Purpose: To estimate the benefit and cost of using radiotherapy (RT) in the initial management of lung cancer in the general population.

Methods: We identified indications for RT in the initial management of small cell and non–small cell lung cancer through a review of the literature. The proportion of patients with each specific indication for treatment was determined using epidemiological observations from cancer registry data and from the literature. We estimated the benefit gained from RT use for each indication in the model using values published in the literature. We estimated the cost of RT for each indication using published Canadian data. The total benefit and cost was calculated for all indications combined. Results are reported in 2001 Canadian dollars.

Results: The mean benefit was 7 months of survival for each lung cancer patient treated with curative intent and 3 months of symptom control for each patient treated with palliative intent. The average cost was $9,881 per life year gained and $13,938 per year of symptom control gained. Sensitivity analysis revealed values between $7,905 and $19,762 per year of survival gain and between $10,368 and $27,875 per year of symptom control gained.

Conclusions: Using RT in the initial management of lung cancer can provide considerable gains in survival and symptom control. The cost of RT for the initial management of lung cancer is inexpensive compared with a common cut off of $50,000 per life year gained.

Objectives: The aim of this study was to assess the cost-effectiveness of drotrecogin alfa (activated) compared with best supportive care in a UK cohort of adult intensive-care patients with severe sepsis.

Methods: A systematic review of evidence on the clinical- and cost-effectiveness of drotrecogin alfa (activated) was undertaken, and a decision-analytic model was developed to estimate the cost-effectiveness of treatment in the United Kingdom. Trial data from the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study have been synthesized with other data, including UK data on severe sepsis, to estimate the costs and consequences of treatment over time.

Results: For patients with severe sepsis and multiple organ dysfunction, the estimates of cost per life year and cost per quality-adjusted life year (QALY) are £4,931 and £8,228, respectively. For patients with severe sepsis alone, the cost per life-year and cost per QALY are £5,495 and £9,161, respectively.

Conclusions: Whereas the therapeutic cost for drotrecogin alfa (activated) appears high (at around £5,000 per patient) and the potential impact on the provider budget is considerable, drotrecogin alfa (activated) is clinically effective, represents a cost-effective use of resources, and is a significant advance in the treatment of severe sepsis in patients requiring intensive care.

Objectives: The cost-effectiveness of alternating pressure-relieving devices, mattress replacements, and mattress overlays compared with a standard hospital (high-specification foam mattress) for the prevention and treatment of pressure ulcers in hospital patients in the United Kingdom was investigated.

Methods: A decision-analytic model was constructed to evaluate different strategies to prevent or treat pressure ulcers. Three scenarios were evaluated: the prevention of pressure ulcers, the treatment of superficial ulcers, and the treatment of severe ulcers. Epidemiological and effectiveness data were obtained from the clinical literature. Expert opinion using a rating scale technique was used to obtain quality of life data. Costs of the devices were obtained from manufacturers, whereas costs of treatment were obtained from the literature. Uncertainty was explored through probabilistic sensitivity analysis.

Results: Using £30,000/QALY (quality-adjusted life year) as the decision-maker's cut off point (the current UK standard), in scenario 1 (prevention), the cost-effective strategy was the mattress overlay at 1, 4, and 12 weeks. In scenarios 2 and 3, the cost-effective strategy was the mattress replacement at 1, 4, and 12 weeks. Standard care was a dominated intervention in all scenarios for values of the decision-maker's ceiling ratio ranging from £5,000 to £100,000/QALY. However, the probabilistic sensitivity analysis results reflected the high uncertainty surrounding the choice of devices.

Conclusions: Current information suggests that alternating pressure mattress overlays may be cost-effective for the prevention of pressure ulcers, whereas alternating pressure mattress replacements appears to be cost-effective for the treatment of superficial and severe pressure ulcers.

Objectives: The aim of this study was to identify and discuss appropriate approaches to integrate ethical inquiry in health technology assessment (HTA).

Methods: The key question is how ethics can be integrated in HTA. This is addressed in two steps: by investigating what it means to integrate ethics in HTA, and by assessing how suitable the various methods in ethics are to be integrated in HTA according to these meanings of integration.

Results: In the first step, we found that integrating ethics can mean that ethics is (a) subsumed under or (b) combined with other parts of the HTA process; that it can be (c) coordinated with other parts; or that (d) ethics actively interacts and changes other parts of the HTA process. For the second step, we found that the various methods in ethics have different merits with respect to the four conceptions of integration in HTA.

Conclusions: Traditional approaches in moral philosophy tend to be most suited to be subsumed or combined, while processual approaches being close to the HTA or implementation process appear to be most suited to coordinated and interactive types of integration. The article provides a guide for choosing the ethics approach that appears most appropriate for the goals and process of a particular HTA.

Objectives: The INTEGRATE-HTA project provided methodology to evaluate complex technologies. This study provides guidance on how to retrieve and critically appraise available evidence on moderators and predictors of treatment effects and on patient preferences for treatment outcomes as a source of complexity.

Methods: Search filters for PubMed were developed by hand-searching a large volume of articles reporting on relevant aspects. Search terms were retrieved from selected papers and algorithmically combined to find the optimal combination of search terms. For the development of the appraisal checklists literature was searched in PubMed and Google Scholar together with citation chasing. For the CHecklist for the Appraisal of Moderators and Predictors (CHAMP) a Delphi procedure was used to value a set of eligible appraisal criteria retrieved from the literature.

Results: Search filters were developed optimized for different accuracy measures. The final version of CHAMP consists of a seventeen questions covering the design, analysis, results and transferability of results of moderator and predictor analysis. The final checklist for appraisal of literature on patient preferences for treatment outcomes consist of six questions meant to help the user to identify relevant quality issues together with a guidance toward existing tools concerning the appraisal of specific preference elicitation methods.

Conclusions: Incorporating knowledge on subgroups for whom a specific treatment will produce more benefit holds the promise of better targeting and, ultimately, enhancing overall effectiveness and efficiency of healthcare technology. Finally, incorporating information on preferences for treatment outcomes will foster health technology assessment that addresses outcomes that are important to patients.

Healthcare systems account for a substantial proportion of global carbon emissions and contribute to wider environmental degradation. This scoping review aimed to summarize the evidence currently available on incorporation of environmental and sustainability considerations into health technology assessments (HTAs) and guidelines to support the National In stitute for Health and Care Excellence and analogous bodies in other jurisdictions developing theirown methods and processes. Overall, 7,653 articles were identified, of which 24 were included in this review and split into three key areas – HTA (10 studies), healthcare guidelines (4 studies), and food and dietary guidelines (10 studies). Methodological reviews discussed the pros and cons of different approaches to integrate environmental considerations into HTAs, including adjustments to conventional cost-utility analysis (CUA), cost–benefit analysis, and multicriteria decision analysis. The case studies illustrated the challenges of putting this into practice, such as lack of disaggregated data to evaluate the impact of single technologies and difficulty in conducting thorough life cycle assessments that consider the full environmental effects. Evidence was scant on the incorporation of environmental impacts in clinical practice and public health guidelines. Food and dietary guidelines used adapted CUA based on life cycle assessments, simulation modeling, and qualitative judgments made by expert panels. There is uncertainty on how HTA and guideline committees will handle trade-offs between health and environment, especially when balancing environmental harms that fall largely on society with health benefits for individuals. Further research is warranted to enable integration of environmental considerations into HTA and clinical and public health guidelines.

Objectives: The aim of this study was to compare the cost and the effectiveness of two biennial fecal occult blood screening tests for colorectal cancer: a guaiac nonrehydrated test (G-FOBT) and an immunochemical test (I-FOBT) with the absence of screening.

Methods: A Markov model was developed to compare these strategies in a general population of subjects aged 50 to 74 over a 20-year period.

Results: Compared with the absence of screening, G-FOBT and I-FOBT were associated with a decrease in colorectal cancer mortality of 17.4 percent and 25.2 percent, respectively. With regard to cost-effectiveness, expressed as cost per life-year gained, I-FOBT was the most effective and most costly alternative. Compared with no screening, G-FOBT and I-FOBT presented similar discounted incremental cost-effectiveness ratios: €2,739 and €2,819 respectively per life-year gained. When compared with G-FOBT, I-FOBT presented an incremental cost-effectiveness ratio of €2,988 per life-year gained. Sensitivity analyses showed the strong influence of the I-FOBT lead time, of the participation rate to screening for I-FOBT, and of the purchase price of the I-FOBT on the discounted incremental cost-effectiveness ratios.

Conclusions: Compared with the absence of screening and with G-FOBT, the biennial two-stool immunochemical test can be considered a promising method for mass screening for colorectal cancer.

Objectives: The majority of patients in India access private sector providers for curative medical services. However, there is scanty information on the cost of treatment of critically ill patients in this setting. The study evaluates the cost and extent of financial subsidy required for patients admitted to an intensive care unit (ICU) in India.

Methods: Data on direct medical, direct nonmedical, and indirect cost were prospectively collected from critically ill patients admitted to a tertiary teaching hospital in India. Willingness-to-pay (WTP) amount was obtained from the next-of-kin following admission and the actual cost paid by the family at discharge was recorded.

Results: The main diagnoses (n = 499) were infection (26 percent) and poisoning (21 percent). The mean APACHE-II score was 13.9 (95 percent confidence interval [CI], 13.3–14.5); 86 percent were ventilated. ICU stay was 7.8 days (95 percent CI, 7.3–8.3). Hospital mortality was 27.9 percent. Direct medical cost accounted for 77 percent (US$ 2164) of the total treatment cost (US$ 2818). Indirect cost and direct nonmedical cost contributed to 19 percent (US$ 547.5) and 4 percent (US$ 106.5), respectively. Average total and daily ICU cost were US$ 1,897 and US$ 255, respectively. Although the family's WTP was 53 percent (US$ 1146; 95 percent CI, 1090–1204) of direct medical cost, their final contribution was 67.7 percent (US$ 1465; 95 percent CI, 1327–1604).

Conclusions: The cost of an ICU admission in our setting is US$ 2818. Although the family's contribution to expenses exceeded their initial WTP, a substantial subsidy (33 percent) is still required. Alternate financing strategies for the poor and optimization of ICU resources are urgently required.

To share the existing, albeit limited, experience among nations and to explore the feasibility of international collaboration on the identification and early evaluation of health care technologies, an workshop was arranged in September 1997. Twenty-seven policy makers and researchers from twelve countries attended the meeting and concluded that: the policy environment in most European countries is characterized by insufficient data on safety, effectiveness, and cost-effectiveness of health care innovations; that an early warning system is perceived as an essential mechanism for facilitating communication among policy makers, technology experts, and health professionals; and that collaboration on early warning activities might be even more useful than traditional collaboration in health technology assessment.

Objectives: Despite controversies, endoscopic thoracic sympathectomy (ETS) has been used as a treatment for excessive sweating of hands and face and for facial blushing. This study aims to evaluate the effectiveness of ETS for the current indications in a systematic review.

Methods: Controlled clinical trials and cohort studies with more than 100 patients were included. Abstracts were searched from MEDLINE and CCTR from 1966 to June 2004. Two reviewers extracted the data and assessed study quality. Data on effectiveness and safety were synthesized qualitatively.

Results: We did not find any controlled clinical trials. Fifteen prospective studies were included. The internal and external quality of these studies were poor overall. Follow-up was commonly less than 2 years, during which time excessive sweating and facial blushing seemed to decrease among most patients. Immediate complications related to thoracoscopy occurred in up to 10 percent of patients. Compensatory sweating below breast level was reported in up to 90 percent of the patients. Other common side effects included dryness of face and hands, gustatory sweating, and neuralgic pain. Several other less common side effects were reported.

Conclusions: The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.

Objectives: The aim of this study was to describe the history of health technology assessment (HTA) in France.

Methods: The approach was a descriptive review done by people who have been very much involved in this history.

Results: The interest in HTA and evaluation as a tool for health decision making goes back to the 1970s in France. During the 1980s, there were several attempts to develop a national HTA agency, which finally came to fruition with the development of the Agence Nationale de l'Evaluation Medicale (ANDEM) in 1989. ANDEM's main success, perhaps, was in making HTA known in France by developing its own assessments, writing and validating appropriate methodologies for assessing medical technology and medical practices, and by organizing in France the development of programs of consensus development conferences, which the ANDEM either organized itself or supported and validated. In the mid-1990s, the mandate of ANDEM was extended to hospital accreditation and the agency's name was changed to Agence Nationale d'Accreditation et d'Evaluation en Sante (ANAES). Finally, in 2005, the National Authority for Health (HAS) was formed to consolidate efforts to centralize the programs of HTA, aiming at helping decision making regarding reimbursement and pricing, in one agency and to define the optimal use of health technology in France.

Conclusions: HTA has become a strong influence in the healthcare system in France. These developments may be considered rather typical of the approach to public policy questions in France, where regulation is more in use than in other countries (at least in the healthcare field). At the same time, this approach has made lobbying and other attempts to influence decisions common as well, so one might say that HTA is more politicized than in some other countries in Europe.

Objective: To estimate the cost-effectiveness (CE) of interferon beta-1b (IFNβ-1b) in slowing disability progression in persons with relapsing-remitting multiple sclerosis (RRMS).

Methods: Treatment program costs and health outcomes are modeled for cohorts of 1,000 females and 1,000 males followed 40 years from onset. Fifteen scenarios model MS natural history progression, treatment efficacy, direct treatment costs, and MS healthcare costs. A single randomized placebo-controlled trial of IFNβ-1b found reduced disease activity by MRI, reduced frequency and severity of exacerbations, and a tendency toward slower disability progression.

Disability years avoided are modeled as the primary health outcome analyzed. A ministry of health (MOH) perspective is adopted, using Nova Scotia population-based data. Annual IFNβ-1b direct treatment costs (Can $16,685) are high relative to both MOH healthcare costs per person with MS (Can $2,000) and estimated MOH costs avoided.

Results: Given “reference case” assumptions for women with RRMS, treatment reduces lifetime disability years by 10%. Cost per disability year avoided before discounting is Can $189,230 (US $124,892), and Can $274,842 (US $181,395) after discounting at 5%. Estimates for alternative scenarios vary greatly, leaving main findings unchanged.

Conclusions: Using the Expanded Disability Status Scale, cost per disability year avoided due to interferon beta-1b treatment in RRMS is quite high. Comparable CE estimates, using MS-specific or generic health-related quality-of-life outcome measures, are even higher. Further research is required to better measure treatment effects, modification of MS natural history, and net societal costs of IFNβ-1b in RRMS.

Objectives: Online Health Communities (OHCs) are increasingly being used by patients in the Web 2.0 era. Today's patients have instant access to a great deal of medical information and contacts. Despite the considerable development of OHCs, little is known regarding the impact on the patient–physician relationship. This research aims at filling this gap and examines how interpersonal trust on peer-to-peer OHCs influences two key relational variables, namely patient trust in the physician and patient satisfaction with the physician. It also investigates their influences on the patient's attitude toward the physician.

Methods: Drawing on both the relational and medical literatures, we propose a research model that brings out the relationships between interpersonal trust in OHCs, and patients’ trust, satisfaction and attitude toward the physician. We then conduct a quantitative survey of 512 OHC users in France, using structural equation modeling to test our hypotheses.

Results: Our findings indicate that interpersonal trust in OHCs exerts a positive influence on both patients’ trust in and satisfaction with their physician. It also highlights that these two relational variables have a positive influence on patient attitude toward the physician. Our findings also indicate that patient trust influences patient satisfaction with the physician.

Conclusions: This research highlights the importance of OHCs, which can be seen as valuable instruments for enhancing patient–physician relationships. It shows that healthcare managers should seek to enhance interpersonal trust among OHC users, because this trust has a positive influence on patient satisfaction with, trust in and attitude toward the physician.

Objectives: To report on a workshop, and subsequent discussions, that reviewed the achievements and progress of the EuroScan collaboration since its establishment in 1999 to share information on the methods and results of early identification and assessment of new and emerging health technologies; considered challenges to the collaboration; and discussed its possible future direction.

Methods: A workshop was held in Stockholm in September 2006, with thirty-two participants from ten countries and representatives from EuroScan member agencies, policy makers involved in policy or decision making relating to new technologies, and invited external commentators from international HTA networks. The workshop used a mix of presentations, panel and audience discussions, and small group work to consider the achievements and challenges put forward.

Results: EuroScan has developed as a sustainable network, and has made progress on all tasks in its initial action plan, with the EuroScan information sharing database on new and emerging technologies being one of the collaboration's key achievements. Identified immediate concerns for the network included consideration of the impact of its current name and membership model; acknowledgement and publication of the full range of benefits of membership; contribution to and development of the database to encourage increased information sharing; and EuroScan's ongoing interaction with the wider HTA world.

Conclusions: The workshop was a useful mechanism for reviewing the work of EuroScan and for creating a platform to take the collaboration forward. The workshop affirmed the benefits of the network to individual members; posed some significant challenges to the network to consider; and acted as a stimulus for an interim name change to better represent the global membership, and a major review of the EuroScan database of identified and assessed emerging health technologies.

A retrospective study comparing 700 consecutive total hip arthroplasties, utilizing four types of implants, was performed. Questionnaires based on hip scores were sent to 593 living patients. Useful responses were received from 363 (61 %) patients. Hip scores and quality-adjusted life-years were calculated. Multiple regression analysis, controlling for all possible biases, demonstrated one cementless implant as superior to all others. We believe that the use of mailed questionnaires is a simple and convenient system of follow-up, saving patients the need for outpatient clinic visits. The validity of such replies, however, has yet to be established.

Introduction: HTA agencies, especially in developing countries, are under resourced and unable to conduct the desired amount of assessments. Adapting HTA reports (HTAs) from other jurisdictions is an alternative for saving resources.

Objectives: To explore HTA transferability experiences in Latin-America and Caribbean (LAC): are decision makers (DMs) using HTAs from other jurisdictions? Are researchers adapting HTAs when developing local reports? How useful is the information found in HTAs from other jurisdictions?

Methods: Web-based survey sent to 13031 HTA researchers and DMs.

Results: We received 671 responses from 19 countries. DMs reported using HTAs from other jurisdictions to guide decisions in the majority of the situations: 52.6 percent HTAs from outside LAC (e.g., Europe), 23.1 percent from other LAC countries, and only 24.3 percent HTAs from their own countries. 63 percent of researchers reported using HTAs from other jurisdictions. Usefulness scored significantly higher for HTAs from other jurisdictions as compared to local HTAs (7.1 versus 6.0 in a 1–10 scale; p < .01). Both DMs and researchers considered the information regarding safety and effectiveness more applicable than the information on social aspects, or economic evaluation. Barriers that limit transferability had significantly different scores for HTAs from other LAC countries as compared to those from regions outside LAC (i.e., poor methodological quality 6.7 versus 5.3, different epidemiological context 6.0 versus 7.4; all p < .01).

Conclusions: HTAs from outside the region are commonly used. However, DMs and researchers agreed that HTAs from LAC had the greatest potential for transferability, provided that barriers such as poor methodological quality could be overcome.

Objectives: Order sets are widely used in hospitals to enter diagnosis and treatment orders. To determine the effectiveness of order sets in improving guideline adherence, treatment outcomes, processes of care, efficiency, and cost, we conducted a systematic review of the literature.

Methods: A comprehensive literature search was performed in various databases for studies published between January 1, 1990, and April 18, 2009. A total of eighteen studies met inclusion criteria. No randomized controlled trials were found.

Results: Outcomes of the included studies were summarized qualitatively due to variations in study population, intervention type, and outcome measures. There were no important inconsistencies between the results reported by studies involving different types of order sets. While the studies generally suggested positive outcomes, they were typically of low quality, with simple before-after designs and other methodological limitations.

Conclusions: The benefits of order sets remain eminently plausible, but given the paucity of high quality evidence, further investigations to formally evaluate the effectiveness of order sets would be highly valuable.

Objectives: The aim of this study was to summarize and assess economic evaluations of poison centers (PCs) from the perspectives of society, the payer, and the healthcare system.

Methods: A systematic review was performed to identify complete economic evaluations regardless of the language or publication status. Two reviewers evaluated the abstracts for eligibility, extracted the data, and assessed the study quality using a standardized tool.

Results: In total, 422 non-duplicated studies were retrieved, but only nine met the eligibility criteria. Five of the eligible studies were published in the 1990s, and four were published in the 2000s. Six studies met at least seven of ten quality criteria. In all studies, the presence of PCs was compared with a scenario of their absence. Eight studies used cost–benefit analyses and one used a cost-effectiveness approach. The cost–benefit ratios ranged from 0.76 to 7.67, which indicates that each United States dollar (USD) spent on poison centers can save almost 8 USD on medical spending. A cost-effectiveness analysis showed that each successful outcome achieved by a PC avoids a minimum of 12,000 USD to 56,000 USD in other healthcare spending.

Conclusions: The data in our review show that PCs are economically viable. PCs improve the efficiency of healthcare expenditure and contribute to the sustainability of the healthcare system. An investment in PCs is a rational public health policy approach that contrasts the current trend of reducing spending on PCs.

Objectives: This study examines the cost-effectiveness of the OPTI-SCRIPT intervention on potentially inappropriate prescribing in primary care.

Methods: Economic evaluation, using incremental cost-effectiveness and cost utility analyses, conducted alongside a cluster randomized controlled trial of twenty-one general practices and 196 patients, to compare a multifaceted intervention with usual practice in primary care in Ireland. Potentially inappropriate prescriptions (PIPs) were determined by a pharmacist. Incremental costs, PIPs, and quality-adjusted life-years (QALYs) at 12-month follow-up were estimated using multilevel regression. Uncertainty was explored using cost-effectiveness acceptability curves.

Results: The intervention was associated with a nonsignificant mean cost increase of €407 (95 percent CIs, −357–1170), a significant mean reduction in PIPs of 0.379 (95 percent CI, 0.092–0.666), and a nonsignificant mean increase in QALYs of 0.013 (95 percent CIs, −0.016–0.042). The incremental cost per PIP avoided was €1,269 (95 percent CI, −1400–6302) and the incremental cost per QALY gained was €30,535 (95 percent CI, −334,846–289,498). The probability of the intervention being cost-effective was 0.602 at a threshold value of €45,000 per QALY gained and was at least 0.845 at threshold values of €2,500 per PIP avoided and higher.

Conclusions: While the OPTI-SCRIPT intervention was effective in reducing potentially inappropriate prescribing in primary care in Ireland, our findings highlight the uncertainty with respect to its cost-effectiveness. Further studies are required to explore the health and economic implications of interventions targeting potentially inappropriate prescribing.