Decision analysis in endocrinology and metabolism.

Decision analysis is a powerful tool for synthesizing and analyzing clinical decisions in the practice of endocrinology and metabolism. The technique involves defining strategies for comparison, choosing a time horizon, constructing a decision tree and model, selecting outcomes and assigning probabilities, taking into account the value of time, calculating the net clinical and cost outcomes, and performing sensitivity analysis. This technique and its utility for different populations and changing health care settings are illustrated for the decision of screening for mild thyroid failure with a thyroid-stimulating hormone assay at the periodic health examination.

Systemwide provider performance in a Medicaid program. Profiling the care of patients with chronic illnesses.

Objectives: This study illustrates how claims data can be applied to examine cost and clinical performance of providers in the Medicaid program.

Methods: The authors conducted a cross-sectional analysis of Medicaid beneficiaries in Maryland with diabetes mellitus, hypertension, and asthma treated on an ambulatory basis by hospital-based outpatient departments, physician office-based providers, and community health centers. The study year was July 1987 to June 1988.

Screening for mild thyroid failure at the periodic health examination: a decision and cost-effectiveness analysis.

Objective: To estimate the cost-effectiveness of periodic screening for mild thyroid failure by measurement of serum thyroid stimulating hormone (TSH) concentration.

Design: Cost-utility analysis using a state-transition computer decision model that accounted for case finding, medical consequences of mild thyroid failure, and costs of care during 40 years of simulated follow-up.

Setting: Periodic health examinations in offices of primary care physicians.

Quality assessment: is the focus on providers or on patients?

Most studies of ambulatory care quality are based on chart reviews of episodes of care in single settings, rather than on care received by a patient over time and across settings. The purpose of this study was to compare ambulatory care quality scores based on information from the usual source of care to scores based on information from all providers seen during a year. The quality of well child care for 55 two-year-olds and asthma care for 70 children and adults continuously enrolled in the Maryland Medicaid program throughout 1988 was assessed.

Measuring effectiveness and outcomes of interventions for renal disease.

Effectiveness research, often called patient outcome research, is an evolving research discipline that attempts to provide information about the appropriate use of medical practices. This field of research uses epidemiological methods (observational and randomized controlled trials), analyses of variation and outcomes in medical practices, formal literature reviews and meta-analyses, quality of life measurement, decision analysis, patient preference assessment, patient satisfaction assessment, and economic and cost-effectiveness analysis. Several recent studies have applied a variety of these methods to provide data that will assist health professionals in the field of nephrology to make more informed clinical decisions.

The review process used by US health care plans to evaluate new medical technology for coverage.

Objective: To examine the process and information used by medical directors (MDs) of private health plans to make medical coverage determinations for new medical technologies, and to assess the influence of plan characteristics on the process.

Design: Cross-sectional national survey.

Participants: Two hundred thirty-one MDs at private health plans representing 66% and 72% of the US population covered by HMOs and indemnity plans, respectively.

Ambulatory care practice variation within a Medicaid program.

Study Questions: What is the extent of variation in patterns of ambulatory care practice across one state's Medicaid program once case mix is controlled for? How much of this variation in resource consumption is explained by factors linked to the provider, patient, and geographic subarea?

Data Sources/study Setting: Practices of all providers delivering care to persons who were continuously enrolled in the Maryland Medicaid program during FY 1988 were studied. A computerized summary of all services received during this year for 134,725 persons was developed using claims data. We also obtained data from the state's beneficiary and provider files and the American Medical Association's masterfile.

Screening for dialysis access graft malfunction: comparison of physical examination with US.

Purpose: To test the reliability and performance of two physical diagnosis algorithms for use in physical examination of vascular access grafts.

Materials And Methods: Grafts were assessed in 39 patients by means of physical examination performed by four observers. Grafts were characterized as having a thrill, pulse, or indeterminate examination at three locations (arterial, midpoint, venous).

Awareness of providers' use of new medical technology among private health care plans in the United States.

In a national survey of medical directors at 231 U.S. private health care plans that cover over two thirds of the privately insured population, we studied whether medical directors are aware when a new technology, such as laser therapy, is being used in procedures for which claims are submitted, the factors alerting them to such use, and the factors prompting them to make a specific coverage decision for the technology.

The role of perspective in defining economic measures for the evaluation of medical technology.

Perspectives in an economic analysis of medical technology reflect who makes decisions about the use of or payment for medical resources. Commonly used perspectives include those of providers, insurers, the individual, and society. Perspective is a critical determinant of study design, affecting the time horizon, types of resources considered, and economic cost measures assigned to those resources.

The clinical-economic trial: promise, problems, and challenges.

The clinical-economic trial is a study design that is appearing with greater frequency in medical and public health literature. Some experienced investigators view these trials with skepticism; to policy makers they represent a promising step in the control of rising health care costs. The success of clinical-economic trials in meeting the important goal of more rational and efficient use of health care resources will depend on the strengths and limitations of the research method.

Black-white differences in subclinical cardiovascular disease among older adults: the Cardiovascular Health Study. CHS Collaborative Research Group.

Cardiovascular and all-cause mortality are higher in black than white Americans, but racial differences in clinical and subclinical cardiovascular disease (CVD) have not been examined in older adults. Clinical and subclinical CVD and its risk factors were compared in 4926 white and 244 black men and women aged 65 years and older. Black participants had lower socioeconomic status and generally higher prevalences of CVD and its risk factors, except for adverse lipid profiles.

Hematological and biochemical laboratory values in older Cardiovascular Health Study participants.

Objective: To define reference hematologic and biochemical lab values in older individuals.

Design: Randomly selected, age- and gender-stratified participants.

Setting: Visits by participants to four research clinics.

Small area variations in health care delivery in Maryland.

Objective: Our purpose is a descriptive analysis of variations in hospital use among small areas of Maryland.

Data Source: The data are Maryland patient discharge records from acute care hospitals for 1985-1987 and small area population estimates by age, gender, race, and income.

Findings: The common finding was excess geographic variability among Maryland's 115 areas.

Economic impact of immunization against rotavirus gastroenteritis. Evidence from a clinical trial.

Objective: To estimate the economic impact of immunization against rotavirus gastroenteritis in an infant population in the United States.

Design: Cost identification and break-even analyses from the perspective of society, nested within a phase 3, randomized, double-blind, placebo-controlled trial.

Patients: Infants (N = 1278), aged 6 to 22 weeks, enrolled during the summer and fall of 1991 and followed up until July 1, 1992.

A survey of current problems in meta-analysis. Discussion from the Agency for Health Care Policy and Research inter-PORT Work Group on Literature Review/Meta-Analysis.

The United States Agency for Health Care Policy and Research brought together representatives from each of the Patient Outcomes Research Teams (PORTs) as the Inter-PORT Meta-Analysis Work Group. The purpose of the meeting was to discuss a wide range of problems the panel had encountered in the area of meta-analysis. Several actual problems were presented, and tentative solutions to those problems were given.

A review of the first year of Medicare coverage of erythropoietin.

Recombinant human erythropoietin (rHuEPO) is a new drug for treating anemia associated with end stage renal disease (ESRD). In a study of rHuEPO diffusion, costs, and effectiveness, we analyze ESRD program data and all claims submitted to Medicare for reimbursement of rHuEPO administered to ESRD dialysis patients. Access to rHuEPO was rapid and extensive during the first year of Medicare coverage.

Costs vs quality in different types of primary care settings.

Objective: To determine the relationship between efficiency in use of resources and quality of care provided by physicians serving as the usual source of care for patients in a state Medicaid program.

Design: Retrospective quality-of-care review of 2024 outpatient medical records of 135 providers sampled from system-wide Medicaid claims data in Maryland.

Subjects: Providers in three types of practice settings (hospital outpatient clinic, community health center, and physician's office) were stratified into three case mix-adjusted resource use groups (high, medium, and low).

Simulated lifetime costs of three types of employer-based, periodic, breast cancer screening programs for working-age women.

Purpose: To estimate the lifetime cost of three types of employer-sponsored breast cancer screening programs and to identify factors influencing cost.

Design: A computerized decision analysis model was constructed to compare lifetime costs of providing breast cancer screening in each of three screening programs: on-site within an employer, mobile unit visiting the employer, and off-site.

Subjects: Three hypothetical cohorts of 10,000 female employees 38 years of age at time of first screening.

The production of dialysis by for-profit versus not-for-profit freestanding renal dialysis facilities.

Objective: A study was conducted to determine whether for-profit and not-for-profit freestanding renal dialysis facilities differ with respect to efficiency in the production of dialysis treatments.

Data Sources/study Setting: National data on 1,224 Medicare-certified freestanding dialysis facilities were obtained from the Health Care Financing Administration's (HCFA) 1990 Independent Renal Dialysis Facility Cost Report. Data on Medicare patients receiving care at these facilities during 1990 were obtained from HCFA's End Stage Renal Disease (ESRD) Program Management and Medical Information System (PMMIS).

Measuring, managing, and improving quality in the end-stage renal disease treatment setting: committee statement.

The Institute of Medicine (IOM) committee that organized the conference reported in this issue of the journal on assessing quality of care and quality of life, wishes to emphasize that it regards the task of measuring quality as one that can be approached systematically, albeit with caution. Outcomes of end-stage renal disease (ESRD) care by dialysis and transplantation (and variations of outcomes among treatment units) and related processes of care need to be measured in ways useful to clinicians. In addition to clinical measures of outcome, the committee also favored giving greater attention to functional outcomes and health-related quality of life.

Economic and cost-effectiveness investigations of radiologic practices.

Economic evaluations provide scientific data regarding the cost implications of radiologic practices and, most important, which strategies for patient care yield the best outcomes for the least cost. Although this article is meant to enrich understanding of cost-effectiveness studies, it cannot be regarded as a complete training program for undertaking such investigations. Just as training in clinical science is important for radiology research, training in the economics of health and medical care is important for performing economic investigations.

Alternative methods for formal literature review and meta-analysis in AHCPR Patient Outcomes Research Teams. Agency for Health Care Policy and Research.

Formal literature review and synthesis is an important component of Patient Outcomes Research Teams (PORTs) and the development of clinical practice guidelines supported by the Agency for Health Care Policy and Research (AHCPR). Investigators face unresolved methodological issues and practical problems in carrying out this work because the use of such systematic reviews is relatively new in medicine. In addition, standard meta-analytic methods may not readily be applied to the literature pertinent to most PORTs.

Early adoption of cyclosporine and recombinant human erythropoietin: clinical, economic, and policy issues with emergence of high-cost drugs.

The discovery of new drugs and their introduction into US markets will become an intense area of focus should health care reform result in Medicare insurance coverage for prescription drugs. Particular attention will be focused on high-cost drugs. Two high-cost drugs, cyclosporine and recombinant human erythropoietin (rHuEPO), introduced into the clinical management of patients with kidney disease during the past decade, provide some experience concerning the forces affecting the use of expensive drugs in a cost-conscious health care system.