Objectives: Setting funding priorities among research projects for complementary and alternative therapies is especially vulnerable to arbitrary, partisan criteria and opportunistic readings of controversial evidence. This study develops a procedural approach to characterizing, in a transparent and even-handed way, the available evidence on these treatments and demonstrates a simple analytical scheme for prioritizing competing, but typically incommensurable, research projects for public support.

Methods: A simple five-step scheme for categorizing therapies is developed and justified, based on a taxonomy of the study designs used to generate research evidence. Once identified, candidate therapies are assigned to ordered categories along these design criteria and effectively grouped into equivalence classes by type of evidence. Finally, a partial ordering on the therapies is formed within each class by means of secondary screening criteria.

Results: Twenty-five candidate therapies are assigned to equivalence classes. The intent, in effect, is to restrict comparisons to those therapies that fall within a particular class of similar study designs. Within-class orderings avoid the problem of having better-known or better-supported therapies crowd out lesser known ones when it comes to allocating dollars for more research. A set of criteria and procedure for prioritizing spending for further research is demonstrated.

Conclusions: Relying on an open, formal procedure for comparing unconventional therapies offers protection against prejudgment in setting funding priorities, especially when weak clinical evidence relates more to a low investment in research than lack of efficacy.Special thanks are due to Mary Ann Richardson, DrPH, formerly of the UT School of Public Health, currently with the National Center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, Maryland. Dr. Richardson introduced me to this problem and graciously provided information on several unconventional therapies. Partial funding was provided by UT's Center for Alternative Medicine through a contract with the Office of Alternative Medicine, U.S. National Institutes of Health.

Objectives: To assess the cost-effectiveness of alternative initial strategies in the management of uninvestigated dyspepsia in adult patients presenting to a primary care physician in Canada.

Methods: Clinical decision-making was modeled based on outcomes data from the literature and expert opinion. Costs were obtained from official reimbursement lists, and a detailed microcosting analysis of a gastroscopy. Costs were analysed over a one-year period after initial presentation, including consideration of a single relapse of symptoms. The main outcome was a symptomatic cure. The seven management strategies based on different initial tests were endoscopy, double-contrast barium meal, empirical eradication therapy, empirical antisecretory treatment, urea breath test (UBT), laboratory serology, and sequential testing (laboratory serology followed, if Helicobacter pylori positive, by UBT).

Results: In patients under age 45, endoscopy, double-contrast barium meal, and sequential testing were not cost-effective approaches. UBT was the most effective and most costly strategy costing $8,238 per additional patient cure compared with laboratory serology. In patients over age 45, UBT was again the most effective and most costly strategy, but endoscopy was the most reliable in detecting gastric cancers. Clinical variables that impacted these findings were the probability of symptomatic relapse in patients with nonulcer dyspepsia (NUD) after successful versus failed H. pylori eradication, the probability of finding a duodenal ulcer (DU) in a young dyspeptic patient, the specificity of UBT, and the prevalence of H. pylori in patients with DU.

Conclusions: A “test-and-treat” approach was favored, with UBT being the most effective but most costly initial test in adult dyspeptics under age 45. The choice of the most cost-effective approach is dependent on the benefits of H. pylori eradication in patients with NUD. In patients over age 45, UBT is the most effective and most costly, but endoscopy results in the early detection of most gastric cancers.The authors are indebted to the other members of the UBTAN Group, including Drs. Phil Sherman, Alan Thomson, and Sander Veldhuyzen van Zanten. The authors also thank Paul Sinclair, Eileen Grace, and Lawrence Joseph for their much valued comments and opinions.AB and CAF are research scholars of the Fonds de la Recherche en Santé du Québec. This work was supported in part by an “at arms length” grant from AstraZeneca Canada.

Objectives: To examine quantitatively the effects of an increase in patient copayments from 10% to 20% on the demand for medical services in Japan.

Methods: The subjects of the study were the employees insured by the 1,797 health insurance societies, belonging to the National Federation of Health Insurance Societies, in 1996 and 1998. Indicators of medical service demands analyzed include the inpatient, outpatient, and dental case rates, the number of serviced days per case, the medical cost per day and the medical cost per insured.

Results: When the effects of an increase in patient copayments from 10% to 20% were evaluated, taking into account the average age, the average monthly salary, the total number, the gender (male-to-female) ratio and the dependent ratio of the insured, the estimated change in the case rate was −6.96% for inpatient, −4.79% for outpatient, and −5.77% for dental care. The estimated change in the number of serviced day per case was −4.66% for inpatient, −5.67% for outpatient, and −1.82% for dental care. The estimated change in the medical cost per day was −3.15% for inpatient, −13.00% for outpatient, and −11.48% for dental care. The estimated change in the medical cost per insured was −14.08% for inpatient, −21.54% for outpatient, and −18.11% for dental care.

Conclusions: The increase in patient copayments from 10% to 20% enabled insurers to substantially reduce medical costs by cost shifting from the insurer to the insured, with resultant changes in the case rate and the number of service days per case.We thank Ms. Danita Joell for administrative assistance. This study was founded by a grant-in-aid for scientific research (c) from the Japan Ministry of Education, Science, and Culture (grant number 11670373).

Objectives: This study reports the cost-effectiveness of interventions with nonsignificant differences in effect, and considers reporting of cost-effectiveness in situations where nonsignificant differences arise in some but not all end points.

Methods: Data on costs and effects associated with three end points (adequate assessment, risk factors, and life-years) were derived from a trial of methods to promote secondary prevention of coronary heart disease. Incremental cost per life-year gained figures were calculated, and the uncertainty around these was displayed on cost-effectiveness planes in the form of ellipses.

Results: There was a significant difference in one of the intermediate end points (adequate assessment) but nonsignificant differences in the other intermediate end point (risk factors) and the final end point (life-years). Estimation of cost per life-year figures revealed the cost-effectiveness of the interventions to be unfavorable.

Conclusions: Cost-effectiveness ratios based on final end points should be calculated even in situations where nonsignificant differences in life-years arise, to avoid publication bias and to provide decision makers with useful information. Uncertainty in the incremental cost-effectiveness ratios should be estimated and presented graphically.We thank Rebecca Turner for comments on an earlier draft; Professor Paul Fenn for permission to adapt an existing model; and Dr. Andy Briggs for advice on interpretation and presentation of results and comments on an earlier draft. In addition to the authors of the paper, the ASSIST trial collaborative group includes G. Fowler, E. Fullard, A. Fuller, M. Murphy, A. Neil, T. Schofield, R. Turner, S. Thompson, F. Wells, R. Wiles, and L. Youngman. This research was funded by a grant from the national research and development program grant of the NHS Executive.

Objectives: To introduce a health-related quality of life measure for home care and institutional long-term care settings based on the Minimum Data Set (MDS) and the Health Utilities Index Mark 2 (HUI2).

Methods: Health attributes of Health Related Quality of Life (HRQOL) were identified, and suitable constructs were determined. Items from the MDS were mapped to the HUI2. Scores for the Minimum Data Set Health Status Index (MDS-HSI) were calculated using the HUI2 scoring function. Measurement properties are examined and reported. HRQOL scores were compared across study populations and to an external reference population. Random samples were drawn from long-term care clients in private households (n=377), supportive housing apartments (n=80), two residential care facilities (n=166), and a chronic care hospital (n=274) in Ontario, Canada. All sampled residents were assessed for health-related items using the MDS.

Results: The MDS-HSI results provide preliminary evidence of good validity. Institutional populations had lower overall HRQOL scores than community populations. Comparisons to existing Canadian national data support construct validity.

Conclusions: The MDS-HSI provides a summary outcome measure and an indicator of health status in the six supporting attributes. Longitudinal research is required to assess the sensitivity of the measure to changes over time. Further research is also required to establish the consistency between the preference weights used in this application of the HUI2 and those that would be derived from a frail elderly population.This research was supported by the Seniors Independence Program (grant 4687-06-93-458) and the Providence Centre Foundation. Thanks to Copernicus Lodge, Providence Centre, and the Red Cross Homemaker Program for participating in this study. Also thanks to Roger Roberge and Dan Dekoker from Statistics Canada for their help in obtaining and analyzing the NPHS data. International copyright for the MDS-NH and MDS-HC is held by interRAI. International copyright for HUI2 and HUI3 materials are held by Health Utilities, Inc.

This study deals with the question of how to model health effects after the cessation of a randomized controlled trial (RCT). By using clinical trial data on severe congestive heart failure patients, we illustrate how survival beyond the cessation of an RCT can be predicted based on parametric survival models. In the analysis, we compare predicted survival and the resulting incremental cost-effectiveness ratio (ICER) of different survival models with actual survival/ICER. Our main finding is that the results are sensitive to the choice of survival model and that an extensive sensitivity analysis in the CE analysis is required.We thank John Kjekshus for providing us with data from the consensus and a ten-year follow-up study. Comments from Magnus Johannesson on a previous version of the article are also highly appreciated.

Objectives: To determine the need for and implement health technology assessment (HTA) to inform decision making and policy within a regional health care system in Calgary (Alberta, Canada).

Methods: Published literature and organizational materials for the Calgary Health Region (CHR) and HTA units worldwide were reviewed. Key individuals within the provincial health ministry (Alberta Health and Wellness), CHR, the University of Calgary (U of C), funding agencies, and HTA organizations were consulted in a structured fashion. A structure for a regional HTA program was developed, taking into account relationships between these organizations.

Results: A locally focused HTA and implementation unit was deemed desirable. The Calgary Health Technology Implementation Unit (CaHTIU) was established. The CaHTIU was designed to efficiently integrate with CHR planning as well as undertake independent research activities. HTA activities focus primarily on CHR needs and are managed by a Health Technology Advisory Committee (HTAC) that consists of CHR management and other key individuals. Working groups contribute to and coordinate HTAs and implementation under the leadership of the unit Director, and include content as well as management individuals. The unit cooperates where appropriate with extant Canadian HTA organizations.

Conclusions: The Calgary HTA unit is unique in Canada, because it functions within a regional health care system as well as a research institution. Advantages include a local focus in terms of applied HTAs, a systematic process for implementation of recommendations, and a collaborative atmosphere for research within the U of C.This work was supported by the Calgary Health Technology Implementation Unit. The authors thank Dr. Lloyd Sutherland of the University of Calgary and Dr. Dev Menon of the Institute of Health Economics for their important roles in the formation of the Calgary Health Technology Implementation Unit.

Objectives: To systematically assess the evidence for effectiveness of hyperbaric oxygen therapy in the treatment of conditions of significance in the West Midlands region and to determine whether there is a case for establishing a hyperbaric oxygen unit in the region.

Methods: Systematic review of the literature assessing randomized controlled trials from 1968 onward.

Results: A total of 154 full-text articles was obtained of which 13 relevant randomized control trials were identified. There was little consistency in the studies. Treatment protocols, study groups, time to treatment, and other characteristics and outcomes measured all varied considerably. No convincing evidence of effectiveness was identified.

Conclusions: Although hyperbaric oxygen therapy is clearly appropriate in the treatment of decompression sickness and air/gas embolism, there is no convincing evidence of effectiveness for the conditions reviewed, despite its widespread use. Although this review has found no evidence to support the establishment of a unit in the West Midlands, there is a physiological case for an effect in conditions involving hypoxia and, given the limited volume (and in some cases quality) of published research, a case for a national research program.I thank the staff of the West Midlands Development and Evaluation Service Systematic Reviews Course (Dr. Amanda Burls, Dr. Chris Hyde, and Ms. Jackie Young), who reviewed the report.

Objectives: To study the effects of health financing systems on patient care-seeking behavior in rural China.

Methods: A multistage sampling method was used to select county, township, and village health facilities. A total of 1,232 outpatients was interviewed during two weeks.

Results: Health-financing systems appeared to influence patient behavior. In the insured group, the proportion of patients being hospitalized was higher than that in the uninsured group. Among the different insurance schemes, the private insurance group had the highest proportion of self-medication, but the cooperative insurance group had the lowest; the government insurance group had the most delay days, but the cooperative insurance group had the fewest. A logistic regression analysis suggested that only “out-of-pocket” payment might decrease the access to hospitalization.

Conclusions: The empirical data suggest that health-financing systems appear to influence patient behavior for prescription and access to health care, especially some costly health care, that is, hospitalization. The data also suggest that China needs to increase the coverage of health insurance, especially in rural areas to improve the access to health care.This article resulted from a collaborative research project between IHCAR, Karolinska Institutet and School of Public Health, Fudan University (former Shanghai Medical University)-Health care financing in transitional society-financially supported by the Swedish International Development Cooperation Agency (Sida). Many thanks to Vinod Diwan, Lennart Bogg, and Göran Tomson at IHCAR and Clas Rehnberg at the Stockholm School of Economics for their assistance in the preparation of the article.

Objectives: To expand care for chronic haemodialysis (HD) patients throughout England and Wales by studying two aspects of service delivery that are important: to identify relative performance of haemodialysis satellite units (HDSUs), and understand the factors that influence the performance. As a first step toward these aspects, this work reports a study of apparent comparative efficiency in the delivery of HDSUs and demonstrates the potential of data envelopment analysis (DEA).

Methods: DEA was applied to data obtained from a national survey of the organizational structures and processes of delivering care at HDSUs in England and Wales.

Results: DEA was found to be a judicious approach for performance assessment of HDSUs, although valid results depend on appropriate model specification and quality of data available. The available data were not of sufficient comprehensiveness or quality to produce definitive results but suggested that overall efficiency could improve; these data suggested by as much as 10% overall (mean efficiency score 90%) and variably within the sample (46 [65%] that HDSUs were potentially inefficient, the lowest unit scoring 38%).

Conclusions: Addressing questions raised by comparative inefficiency could help plans to improve capacity to deal with the growing demand for HD delivered in HDSUs. The application was an important start and needs to be followed by further research to establish model validity and obtain authoritative results.The authors thank HDSU staff who participated in the national satellite survey and colleagues contributing to the main project “An evaluation of the costs and effectiveness of and quality of care of renal replacement therapy provision in renal satellite units in England and Wales.” Particular thanks to Alison Armitage, Tricia Nicholson, and Joy Townsend. Funding was provided by the NHS Research and Development Health Technology Assessment Programme and South East NHS Executive Research and Development Directorate. The opinions and any errors made are the authors' responsibility alone.

The use of probabilistic analysis as a means for analyzing uncertainty within economic analysis has grown in popularity in recent years as it has been recognized as the most complete method for propagating uncertainty with respect to input parameters in terms of uncertainty about outcomes of interest. The World Health Organization (WHO) in a series of recent reports and publications have recognized the role of probabilistic analysis in what they term generalized cost-effectiveness analysis. However, there are fundamental problems with the analysis and the interpretation of such analysis as proposed by WHO. This study highlights three specific points for concern and offers constructive criticism by recommending more appropriate approaches.

Objectives: To identify and assess the effects of general practitioner and patient characteristics on global adherence to pharmacotherapeutic guidelines.

Methods: In a cross-sectional study in the northern Netherlands, a two-level multilevel model was applied to patients (n=269,067) in 190 practices with a total of 251 general practitioners. The dependent variable was the global adherence to pharmacotherapeutic guidelines as a measure of good prescribing in a general practice setting.

Results: The mean global adherence was 82%. Two general practice variables, organization form and degree of urbanization influenced the global adherence, whereas all patient variables (age and gender) and the patient-related prescription characteristics (costs, volume, different ATC-codes) were significant predictors for the global adherence. The total explained variance was 28%.

Conclusions: Patient characteristics have a greater influence on prescribing behavior than general practitioner characteristics.We thank the health care insurance organization (Regionaal Ziekenfonds Groningen [RZG]) for supplying the data set. We also thank Eddie Bruin from the health care insurance organization for his assistance with data collection and Tom Snijders for data analysis and statistical advice.

We are developing a decision support tool to help clinicians and policy makers estimate the impact of various coronary heart disease (CHD) treatments on disease outcomes for populations. We have created seven modules that correspond to states commonly encountered with CHD, that is, congestive heart failure, tachyarrhythmia, stable angina pectoris, acute coronary syndrome, bradycardia, postmyocardial infarction, and postcoronary artery bypass grafting, and a healthy individual module. Within each module, we created event-decision- intervention-outcome flow pathways to simulate risk of a clinical event and the expected outcome as the result of a particular intervention. We will combine disease state probability estimates based on the experience of the Olmsted County, Minnesota, population and estimates of intervention efficacy based on clinical trial data to estimate the impact of interventions on a population. We plan to make this tool available to the public through the internet.“This project was made possible through a Cooperative Agreement between the Center for Disease Control and Prevention (CDC) and the Association of Teachers of Preventive Medicine (ATPM), award # TS-0892; its contents are the responsibility of the authors and do not necessarily reflect the official views of the CDC or ATPM. Supported in part by an unrestricted research grant from McNeil Consumer Healthcare.”

The issue of evidence for decision-making, including formal policy-making and public health policy, has increased rapidly in prominence during the past few years. The term “evidence-based” was first used in health care in 1992, when Sackett and others coined the term “evidence-based medicine” (42). More recently, many have asked if public health activities are based on evidence (2;8;13;19;30).

Venous thrombosis (the formation, development, or existence of a blood clot in a vein) is common and carries a substantial risk for long-term suffering or death. Deep vein thromboses that break away from the vein, flow to the lungs, and block circulation (pulmonary emboli) cause over 1,000 deaths annually in Sweden and are the single most common cause of death during pregnancy and in surgical intervention where prophylaxis is not used. The risk for this disorder increases with age. At older ages it is more common in men; at younger ages it is more common in women. Annually, over 11,000 people are hospitalized for venous thrombosis or pulmonary embolism, and approximately 40,000 patients visit a physician in ambulatory care. In a longer perspective, many people are affected by leg swelling, varicose veins, and slowly healing leg ulcers (conditions not addressed in this report).

The first (known) national consensus conference on matters of health care ever held in an east European country was conducted in Latvia in September of 2002. This conference marks one of the steps in the government's efforts to establish a sustainable mechanism for health technology assessment (HTA). The conference was organized by the agency now given the responsibility to develop HTA in Latvia.