Objectives: The delay between patient discharge and the completion of the final discharge note have prompted hospitals to consider new information technologies. This study compared the relative cost-effectiveness of an automated medical documentation system to the current system in place at a Canadian hospital. There are significant expenditures associated with the choice of medical documentation system, yet the benefit to the patient population has not been studied.

Methods: A systematic review of the literature was carried out. Cost data for the current documentation system were obtained from the study hospital. The costs of purchasing the automated system were obtained from the manufacturer. Other resource cost implications of the automated system were estimated based on information obtained from the Centre for Applied Health Informatics at the study hospital. The outcome was determined to be the average time (days) between patient discharge and note completion. A cost-effectiveness analysis was conducted. Sensitivity analyses were used to determine the robustness of the results.

Results: The automated documentation system was associated with higher costs but better outcomes than the current system. The incremental cost-effectiveness ratio used for comparing the automated medical documentation system with the traditional system indicated that the incremental daily cost for decreasing a day in average note completion time per discharge note was 0.331 Canadian $/day over the study period (4 years).

Conclusions: Although the automated documentation system was more expensive than the current system, it also provided qualitative benefits that were not considered in the cost-effectiveness analysis.

Objectives: Health technology assessment (HTA) is a policy-oriented form of research designed to inform decision-makers on the introduction, use, and dissemination of health technology. Whereas research on knowledge transfer has focused on knowledge producers, little attention has been given to the user's perspective. This study examines how health-care provider, administrator, and patient associations across Canada use HTA reports and the limitations they encounter when accessing and using scientific knowledge.

Methods: This study draws from semistructured interviews (n = 42) conducted with three types of user, located in British Columbia, Alberta, Saskatchewan, Ontario, and Quebec. Applying well-established conceptual categories in knowledge utilization research, our qualitative analyses sought to define more precisely how HTA is used by interviewees as well as the most significant barriers they encounter.

Results: The vast majority of users recognize the usefulness and credibility of HTA reports. Of interest, the way they use HTA takes different forms. Although administrators and health-care providers are in a better position than patient associations to act directly on HTA messages—making an instrumental use of HTA—we also found conceptual and symbolic uses across all groups. Our results also indicate that significant organizational, scientific, and material limitations hinder the use of scientific evidence. Overcoming such barriers requires a greater commitment from both HTA producers and users.

Conclusions: This study argues that, to ensure better uptake of HTA, it should become a shared responsibility between HTA producers and various types of user.

Objectives: The diffusion of cost-utility analyses (CUAs) through the medical literature was examined, documenting visible patterns and determining how they correspond with expectations about the diffusion of process innovations.

Methods: This study used 539 CUAs from a registry. It includes data elements comprising year of publication, the research center in which the study was performed, the clinical area covered by the CUA, and the specific journal. Finally, each paper was assigned to a journal type that could be one of the three categories: health services research, general medicine, or clinical specialty.

Results: When the average number of publications is plotted against time, the plot reveals an S-shaped curve. It appears that, whereas CUAs initially were published more frequently in general medical or health services research journals, there was a clear increase in the diffusion of CUA into subspecialty journals over time. The concentration ratio for research centers as measured by the Herfindhal–Hirschman Index decreased over time.

Conclusions: The spread of CUA through the medical literature follows patterns identified for the diffusion of other new technologies and processes. Future research should focus on what impact this spread has had on the practice of medicine and formulation of health policy.

Objectives: The aim of this study was to evaluate the use of interdisciplinary review teams that have been the main and central work form in making health technology assessments at the Norwegian Centre for Health Technology Assessment.

Methods: Evaluation questionnaires were sent to all 112 participants in the 17 review teams for the period of January 1998 to June 2003 after completion of the literature assessment. Questions were on the theme/mandate of the assessments, composition of the review team, organization of the work, the working method, and update of the report.

Results: The teams ranged from 4 to 14 persons regarded as opinion leaders in their field. The project periods lasted from 4 to 33 months. In all, fifty-five participants gave fifty-eight responses (51.8 percent) to the questionnaires. A total of 83 percent thought the theme was well argued, and 62 percent thought the mandate for the assessments was sufficiently clear. Approximately 80 percent were positive to the composition of the review team. In all, 22 percent expressed that the work method was too extensive and 43 percent wanted more tuition. General comments were that the working method gave competence in assessing medical literature, relevant professional training, and tuition in a working method that ensured the legitimacy of their work.

Conclusions: The review team participants were satisfied with most aspects of the work. The Norwegian Centre for Health Technology Assessment will continue using interdisciplinary review teams in making health technology assessments.

Objectives: This work has investigated under what conditions cost-effectiveness data from a cluster randomized trial (CRT) are suitable for analysis using a cluster-adjusted nonparametric bootstrap. The bootstrap's main advantages are in dealing with skewed data and its ability to take correlations between costs and effects into account. However, there are known theoretical problems with a commonly used cluster bootstrap procedure, and the practical implications of these require investigation.

Methods: Simulations were used to estimate the coverage of confidence intervals around incremental cost-effectiveness ratios from CRTs using two bootstrap methods.

Results: The bootstrap gave excessively narrow confidence intervals, but there was evidence to suggest that, when the number of clusters per treatment arm exceeded 24, it might give acceptable results. The method that resampled individuals as well as clusters did not perform well when cost and effectiveness data were correlated.

Conclusions: If economic data from such trials are to be analyzed adequately, then there is a need for further investigations of more complex bootstrap procedures. Similarly, further research is required on methods such as the net benefit approach.

Objectives: The objective of this study was to conduct a cost-effectiveness analysis of Herceptin® from the hospital's point of view. This new biotechnological pharmaceutical is a humanized monoclonal antibody that targets the HER2 receptor, an important anti-cancer target.

Methods: A cost model with standard diagnostic and treatment options for breast cancer was set up for a Belgian university hospital in close collaboration with its specialists. Direct and indirect costs were calculated for each diagnostic and treatment option using the micro-costing method. Effectiveness was estimated through a literature study. The model allowed us to take cost consequences in other stages of the model into account and to calculate changes in monthly treatment costs from different “starting points.” With an incremental cost-effectiveness analysis, differences in costs and effectiveness with and without Herceptin® were compared.

Results: Over the complete treatment period from diagnosis until the metastatic phase, monthly costs for the hospital rose from €85.07 to €90.35 for stage I diagnosed breast cancer when adding Herceptin® to the model. In the metastatic phase alone, these costs rose from €1,132.33 to €1,256.23. With Herceptin®, we found an extra cost of €3,981.44 per extra life-month.

Conclusions: This cost-effectiveness ratio was rather high, because Herceptin® was quite expensive and the product was additive in its current use and did not replace existing treatments. Future research will concentrate on alternative applications of Herceptin® based on ongoing Herceptin® trials and expert opinions.

Cost-effectiveness analysis has much conceptual attractiveness in priority setting but is not used to its full potential to assist policy-makers on making choices in health in developed or in developing countries. We call for a shift away from present economic evaluation activities—that tend to produce ad hoc and incomparable economic evaluation studies and, therefore, add little to the compendium of knowledge of cost-effectiveness of health interventions in general—toward a more systematic approach. Research efforts in economic evaluation should build on the foundations of cost-effectiveness research of the past decades to arrive at an informative methodology useful for national policy-makers. This strategy means that governments should steer sectoral cost-effectiveness analysis to obtain systematic and comprehensive information on the economic attractiveness of a set of new and current interventions, using a standardized methodology and capturing interactions between interventions. Without redirecting the focus of economic evaluation research, choosing in health care bears the risk to remain penny-wise but pound-foolish.

Objectives: As health technology assessments (HTA) may have considerable impact on health-care decisions, it is essential to guarantee the expected quality of these assessments. Variations in the methods used or lack of transparency can affect the important role of HTA reports.

Methods: In our study, we analyzed the methods used in two corresponding HTA reports to assess the validity of two key papers, which were included in both reports. Also the discussions and the final conclusions of both reports were compared.

Results: The authors of the two HTA reports used different instruments to assess the validity of the original studies. A minor problem is differences that were found in the assessments of identical validity aspects of the included studies and in the information provided in the HTA reports. A more serious problem was found in both HTA reports which identified the weakness of the key papers and expressed these limitations in the discussions (read mainly by scientists) but not in the conclusions (read mainly by policy-makers).

Conclusions: The results of this study may be important for any institution that prepares recommendations for policy-makers. In the case of HTA reports, no new checklists are necessary as the checklist offered by the INAHTA contains the needed information. It may be necessary, however, to consider an “intramural quality board,” which helps the member organizations guarantee both the transparency of the original studies included in HTA reports and the transparency of the HTA report itself.

Albrecht, Johan A. See Neyt

Objectives: There has been a rapid growth in the use of patient-assessed outcomes (PAOs) that are measured in the assessment of health technologies. The process of collection of such measures can be costly, and there may be problems associated with the ability of the patient to complete them. The use of electronically stored routine data may reduce costs and overcome the problems associated with patient completion. The feasibility of using routine data surrogates for the UK Inflammatory Bowel Disease Questionnaire (UKIBDQ) and the Short Form 36 (SF-36) was examined.

Methods: Clinical terms and codes for the UKIBDQ and SF-36 questions were identified, and data from electronic routine sources were sought on patients participating in a randomized controlled trial. The presence or absence of relevant symptoms was used to generate surrogate scores, which were compared with the original scores.

Results: Most questions in the UKIBDQ and SF-36 were codable but only one third of the terms were recorded routinely in electronic form. The surrogate total IBDQ score had reasonable reliability (Kuder–Richardson coefficient = 0.51), but this reliability could not be determined for the SF-36. Intraclass correlations between routine and designed data were poor to weak.

Conclusions: Although electronic routine data sources had the capacity to develop surrogate measures for patient assessed outcomes, there was evidence of wide underutilization of coding systems leading to an underreporting of symptoms. This finding is consistent with previous literature where only poor correlations were illustrated between patient assessed outcomes and surrogate scoring of symptoms.

Objectives: This study aimed to determine the cost-effectiveness ofinfluenza vaccination in people 65–74 years of age in the absence of comorbidity.

In a recent publication in the “International Journal of Technology Assessment in Health Care” (7), Kildemoes and Kristiansen claim to address “Cost-effectiveness of interventions to reduce the thrombolytic delay for acute myocardial infarction.” Their study is based on a “Master of Public Health Assessment” thesis published by Kildemoes in the year 2001 (6). Three years ago, the author was informed that several of her assumptions were incorrect. In this letter, we will address six of the erroneous assumptions made by Kildemoes and Kristiansen.

Objectives: This study aimed to investigate the screening performance of measuring blood pressure and other variables in identifying those who willdevelop, or die from, ischemic heart disease and stroke and too quantify by howmuch drugs that lower blood pressure will reduce the risk of ischemic heart disease and stroke in those designated “screen positive.”

We appreciate the interests in our work and observe that we agree that earlier thrombolysis for AMI can reduce the AMI case fatality. The question is how much and at what price. There are no data available to directly address this issue, and we developed a simulation model to quantify costs and health consequences of less thrombolytic delay by using public awareness campaigns, telemedicine, or a combination of the two. Inevitably, such a model needs to be based on several uncertain parameter values. We performed a range of sensitivity analyses so readers of the analysis could see the effect of replacing our base case values with others that the reader might consider more appropriate. Due to space restrictions, we had to omit a table with sensitivity analyses that would have addressed several of the concerns Terkelsen and coworkers have.

§1.1. Recent data documents that not a “majority” but only 40% of Danish patients arrive at the hospital within 30 minutes of ambulance call (7;8). §1.2. The Dutch study confirmed that, even in areas with 13 minutes transport time to the hospital, comparable to the Danish scenery, a prehospital thrombolytic strategy reduced treatment delay by nearly 1 hour (5). §1.3. We appreciate that the authors confirm our viewpoint, that is, quoting that “the mortality reduction more than doubles up,” “if hospital delay is totally eliminated (corresponding to a delay reduction of 1 hour).” In the future, patients should be diagnosed before hospital admission and either treated before hospital admission with thrombolysis or transferred directly to interventional center for primary PCI. In both settings, the delay at the local hospital, averaging 1 hour, would be eliminated (1;8). §2.0. Kildemoes and Kristiansen may have misunderstood our arguments regarding the Boersma formula. We recommend that they read our previous viewpoint (9). We have no reason to believe that distribution of patient delay in Denmark differs significantly from other countries. Moreover, we are surprised that the case fatality estimates implemented by Kildemoes and Kristiansen differs significantly from findings in a recent Danish Health Technology Assessment and findings in previous meta-analyses (2;4;6). §3.1. For 7 years, the present group of authors have worked with telemedicine in the prehospital evaluation of patients. Our close collaborators, the ambulance operators and the company delivering telemedicine equipment, have confirmed our cost data, whereas they disagree with the cost data implemented by Kildemoes and Kristiansen. §3.2. Equipment for twelve-lead ECG acquisition is necessary when implementing prehospital diagnosis, irrespective of whether the diagnoses are established by telemedicine, by paramedics, or by physicians. §5. A 1-hour reduction in treatment delay is achievable by a prehospital diagnostic strategy, both in the setting of prehospital thrombolysis and in the setting of prehospital referral to interventional centers for primary PCI (6;8). This reduction in treatment delay should have a major impact on AMI fatality (also in Denmark; 3;6).

Objectives: This study examined the clinical- and cost-effectiveness of image-guided Hickman line insertions versus blind Hickman line insertions undertaken by nurses in adult cancer patients.

Objectives: This study reviewed the evidence for the effectiveness of different isolation policies and screening practices in reducing the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in hospital inpatients in an effort to develop transmission models to study the effectiveness and cost-effectiveness of isolation policies in controlling MRSA.

Effectiveness in health-care management has been defined as the relationship between what a manager achieves in terms of performance and what he or she is expected to achieve; that is, effectiveness is the extent to and means by which an organization carries out its defined functions (6). The implicit, albeit core functions of hospitals and primary care centers in providing patient access, professional and center responsiveness, effective and safe services, and improved health outcomes, have increasingly been blurred by other more explicit objectives, such as cost-containment and process reengineering. Indiscriminate cost-cutting and “reengineering mania” have become popular among health-care policy-makers all over the world. Such strategies have even been adopted by countries (including Spain) whose health-care expenditures have for decades ranked below the European average (9). However, the effects of these widespread trends have never been properly assessed. They seem to impose a common threat on professional job satisfaction, and in Europe, there are more impatient patients on the waiting list than ever (8)

Objectives: This study assesses the implications and cost-effectiveness of extending the role of midwives to include the routine (24-hour) examination of the healthy newborn usually carried out by junior doctors.

Objectives: A systematic review was performed to examine the effects of cholesterol, breast cancer, and cervical cancer screening on actual or intended health-promoting behaviors and health-related beliefs.