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Biomedical subjects

Allison B Rosen

Publications and source records attributed to Allison B Rosen.

At least 19 recordsLinked to original sources
PubMed2006

The value of medical spending in the United States, 1960-2000.

BACKGROUND: The increased use of medical therapies has led to increased medical costs. To provide insight into the value of this increased spending, we compared gains in life expectancy with the increased costs of care from 1960 through 2000. METHODS: We estimated life expectancy in 1960, 1970, 1980, 1990, and 2000 for four age groups. To control for the influence of nonmedical factors on survival, we assumed in our base-case analysis that 50 percent of the gains were due to medical care. We compared the adjusted increases in life expectancy with the lifetime cost of medical care in the same years. RESULTS: From 1960 through 2000, the life expectancy for newborns increased by 6.97 years, lifetime medical spending adjusted for inflation increased by approximately 69,000 dollars, and the cost per year of life gained was 19,900 dollars. The cost increased from 7,400 dollars per year of life gained in the 1970s to 36,300 dollars in the 1990s. The average cost per year of life gained in 1960-2000 was approximately 31,600 dollars at 15 years of age, 53,700 dollars at 45 years of age, and 84,700 dollars at 65 years of age. At 65 years of age, costs rose more rapidly than did life expectancy: the cost per year of life gained was 121,000 dollars between 1980 and 1990 and 145,000 dollars between 1990 and 2000. CONCLUSIONS: On average, the increases in medical spending since 1960 have provided reasonable value. However, the spending increases in medical care for the elderly since 1980 are associated with a high cost per year of life gained. The national focus on the rise in medical spending should be balanced by attention to the health benefits of this increased spending.

Adolescent↗
PubMed2006

Bias in published cost effectiveness studies: systematic review.

OBJECTIVE: To investigate if published studies tend to report favourable cost effectiveness ratios (below 20,000 dollars, 50,000 dollars, and 100,000 dollars per quality adjusted life year (QALY) gained) and evaluate study characteristics associated with this phenomenon. DESIGN: Systematic review. Studies reviewed 494 English language studies measuring health effects in QALYs published up to December 2001 identified using Medline, HealthSTAR, CancerLit, Current Content, and EconLit databases. MAIN OUTCOME MEASURES: Incremental cost effectiveness ratios measured in dollars set to the year of publication. RESULTS: Approximately half the reported incremental cost effectiveness ratios (712 of 1433) were below 20,000 dollars/QALY. Studies funded by industry were more likely to report cost effectiveness ratios below 20,000 dollars/QALY (adjusted odds ratio 2.1, 95% confidence interval 1.3 to 3.3), 50,000 dollars/QALY (3.2, 1.8 to 5.7), and 100,000 dollars/QALY (3.3, 1.6 to 6.8). Studies of higher methodological quality (adjusted odds ratio 0.58, 0.37 to 0.91) and those conducted in Europe (0.59, 0.33 to 1.1) and the United States (0.44, 0.26 to 0.76) rather than elsewhere were less likely to report ratios below 20,000 dollars/QALY. CONCLUSION: Most published analyses report favourable incremental cost effectiveness ratios. Studies funded by industry were more likely to report ratios below the three thresholds. Studies of higher methodological quality and those conducted in Europe and the US rather than elsewhere were less likely to report ratios below 20,000 dollars/QALY.

Conflict of Interest↗
PubMed2006

Indications for and utilization of ACE inhibitors in older individuals with diabetes. Findings from the National Health and Nutrition Examination Survey 1999 to 2002.

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) improve cardiovascular outcomes in high-risk individuals with diabetes. Despite the marked benefit, it is unknown what percentage of patients with diabetes would benefit from and what percentage actually receive this preventive therapy. OBJECTIVES: To examine the proportion of older diabetic patients with indications for ACE or ARB (ACE/ARB). To generate national estimates of ACE/ARB use. DESIGN AND PARTICIPANTS: Survey of 742 individuals> or =55 years (representing 8.02 million U.S. adults) self-reporting diabetes in the 1999 to 2002 National Health and Nutrition Examination Survey. MEASUREMENTS: Prevalence of guideline indications (albuminuria, cardiovascular disease, hypertension) and other cardiac risk factors (hyperlipidemia, smoking) with potential benefit from ACE/ARB. Prevalence of ACE/ARB use overall and by clinical indication. RESULTS: Ninety-two percent had guideline indications for ACE/ARB. Including additional cardiac risk factors, the entire (100%) U.S. noninstitutionalized older population with diabetes had indications for ACE/ARB. Overall, 43% of the population received ACE/ARB. Hypertension was associated with higher rates of ACE/ARB use, while albuminuria and cardiovascular disease were not. As the number of indications increased, rates of use increased, however, the maximum prevalence of use was only 53% in individuals with 4 or more indications for ACE/ARB. CONCLUSIONS: ACE/ARB is indicated in virtually all older individuals with diabetes; yet, national rates of use are disturbingly low and key risk factors (albuminuria and cardiovascular disease) are being missed. To improve quality of diabetes care nationally, use of ACE/ARB therapy by ALL older diabetics may be a desirable addition to diabetes performance measurement sets.

Age Factors↗
PubMed2006

Do drug formulary policies reflect evidence of value?

OBJECTIVE: To investigate the extent to which preferred drug lists and tiered formularies reflect evidence of value, as measured in published cost-utility analyses (CUAs). METHODS: Using 1998-2001 data from a large registry of cost-effectiveness analyses, we examined the 2004 Florida Medicaid preferred drug list and the 2004 Harvard Pilgrim Pharmacy Program 3-tier formulary, and compared cost-utility ratios (standardized to 2002 US dollars) of drugs with preferred and nonpreferred status. RESULTS: Few drugs on the formularies had any cost-utility data available. Of those that did, median cost-utility ratios were somewhat higher (less favorable) for Florida's preferred drugs compared with the nonpreferred drugs (25,465 dollars vs 13,085 dollars; P = .09). Ratios did not differ for drugs on tiers 1 and 2 of the Harvard Pilgrim formulary, although they were higher for tier 3 and for excluded drugs (18,309 dollars, 18,846 dollars, 52,119 dollars, and 22,580 dollars, respectively; P = .01). Among therapies reported to be cost-saving or to have cost-utility ratios below 50,000 dollars, 77% had favored status in Florida Medicaid and 73% in Harvard Pilgrim. Among dominated drug interventions (reported to be more costly and less effective than alternatives), 95% had favored status in Florida Medicaid and 56% in Harvard Pilgrim. CONCLUSIONS: This study underscores the paucity of published cost-utility data available to formulary committees. Some discrepancies prevail between the value of drugs, as reflected in published cost-utility ratios, and the formulary placement policies of 2 large health plans.

Boston↗
PubMed2006

Rising out-of-pocket costs in disease management programs.

OBJECTIVES: To document the rise in copayments for patients in disease management programs and to call attention to the inherent conflicts that exist between these 2 approaches to benefit design. METHODS: Data from 2 large health plans were used to compare cost sharing in disease management programs with cost sharing outside of disease management programs. RESULTS: The copayments charged to participants in disease management programs usually do not differ substantially from those charged to other beneficiaries. CONCLUSIONS: Cost sharing and disease management result in conflicting approaches to benefit design. Increasing copayments may lead to underuse of recommended services, thereby decreasing the clinical effectiveness and increasing the overall costs of disease management programs. Policymakers and private purchasers should consider the use of targeted benefit designs when implementing disease management programs or redesigning cost-sharing provisions. Current information systems and health services research are sufficiently advanced to permit these benefit designs.

Cost Sharing↗
PubMed2005

Cost-effectiveness of full medicare coverage of angiotensin-converting enzyme inhibitors for beneficiaries with diabetes.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors slow renal disease progression and reduce cardiac morbidity and mortality in patients with diabetes. Patients' out-of-pocket costs pose a barrier to using this effective therapy. OBJECTIVE: To estimate the cost-effectiveness to Medicare of first-dollar coverage (no cost sharing) of ACE inhibitors for beneficiaries with diabetes. DESIGN: Markov model with costs and benefits discounted at 3%. DATA SOURCES: Published literature and Medicare claims data. TARGET POPULATION: 65-year-old Medicare beneficiary with diabetes. TIME HORIZON: Lifetime. PERSPECTIVE: Medicare and societal. INTERVENTIONS: We evaluated Medicare first-dollar coverage of ACE inhibitors compared with current practice (no coverage) and the new Medicare drug benefit. OUTCOME MEASURES: Costs (2003 U.S. dollars), quality-adjusted life-years (QALYs), life-years, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Compared with current practice, first-dollar coverage of ACE inhibitors saved both lives and money (0.23 QALYs gained and 1606 USD saved per Medicare beneficiary). Compared with the new Medicare drug benefit, first-dollar coverage remained a dominant strategy (0.15 QALYs gained, 922 USD saved). RESULTS OF SENSITIVITY ANALYSIS: Results were most sensitive to our estimate of increase in ACE inhibitor use; however, if ACE inhibitor use increased by only 7.2% (from 40% to 47.2%), first-dollar coverage would remain life-saving at no net cost to Medicare. In analyses conducted from the societal perspective, benefits were similar and cost savings were larger. LIMITATIONS: Results depend on accuracy of the underlying data and assumptions. The effect of more generous drug coverage on medication adherence is uncertain. CONCLUSIONS: Medicare first-dollar coverage of ACE inhibitors for beneficiaries with diabetes appears to extend life and reduce Medicare program costs. A reduction in program costs may result in more money to spend on other health care needs of the elderly.

Aged↗
PubMed2005

A synthesis of cost-utility analysis literature in infectious disease.

The purpose of this review is to understand infectious disease-related cost-utility analyses by describing published analyses, examining growth and quality trends over time, examining factors related to quality, and summarising standardised results. 122 cost-utility analyses and 352 cost-utility ratios were identified. Pharmaceutical interventions were most common (47.5%); three author groups accounted for 42.8% of pharmaceutical ratios. High-volume journals (three or more published cost-utility analyses) published higher quality analyses than low-volume journals (p<0.001). Use of probabilistic sensitivity analysis and discounting at 3% were more frequently found in the years after the US Public Health Service Panel on Cost-Effectiveness in Health and Medicine recommendations (p<0.01). Median ratios varied from US13,500 dollars/quality-adjusted life year (QALY) for immunisations to US810,000 dollars/QALY for blood safety. Publication of infectious disease cost-utility analyses is increasing. The results of cost-utility analyses have important implications for the development of clinical guidelines and resource allocation decisions. More trained investigators and better peer-review processes are needed.

Anti-Bacterial Agents↗
PubMed2005

Diffusion of published cost-utility analyses in the field of health policy and practice.

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.

Cost-Benefit Analysis↗
PubMed2005

Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter?

PURPOSE: Despite widespread public attention and numerous ongoing patient safety initiatives, physicians are skeptical of the most commonly prescribed interventions to reduce medical errors. This study examined the association between the published evidence of effectiveness of interventions to reduce medical errors and physicians' ratings of the effectiveness of those interventions. It further assessed whether academic affiliation was associated with physicians' ratings of effectiveness. METHOD: The authors conducted a literature review seeking evidence of effectiveness of 13 interventions to reduce medical errors. A four-page questionnaire was sent to a random sample of 1,332 U.S. physicians in the spring of 2002. A total of 831 (62%) responded, providing ratings of the perceived effectiveness of these interventions to reduce medical errors. RESULTS: We identified published evidence of effectiveness for six of the 13 interventions. Physicians rated 34% of these and 29% of the interventions without published evidence as "very effective" (p < .01). Physicians with an academic affiliation and those in practice for more years were slightly more likely to rate interventions with published evidence as "very effective." CONCLUSIONS: Physicians' ratings of the effectiveness of interventions to reduce medical errors are only weakly associated with published evidence of effectiveness. More evidence, better dissemination strategies for existing evidence such as inclusion in medical school curriculum or recertification examinations, and a focus on removing barriers to interventions may be needed to engage physicians in moving patient safety interventions into medical practice.

Attitude of Health Personnel↗
PubMed2005

Cost-utility analyses in orthopaedic surgery.

BACKGROUND: The rising cost of health care has increased the need for the orthopaedic community to understand and apply economic evaluations. We critically reviewed the literature on orthopaedic cost-utility analysis to determine which subspecialty areas are represented, the cost-utility ratios that have been utilized, and the quality of the present literature. METHODS: We searched the English-language medical literature published between 1976 and 2001 for orthopaedic-related cost-utility analyses in which outcomes were reported as cost per quality-adjusted life year. Two trained reviewers independently audited each article to abstract data on the methods and reporting practices used in the study as well as the cost-utility ratios derived by the analysis. RESULTS: Our search yielded thirty-seven studies, in which 116 cost-utility ratios were presented. Eleven of the studies were investigations of treatment strategies in total joint arthroplasty. Study methods varied substantially, with only five studies (14%) including four key criteria recommended by the United States Panel on Cost-Effectiveness in Health and Medicine. According to a reader-assigned measure of study quality, cost-utility analyses in orthopaedics were of lower quality than those in other areas of medicine (p = 0.04). While the number of orthopaedic studies has increased in the last decade, the quality did not improve over time and did not differ according to subspecialty area or journal type. For the majority of the interventions that were studied, the cost-utility ratio was below the commonly used threshold of $50,000 per quality-adjusted life year for acceptable cost-effectiveness. CONCLUSIONS: Because of limitations in methodology, the current body of literature on orthopaedic cost-utility analyses has a limited ability to guide policy, but it can be useful for setting priorities and guiding research. Future research with clear and transparent reporting is needed in all subspecialty areas of orthopaedic practice.

Arthroplasty, Replacement↗
PubMed2004

Comparison of efficacy, safety, and cost of low-molecular-weight heparin with continuous-infusion unfractionated heparin for initiation of anticoagulation after mechanical prosthetic valve implantation.

We compared the efficacy, safety, and impact on postoperative hospital length of stay and inpatient hospital costs of low-molecular-weight heparin with that of unfractionated heparin as a "bridge" to achieving therapeutic levels of anticoagulation with warfarin in patients with newly implanted prosthetic heart valves. The patients who received low-molecular-weight heparin had a shorter length of stay and decreased postoperative costs compared with the control subjects receiving unfractionated heparin.

Anticoagulants↗
PubMed2004

Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes.

BACKGROUND: Diabetes causes 45% of incident end-stage renal disease (ESRD). Risk of progression is higher in those with clinical risk factors (albuminuria and hypertension), and in ethnic minorities (including blacks, Asians, and Latinos). Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) slow the progression of diabetic nephropathy, yet little is known about their use among patients at high risk for progression to ESRD. OBJECTIVES: To examine the prevalence of ACE or ARB (ACE/ARB) use overall and within patients with high-risk clinical indications, and to assess for ethnic disparities in ACE/ARB use. DESIGN: Observational cohort study. SETTING: Kaiser Permanente Northern California (KPNC) Diabetes Registry, a longitudinal registry that monitors quality and outcomes of care for all KPNC patients with diabetes. PATIENTS: Individuals (N= 38887) with diabetes who were continuously enrolled with pharmacy benefits during the year 2000, and had self-reported ethnicity data on survey. INTERVENTIONS AND MEASUREMENTS: Pharmacy dispensing of ACE/ARB. RESULTS: Forty-one percent of the cohort had both hypertension and albuminuria, 30% had hypertension alone, and 12% had albuminuria alone. Fourteen percent were black, 11% Latino, 13% Asian, and 63% non-Latino white. Overall, 61% of the cohort received an ACE/ARB. ACE/ARB was dispensed to 74% of patients with both hypertension and albuminuria, 64% of those with hypertension alone, and 54% of those with albuminuria alone. ACE/ARB was dispensed to 61% of whites, 63% of blacks, 59% of Latinos, and 60% of Asians. Among those with albuminuria alone, blacks were significantly (P =.0002) less likely than whites to receive ACE/ARB (47% vs 56%, respectively). No other ethnic disparities were found. CONCLUSIONS: In this cohort, the majority of eligible patients received indicated ACE/ARB therapy in 2000. However, up to 45% to 55% of high-risk clinical groups (most notably individuals with isolated albuminuria) were not receiving indicated therapy. Additional targeted efforts to increase use of ACE/ARB could improve quality of care and reduce ESRD incidence, both overall and in high-risk ethnic groups. Policymakers might consider use of ACE/ARB for inclusion in diabetes performance measurement sets.

Aged↗
PubMed2004

Colorectal cancer screening disparities related to obesity and gender.

BACKGROUND: Obesity is associated with a higher incidence of colorectal cancer and increased colorectal cancer mortality. Obese women are less likely to undergo breast and cervical cancer screening than nonobese women. It is not known whether obesity is associated with a lower likelihood of colorectal cancer screening. OBJECTIVE: To evaluate whether there is an association between body mass index (BMI) and rates of colorectal cancer screening. To examine whether BMI-related disparities in colorectal cancer screening differ between men and women. DESIGN AND SETTING: The Behavioral Risk Factor Surveillance System, a cross-sectional random-digit telephone survey of noninstitutionalized adults conducted by the Centers for Disease Control and Prevention and state health departments in the 50 states and Washington, DC in 1999. PATIENTS: Survey respondents (N= 52886) between 51 and 80 years of age representing 64563332 U.S. adults eligible for colorectal cancer screening. INTERVENTIONS AND MEASUREMENTS: Adjusted rates of self-reported colorectal cancer screening with fecal occult blood testing within the past year or endoscopic screening (sigmoidoscopy or colonoscopy) within the past 5 years. RESULTS: The colorectal cancer screening rate was 43.8% overall. The rate of screening by FOBT within the last year or endoscopic screening within the past 5 years was 39.5% for the morbidly obese group, 45.0% for the obese group, 44.3% for the overweight group, and 43.5% for the normal weight group. The difference in screening rates was entirely attributable to differences in BMI among women. After statistical adjustment for potential confounders, morbidly obese women were less likely than normal weight women to be screened (adjusted rate difference, -5.6%; 95% confidence interval, -8.5 to -2.6). Screening rates among normal weight, overweight, and obese women, and among men in different weight groups did not differ significantly. CONCLUSIONS: Colorectal cancer screening rates among age-eligible persons in the U.S. are disturbingly low. Morbidly obese women, who are at higher risk than others to develop and to die from colorectal cancer, are less likely to be screened. Efforts to increase colorectal cancer screening are needed for all age-eligible groups, but should also include targeted screening of morbidly obese women since they could reap substantial clinical benefits from screening.

Aged↗
PubMed2004

Cost-utility analysis studies of depression management: a systematic review.

OBJECTIVE: Depression is common, costly, treatable, and a major influence on quality of life. Cost-utility analysis combines costs with quantity and quality of life into a metric that is meaningful for studies of interventions or care strategies and is directly comparable to measures in other such studies. The objectives of this study were to identify published cost-utility analyses of depression screening, pharmacologic treatment, nonpharmacologic therapy, and care management; to summarize the results of these studies in an accessible format; to examine the analytic methods employed; and to identify areas in the depression literature that merit cost-utility analysis. METHOD: The authors selected articles regarding cost-utility analysis of depression management from the Harvard Center for Risk Analysis Cost-Effectiveness Registry. Characteristics of the publications, including study methods and analysis, were examined. Cost-utility ratios for interventions were arranged in a league table. RESULTS: Of the 539 cost-utility analyses in the registry, nine (1.7%) were of depression management. Methods for determining utilities and the source of the data varied. Markov models or cohort simulations were the most common analytic techniques. Pharmacologic interventions generally had lower costs per quality-adjusted life year than nonpharmacologic interventions. Psychotherapy alone, care management alone, and psychotherapy plus care management all had lower costs per quality-adjusted life year than usual care. Depression screening and treatment appeared to fall within the cost-utility ranges accepted for common nonpsychiatric medical conditions. CONCLUSIONS: There is a paucity of literature on cost-utility analysis of depression management. High-quality cost-utility analysis should be considered for further research in depression management.

Adult↗
PubMed2002

Views of practicing physicians and the public on medical errors.

BACKGROUND: In response to the report by the Institute of Medicine on medical errors, national groups have recommended actions to reduce the occurrence of preventable medical errors. What is not known is the level of support for these proposed changes among practicing physicians and the public. METHODS: We conducted parallel national surveys of 831 practicing physicians, who responded to mailed questionnaires, and 1207 members of the public, who were interviewed by telephone after selection with the use of random-digit dialing. Respondents were asked about the causes of and solutions to the problem of preventable medical errors and, on the basis of a clinical vignette, were asked what the consequences of an error should be. RESULTS: Many physicians (35 percent) and members of the public (42 percent) reported errors in their own or a family member's care, but neither group viewed medical errors as one of the most important problems in health care today. A majority of both groups believed that the number of in-hospital deaths due to preventable errors is lower than that reported by the Institute of Medicine. Physicians and the public disagreed on many of the underlying causes of errors and on effective strategies for reducing errors. Neither group believed that moving patients to high-volume centers would be a very effective strategy. The public and many physicians supported the use of sanctions against individual health professionals perceived as responsible for serious errors. CONCLUSIONS: Though substantial proportions of the public and practicing physicians report that they have had personal experience with medical errors, neither group has the sense of urgency expressed by many national organizations. To advance their agenda, national groups need to convince physicians, in particular, that the current proposals for reducing errors will be very effective.

Attitude of Health Personnel↗