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Biomedical subjects

A L Hillman

Publications and source records attributed to A L Hillman.

At least 19 recordsLinked to original sources
PubMed1998

Competing practice guidelines: using cost-effectiveness analysis to make optimal decisions.

In this paper, cost and effectiveness data for six clinical interventions are applied simultaneously to a hypothetical population of 100,000 patients to show how selecting guidelines to maximize overall population benefit compares with selecting the best guidelines for individual patients. By entering effectiveness (added survival) and cost information from recent prevention, screening, diagnostic, and therapeutic guidelines into a computer-based optimization model, the options that maximized overall population effectiveness while keeping additional cost within varying specified constraints were identified. In 57% of selection opportunities, the clusters of guidelines that yielded maximum population benefit differed from those that maximized benefit for individual patients. Some choices were more stable than others over ranges of cost constraints. Clinical practice guidelines chosen to maximize cost-effectiveness for individual patients often do not maximize cost-effectiveness for populations of patients. To allocate resources as efficiently as possible, decision makers should consider other sources of information in addition to the recommendations of specific practice guidelines. "Robust" guidelines that simultaneously address both individual and societal health benefit should be sought.

Cost-Benefit Analysis↗
PubMed1998

Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care.

OBJECTIVES: A randomized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization (HMO). METHODS: Half of 52 primary care sites received the intervention, which included written feedback and a financial bonus. Mammography, breast exam, colorectal screening, and Pap testing compliance rates were evaluated. RESULTS: From 1993 to 1995, screening rates doubled overall (from 24% to 50%), with no significant differences between intervention and control group sites. CONCLUSIONS: Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO.

Aged↗
PubMed1998

"Virtual" clinical trials: case control experiments utilizing a health services research workstation.

We created an interface to a growing repository of clinical and administrative information to facilitate the design and execution of case-control experiments. The system enables knowledgeable users to generate and test hypotheses regarding associations among diseases and outcomes. The intuitive interface allows the user to specify criteria for selecting cases and defining putative risks. The repository contains comprehensive administrative and selected clinical information on all ambulatory and emergency department visits as well as hospital admissions since 1994. We tested the workstation's ability to determine relationships between outpatient diagnoses including hypertension, osteoarthritis and hypercholesterolemia with the occurrence of admissions for stroke and myocardial infarction and achieved results consistent with published studies. Successful implementation of this Health Services Research Workstation will allow "virtual" clinical trials to validate the results of formal clinical trials on a local population and may provide meaningful analyses of data when formal clinical trials are not feasible.

Case-Control Studies↗
PubMed1997

The effects of health insurance on access to new medical technologies.

We examined the use of percutaneous transluminal coronary angioplasty, kidney stone lithotripsy, and bone marrow transplant among patients with different health insurance plans in California. HMO enrollees were less likely to receive these procedures compared with fee-for-service patients. Our results have implications for the inflationary effects of technology under managed care.

Angioplasty, Balloon, Coronary↗
PubMed1996

Gene therapy: socioeconomic and ethical issues. A roundtable discussion.

Gene therapy research has the potential to revolutionize the way in which many human diseases are treated. Despite its enormous potential, roundtable panelists concluded that the field needs time to mature scientifically without pressure to develop a marketable therapeutic product. In addition, health care decision makers, physicians, and the lay public need to be educated on the future medical, economic, and ethical ramifications of gene therapy.

Clinical Trials as Topic↗
PubMed1996

The cost-effectiveness of terazosin and placebo in the treatment of moderate to severe benign prostatic hyperplasia.

OBJECTIVES: To evaluate the cost-effectiveness and functional status effects of terazosin, an alpha(1)-adrenoceptor antagonist, compared with placebo in the treatment of men with moderate to severe, symptomatic, benign prostatic hyperplasia (BPH). METHODS: Prospective, randomized, double-blind, placebo-controlled multicenter trial of 2084 patients was conducted at 15 academic regional centers and 141 community-based satellite centers. Information about the use of health care resources and non-disease-specific functional status measures was collected by a standardized telephone interview of patients at baseline and every month thereafter for 12 months. Other information, such as American Urologic Association (AUA) disease-specific functional status scores, was obtained from the patient study records. Patients had a mean age of 65.7 years (range, 46 to 94), with a clinical diagnosis of BPH. At baseline men had at least moderate BPH symptoms by AUA Symptom score (13 or more) and Bother Score (8 or more). On entry, patients at regional sites had peak urinary flow rates 15 mL/s or less and total voided urine volumes 150 mL or greater. A total of 1053 patients were randomized to terazosin and 1031 to placebo treatment. Primary outcome measures included payments for all direct medical resource consumption (inpatient care, emergency department care, outpatient care, and medications); changes in three AUA disease-specific functional status indicators, (Symptom, Bother, and Quality of Life scores), and non-disease-specific functional status measures (days of work loss, days of customary activity loss, and days of bed rest). RESULTS: Total payments for health care resource (including study drug medication), adjusted to reflect 1000 patients per treatment group, were $3,781,803 and $3,568,263 in the placebo and terazosin groups, respectively. All three AUA disease-specific functional status scores improved significantly more in the terazosin group than in the placebo group. We found no difference between terazosin and placebo in all three nonspecific functional status measures. CONCLUSIONS: Compared with placebo, terazosin therapy for moderate to severe symptomatic BPH results in approximately equivalent payments for direct medical care, better disease-specific functional status improvement, and comparable change in non-disease-specific functional status measures.

Adrenergic alpha-Antagonists↗
PubMed1995

Economic modeling to assess the costs of treatment with finasteride, terazosin, and transurethral resection of the prostate for men with moderate to severe symptoms of benign prostatic hyperplasia.

OBJECTIVES: We developed a decision analytic model to compare the costs of treatment for an initial 2-year period with finasteride, terazosin, and transurethral resection of the prostate (TURP) in men with at least moderate symptoms of benign prostatic hyperplasia (BPH). Outcome measures were BPH treatment costs, duration of symptomatic improvement, and lost productivity days (work or other customary activity). METHODS: Patterns of health care resource use associated with the treatment of moderate to severe BPH and BPH-related complications were evaluated by a survey of urologists and validated by a urology consensus panel. BPH safety and efficacy studies in the published literature were used to provide probabilities of treatment success. Both a national health care resource database (Systemetrics) and Medicare data were used to estimate the costs of specific health care services (such as physician services and laboratory tests). RESULTS: The probabilities of first-year success (defined as symptomatic improvement) for surgery, finasteride, and terazosin were 88%, 67%, and 74%, respectively. The most expensive intervention was surgery, followed by finasteride and terazosin, at estimated 24-month costs of $6411, $2860, and $2422 for private insurance and $3874, $2161, and $1820 for Medicare, respectively. Duration of symptom improvement was comparable for the three treatments. Estimates of usual activity days lost (work or other customary activity) were 22, 8, and 8 days for surgery, finasteride, and terazosin, respectively. CONCLUSIONS: As a primary intervention for patients considering conventional clinical approaches to BPH treatment, pharmacotherapy is expected to be less expensive than TURP over the initial 2 years of therapy.

Adrenergic alpha-Antagonists↗
PubMed1995

Declining cost-effectiveness of screening for disease. The case of gastric cancer in Japan.

We examined the cost-effectiveness of screening for gastric cancer in hypothetical cohorts of asymptomatic Japanese ages 40, 50, 60, and 70, followed for 10 years. Current screening recommendations in Japan are not optimal. Although indirect x-ray is the correct method, screening for gastric cancer may not be cost-effective for Japanese under the age of 50. Policymakers worldwide should monitor the changing incidence of disease as they consider and recommend screening policies.

Adult↗
PubMed1995

Diffusion of laparoscopic cholecystectomy among general surgeons in the United States.

Introduced in 1989, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic gallstones. This study describes the diffusion of laparoscopic cholecystectomy among general surgeons; assesses the importance of various reasons for surgeons adopting the procedure; and examine the influence of surgeon, practice, and health care market characteristics on the timing of adoption. The data were obtained from a survey of a national sample of surgeons. Most surgeons (81%) adopted laparoscopic cholecystectomy by early 1992. More than three fourths of adopters identified the desire to keep up with the state-of-the-art and improved patient outcomes as very or extremely important reasons for adoption. Results of proportional hazards regression analysis indicate that individual surgeons' adoption behavior generally was consistent with expected utility maximization in an uncertain new technological environment. Of particular interest, fee-for-service payment and more competitive practice settings and markets were associated with earlier adoption. These findings suggest that the "technological imperative" and surgeons' perception of the relative clinical and financial advantages of laparoscopic cholecystectomy were important reasons for the rapid diffusion of laparoscopic cholecystectomy. Policies that accelerate current trends toward payment of physicians based on salary or capitation and promote the growth of multispecialty group practice could slow the diffusion of new physician-based product innovations in health care.

Adult↗
PubMed1995

Cost-effectiveness: from whose perspective?

Evaluating the cost-effectiveness of medical interventions, particularly pharmaceuticals, has been the focus of much debate in this country over the past few years. Although the support for efficient utilization of monies is widespread, the delicate balance between optimizing patient outcome with the costs to do so in high-risk patients is especially difficult. Although research in the field of cost-effectiveness is widespread, at present there are few guidelines in this country. Furthermore, the introduction of bias is a serious concern in the interpretation and validation of studies, often limiting their utility. Guidelines that can be implemented to minimize bias in economic research have been identified to include administrative, methodology-based, and ethical parameters. The standardization and implementation of such guidelines can reduce bias in economic research and optimize study validity. This review focuses on these issues and suggests that initial steps to produce unbiased economic research include total disclosure, appropriate comparator selection, complete release of all relevant data, and the cooperation of all involved parties.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Hospital adoption of medical technology: an empirical test of alternative models.

OBJECTIVE: This study examines hospital motivations to acquire new medical technology, an issue of considerable policy relevance: in this case, whether, when, and why hospitals acquire a new capital-intensive medical technology, magnetic resonance imaging equipment (MRI). STUDY DESIGN: We review three common explanations for medical technology adoption: profit maximization, technological preeminence, and clinical excellence, and incorporate them into a composite model, controlling for regulatory differences, market structures, and organizational characteristics. All four models are then tested using Cox regressions. DATA SOURCES: The study is based on an initial sample of 637 hospitals in the continental United States that owned or leased an MRI unit as of 31 December 1988, plus nonadopters. Due to missing data the final sample consisted of 507 hospitals. The data, drawn from two telephone surveys, are supplemented by the AHA Survey, census data, and industry and academic sources. PRINCIPAL FINDING: Statistically, the three individual models account for roughly comparable amounts of variance in past adoption behavior. On the basis of explanatory power and parsimony, however, the technology model is "best." Although the composite model is statistically better than any of the individual models, it does not add much more explanatory power adjusting for the number of variables added. CONCLUSIONS: The composite model identified the importance a hospital attached to being a technological leader, its clinical requirements, and the change in revenues it associated with the adoption of MRI as the major determinants of adoption behavior. We conclude that a hospital's adoption behavior is strongly linked to its strategic orientation.

Capital Expenditures↗
PubMed1995

The impact of physician financial incentives on high-risk populations in managed care.

The challenge of managed care is to design a system in which rules and incentives together create a system of checks and balances that ensure both efficient and high-quality care. Incentives need to be administered so that physicians--both primary care providers and specialists--are not forced to choose between personal and/or organizational financial viability and patients' care. To accomplish this goal, payment needs to be linked both to quality and productivity and appropriately risk-adjusted. Quality assurance programs must ensure that both efficient and high-quality care is being provided and must maintain the satisfaction of both physicians and members. AIDS patients may be harmed by a system in which the more services a physician performs, the more he or she is paid--the traditional way in which American health care has been delivered heretofore. Managed care may undermine the care of high-risk patients if it arbitrarily reduces the high volume of care they require. However, a managed care system with effective checks and balances on financial incentives and quality of care can ensure that an efficient and high standard of care is being met--across all populations, including both healthy and high-risk patients.

Acquired Immunodeficiency Syndrome↗