Objectives: Many existing healthcare interventions diffused before modern evidence-based standards of clinical- and cost-effectiveness. Disinvestment from ineffective or inappropriately applied practices is growing as a priority for international health policy, both for improved quality of care and sustainability of resource allocation. Australian policy stakeholders were canvassed to assess their perspectives on the challenges and the nature of disinvestment.

Methods: Senior health policy stakeholders from Australia were criterion and snow-ball sampled (to identify opinion leaders). Participants were primed with a potential disinvestment case study and took part in individual semistructured interviews that focused on mechanisms and challenges within health policy to support disinvestment. Interviews were taped and transcribed for thematic analysis. Participant comments were de-identified.

Results: Ten stakeholders were interviewed before saturation was reached. Three primary themes were identified. (i) The current focus on assessment of new and emerging health technologies/practices and lack of attention toward existing practices is due to resource limitations and methodological complexity. Participants considered a parallel model to that of Australia's current assessment process for new medical technologies is best-positioned to facilitate disinvestment. (ii) To advance the disinvestment agenda requires an explicit focus on the potential for cost-savings coupled with improved quality of care. (iii) Support (financial and collaborative) is needed for research advancement in the methodological underpinnings associated with health technology assessment and for disinvestment specifically.

Conclusions: In this exploratory study, stakeholders support the notion that systematic policy approaches to disinvestment will improve equity, efficiency, quality, and safety of health care, as well as sustainability of resource allocation.

Objectives: A vaccine to prevent diseases due to human papillomavirus (HPV) types 6, 11, 16, and 18 is now available in France. The objective of this study was to assess the health and economic impact in France of implementing a quadrivalent HPV vaccine alongside existing screening practices versus screening alone.

Methods: A Markov model of the natural history of HPV infection incorporating screening and vaccination, was adapted to the French context. A vaccine that would prevent 100 percent of HPV 6, 11, 16, and 18-associated diseases, with lifetime duration and 80 percent coverage, given to girls at age 14 in conjunction with current screening was compared with screening alone. Results were analyzed from both a direct healthcare cost perspective (DCP) and a third-party payer perspective (TPP). Indirect costs such as productivity loss were not taken into account in this analysis.

Results: The incremental cost per life-year gained from vaccination was €12,429 (TPP) and €20,455 (DCP). The incremental cost per quality-adjusted life-year (QALY) for the introduction of HPV vaccination alongside the French cervical cancer screening program was €8,408 (TPP) and €13,809 (DCP). Sensitivity analyses demonstrated that cost-effectiveness was stable, but was most sensitive to the discount rate used for costs and benefits.

Conclusions: Considering the commonly accepted threshold of €50,000 per QALY, these analyses support the fact that adding a quadrivalent HPV vaccine to the current screening program in France is a cost-effective strategy for reducing the burden of cervical cancer, precancerous lesions, and genital warts caused by HPV types 6, 11, 16, and 18.

Objectives: The aim of this study was to develop a methodology for calculating the need for positron emission tomography (PET) scanners in a country and illustrate this methodology for Belgium.

Methods: First, levels of evidence were assigned to PET in different indications according to a standard hierarchical classification system. The level reached depends on whether there is evidence on diagnostic accuracy, impact on diagnostic thinking, therapeutic impact, impact on patient outcomes, or cost-effectiveness. Second, the number of patients eligible for PET for each indication was derived from a registry of PET. Third, the number of PET scanners needed in Belgium was estimated for different baseline hypotheses about maximum annual capacity of a scanner and the minimally required level of evidence.

Results: The number of PET scanners needed crucially depends on the level of evidence considered acceptable for the implementation of PET: the higher the level of evidence required, the lower the number of PET scanners needed. Belgium needs at least three and at most ten PET scanners. This contrasts with the thirteen currently approved.

Conclusions: Scientific evidence and information on the eligible population for a specific procedure are crucial elements for policy makers who wish to make evidence-based decisions about programming and planning of heavy medical equipment.

Objectives: Although endoscopic ultrasound (EUS) staging of esophageal cancer is established in clinical practice, high-quality evidence about its impact on patient outcomes is not available. This study aims to determine the impact of EUS for esophageal cancer staging on patient management and survival.

Methods: A systematic review was conducted using Medline, PreMedline, Embase, and The Cochrane Library. Included studies were (i) comparative studies reporting survival following EUS esophageal cancer staging, (ii) therapeutic impact studies reporting change in patient management following EUS. The quality of included studies was critically appraised.

Results: One systematic review, five studies reporting therapeutic impact, and two studies reporting patient survival were identified. The design and quality of the therapeutic impact studies varied widely. Management changed in 24–29 percent of patients following EUS staging of esophageal cancer (two studies). No studies provided data on the avoidance of surgery for this indication. One retrospective cohort study with historical control found EUS staging of esophageal cancer improved patient survival; a second study with similar design limitations did not find a survival benefit for EUS staging in patients undergoing resection. These studies had a high potential for bias, limiting the value of these findings.

Conclusions: Two studies provided evidence of a change in patient management following EUS for staging esophageal cancer, a higher level of evidence for a clinical benefit than can be obtained from accuracy studies alone. This evidence contributed to a recommendation for public funding of EUS in staging esophageal cancer in Australia.

Objectives: In the United States, medical devices represent an eighty-billion dollar a year market. The U.S. Food and Drug Administration rejects a significant number of applications of devices that reach the investigational stage. The prospects of improving patient condition, as well as firms' profits, are thus substantial, but fraught with uncertainties at the time when investments and design decisions are made. This study presents a quantitative model focused on the risk aspects of early technology assessment, designed to support the decisions of medical device firms in the investment and development stages.

Methods: The model is based on the engineering risk analysis method involving systems analysis and probability. It assumes use of all evidence available (both direct and indirect) and integrates the information through a linear formula of aggregation of probability distributions. The model is illustrated by a schematic version of the case of the AtrialShaper, a device for the reduction of stroke risk that is currently in the preprototype stage.

Results: The results of the modeling provide a more complete description of the evidence base available to support early-stage decisions, thus allowing comparison of alternative designs and management alternatives.

Conclusions: The model presented here provides early-stage decision-support to industry, but also benefits regulators and payers in their later assessment of new devices and associated procedures.

Objectives: In a resource-constrained reality, physicians are facing polar demands—those of healthcare managements to adopt cost-conscious behaviors and those of ethical standards that obligate physicians to consider only their patients' best interests. In our study, we aimed to determine the attitudes, practices, and knowledge of healthcare costs among Israeli physicians.

Methods: A questionnaire was developed and mailed to a representative sample of physicians in Israel. The overall response rate was 51 percent. The study reviewed self-reported levels of cost consciousness in practice, attitudes, obstacles related to cost containment, and knowledge of the costs of medical resources.

Results: Forty-two percent of the physicians reported high levels of cost consciousness in their daily practice; 70 percent reported greater current cost consciousness in comparison to 5 years ago; 76 percent of the responses legitimized institutional demands for cost containment. Although 83 percent of the physicians that responded expressed the belief that economic thinking was inherently the role of management, only 39 percent thought it was part of the physician's role. It was found that predominant predictors of agreement to cost consciousness concepts were employment by a community health plan, a managerial position, participation in health economics seminars, and male gender.

Conclusions: Cost consciousness among physicians is related to a broad array of parameters. Interventions must emphasize the benefits of evidence-based medicine as an anchor for both cost containment and quality care, as well as providing assistance to physicians in accepting economic decision-making as part of their professional role.

Objectives: The purpose of this study is to compare the approaches used for valuing family caregiver and care recipient time devoted to providing and receiving care.

Methods: Valuation approaches were operationalized within a cohort of cystic fibrosis care recipients (n = 110). Base-case analyses, grounded in human capital theory, applied earnings estimates to caregiving time to impute the market value of time lost from labor. Unpaid labor and leisure time was valued with a replacement cost (homemaker's wage rate). Total time costs were computed and sensitivity analyses were conducted to describe the effects of alternative valuation methods on total costs.

Results: The mean time cost per care recipient–caregiver dyad over 28 days was $2,026CAD. The majority (76 percent) of time costs were due to losses from unpaid labor and leisure time. Varying the valuation of paid labor time did not result in significantly different total time costs (p = .0877). However, varying the method of valuing unpaid labor and leisure time did significantly affect total costs (p < .0001).

Conclusions: Care recipients and caregivers primarily lost time from unpaid labor and leisure in the treatment of cystic fibrosis. Moreover, when the above losses were aggregated, the method of valuation greatly influenced overall results. The findings clearly indicate that omitting caregiver and unpaid labor and leisure costs may result in an inaccurate assessment of ambulatory and home-based healthcare programs.

Objectives: The aim of this study was to explore the needs and requirements of decision makers in our regional healthcare system for health technology assessment (HTA) products to support portfolio development planning for a new HTA agency in Madrid, Spain.

Methods: A Delphi study was conducted during 2003. Questionnaires were developed based on a review of products and services offered by other agency members of the International Network of Agencies for Health Technology Assessment, and included preference and prioritization questions to evaluate twenty-two different products and services. The initial Delphi panel involved eighty-seven experts from twenty-one public hospitals, eleven primary healthcare centers, six private hospitals, and eight departments of the Regional Ministry of Health of the Community of Madrid.

Results: The global participation rate was 83.9 percent. Ten of the twenty-two possible products were rated of high interest by more than 80 percent of respondents. Important differences in preferences and priorities were detected across different settings. Public hospitals and primary healthcare centers shared a more “micro” perspective, preferring classic technology-centered HTA products, whereas private hospitals and Ministry representatives demanded more “macro” products and services such as organizational model and information system assessments.

Conclusions: The high participation rate supports the representativeness of the results for our regional context. The strategic development of an HTA portfolio based on decision makers’ needs and requirements as identified in this type of exercise should help achieve a better impact on policy development and decision making.

Objectives: The aim of this study was to assess whether publications of importance for improving the health system and its technologies are highly cited intrascientifically.

Methods: Bibliometric assessment of the 596 publications used as sources in the fifty SBU Alerts from 2001to 2004 from the Swedish Council on Technology Assessment in Health Care was carried out using the Thomson Scientific citation indexes. Normalized citation scores were calculated for all included studies. Additional factors such as the time and place of the research, subject categories, and journal source were analyzed.

Results: On average, the sources in SBU Alert have been cited eight times more than the world average consistently during the time period and across research areas. Articles used as its scientific basis are often published in a few, high impact, general medical journals. However, many of the articles are published in field-specific journals with low impact factors. Most articles used in SBU Alert are published by authors based in the United States or the United Kingdom. However, Swedish, Danish, and Dutch publications are overrepresented in its science base, whereas Japanese, Taiwanese, Indian, and Russian publications are underrepresented.

Conclusions: Publications used as sources in a Swedish system for identification and early assessment of new methods in health care are also highly cited within the scientific community. This finding increases the appropriateness of using bibliometric indicators in evaluations of clinical research and suggests that decision makers through SBU Alert are getting scientifically sound advice.

In light of growing demands for public accountability, the broadening scope of health technology assessment organizations (HTAOs) activities and their increasing role in decision-making underscore the importance for them to demonstrate their performance. Based on Parson's social action theory, we propose a conceptual model that includes four functions an organization needs to balance to perform well: (i) goal attainment, (ii) production, (iii) adaptation to the environment, and (iv) culture and values maintenance. From a review of the HTA literature, we identify specific dimensions pertaining to the four functions and show how they relate to performance. We compare our model with evaluations reported in the scientific and gray literature to confirm its capacity to accommodate various evaluation designs, contexts of evaluation, and organizational models and perspectives. Our findings reveal the dimensions of performance most often assessed and other important ones that, hitherto, remain unexplored. The model provides a flexible and theoretically grounded tool to assess the performance of HTAOs.

Objectives: The aim of this study was to evaluate the costs and effectiveness associated with no screening, Helicobacter pylori serology screening, and the 13C-urea breath test (UBT) for gastric cancer in the Chinese population.

Methods: A Markov model simulation was carried out in Singaporean Chinese at 40 years of age (n = 478,500) from the perspective of public healthcare providers. The main outcome measures were costs, number of gastric cancer cases prevented, life-years saved, quality-adjusted life-years (QALYs) gained from the screening age to death, and incremental cost-effectiveness ratios (ICERs), which were compared among the three strategies. The uncertainty surrounding ICERs was addressed by scenario analyses and probabilistic sensitivity analysis using Monte Carlo simulation.

Results: The ICER of serology screening versus no screening was $25,881 per QALY gained (95 percent confidence interval (95 percent CI), $5,700 to $120,000). The ICER of UBT versus no screening was $53,602 per QALY gained (95 percent CI, $16,000 to $230,000). ICER of UBT versus serology screening was $470,000 per QALY gained, for which almost all random samples of the ICERs distributed above $50,000 per QALY.

Conclusions: It cannot be confidently concluded that either H pylori screening was a cost-effective strategy compared with no screening in all Chinese at the age of 40 years. Nevertheless, serology screening has demonstrated much more potential to be a cost-effective strategy, especially in the population with higher gastric cancer prevalence.

Objectives: The aims of this study were to estimate preferences and willingness-to-pay (WTP) for genetic screening for CYP2D6 polymorphisms among a group of former and currently depressed patients.

Methods: A Web-based discrete choice questionnaire was sent to 89 respondents, age 18–65. Four attributes were included: (i) shifts in antidepressant medication before symptom relief, (ii) time with antidepressant medication without symptom relief, (iii) time with antidepressant medication without symptoms but with adverse side-effects, (iv) cost of genetic screening. We used a switching model with two scenarios, one representing patients’ own treatment history and the other a treatment scenario with genetic screening.

Results: In a main-effects model involving the four attributes all coefficients had the expected sign, indicating that as the number of shifts, price or time without symptom relief, and/or dosage-adjustments increased, the likelihood of choosing the screening test decreased. Price and number of shifts in medicine were significant. Marginal WTP for 5 percent probability of a reduction of one in antidepressant shifts was DKK2,599 (€350).

Conclusions: Patients value reductions in shifts in antidepressants and price when choosing between genetic screening and no screening. They do not focus on how the reductions are provided, nor do they value the genetic information the test provides irrespective of its effect on outcome. Given, that the test is able to provide a reduction of one shift in the number of antidepressant shifts with a probability of 5 percent, WTP for the test exceeds its cost.

Objectives: The aims of this study were, first, to define the main advantages and disadvantages of using bibliographic search protocols; second, to define a series of criteria that could aid in prioritizing the information resources to be consulted for each research project; and third, to rank these criteria.

Methods: First, a survey was e-mailed to the Spanish Health Technology Assessment Agencies (AUnETS) group, with the aim of evaluating the usefulness of using bibliographic search protocols. Second, a consensus group meeting with the information specialists of the AUnETS group was organized, where SWOT analysis technique (strengths, weaknesses, opportunities, and threats) was used, also to discuss the utility of using search protocols. Third, the same group designed a final prioritization criteria questionnaire intended for Health Technology Assessment International's Information Resources Group (HTAi IRG), based on a draft version written by the information specialist from the Basque Office for HTA. Finally, this questionnaire was e-mailed to the HTAi IRG experts, and their responses were analyzed.

Results: Some of the advantages defined were systematization of the searches and transparency and repeatability of the process. The perceived disadvantages were inflexibility to be adapted to some situations, inability to establish time frameworks and the difficulty of incorporating experts’ opinions into closed protocols. Five areas of prioritization criteria were defined: study topic; characteristics of the database and other information resources; database interface; characteristics of the organization; kind of research output for which the information is intended. A ranked list of prioritization criteria was established based on the responses of the HTAi IRG group.

Conclusions: The information specialists consulted agreed that search protocols are useful tools for guiding systematic searches. The twenty-one prioritization criteria defined will be used by the information specialists for determining, which databases to consult.

Objectives: The aim of this study was to estimate the potential cost-effectiveness and expected value of perfect information of a recently derived clinical prediction rule for patients presenting to emergency departments with chest discomfort.

Methods: A decision analytic model was constructed to compare the Early Disposition Prediction Rule (EDPR) with the current standard of care. Results were used to calculate the potential cost-effectiveness of the EDPR, as well as the Value of Information in conducting further research. Study subjects were adults presenting with chest discomfort to two urban emergency departments in Vancouver, British Columbia, Canada. The clinical prediction rule identifies patients who are eligible for early discharge within 3 hours of presentation to the emergency department. The outcome measure used was inappropriate emergency department discharge of patients with acute coronary syndrome (ACS).

Results: The incremental cost-effectiveness ratio of the EDPR in comparison to usual care was (negative) $2,999 per inappropriate ACS discharge prevented, indicating a potential cost-savings in introducing the intervention. The expected value of perfect information was $16.3 million in the first year of implementation, suggesting a high benefit from conducting further research to validate the decision rule.

Conclusions: The EDPR is likely to be cost-effective; however, given the high degree of uncertainty in the estimates of costs and patient outcomes, further research is required to inform the decision to implement the intervention. The potential health and monetary benefits of this clinical prediction rule outweigh the costs of doing further research.

Objectives: The goal of meeting the desire of older adults to remain independent in their home setting while controlling healthcare costs has led to the conceptualization of “smart homes.” A smart home is a residence equipped with technology that enhances safety of residents and monitors their health conditions. The study aim is to assess older adults’ perceptions of specific smart home technologies (i.e., a bed sensor, gait monitor, stove sensor, motion sensor, and video sensor).

Methods: The study setting is TigerPlace, a retirement community designed according to the Aging in Place model. Focus group sessions with fourteen residents were conducted to assess perceived advantages and concerns associated with specific applications, and preferences for recipients of sensor-generated information pertaining to residents’ activity levels, sleep patterns and potential emergencies. Sessions were audio-taped; tapes were transcribed, and a content analysis was performed.

Results: A total of fourteen older adults over the age of 65 participated in three focus group sessions Most applications were perceived as useful, and participants would agree to their installation in their own home. Preference for specific sensors related to sensors’ appearance and residents’ own level of frailty and perceived need. Specific concerns about privacy were raised.

Conclusions: The findings indicate an overall positive attitude toward sensor technologies for nonobtrusive monitoring. Researchers and practitioners are called upon to address ethical and technical challenges in this emerging domain.

Objectives: We examined the impact of household income on the use of medical services in Japan, where there is a “health care for all” policy, with important, centralized influence by the national government designed to ensure universal access.

Methods and Subjects: All healthcare societies operating in 2003 were included in the study, representing 14,776,193 insured adults and 15,496,752 insured dependents. The mean case rate (the average number of monthly bills per patient), the mean number of service days per person, and the mean medical cost per person served as indicators of medical service use. Multiple regression analysis was performed by the forced entry method using case rate, the number of service days, and medical cost as outcome variables, and average monthly salary, dependent ratio, average age, and premium rate as the explanatory variables.

Results: In the multiple regression analyses, average monthly salary showed a high positive correlation of outpatient and dental indicators, including case rate, the number of service days, and medical cost. If the average monthly salary were reduced 20 percent lower than the mean, the estimated changes (95 percent CI) in case rate for the insured were −7.49 (−8.14 ∼ −6.84) percent for outpatient visits and −8.16 (−8.77 ∼ −7.56) percent for dental services.

Conclusions: Average monthly salary intensifies the effects of copayments on the case rate, the number of service days, and medical cost in the “Employees Health Insurance” in Japan. Thus, a low salary appears to discourage patients from seeking medical and dental services.

In the first paragraph in the “Description of Studies” subsection and the sole paragraph of the “Procedure Time” subsection of the “RESULTS” section on page 257 of Volume 23 Number 2 of International Journal of Technology Assessment in Health Care, two tables are listed as “published on the Web site.” However, no link was provided.