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Biomedical subjects

A S Detsky

Publications and source records attributed to A S Detsky.

At least 73 records · Page 4Linked to original sources
PubMed1992

Is steroid receptor data useful in patients with metastatic breast cancer?

Optimal therapy for patients with metastatic breast cancer is unknown. For those with rapidly progressive disease or liver metastases, combination chemotherapy is believed to be the treatment of choice. However, most patients do not fall into that category. For them, two treatment approaches can be considered: (1) ignore estrogen receptor/progesterone receptor (ER/PR) data and treat all patients with hormonal therapy or (2) use ER/PR data and treat patients with ER-/PR- tumors with combination chemotherapy and treat all other patients with hormonal therapy. This report presents a decision analysis for assessing the usefulness of ER/PR data in this situation. The probabilities of response to hormonal therapy were obtained from literature reviews. Patients' utilities or preferences for the various outcomes were estimated by using physicians as patient surrogates. The baseline analysis favored ignoring ER/PR data and treating all patients with hormonal therapy. Extensive sensitivity analyses showed that the decision was most affected by patients' utilities for the various outcomes. The conclusion is that patients' utilities are most important in deciding the usefulness of ER/PR data in metastatic breast cancer.

Antineoplastic Agents↗
PubMed1992

Cost and health implications of cholesterol lowering.

BACKGROUND: A broad, scientific consensus supports the role of cholesterol as a risk factor for coronary heart disease and agrees that lowering cholesterol levels will reduce coronary heart disease incidence. Cost-effectiveness analysis is a potentially powerful method for measuring the benefits to be achieved by expenditures of health care dollars. METHODS AND RESULTS: The literature related to the effectiveness and cost-effectiveness of cholesterol lowering was reviewed. Application of cost-effectiveness methodology to the question of cholesterol reduction generally supports the use of population-wide educational programs and the aggressive use of cholesterol-lowering therapy for the secondary prevention of subsequent coronary events in persons with preexisting coronary heart disease. For primary prevention, however, therapy with medication has a favorable cost-effectiveness ratio only in identifiable high-risk persons, and the different costs of the various available medications should be taken into account. Therapy with medications, especially for primary prevention, would be more appealing if the price of the available medications were lower. CONCLUSIONS: High priority should be given to research that could validate these cost-effectiveness projections as well as to further studies of the elderly and women, in whom direct data on the precise costs, risks, and benefits of interventions to lower cholesterol remain sparse.

Anticholesteremic Agents↗
PubMed1992

Management of suspected giant cell arteritis: a decision analysis.

We used decision analysis to compare 4 strategies for managing suspected giant cell arteritis (GCA): treat no patients, treat all patients, perform temporal artery biopsy and only treat positive cases, or biopsy and treat all cases irrespective of the result. The "treat no patients" strategy is preferred only if the likelihood of disease is less than 2%. The "biopsy and treat positive cases" strategy predominates for intermediate likelihood of disease (50%) and is insensitive to altering the probability of any key variables. The "biopsy but treat irrespective of the result" strategy becomes preferred at likelihood of disease of 81%. However, this result was sensitive to alteration of the key variables. Empirical therapy without biopsy would only be preferred if the likelihood of disease exceeded 90% and the disutility one attaches to treating under uncertainty is low at high probability of disease. Management of suspected GCA should be guided by the results of temporal artery biopsy in the majority of cases. At high likelihood of disease, temporal artery biopsy may be of value independent of its usefulness in determining management strategy. Further research should be directed towards improving the accuracy of diagnosis, defining the risk of iatrogenic complications and estimating utilities for the outcomes.

Adrenal Cortex Hormones↗
PubMed1991

Comparison of an aggressive (U.S.) and a less aggressive (Canadian) policy for cholesterol screening and treatment.

OBJECTIVE: To determine the point at which adverse quality-of-life effects engendered by an aggressive cholesterol-lowering strategy dictate the use of a less aggressive approach. DESIGN: Decision analysis was used to compare the effects of the National Cholesterol Education Program (NCEP) guidelines, an aggressive program, with those of the Canadian Task Force on the Periodic Health Examination (CTF) guidelines, a more conservative program. Quality-adjusted life expectancy was calculated for a theoretical cohort of middle-aged men treated according to each program using Markov cohort analysis. MEASUREMENTS: Guidelines were applied to the population of the Lipid Research Clinics Coronary Primary Prevention Trial (LRC-CPPT), under the assumption that cholesterol levels had the distribution of the age- and sex-matched general population. Outcomes were calculated using a three-state (health, coronary heart disease, and death) Markov model. State transition probabilities were calculated using bivariate (age and cholesterol) proportional hazards and logistic regression functions. MAIN RESULTS: The result was a "toss-up"; the number of expected quality-adjusted life years was similar for both programs at all time intervals, although the conservative program was consistently slightly favored. The result was very sensitive to the disutility of dietary therapy (threshold value, 0.0014 compared with the baseline estimate of 0.02) but was also affected by the time frame of the analysis and the rate at which adverse effects of treatment decline. CONCLUSIONS: Even small disutilities associated with treatment may outweight the benefits of aggressive cholesterol-lowering strategies. Research should be directed toward measuring these disutilities and finding ways to reduce their size. Incorporation of the disutility of treatment into policy formulation may result in less interventionist and less costly policies.

Adult↗
PubMed1991

Percutaneous injuries among health care workers. The real value of human immunodeficiency virus testing of 'donor' blood.

A decision analysis was conducted to examine whether health care workers should receive short-term (42 days) zidovudine treatment following percutaneous exposure to blood, as well as to determine the value of testing "donor" (patient's) blood. Three alternative options were analyzed: treat all, treat none, and test. In the treat all option, all health care workers receive short-term zidovudine therapy immediately after exposure; in the treat none option, no one receives zidovudine; and in the test option, donor blood is tested, and if it is human immunodeficiency virus (HIV) positive, zidovudine is given. Baseline variables were obtained from the literature. Each outcome was expressed as a utility; this is a method of quantifying the values that persons place on different health states. The results showed that the test option was preferred. Sensitivity analyses indicated that even if the risk of seroconversion were zero or the effectiveness of zidovudine were zero or the drug were withheld, this option was preferred, thus indicating some value of testing other than merely identifying health care workers who should receive zidovudine. In the baseline analysis, this was derived from the fact that approximately 95% of the health care workers would be reassured by a negative test; ie, only approximately 5% of donors are HIV positive. If the prevalence of HIV seropositivity exceeded 42%, the treat none option was preferred. This was found to be due to the fact that increased numbers of health care workers would be told that they were exposed to HIV-positive blood. The "worrying factor" associated with such an exposure was such that above 42% HIV seropositivity, the treat none option was preferred overall. Thus, the real value of testing donor blood is in identifying those persons (greater than 95%) who could be told that they were exposed to HIV-negative blood, that is, reducing their worrying factor to zero. Because acquired immunodeficiency syndrome is a fatal disease, and given that zidovudine is the only available therapeutic option at present, the drug has an important role to play if its effectiveness is greater than zero.

Allied Health Personnel↗
PubMed1990

A clinician's guide to cost-effectiveness analysis.

Cost-effectiveness analysis can be used to help set priorities for funding health care programs. For each intervention, the costs and clinical outcomes associated with that strategy must be compared with an alternate strategy for treating the same patients. If an intervention results in improved outcomes but also costs more, the incremental cost per incremental unit of clinical outcome should be calculated. The incremental cost-effectiveness ratios for various programs can be ranked to set funding priorities. By using this list, the person responsible for allocating resources can maximize the net health benefit for a target population derived from a fixed budget. Clinicians may not share this objective because, individually, they are appropriately concerned solely with the effectiveness of a specific intervention for their patients and are not concerned with the benefit derived from spending those resources on other patients in the target population. In addition, allocation may be driven by distributional and political objectives. Nevertheless, cost-effectiveness analysis demonstrates the consequences of allocation decisions. Because clinicians should participate in policy making, they must understand d the role of this technique in setting funding priorities.

Cost-Benefit Analysis↗
PubMed1990

Containing Ontario's hospital costs under universal insurance in the 1980s: what was the record?

In recent years the Ontario government has been concerned that the proportion of public expenditures devoted to health care is at an all-time high. In addition, the media have devoted considerable attention to specific incidents that may represent inadequate funding of hospital services. To shed light on the debate on health care expenditures we analysed the trend in expenditures of Ontario's hospital sector in the 1980s in terms of the amount of inputs (e.g., labour) used to produce hospital services (e.g., a patient-day or admission) and after adjustment for general inflation. As in the 1970s the number of inputs grew relatively slowly during the 1980s. Inputs per patient-day grew at an annual rate of 0.46% and inputs per admission at an annual rate of 2.4%. Cost increases were largely accounted for by hospital wage increases; this could have been due to Ontario's rapidly expanding economy. These findings indicate that Ontario has continued to be successful in containing the number of inputs used in the hospital sector. However, after two decades of substantial success with publicly acceptable cost control, the government faces increased scrutiny as the media and the public focus attention on several areas of perceived inadequate funding in health care services.

Costs and Cost Analysis↗
PubMed1989

Are clinical trials a cost-effective investment?

To assess the economic attractiveness of clinical research, this study measures the cost-effectiveness of seven selected randomized trials. The model considers the cost of performing a trial and the benefits to the health status of a target population one could expect before the trial was performed. The incremental cost-effectiveness for performing the trials ranged from a low of $2 to $3 per life-year saved for a trial of aspirin in unstable angina to a high of $396 to $685 per life-year saved for the randomized trial portion of the Coronary Artery Surgery Study. These ratios were substantially lower (ie, more economically attractive) than the cost-effectiveness ratios associated with performing interventions of proved effectiveness. This study shows that a selected group of clinical trials, some of which were controversial and expensive, were indeed a good investment. This information may be helpful to policymakers who consider allocating funds to biomedical research.

Biomedical Research↗
PubMed1989

Nonionic contrast media: economic analysis and health policy development.

The replacement of old radiologic contrast media with supposedly safer but more expensive media has created a dilemma for radiologists and hospital administrators. To quantitate the nature of this trade-off we performed a cost-utility analysis using optimistic assumptions that favoured the new media. A complete conversion to the new media would result in an incremental cost of at least $65,000 to gain 1 quality-adjusted life-year (QALY). For a selective strategy in which only high-risk patients would receive the new media the cost would be about $23,000 per QALY gained. However, the incremental cost for low-risk patients is over $220,000 per QALY gained. Conversion to the new contrast media, although not necessarily the most efficient use of scarce resources, has already occurred in Ontario, primarily because of press publicity, pressure from insurers and a political unwillingness of policymakers to decide the fate of identifiable victims. We found that funding of a new intervention associated with a high cost-utility ratio rather than interventions with lower ratios might save some identifiable victims at the expense of a larger number of unidentifiable ones.

Adult↗
PubMed1989

Parenteral nutrition with branched-chain amino acids in hepatic encephalopathy. A meta-analysis.

Meta-analytic methods were applied to review clinical trials published in English that have assessed the efficacy of parenteral nutrition for cirrhotic patients with acute hepatic encephalopathy. Modified amino acid solutions containing increased amounts of branched-chain amino acids were used as part of the treatment regimen in all studies. Pooled analysis of five randomized controlled studies showed a highly significant improvement in mental recovery (p less than 0.001) from high-grade encephalopathy over follow-up times varying from 5 to 14 days. The significance level of the treatment effect did not change when the analysis was repeated using alternative methods of counting and attributing events in these trials. Sharp differences in direction of treatment effect precluded pooling case fatality data. Two studies reported an increased risk of death in the treatment group. Two others showed a clear benefit from administration of parenteral nutrition: the aggregate relative risk reduction was 0.59 (95% confidence interval: 0.23-0.80, p = 0.002). Addition of unpublished data from a third positive study increased the relative risk reduction to 0.82 (p less than 0.0001), and the most conservative interpretation of the published data still yielded a significant reduction in mortality (p = 0.023). However, given the uncertainty about effects on mortality and short follow-up times in all studies, a confirmatory randomized controlled trial with longer follow-up periods is warranted.

Adolescent↗
PubMed1989

Meta-analysis in medical research: strong encouragement for higher quality in individual research efforts.

In this article, we counter some criticism regarding the desirability of performing meta-analysis in clinical research. These criticisms, we argue, are based mainly on current difficulties in deriving firm conclusions based on meta-analysis, resulting from poor methodology and reporting of primary studies. This is not a fault of meta-analysis. In fact, with a better understanding of meta-analysis in the context of the full scientific research process, meta-analysis is seen as a key element for improving individual research efforts and their reporting in the literature. This in turn will further enhance the role of meta-analysis in helping clinicians and policy makers answer clinical questions.

Humans↗
PubMed1989

A cost-utility analysis of preoperative total parenteral nutrition.

It has been suggested that preoperative total parenteral nutrition may be used to reduce the risk of nutrition-associated postoperative complications in high-risk patients. These patients can be identified based on their nutritional status. The efficiency of this intervention is assessed using the technique of cost-utility analysis. Data from multiple sources is integrated to perform the economic assessment. The cost-utility ratios for treating several malnourished patients with localized upper gastrointestinal cancer are below $40,000. These cost-utility ratios compare favorably with published results of other programs. The ratios increase considerably if patients who are better nourished (at lower risk of postoperative complication) receive the intervention. The analysis is very sensitive to the efficacy of the intervention.

Cost-Benefit Analysis↗