Background: Repetitive transcranial magnetic stimulation (rTMS) is a new treatment with promise for resistant depression.

Objective: We tested the economic feasibility of this new method compared with electroconvulsive therapy (ECT).

Method: An economic decision analysis was used to compare the costs of three different treatment strategies for nonpsychotic severe depression. The strategies were: ECT alone; rTMS alone; and rTMS followed by ECT for nonresponders (rTMS-to-ECT). We calculated 12-month costs and quality adjusted life years (QALYs) for the three treatment options for all nonpsychotic, severely depressed United States patients who would have otherwise undergone ECT. A sensitivity analysis was performed to test the degree of change in outcome with various parameter changes.

Objective: We sought to determine the prevalence of attention-deficit/hyperactivity disorder in a population of children who underwent neonatal heart surgery involving repair of the aortic arch for Norwood Stage I, interrupted aortic arch, and combined repair of aortic coarctation with ventricular septal defect. Methods: Children between the ages of 5 and 16 were surveyed using the ADHD-IV and the Child Heath Questionnaire-50. Classification as attention-deficit/hyperactivity disorder was defined for this study as either a parent-reported diagnosis of attention-deficit/hyperactivity disorder or ADHD-IV inattention score of ⩾93 percentile. Results: Of the 134 surveys, 57 (43%) were returned completed. A total of 25 (44%) children either had a diagnosis of attention-deficit/hyperactivity disorder and/or ADHD-IV inattention score ⩾93 percentile. Eleven of the 13 (85%) children with interrupted aortic arch, 3 of the 7 (42.9%) children with combined coarctation/ventricular septal defect repair, and 9 of the 33 (27.3%) children with hypoplastic left-heart syndrome were classified as having attention-deficit/hyperactivity disorder. Only 7 of the 25 (28%) children received medical treatment for this condition. Quality of life indicators in the Child Heath Questionnaire-50 Questionnaire were highly correlated with the ADHD-IV scores. Conclusion: The risks for the development of attention-deficit/hyperactivity disorder are multifactorial but are significantly increased in this post-surgical population. This study revealed a low treatment rate for attention-deficit/hyperactivity disorder, and a significant impact on the quality of life in these children.

Methods of meta-analysis, computer modeling, and issue analysis are used to answer four key questions related to efficacy, cost, and political feasibility of legislating insurance coverage for mammography. The findings are presented, and the strengths and weaknesses of the combined use of these methods to inform policy debate at the regional level are discussed.

Objectives: To identify and examine the methodologic issuesrelated to evaluating the effectiveness of treatment adherence toclinical guidelines. The example of antiretroviral therapy guidelinesfor human immunodeficiency virus (HIV) disease is used to illustratethe points.

Methods: Regression analysis was applied to observational HIV clinic datafor patients with CD4+ cell counts less than 500 per μL and greaterthan 50 per μL at baseline (n = 704),using Cox proportional hazardstime-varying covariates models controlling for baseline risk. Theresults are compared with simpler models (Cox model [withouttime-varying covariates] and logistic regression). In addition, theeffect of including a measure of exposure to antiretroviralguidelines in the model is explored.

Results: This study has three implications for modelingclinical guideline effectiveness. To capture events that are time-sensitive, a duration model should be used, and covariates that aretime-varying should be modeled as time-varying. Thirdly,incorporating a threshold measure of exposure to reflect the minimumperiod of time for guideline adherence required for a measurableeffect on patient outcome should be considered.

Conclusions: The methods proposed in this paper are importantto consider if guidelines are to evolve from being a tool forsummarizing and transferring the results of research from theliterature to clinicians into a practical tool that influencesclinical practice patterns. However, the methodology tested in thisstudy needs to be validated using additional data on similar patientsand using data on patients with other diseases.