Both observational studies and nonrandomized controlled trials have found the presence of support during pregnancy to be associated with superior outcomes in terms of preventing abortion, extending the length of gestation, and reducing interventions in labor. However, randomized controlled trials of supportive interventions in pregnancy have not demonstrated any physical benefits from the interventions. It is also unlikely there are any significant adverse effects. Psychological benefits do appear to result from supportive interventions, including better enjoyment of the pregnancy and better postnatal status.

Hospital-based “firms” provide a means for combatting the fragmentation experienced by both patients and caregivers in the modern teaching hospital environment. A “firm” is an academic group practice that includes attending physicians, physician trainees, nurses, other staff, and patients. Each person's relationship with a firm lasts throughout his or her association with a particular institution. This article describes the firm system that was recently implemented on the Medical Service of the Cleveland VAMC. This system incorporates both inpatient and outpatient general medical services and provides for unbiased assignment of patients, physicians, and nurses.

Motor vehicle crashes are a leading cause of morbidity and mortality. In the Haddon matrix, crashes are divided into three phases and factors affecting each phase. In the context of this matrix, the effectiveness, use, and legislation of safety belts and airbags are discussed, using process, injury, and economic outcome measures.

Objectives: The aim of this study was to estimate the potential cost-effectiveness and expected value of perfect information of a recently derived clinical prediction rule for patients presenting to emergency departments with chest discomfort.

Methods: A decision analytic model was constructed to compare the Early Disposition Prediction Rule (EDPR) with the current standard of care. Results were used to calculate the potential cost-effectiveness of the EDPR, as well as the Value of Information in conducting further research. Study subjects were adults presenting with chest discomfort to two urban emergency departments in Vancouver, British Columbia, Canada. The clinical prediction rule identifies patients who are eligible for early discharge within 3 hours of presentation to the emergency department. The outcome measure used was inappropriate emergency department discharge of patients with acute coronary syndrome (ACS).

Results: The incremental cost-effectiveness ratio of the EDPR in comparison to usual care was (negative) $2,999 per inappropriate ACS discharge prevented, indicating a potential cost-savings in introducing the intervention. The expected value of perfect information was $16.3 million in the first year of implementation, suggesting a high benefit from conducting further research to validate the decision rule.

Conclusions: The EDPR is likely to be cost-effective; however, given the high degree of uncertainty in the estimates of costs and patient outcomes, further research is required to inform the decision to implement the intervention. The potential health and monetary benefits of this clinical prediction rule outweigh the costs of doing further research.

Objectives: We developed specific evaluation criteria to assess patient and public involvement in resource allocation decisions in health care.

Methods: We reviewed the literature from health and other sectors relevant to stakeholder involvement and conducted twenty-seven key informant interviews with stakeholders knowledgeable about patient and public involvement in Canadian drug resource allocation decisions. We used an inductive qualitative thematic approach to analyze the interviews with codes and categories developed directly from individuals’ interview transcripts.

Results: Integrating respondents’ comments and the literature review, we identified nine evaluation criteria of patient and the public involvement in healthcare resource allocation decision making: clarity regarding rationale and roles of patient and public members, sufficient support, adequate representation of relevant views, fair decision-making processes, legitimacy of committee processes, adequate opportunity for participation, meaningful degree of participation, noticeable effect on decisions, and considerations of the efficiency of patient and public involvement.

Conclusions: Our results will help to develop methods to evaluate patient and public involvement in healthcare decision making.

Background: Rapid on site evaluation (ROSE) allows immediate processing and interpretation of the aspirate in the procedural suite. It improves diagnostic yield and lowers patient care costs. There are limited data on its cost-effectiveness with endobronchial ultrasound (EBUS).

Methods: We developed an economic model with two arms, no ROSE (our current practice) and simulated ROSE. To simulate ROSE, a cytopathologist retrospectively identified the first diagnostic slide in each case. Using a decision analytic modeling technique under a hospital diagnostic unit perspective, the benefits of simulated ROSE were estimated as cost-savings. The model input was estimated from actual data, consulting experts, and the literature. The benefits were estimated as cost savings per patient and for the province of Alberta per year. Due to differences in the procedure, sarcoidosis and cancer patients were analyzed separately. The costs are shown in 2012 Canadian dollars, CAD.

Results: In our model without ROSE, the procedure cost/patient was CAD 646.00(USD 523.32) for cancer and CAD 1,170.00 (USD 947.73) for sarcoidosis. With simulated ROSE cost savings of CAD 63.00(37.00 to 89.00) [USD 51.04(29.97 to 72.10)], CAD 544.00(490.00 to 598.00) [USD 440.65(397.05 to 484.44)] for cancer and sarcoidosis, respectively. Extrapolating this to provincial data, our model estimates that EBUS with ROSE would lead to savings of CAD 50,000.00(30,000 to 71,000) [USD 40,501.24 (24,300.75 to 57,531.34)] for cancer and CAD 109,000.00 (87,000 to 130,000) [USD 88,337.07 (70,546.45 to 105,313.04) for sarcoidosis.

Conclusion: The use of ROSE with EBUS is cost saving. The projected savings were CAD 50,000.00 (USD 40,501.24) and CAD 109,000.00(USD 88,337.07) in cancer and sarcoidosis, respectively, for the province of Alberta, Canada.

Objectives: The aim of this study was to determine adults’ Willingness To Pay (WTP) for CardioVascular Disease (CVD) intervention programs of different intensities.

Methods: Three hundred fourteen participants were randomized to two study conditions: (i) CVD risk assessment/communication; (ii) CVD risk assessment/communication + a behavior change program. The behavior change program was aimed at increasing physical activity, reducing saturated fat intake and smoking cessation. It consisted of a tailored Web site and individual coaching with a self-selected dose. At post-assessment, WTP and perceived autonomy support items were included. The intervention dose was registered throughout the trial and post-hoc intervention dose groups were created. Pearson Chi-Square tests, Student's t-tests, one-way analyses of variance were used to examine WTP-differences between the study conditions and intervention dose groups.

Results: Twenty-four months after baseline, 61 and 135 participants of the control and intervention condition, respectively, completed the questionnaires. No WTP difference was found between the study conditions. However, participants that selected a higher intervention dose were willing to pay significantly more for their program (p < .05).

Conclusions: In general, people want to pay the same amount of money for a CVD prevention program, irrespective of the inclusion of a behavior change program. However, there seems to be an association between the self-selected dose of the latter program and the WTP.

In healthcare decision making, there is an important functional separation between assessment and appraisal. In the U.K. National Health Service (NHS), this distinction is illustrated by the separation of roles between the Health Technology Assessment Programme and the National Institute for Clinical Excellence. However, it can be seen at every level within the healthcare system. Assessment of a technology is a scientific task that synthesizes all relevant evidence on effectiveness and cost-effectiveness; its results are therefore generalizable. Appraisal of the technology is informed by the assessment but adds context-specific judgments on the applicability of the evidence, the feasibility and impact of alternative options, relative priorities, and wider social and ethical aspects. An explicit distinction between assessment and appraisal is helpful in achieving clarity, consistency, and consensus. It also makes clear the need for a wide range of assessment reviews to support decision making by commissioners, providers, and users of health services. Increasingly, the secondary research supported by the NHS R&D Programme is being distributed electronically. It is also being used to identify areas in which further primary research should be commissioned.

This article presents an overview of technology assessment in the United States. The authors argue that while there are numerous institutions carrying out assessments, the United States requires an overall plan that would provide a national system for technology assessment. If technology assessment were more organized and systematized, the authors argue, it would be more efficient and would reach the public and the medical world effectively.

This review focuses on the component of health education directed at achieving changes in health behavior. Much of the work in this field has centered on health behavior that has a role in preventing future disease. Because the evidence is strongest in relation to coronary heart disease (17), considerable effort has been devoted to this area. Walter et ai. (34) indicated that the most relevant forms of health behavior to be considered in school-based programs on heart disease are those relating to diet, physical activity, and smoking. Programs relating to each of these behaviors are addressed here.

Battista has written a thoughtful and timely challenge to the field of health technology assessment (HTA). As the author points out, HTA is changing and evolving. One of the greatest challenges is that HTA now seems firmly established in a number of countries, and is being looked to more and more for the “answers.” We accept and endorse Battista's central thesis, and essentially all of his critical questions, including his ideas about future research topics. We hope to evoke further thoughts in the reader and perhaps stimulate other responses, either private and public.

Objectives: The aim of this study was to present and illustrate an instrument to measure the level of innovation at country level.

Methods: The data used are the Organisation for Economic Co-operation and Development (OECD) health data 2009, in particular the information on use of medical technology. Two composite scales expressing a relative level of adoption of innovations in health care are regressed, using multilevel regression analysis, on country characteristics. The country characteristics are selected as proxies on availability or scarcity of resources in a country. We expect that scarcity will promote adoption of innovations that enhance efficiency, and that availability of resources will promote advanced, expensive innovations.

Results: Two scales were constructed. One scale indicates the use of efficiency-enhancing innovations (day case treatment), and the other scale indicates availability of advanced technical innovations. The application of day case treatment is significantly associated with education level (+), the ratio of people aged 15–64 versus younger and older people (+) and the number of hospital beds (−). Availability of advanced medical devices are associated with the expenditure on health (+), demographic dependency (−), number of hospital beds (+), and the annual reduction of hospital beds (−).

Conclusions: Diffusion of innovations is influenced by characteristics of the country and of the healthcare system; fewer resources encourage diffusion of innovations that enhance efficiency and more resources encourage diffusion of complex, expensive devices. This indicates that decisions by healthcare professionals on which innovation to adopt is embedded in a context that is influenced and shaped by the availability of resources on macro level.

This paper examines the current status of in vitro fertilization and embryo transfer (IVF-ET) as a treatment for various types of infertility. We reviewed studies on the efficacy and safety of IVF-ET and intracytoplasmic sperm injection (ICSI) plus IVF-ET, compared with conventional treatment or no treatment for various infertility diagnoses. Material retrieved included English language publications between 1992 and January 1997 that reported the results of prospective controlled clinical trials, cohort studies, and retrospective comparative studies with large series, and reviews presenting risks, complications, and longer-term health consequences associated with IVF-ET and ICSI. No adequate prospective comparative studies of sufficient power on the use of IVF-ET for specific infertility diagnoses have been reported to date. Most of the published reports concerning results with IVF-ET as a treatment of infertility have been based upon small, uncontrolled studies, with various methodological weaknesses. Reported results are not directly comparable. There are few follow-up data on outcomes after pregnancy is established or on long-term health consequences of the use of IVF-ET on mothers and their babies. IVF-ET has diffused widely without comprehensive assessment of its efficacy and safety. The available evidence supports its use only for severe bilateral tubal occlusion. For other diagnoses of infertility the evidence is limited and does not establish whether IVF-ET is effective. Long-term, well-designed, prospective clinical trials are required to determine when and for what indications IVF-ET is effective and what its health effects are on both mothers and their babies.

We evaluated the cost-effectiveness of (a) a vaccination program for the prevention of hepatitis B; and (b) the two commercially available vaccines (Merck Sharp and Dohme; Pasteur Institute) in Greece, a country of intermediate endemicity. We examined cases of hepatitis-B infection prevented and the expected medical costs among the high-risk groups of medical and nursing students, hospital personnel, and the general population. Employing a vaccination program reduces considerably the risk of infection, especially in the high-risk groups, while it increases the total cost. The vaccines are very comparable in terms of both health and economic outcomes. Sensitivity analysis indicated that vaccine cost, incidence of hepatitis B, and compliance were the key factors for the choice of (a) whether to undertake an extensive program to prevent hepatitis-B infection and its chronic sequelae; and (b) which vaccine to administer.

Objectives: Shoulder complaints (SCs) constitute the second largest group of musculoskeletal disorders after low back pain. The economic burden in terms of costs of healthcare use and costs due to work absenteeism underlines the need for a cost-effectiveness analysis of the interventions involved. The education and activation program (EAP) is a newly developed early intervention to prevent the development of chronic SCs. A cost-effectiveness analysis should provide more information on the effect of an EAP on total costs related to SCs.

Methods: We conducted a cost-effectiveness analysis alongside a randomized clinical trial comparing the effectiveness of the EAP in addition to usual care (EAP group) with that of usual care alone (UC group) in terms of preventing chronicity in patients with acute SCs. The aim of the cost-effectiveness analysis was to compare the observed difference in costs with the clinical effectiveness (i.e., patient-perceived recovery after 26 weeks), using bootstraps.

Results: The comparison of total costs between treatment groups showed no significant (p = .077) difference after 26 weeks. The majority (82 percent) of the cost-effect pairs after bootstrap analysis were located in the northeast quadrant, suggesting more effect but at higher costs.

Conclusions: In view of the clinical relevance of the clinical outcomes and the considerable costs needed to achieve this, it can be concluded that the EAP is currently not cost-effective.

Background: Contrast-induced acute kidney injury (CI-AKI) is defined as a deterioration in renal function after administration of radiologic iodinated contrast media (CM). Iodixanol, showed a lower CI-AKI incidence than low-osmolar contrast media (LOCM). A cost-effectiveness analysis was performed comparing iodixanol and LOCM in intravenous (IV) setting in Italy.

Methods: A Markov model was developed. Patients moved across four health states: CI-AKI free, CI-AKI, myocardial infarction, and death. The simulation horizon was lifetime with 1-month cycles. Costs and outcomes were discounted at 3.5 percent rate. CI-AKI incidence was considered from published literature across different definitions. Cost-effectiveness of iodixanol was assessed in terms of incremental cost per life-year gained. Net monetary benefit (NMB) was also calculated. Both deterministic and probabilistic sensitivity analyses were performed.

Results: Base-case results showed an average survival increase of 0.51 life-years and a savings of €7.25 for iodixanol versus LOCM. The cost-effectiveness of iodixanol was confirmed when other scenarios were explored, such as varying CI-AKI definition, sub-populations with specified risk factors, CM hospital bids prices, and inclusion of adverse drug reactions of allergic nature. An NMB ranging between €6,007.25 and €30,007.25 was calculated.

Conclusion: Base-case results show that IV iodixanol is cost-effective compared with LOCM in the Italian clinical setting of a hospital computed tomography radiology practice. However, some caution is due, mainly linked to inherent limitations of the modeling technique and to the lack of agreement on CI-AKI incidence data in the clinical literature.

While international variations in intervention rates are well recognized, little is known about their implications for patient selection. This paper describes an exploratory study in which the probability of undergoing an elective intervention (surgery for benign prostatic hyperplasia) in an area in the United Kingdom was compared with an area in the United States. It found that the area with high intervention rates was associated with higher levels of surgery in men with low levels of need who are unlikely to gain much benefit.

Objectives: The aim of this study was to examine the use of implicit and explicit Bayesian methods in health technology assessments and to identify whether this has changed over time.

Methods: A review of all health technology assessment (HTA) reports of secondary research published by the UK National Institute of Health Research (NIHR) between 1997 and 2011. Data were extracted on the use and implementation of Bayesian methods, whether defined as such by the original authors (i.e., explicit) or not (i.e., implicit).

Results: A total of 155 of 375 (41 percent) NIHR HTA reports, identified as relevant to this review, contained a Bayesian analysis. Of these, 128 (83 percent) contained an implicit Bayesian analysis, 3 (2 percent) an explicit Bayesian analysis and 24 (15 percent) both implicit and explicit Bayesian analyses. Of the twenty-seven reports that explicitly used Bayes theorem, only six included prior information in the form of (informative) prior distributions. Over time, the percentage of HTA reports that used Bayesian (implicit and/or explicit) methods increased from 0 percent in 1997 to nearly 80 percent in 2011.

Conclusions: This review has shown that there has been an increase in the use of Bayesian methods in HTA, which is likely to be a result of the increase in freely available resources to implement the approach. Areas where Bayesian methods have the potential to advance healthcare evaluations in the future are considered in the discussion.