Women's health issues have in recent years become the focus for an unprecedented degree of sophisticated technologic incursion. While much of rapid technologic advances, confined as it largely is to the richest societies of the globe, has perhaps enabled women to hold their place in the workforce, it has also taken the natural biological processes from the quiet path of individual lives and put them into the hands of expert management. Women's health is now similar to other consumer goods, available for purchase alongside the many commodities of the modern urban lifestyle.

The province of British Columbia (BC), Canada is developing its first population-wide prenatal genetic screening program, known as triple-marker screening (TMS). TMS, initiated with a simple blood test, is most commonly used to screen for fetuses with the chromosomal abnormality known as Down syndrome or neural tube disorders. Women testing TMS-positive are offered diagnostic amniocentesis and, if the diagnosis is confirmed, selective second-trimester abortion. The project described in this study was initiated to address the broad range of issues arising from this testing technology and provides an example of the new type of health technology assessment (HTA) contribution emerging (and likely to become increasing necessary) in health policy development. With the advent of prenatal genetic screening programs, would-be parents gain the promise of identifying target conditions and, hence, the option of selective abortion of affected fetuses. There is considerable awareness that these developments pose challenges in every dimension (ethical, political, economic, and clinical) of the health-care environment. In the effort to construct an appropriate prenatal screening policy, therefore, administrators have understandably sought guidance from within the field of HTA. The report authors concluded that, within the restricted path open to it, the role of government is relatively clear. It has the responsibility to maintain equal access to prenatal testing, as to any other health service. It should also require maintenance of medical standards and evaluation of program performance. At the same time, policy-makers need actively to support those individuals born with disabilities and their families.

Objectives: To conduct a systematic review of selected health determinants, including gender, and their impact on hospitalization rates for depression. Depression includes both depressive and bipolar disorders. Selected health determinants were gender, age, sex, family structure, education, and socioeconomic status.

Methods: Systematic search of conventional and fugitive literature sources. All reports of primary data, systematic reviews, and meta-analysis of primary data were included if they focused on hospitalization for depression and reported data by one or more of the selected health determinants. Two researchers independently evaluated each citation for inclusion and extracted data from the included studies.

Results: There is an important underreporting of health determinants data in studies of hospitalization for depression. No studies examined the role of gender. Age and sex were reported in 83 percent and 80 percent of the 110 included studies. Women showed a higher rate of hospitalization for depression than men (p<.05). Age and diagnosis had different effects in men and women. Adult women were significantly more likely than men to report a depressive disorder, whereas men were more likely to report a bipolar disorder (p<.05). Little can be concluded on the other health determinants.

Conclusions: The importance of reporting hospitalization data and conducting hospital utilization analysis by sex and health determinants, including gender, must be emphasized.

A systematic review and meta-analysis of randomized trials of nonpharmaceutical and nonhormonal interventions to reduce postnatal depression was carried out to summarize the effectiveness of interventions grouped in terms of the nature and timing of the intervention and whether the trial population was universal, selective, or indicated.

Objectives: The increasing availability of information about health care suggests an expanding role for consumers to exercise their preferences in health-care decision-making. Numerous methods are available to assess consumer preferences in health care. We conducted a systematic review to characterize the study of women's preferences about health care

Methods: A MEDLINE search from 1965 to July 1999 was conducted as well as hand searches of the itshape Medical Decision Making Journal (1981–1999) and references from retrieved articles. Only original articles on women's health issues were selected. Information on thirty-one variables related to study characteristics and preferences were extracted by two independent investigators. A third investigator resolved disagreements. Qualitative and quantitative analyses were conducted to synthesize the data.

Results: Four hundred eighty-three studies were identified in the initial search. Seventy articles were selected for review based on title, abstract, and inclusion criteria. There was an increase in published articles and number of methods used to elicit preferences. White women were studied more than black women (p<.001). Preferences were mainly studied in outpatient settings (p<.005) and in the United States, United Kingdom, and Canada (83 percent). Preferences related to participation in decision-making were the most common (21 percent). Only 4 percent of the studies were performed to inform the debate for public policy questions. Willingness to pay was the method most used (11 percent), followed by category scaling (10 percent), rating scale (9 percent), standard-gamble (6 percent). Preferences for individual particular (opposed to sequential and health states) outcomes (68 percent), different treatments/tests (47 percent), and related to a treatment episode (31 percent) were addressed. Information regarding diseases, conditions, or procedures was given in 57 percent of studies. Information provided was mainly written (37 percent) and included positive and negative potential outcomes (67 percent). There is no relationship between the method or tool used for delivery information and the choice performed.

Conclusions: The literature on preferences in women's health care is limited to a fairly homogeneous population (white women from the United States, United Kingdom, and Canada). Additionally, use of utility-based measures to capture preferences has decreased over time while others methods (e.g., time trade-off [TTO], contingent valuation) have increased. Women's preferences are not necessarily uniform even when asked similar questions using similar tools. Little information on women's preferences exists to inform policy-makers about women's health care.

Greater access to web-based information on health-care interventions might result in greater participation by patients in care and self-care decisions, but only improve health outcomes if the indicated actions produce the intended benefits. Unbiased research on benefits and harms of health information can provide a basis for evidence-based patient information systems.

Objectives: To evaluate the quality of the information content on bone-mineral density (BMD) testing posted on consumer health websites (CHWS).

Methods: Five popular engines (Yahoo, MSN, AOL, Lycos, and Go.com) were used to search for patient information on bone densitometry. The fifteen websites that supplied relevant content and were identified by three of the five search engines were selected in order of popularity of the search engine and primacy of placement. Six BMD reports from health technology assessment (HTA) organizations were used as a standard of scientific quality. These were identified from the HTA Database at York University United Kingdom and published between 1996 and 2001. Content was extracted from both document types, and these sets were compared independently by two reviewers.

Results: The majority of CHWS identified by popular search engines do not disclose the limited capacity of BMD to discriminate between low-risk individuals and those who will suffer future fractures. CHWS generally present BMD testing as quick, painless, noninvasive, and as being recommended, based on risk factors that are widespread among the general public. BMD testing information is prominently paired on CHWS sites with information on osteoporosis, with an emphasis on “silent disease” and the devastating consequences of advanced disease. Sponsors of CHWS sites are frequently either providers of BMD testing or companion drugs, and consequently in a position of conflict of interest with regard to decisions to undergo BMD testing. HTA organizations have no documented conflict of interest, nor do they invoke emotional arguments. Their approach is to emphasize the effects of testing on populations, on the basis of referenced research findings.

Conclusions: Content analysis demonstrates the omissions and divergence of information on BMD testing available to consumers on the Internet, as compared with HTA reports. The content of HTA reports has undergone rigorous systematic and peer review; therefore, their findings may be useful to consumers. This information is not generally accessible to patients using the most popular Internet search engines. Inaccurate and incomplete information may cause harm by deflecting patients from optimal decisions.

Certain key parameters such as safety, efficacy, effectiveness, and cost effectiveness have long been established as key in HTA analysis. Equally important, however, are sociolegal and epidemiologic perspectives. A comprehensive analytic framework will consider the implications of using a technology in the context of societal norms, cultural values, and social institutions and relations. The methodology in which this expanded framework has been developed is termed ‘Strategic HTA’ to denote its power for the decision-making process. In addition to systematic reviews of published evidence, it incorporates analyses of the influence of dominant social relations on technological development and diffusion. This essay discusses the social epidemiologic aspects of health technology assessment, which includes factors such as sex and gender. It seeks to show how it is possible to bring data from wide-ranging disciplinary perspectives within the parameters of a single scientific inquiry; to draw from them scientifically defensible conclusions; and thereby to realize a deeper understanding of technology impact within a health care system. Armed with such an understanding, policy officials will be better prepared to resolve the competitive clamor of stakeholder voices, and to make the most “equitable” use of the available resources.

Objectives: To elucidate important differences between a health technology assessment (HTA) and a systematic review, using an HTA of positron emission tomography (PET) as an example.

Methods: Interviews with seventeen individuals who were authors or users of the PET HTA.

Results: Those interviewed identified seven areas in which HTAs often differ from traditional systematic reviews: (i) methodological standards (HTAs may include literature of relatively poor methodological quality if a topic is of importance to decision-makers), (ii) replication of previous studies (relatively common for HTAs but not systematic reviews), (iii) choice of topics (more policy oriented for HTAs, while systematic reviews tend to be driven by researcher interest), (iv) inclusion of content experts and policy-makers as authors (policy-makers more likely to be included in HTAs, although there are potential conflicts of interest), (v) inclusion of economic evaluations (more often with HTAs, although economic evaluations based upon poor clinical data may not be useful), (vi) making policy recommendations (more likely with HTAs, although this must be done with caution), and (vii) dissemination of the report (more often actively done for HTAs).

Conclusions: This case study of an HTA of PET scanning confirms that HTAs are a bridge between science and policy and require a balance between the ideals of scientific rigor and the realities of policy making.

Objectives: The cost-effectiveness of fracture prevention treatments (vitamin D and calcium and hip protectors) in male and female populations older than seventy years of age in the United-Kingdom was investigated.

Methods: A Markov model was developed to follow up, over lifetime, a hypothetical cohort of males and females at high-risk and general risk of fracture. Patients could sustain hip, wrist, vertebral, and/or other fractures. Fracture rates were obtained from population surveys in the United Kingdom. Effectiveness and quality of life data were identified from the clinical literature. Costs were those incurred by the UK National Health Service, and were obtained from several published sources. Uncertainty was explored through probabilistic sensitivity analysis.

Results: In the general-risk female (male) population, the incremental cost per Quality Adjusted Life Year (QALY) was $11,722 ($47,426) for hip protectors. In the male high-risk population, the incremental cost per QALY was $17,017 for hip protectors. In the female high-risk population, hip protectors were cost-saving. Vitamin D and calcium alone was dominated by hip protectors in all four subgroups.

Conclusions: Current information available on interventions to prevent fractures in the elderly in the United Kingdom, suggests that, at the decision-maker's ceiling ratio of $20,000 per QALY, hip protectors are cost-effective in the general female population and high-risk male population, and cost-saving in the high-risk female population, despite the low compliance rate with the treatment.

Objectives: To assess the relative cost-effectiveness of laparoscopic methods of inguinal hernia repair compared with open flat mesh and open non-mesh repair.

Methods: Data on the effectiveness of these alternatives came from three systematic reviews comparing: (i) laparoscopic methods with open flat mesh or non-mesh methods; (ii) open flat mesh with open non-mesh repair; and (iii) methods that used synthetic mesh to repair the hernia defect with those that did not. Data on costs were obtained from the authors of economic evaluations previously conducted alongside trials included in the reviews. A Markov model was used to model cost-effectiveness for a five-year period after the initial operation. The outcomes of the model were presented using a balance sheet approach and as cost per hernia recurrence avoided and cost per extra day at usual activities.

Results:Open flat mesh was the most cost-effective method of preventing recurrences. Laparoscopic repair provided a shorter period of convalescence and less long-term pain compared with open flat mesh but was more costly. The mean incremental cost per additional day back at usual activities compared with open flat mesh was €38 and €80 for totally extraperitoneal and transabdominal preperitoneal repair, respectively.

Conclusions:Laparoscopic repair is not cost-effective compared with open flat mesh repair in terms of cost per recurrence avoided. Decisions about the use of laparoscopic repair depend on whether the benefits (reduced pain and earlier return to usual activities) outweigh the extra costs and intraoperative risks. On the evidence presented here, these extra costs are unlikely to be offset by the short-term benefits of laparoscopic repair.

Objectives: To compare the cost-effectiveness of alternative methods of screening for retinopathy of prematurity (ROP) in the United Kingdom, including the existing method of indirect ophthalmoscopy by ophthalmologists and digital photographic screening by nurses.

Methods: A decision tree model was used to compare five screening modalities for the UK population of preterm babies, using a health service perspective. Data were taken from published sources, observation at a neonatal intensive care unit (NICU), and expert judgment.

Results: We estimated that use of standard digital cameras by nurses in NICUs would cost more than current methods (£371 compared with £321 per baby screened). However, a specialist nurse visiting units with a portable camera would be cheaper (£172 per baby). These estimates rely on nurses capturing and interpreting the images, with suitable training and supervision. Alternatively, nurses could capture the images then transmit them to a central unit for interpretation by ophthalmologists, although we estimate that this would be rather more expensive (£390 and £201, respectively, for NICU and visiting nurses). Sensitivity analysis was used to examine the robustness of estimates.

Conclusions: It is likely that there is an opportunity to improve the efficiency of the ROP screening program. We estimate that screening by specialist nurses trained in image capture and interpretation using portable digital cameras is a cost-effective alternative to the current program of direct visualization by ophthalmologists. This option would require the development of a suitable portable machine. Direct comparative research is strongly needed to establish the accuracy of the various screening options.

Objectives:To compare the six-year outcome of a multidisciplinary rehabilitation program with continued care within primary care in terms of health-related quality of life and cost-effectiveness. Furthermore, predictors of total costs to society were examined.

Methods:A prospective, matched, controlled, six-year follow-up was designed. The study included 236 patients (42 men, 194 women) nineteen to sixty-one years of age with prolonged musculoskeletal disorders. The intervention comprised a four-week multidisciplinary rehabilitation and an active one-year follow-up based on a bio-psycho-social approach. The control group received continued care within primary care. The main outcome measures were quality of life measured using the Nottingham Health Profile, motivation identified by an interview and patient-specific total costs to society. Differences in mean costs between groups and cost-effectiveness were evaluated by applying nonparametric bootstrapping techniques.

Results: Total costs per treated patient in the rehabilitation group and the control group were £43,464 (SD=31,093) and £44,123 (SD=33,333), respectively (p=.896). Multidisciplinary rehabilitation improved quality of life somewhat more cost-effectively. Motivation was revealed as a predictor of total costs.

Conclusion: In the long-run, the evaluated multidisciplinary rehabilitation improved the highly motivated patients' quality of life most cost-effectively. The latently motivated patients may require rehabilitation, which is less intensive and with a longer duration, to improve their health in a whole-person perspective. The burden of prolonged musculoskeletal disorders to society was reaffirmed. Motivation could be a predictor of total costs, a factor which has to be taken into account in the examination procedure.

Objectives: The aim of the study reported here was to investigate whether the use of magnetic resonance imaging (MRI) impacts on the clinical management of patients presenting with chronic knee problems, reduces costs, and improves patient outcome.

Methods: A single-center randomized controlled trial was conducted. Patients attending with knee problems in whom surgery was being considered were randomized either to investigation using an MRI scan or to investigation using arthroscopy. The study investigated benefits in terms of avoidance of surgery and patient health-related quality of life (using SF-36 and EQ-5D). Costs were assessed from the perspectives of the National Health Service and patients. All analyses were by intention to treat.

Results: The trial recruited 118 patients. No statistically significant differences were found between groups in terms of health outcome. However, the use of MRI was associated with a positive diagnostic/therapeutic impact: a significantly smaller proportion of patients in the MRI group underwent surgery (MRI=0.41, No-MRI=0.71; p value=.001). There was a similar mean overall cost for both groups.

Conclusions: The use of MRI in patients with chronic knee problems, in whom surgery was being considered, did not increase costs overall, was not associated with worse outcomes, and avoided surgery in a significant proportion of patients.

Objectives: Summary physical health scores for the Short Form (SF) measures are computing using positive weights for physical items and negative weights for mental health items. Mental health summary scores use positive weights for mental items and negative weights for physical. The RAND Health Status Inventory (HSI) measures do not use negative weights. Do these different approaches to scoring matter? The objective was to compare summary scores using both the SF and RAND-HSI.

Methods: SF-36 and the Health Utilities Index Mark 3 (HUI3) were administered to a cohort of patients waiting for elective total hip arthroplasty (THA). SF-12 and HUI3 were administered to a cohort of high-risk primary-care patients. Summary scores were generated and compared. Single-attribute utility scores for emotion in HUI3 were also computed. Canadian and US norms for SF, RAND-HSI, and HUI3 were used to interpret results.

Results: For THA patients, mean physical health scores were 28 and 36 for SF and RAND-HSI. Mean mental health scores were 55 and 42. For the primary-care patients, the scores were 34 and 36 for physical and 46 and 40 for mental health.

Conclusions: SF and RAND-HSI provided somewhat similar summary scores in the THA study. However, SF and RAND-HSI mental health scores differed in the primary-care patient cohort and results from HUI3 corroborate the mental health deficits identified by the RAND-HSI. It may be wise for investigators to use both SF and RAND-HSI scoring systems.

The longer you can look back, the better you can look forward

—Sir Winston Churchill

Objectives: To compare the hospitalization day price, and the hospitalization costs 100 years ago with the present situation.

Methods: Municipal and hospital archives of two cities, Maastricht in The Netherlands and Tongeren in Belgium, were studied systematically for reports of costs. These were compared with the present accounts.

Results: Starting from the second part of the nineteenth century, an official day price was calculated each year by averaging the total hospital expenditures by the total number of hospitalization days. Of all expenditures, nutrition accounted for nearly 50% of expenses. Differences with the current situation are striking. Nowadays, the day price is a negotiated tariff. Management and salaries make up more than 70% of the present expenditures.

Conclusions: Hospitalization day prices have been used for approximately 150 years to determine hospitalization costs. Since then, the total hospital expenditures and the relative cost components have changed considerably. Compared with the spending power of people, the cost of one day in the hospital increased substantially.

Objectives: The clinical assessment efficiency of the CAGE questionnaire for alcohol abuse based on diagnostic accuracy has not been fully established to date because of the varied and inconclusive gold standards used as diagnostic criteria. CAGE has also been highlighted to miss almost half of the risk-drinkers due to the use of inadequetly set criteria for the positive recognition of alcohol abuse. This study aims to establish the diagnostic accuracy of CAGE at different treatment settings.

Methods: A hybrid of the receiver operating characteristic (ROC) and the Taguchi method was used, as this approach proved to evaluate the diagnostic performance and accuracy in hypothetical clinical settings. Data were used from three cross-clinical treatment settings, i.e., general medicine outpatients, medical inpatients, and psychiatric inpatients, and analyzed by means of a step-wise application of managable number of statistical indices such as the area under the ROC curve (AUC), leveling factor (p′), and signal-to-noise ratios (S/N; standardized S/N [SS/N]).

Results: The selected settings yielded similar AUCs but portrayed different trade-offs on the ROC curves signaling the presence of different critical CAGE scores. Analysis of the sensitivity and specificity data of i, ii, iii by p′, S/N, SS/N and their dependent relation resulted in the critical CAGE scores of 1,1, and 2; and high diagnostic accuracy levels of 76.84 percent, 86 percent, and 76.84 percent, respectively.

Conclusions: By setting these critical CAGE scores as the minimum detection levels of alcohol abuse, early intervention before the onset of serious alcohol-related problems is possible. This will decrease the health-care costs of the patient and, in addition, reduce the psychological and social burdens inherent to alcohol abuse both on the patient and society. Having its critical scores reliably identified and diagnostic accuracy fully determined, CAGE can now improve the detection rate of problem drinking individuals substantially.