Maintenance of therapeutic change: A usable evaluation design.

Specific strategies for improving maintenance of gains following initial treatment intervention have received relatively little attention. Effective methods for maintaining gains may differ from those needed to effect initial therapeutic change. A design for evaluating the cost-effectiveness of maintenance strategies is discussed, and some appropriate statistical analyses are suggested. This design is particularly suitable for use in ongoing treatment programs and individual practices where "no treatment" controls are impractical. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

In search of power and significance: issues in the design and analysis of stochastic cost-effectiveness studies in health care

Application of techniques such as cost-effectiveness analysis (CEA) is growing rapidly in health care. There are two general approaches to analysis: deterministic models based upon assumptions and secondary analysis of retrospective data, and prospective stochastic analyses in which the design of a clinical experiment such as randomised controlled trial is adapted to collect patient-specific data on costs and effects. An important methodological difference between these two approaches is in the quantification and analysis of uncertainty. Whereas the traditional CEA model utilizes sensitivity analysis, the mean-variance data on costs and effects from a prospective trial presents the opportunity to analyze cost-effectiveness using conventional inferential statistical methods. In this study we explored some of the implications of moving economic appraisal away from deterministic models and toward the experimental paradigm. Our specific focus was on the feasibility and desirability of constructing statistical tests of economic hypotheses and estimation of cost-effectiveness ratios with associated 95% confidence intervals. We show how relevant variances can be estimated for this task and discuss the implications for the design and analysis of prospective economic studies.     

Methods of cost-effectiveness analysis: areas of consensus and debate

Methods of evaluating socioeconomic relationships have evolved over many years, and a number of specific approaches have been developed. Among the techniques available, cost-effectiveness analysis (CEA) has emerged as the most widely used and accepted method. Yet, despite considerable effort by the analytical community to refine this technique into one more useful for making health policy decisions, much debate and confusion still persist among analysts, readers, and policy-makers concerning methods standards and the overall usefulness of CEA in resource allocation decision making. Thus the purpose of this paper is to summarize, critically examine, and comment on existing recommended methods for socioeconomic evaluation of health care interventions. In particular, we examine an exhaustive set of component methods within the general area of cost-effectiveness and comment on areas of apparent consensus and debate. Our review reveals many areas of agreement and many yet to be resolved. Analysts generally agree on the components of the overall framework for an analysis; basic methodologic principles; the general treatment of costs; the principle of marginal analysis; the need for and general approach to discounting; the use of sensitivity analysis; the extent to which ethical issues can be incorporated; and the importance of choosing appropriate alternatives for comparison. The principal areas in which disagreement still persists are choice of study design, measurement and valuation of health outcomes including conversion of health outcomes to economic values, transformation of efficacy results into effectiveness outcomes, and the empirical measurement of costs.     

Preventing Substance Abuse in American Indian and Alaska Native Youth: Promising Strategies for Healthier Communities.

Substance abuse has had profoundly devastating effects on the health and well-being of American Indians and Alaska Natives. A wide variety of intervention methods has been used to prevent or stem the development of alcohol and drug problems in Indian youth, but there is little empirical research evaluating these efforts. This article is an overview of the published literature on substance use prevention among Indian adolescents, providing background epidemiological information, a review of programs developed specifically for Indian adolescents, and recommendations for the most promising prevention strategies currently in practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Primary prevention of child abuse.

Following a discussion of the ecological theory base for the study and design of child abuse prevention programs, the authors examine 3 categories of primary programs: competency enhancement, preventing the onset of abusive behavior, and targeting high-risk groups. Programs that enhance competencies of families focus on parent skills, child development information, and coping strategies to reduce stress. Programs that prevent the onset of abusive behavior involve media campaigns; information, crisis, and referral services; and social networks at the community and neighborhood levels. Programs that target high-risk groups (e.g., low-SES, single parents, complicated pregnancies) focus on therapeutic strategies. Methodological problems in evaluating child abuse prevention include the lack of appropriate comparison groups, poor choice of outcome measures, and the failure to measure proximal programmatic objectives and distal prevention goals. (50 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Developing a Decision Support Tool for Nighttime Construction in Highway Projects

This paper presents a decision support tool that is intended to help highway agencies in evaluating the suitability of nighttime construction for highway projects. This tool was developed as part of a research project sponsored by the Illinois Department of Transportation. The tool is a simple software package that was developed using a Microsoft Excel spreadsheet and Visual Basic for Applications. The proposed tool utilizes the cost-effectiveness analysis as a basis for comparison between daytime and nighttime operations. The proposed tool is mainly used whenever night shift is thought of as an alternative to the conventional daytime shift. Nonetheless, the tool is also generic in the sense that it can be used to compare different alternative plans such as different lane closure strategies or scheduling alternatives.     

Cost-benefit and cost-effectiveness analysis in health care. Growth and composition of the literature

Concern about the escalating costs of health services is reflected in the rapid growth of the literature on cost-benefit and cost-effectiveness analysis (CBA and CEA, respectively) in health care. A search of that literature for 1966--78 produced a bibliography of more than 500 relevant references, growing from half a dozen per year at the beginning of the period to close to 100 each of the most recent 2 years. The literature growth has been more rapid in medical than nonmedical journals and a preference for CEA over CBA appears to be emerging. Studies related to diagnosis and treatment have gained in popularity, while the early prominence of studies with a substantive prevention theme has diminished. Consistent with the increasing medical focus of the literature, numbers of articles oriented toward individual practitioner decision making have grown more rapidly than those oriented toward organizational or societal decision making. In addition to documenting these trends, this article identifies published reviews of health care CBA/CEA and books and articles attempting to convey the principles of CBA/CEA to the health care community. The article concludes with speculation on likely near-future trends in the literature and consideration of the quality implications of the rapid growth.     

Managed care, school health programs, and adolescent health services: opportunities for health promotion

The rapid expansion of managed care creates opportunities and dilemmas for those involved in school health and adolescent health promotion. Managed care organizations (MCOs), public health agencies, and school and adolescent health providers share certain common goals and priorities including an emphasis on prevention, cost-effectiveness, and quality of care--and a willingness to explore innovative approaches to health promotion and disease prevention. However, MCOs often face conflicting challenges, balancing the goals of cost containment and investment in prevention. In considering support for school health programs, MCOs will be interested in evidence about the effectiveness of services in improving health and/or reducing medical expenditures. Mechanisms for improving prevention efforts within MCOs include quality assurance systems to monitor the performance of health plans, practice guidelines from professional organizations, and the contracting process between payers and health care providers. Development of partnerships between MCOs and schools will be a challenge given competing priorities, variation in managed care arrangements, structural differences between MCOs and schools, and variability in services provided by school health programs.     

Recommendations of the Panel on Cost-effectiveness in Health and Medicine

OBJECTIVE: To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations. PARTICIPANTS: The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). EVIDENCE: The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users. CONSENSUS PROCESS: The panel developed recommendations through 2 1/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists. CONCLUSIONS: The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the ?rule of reason,? balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.     

The Stroke Prevention Patient Outcomes Research Team. Goals and methods

BACKGROUND AND PURPOSE: The aim of the present study, based at Duke University and involving 14 other institutions, is to identify the most appropriate and cost-effective clinical strategies for prevention of ischemic (thrombotic or embolic) stroke in high-risk individuals and to design and test an intervention to disseminate this information to providers and the public. METHODS: The study uses (1) secondary data from literature review, Medicare claims, and population-based data from three epidemiological studies and (2) primary data generated in national physician and patient surveys and in demonstration trials. Phases I through III involve data collection and analysis using a decision/cost-effectiveness model and consensus development methods. Phase IV includes intervention in physicians' practice patterns. Data is collected by literature survey and abstraction, review of medical records, claims analysis, and patient and physician surveys. CONCLUSIONS: A structured decision model and a well-defined clinical focus provide a successful organization for a PORT on stroke prevention.     

The mental health of hospital nurses in Tasmania as measured by the 12-item General Health Questionnaire

The goal of this study was to examine the clinical and economic outcomes of alternative diagnostic strategies for differentiating benign from malignant adrenal masses. METHODS: We used cost-effectiveness assessment derived from decision analysis and the economic perspective of the payer of health care services. One-time evaluation with fine-needle aspiration (FNA) and combinations of chemical-shift MRI, noncontrast CT, 131I-6beta-iodomethylnorcholesterol (NP-59) scintigraphy, with or without FNA, in a hypothetical cohort of 1000 patients with incidentally discovered unilateral, nonhypersecretory adrenal masses. We calculated and compared the diagnostic effectiveness, costs and cost-effectiveness of the alternative strategies based on estimates from published literature and institutional charge data. RESULTS: At an assumed baseline malignancy rate of 0.25, diagnostic utility varied from 0.31 (CT0) to 0.965 (NP-59) and diagnostic accuracy from 0.655 [noncontrast CT using a cut-off attenuation value of > or = 0 (CT0)] to 0.983 (NP-59). The average cost per patient per strategy ranged from $746 (NP-59) to $1745 (MRI +/- FNA). The best and worst potential cost-to-diagnostic utility ratios were 773 (NP-59) and 2839 (CT0) and 759 (NP-59) and 1982 (MRI +/- FNA) for cost and diagnostic accuracy, respectively. The NP-59 strategy was the optimal choice regardless of the expected outcome examined: cost, diagnostic utility, diagnostic accuracy or cost-effectiveness. Varying the prevalence of malignancy did not alter the cost-effectiveness advantage of NP-59 over the other diagnostic modalities. CONCLUSION: Based on available estimates of reimbursement costs and diagnostic test performance and using reasonable clinical assumptions, our results indicate that the NP-59 strategy is the most cost-effective diagnostic tool for evaluating adrenal incidentalomas over a wide range of malignancy rates and that additional clinical studies are warranted to confirm this cost-effectiveness advantage.     

Inhibition by gonadotropins of interleukin-1 production by rabbit granulosa and theca cells: effects on gonadotropin-induced progesterone production

BACKGROUND: School-based drug prevention programs have been criticized on methodologic grounds because the unit of analysis is often not the unit of randomization, thus increasing the likelihood of Type I errors. Application of multilevel analytic strategies appropriately corrects this biasing tendency. This study demonstrates the practical use of such analysis. METHODS: Data from 2,370 seventh-grade students participating in a substance use prevention trial were analyzed using a multilevel strategy. We examined the effectiveness of a social pressure resistance training and a normative education (NORM) intervention against an information-only control group. RESULTS: The NORM condition revealed 1-year program effects for cigarette and marijuana use with individuals as the unit of analysis and only marginal effects with classroom as the unit of analysis. No program effects were found using school as the analysis unit. A multilevel strategy revealed program effects for cigarettes and marijuana with both class and school as grouping levels. The effect for alcohol use was significant at the 2-year follow-up. CONCLUSIONS: Interventions establishing conservative drug use norms in classrooms may be an effective strategy in reducing substance use onset among adolescents. Utilization of appropriate analytic strategies is important in the analysis and interpretation of data containing nested structures.     

Cost-effectiveness of evaluating the new technologies

The problem of evaluating cost-effectiveness claims is complex and not readily solved. However, such evaluation represents an important direction for technology assessment as resources become more scarce. Neumann et al.'s analysis (1996) represents one solution to the relatively simple problem of pharmacoeconomic studies. In addition, Fryback and Thornbury included a useful method for approaching the cost-effectiveness of all medical technologies. I note that the cost-effectiveness cutoff of $50,000 per quality-adjusted life year is an incremental one, meaning that new technology must be substantially more cost-effective than older technology. This is currently not the case where incremental improvements over previous technology are often quite small. Interested readers are referred to standard tests in the field, including Drummond, Stoddart, and Torrance (1987), Eisenberg (1986), and Sox, Blatt, Higgins, and Marton (1988).     

Statistical power considerations in the use of cost-effectiveness analysis.

Due to ever-increasing economic constraints, evaluators and administrators of human service delivery systems will find it necessary to eliminate programs from the system. In doing so they must consider the cost as well as the effectiveness of programs. Failure to take into account the statistical and methodological factors that affect the statistical power and Type II error rate of cost-effectiveness studies may lead to invalid inferences and erroneous programmatic decisions. Using a hypothetical evaluation design, the author examines factors relevant to statistical power analysis in cost-effectiveness evaluations. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A cost-effectiveness approach to the Norwegian follow-up programme in colorectal cancer

BACKGROUND: Today, continued periodic follow-up of patients treated for colorectal cancer (CRC) seems often to be routine because of tradition, rather than its demonstrated value. Recently, the Norwegian Gastrointestinal Cancer Group (NGICG) has recommended a standard surveillance programme in this malignancy. In this protocol patients are suggested followed for four years with CEA monitoring, ultrasound of the liver, chest radiograph and colonoscopy at regular intervals. MATERIALS AND METHODS: In this study, the cost-effectiveness of this programme was addressed employing Norwegian cost data and data from the Cancer Registry of Norway. Clinical data from the existing English language literature was used in the analysis. RESULTS: The basic cost of the NGICG recommended programme was 1,232 Pounds per patient. Including extended investigation due to suspected relapse in 45% of cases, the figure raised to 1,943 Pounds per patient. The cost per life year saved was indicated to 9,525 Pounds-16,192 Pounds. The corresponding cost per quality adjusted life year (QALY) was indicated to 11,476 Pounds-19,508 Pounds. CONCLUSION: We conclude the NGICG recommended follow-up programme in CRC cost-effective. Excluding CEA monitoring may improve the cost-effectiveness.     

The cost-effectiveness of preventing tuberculosis in physicians using tuberculin skin testing or a hypothetical vaccine

BACKGROUND: Tuberculin skin testing using the purified protein derivative is recommended as part of a tuberculosis control program for health care workers. However, compliance with skin testing programs has been poor and their cost-effectiveness is unknown. METHODS: A Markov-based decision analysis was performed to determine the cost-effectiveness of tuberculin skin testing over the entire lifetimes of physicians who are now in medical school. Assumptions were deliberately chosen to present a conservative estimate of cost-effectiveness. Indirect costs were not included. RESULTS: Annual testing cost $29,000 per life-year saved and $39,000 per case of pulmonary tuberculosis prevented. In contrast, particulate respirators have been shown to cost millions of dollars per case prevented. Skin testing every 6 months was cost-effective in a subpopulation at high risk of infection (> or = 1.8-fold). During their entire lifetimes, physicians now in medical school can expect to avert 137 cases of pulmonary tuberculosis, prevent 7 tuberculosis deaths, and save 182 life-years because of skin testing programs. Improved compliance with annual skin testing and prophylactic isoniazid could more than triple this benefit. If available, a moderately effective vaccine would be even more cost-effective than tuberculin skin testing programs. CONCLUSIONS: Tuberculin skin testing is cost-effective and should be an integral part of any tuberculosis control program. Vaccination may one day be a feasible and cost-effective alternative to skin testing programs.     

Geographical inequality in the provision of carotid endarterectomy in Scotland. Scottish Vascular Audit Group

BACKGROUND: Carotid endarterectomy (CEA) is a proven method of stroke prevention in patients with symptomatic and asymptomatic high-grade internal carotid artery stenosis. This study examined whether site of residence affects access to CEA in Scotland. METHODS: Scottish Morbidity Record hospital discharge data were collected by the Information and Statistics Division of the National Health Service in Scotland and analysed for the interval 1 January 1989 to 31 December 1995. The number of CEAs performed in the hospitals of each of the 15 regional Health Boards, and CEA rate per 100000 population resident in each Health Board region, were determined. RESULTS: In 1989, 65 CEAs were performed in the hospitals of five Health Boards and in 1995, 431 CEAs were performed in nine Health Boards. In 1989, the CEA rate per 100000 resident population varied between 0 (four regions) and 4 (one region), with one region significantly different from Scotland as a whole (P<0.001). In 1995, the CEA rate varied between 0 (two regions) and 19 (one region), with two regions significantly different from Scotland as a whole (P< 0.01). CONCLUSION: Despite a sixfold increase in the number of CEAs being performed, and a rise in the number of centres performing CEA, there is increasing geographical inequality in the provision of CEA in Scotland.     

Reducing the risk of AIDS in adolescents.

Preventing the spread of human immunodeficiency virus (HIV) infection among adolescents is crucial. Urgently needed are prevention programs that influence diverse populations (e.g., men and women, Blacks and Hispanics). Effective AIDS prevention programs and research must draw from promising programs in other health areas (e.g., smoking prevention, prevention of teenage pregnancy). AIDS prevention programs aimed at adolescents should (a) use an expanded cognitive-social learning theory perspective, (b) consider level of intervention and the unit analysis (e.g., individuals, networks, organizations, and communities), (c) recognize differing goals of primary and secondary prevention, and (d) use social marketing methods in tailoring programs to subgroups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)