancer Centre (NEORCC) and a recognized staffing model, a commercial spreadsheet, developed to economically characterize the principal radiotherapy processes has been used to determine the net incremental annual cost of a multileaf collimator (MLC).

Results: The incremental annual cost of purchasing an MLC is estimated at approximately $85,000 (1997 CDN $). Without increasing patient throughput, this increases the average cost of a course of radiotherapy by approximately CDN $200. Savings can be accrued by decreasing mold room activity, increasing the hourly patient capacity on each treatment machine, and decreasing sick time due to strain injuries.

Conclusions: Although the clinical outcome of techniques facilitated by MLCs, such as intensity-modulated radiation therapy, are unknown at this time, an economic context within which to objectively evaluate this technology is presented. The framework presented suggests a method of quantifying outcome-justified expenditures, such as improved patient outcome and greater treatment flexibility, which, when offset against the incremental annual equipment cost, may be used to help justify the acquisition of multileaf technology.