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B E Hillner

Publications and source records attributed to B E Hillner.

13 recordsLinked to original sources
PubMed1992

Efficacy and cost-effectiveness of autologous bone marrow transplantation in metastatic breast cancer. Estimates using decision analysis while awaiting clinical trial results.

OBJECTIVE: To assess the efficacy and cost-effectiveness of standard chemotherapy and high-dose chemotherapy with autologous bone marrow transplantation (ABMT) in metastatic breast cancer. DESIGN: Decision analysis model using a Markov process. SETTING: Response and recurrence rates from the published literature for standard therapy and from case series of ABMT. Costs were based on local charges and on adjusted Medicare data. PATIENTS: Hypothetical cohorts of women with metastatic breast cancer who had no bone marrow involvement and no comorbid illness. INTERVENTION: The standard chemotherapy cohort received cyclophosphamide, doxorubicin, and fluorouracil. The ABMT cohort was treated with intense induction chemotherapy, then additional high-dose chemotherapy following a remission, with ABMT support. MAIN OUTCOME MEASURES: Anticipated survival, incremental cost per year of life, and incremental cost per quality-adjusted year of life gained using a 5-year time horizon. Rigorous sensitivity analyses were done, including assessing a benefit "tail" of normal life expectancy for those free of disease after 5 years. RESULTS: ABMT was the preferred approach under almost all assumptions, but the size of the benefit varied greatly. ABMT had a survival benefit of 6.0 months at 5 years at an incremental cost of $115,800 per year of life saved. If patients who were free of disease after 5 years had normal survival, the benefit was 18.1 months at an incremental cost of $28,600 per year. The benefit of ABMT was primarily dependent on whether the recurrence risk was constant or decreases after a finite period of time. CONCLUSION: Using reasonable assumptions, ABMT provided a substantial benefit but at a cost that may be untenable. Decision analysis highlights the limitations in the currently available data and the assumptions made for the emotional question of using ABMT in metastatic breast cancer. The model supports the need for randomized clinical trials.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1992

Should women with node-negative breast cancer receive adjuvant chemotherapy?--Insights from a decision analysis model.

The use of adjuvant chemotherapy in women with node-negative breast cancer has been controversial and actively debated since the 1988 National Cancer Institute Clinical Alert. We developed a decision analysis model that used the results of available randomized controlled trials to assess the potential clinical and financial effects of using adjuvant chemotherapy for groups of 45-year-old and 60-year-old women. Using the baseline assumptions, we found that chemotherapy increases quality adjusted life expectancy and survival by a substantial amount at a cost comparable to most accepted medical interventions. The model highlights the uncertainties in duration of benefit from therapy, the need for refinements in risk stratification, the importance of patient preferences about toxicity and benefit, and the need for accurate cost-accounting for oncologic therapies. Decision analysis complements other methods for information gathering, analysis, and synthesis used in clinical research. With the increasing focus on the effectiveness of medical interventions, decision analysis will be an important tool for oncologists to understand.

Breast Neoplasms↗
PubMed1992

Estrogen therapy for geriatric osteoporosis: just one ball in a complex juggling act.

The use of estrogens is the single therapy that has been found consistently to prevent bone loss and fractures in postmenopausal women. Traditional osteoporotic risk factors should be used to select women for bone densitometry. The numeric result provided by densitometry, combined with age-based comparisons, is extremely useful in convincing reluctant women to be treated. The few studies that have been done in geriatric women show that estrogen therapy continues to be effective in reducing bone loss, but the absolute benefit is less than in perimenopausal women. The effects of estrogen therapy extend beyond osteoporosis. A consensus of epidemiologic reports has shown that women who comply with postmenopausal estrogen therapy have a 30% to 50% reduction in the risk of coronary artery disease. Given the frequency of these two conditions, widespread use of estrogen as a national health care policy would be appropriate if it were not for the evidence that estrogens may increase the risk of breast cancer and endometrial cancer. Given these lingering cancer fears, recent calls for a randomized national women's health study of postmenopausal estrogen therapy should be heeded.

Aged↗
PubMed1992

The optimal timing of autologous bone marrow transplantation in Hodgkin's disease patients after a chemotherapy relapse.

PURPOSE: The optimal sequence of salvage chemotherapy (SC) and autologous bone marrow transplantation (ABMT) for Hodgkin's disease (HD) patients who relapse after primary chemotherapy is unknown. We created a decision analysis model to determine the optimal treatment strategy and the most cost-effective approach. METHODS: The decision tree simulated a 25-year-old HD patient who relapsed less than 12 months after mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) chemotherapy. Four strategies used ABMT in some sequence with SC; the final strategy considered SC alone. Clinical data were derived from 17 published reports chosen by explicit criteria. Costs of care were estimated from the published literature and institutional experience. RESULTS: The optimal strategy was ABMT in second relapse, which was superior to the SC-only option by 1.9 years at an incremental cost of $26,200 per each year of life saved. When the probabilities of complete remission and disease-free survival were reduced for SC, similar to the clinical expectation of SC after a seven- or eight-drug regimen like MOPP/doxorubicin, bleomycin, and vinblastine with or without dacarbazine (MOPP/ABV[D]), ABMT in first relapse was the preferred strategy and provided 6 additional months. However, when the data from favorable (or unfavorable) SC and ABMT reports were compared head-to-head in this model, SC followed by ABMT in second relapse was always optimal. CONCLUSIONS: All relapsed HD patients should plan to use ABMT in some sequence with SC, if necessary. In most situations the optimal strategy is ABMT in second relapse. This analysis will assist clinicians in planning treatment for relapsed HD patients. It could be refined if historical series were updated to report the incidence and outcomes of SC relapse from seven- or eight-drug regimens.

Adult↗
PubMed1992

A model of chemotherapy in node-negative breast cancer.

Should all women with node-negative breast cancer receive chemotherapy? Acceptance of such a broad recommendation has been controversial due to the relatively good prognosis of these women and the lack of evidence of an improvement from chemotherapy in overall survival. We studied the question with a decision analytic model, which simulates a clinical trial of a large number of women over several decades, to calculate quality-adjusted life expectancy and the cost-effectiveness of chemotherapy in 45-year-old and 60-year-old women. The model considered a variety of scenarios about the long-term benefits of chemotherapy. The initial analysis found a lifetime benefit of 4 to 5 quality months (range, 2 to 14 months) at a cost of $15,400 to $18,800 per quality year (range, $5,100 to $56,800). If a risk-stratification protocol could identify a low-risk group, then benefit drops to about 1 quality month at a cost of $65,000 to $90,000 per year. For the average woman, chemotherapy increases the quality-adjusted life expectancy by a substantial amount at a generally acceptable cost. However, given the uncertainty of the duration of benefit and current potential for risk-stratification, a broad recommendation for chemotherapy is inappropriate.

Antineoplastic Agents↗
PubMed1992

Optimal management of suspected lower-extremity deep vein thrombosis. An evaluation with cost assessment of 24 management strategies.

Traditionally, patients suspected to have lower-extremity deep vein thrombosis have undergone venography, which is invasive, is expensive, and may cause deep vein thrombosis in healthy individuals. Recent studies have shown the safety and efficacy of alternative noninvasive approaches that employ impedance plethysmography or real-time ultrasonography. We compared these tests using decision analysis to model the consequences of 24 different management strategies for ambulatory patients suspected to have deep vein thrombosis. We also calculated the incremental cost per additional life saved for each strategy. Our analysis revealed that the optimal approach was to perform real-time ultrasonography followed by anticoagulation therapy if deep vein thrombosis is found. This approach was both effective and cost saving compared with no testing or treatment. Serial follow-up studies of patients whose initial study suggested no DVT saved additional lives, but at a cost of $390,000 per each additional life saved for patients with one follow-up study and $3.5 million per each additional life saved for patients with a second follow-up study. Venography should play a limited role in the contemporary evaluation of patients suspected to have deep vein thrombosis. Future research should focus on the determination of clinical predictors of patients who should undergo serial examinations.

Anticoagulants↗
PubMed1991

Efficacy and cost effectiveness of adjuvant chemotherapy in women with node-negative breast cancer. A decision-analysis model.

BACKGROUND: In 1988 the National Cancer Institute issued a Clinical Alert that has been widely interpreted as recommending that all women with node-negative breast cancer receive adjuvant chemotherapy. Acceptance of this recommendation is controversial, since many women who would not have a recurrence would be treated. METHODS: Using a decision-analysis model, we studied the cost effectiveness of chemotherapy in cohorts of 45-year-old and 60-year-old women with node-negative breast cancer by calculating life expectancy as adjusted for quality of life. The analysis evaluated different scenarios of the benefit of therapy: improved disease-free survival for five years, with a lesser effect on overall survival (base line); a lifelong benefit from chemotherapy; and a benefit in disease-free survival with no change in overall survival by year 10. The base-line analysis assumed a 30 percent reduction in the relative risk of recurrence for five years after treatment. RESULTS: For the 45-year-old woman, the base-line analysis found an average lifetime benefit from chemotherapy of 5.1 quality-months at a cost of $15,400 per quality-year. The 60-year-old women gained 4.0 quality-months at a cost of $18,800 per quality-year. Under the more and less optimistic scenarios, the benefit of chemotherapy varied from 1.4 to 14.0 quality-months for both groups. CONCLUSIONS: Chemotherapy substantially increases the quality-adjusted life expectancy of an average woman at a cost comparable to that of other widely accepted therapies. This benefit decreases markedly if the changes in long-term survival are less than in disease-free survival. Given its uncertain duration, the benefit may be too small for many women to choose chemotherapy. Selective use of chemotherapy to maximize the benefit to individual patients may be possible with refinements in risk stratification and explicit assessment of the patients' risk preferences.

Age Factors↗
PubMed1989

Physicians as gatekeepers. The impact of financial incentives.

Incentives encouraging physicians to reduce their use of diagnostic tests are controversial. We studied physicians enrolled in an independent practitioner association who see both fee-for-service and prepaid (health maintenance organization [HMO]) patients concurrently. We asked the following questions: (1) Do physicians order fewer tests for their patients enrolled in an HMO relative to their patients seen on a fee-for-service basis? (2) Are any reductions in testing selective or indiscriminate? We reviewed the charts of 273 new patients, 167 enrolled in a fee-for-service system and 106 enrolled in an HMO, who were seen by 17 physicians "for a check-up," and graded test use as "indicated" or "discretionary." We used multiple logistic regression to control for the effects of patient age and sex. Patients in the HMO underwent fewer tests than did patients in the fee-for-service system, as well as fewer discretionary tests, but received the same proportion of preventive services. We conclude that physicians ordered fewer tests for patients in the HMO, apparently because of selective omission of discretionary tests. Physicians also did not reduce preventive services for patients in the HMO relative to all other physicians.

Adult↗
PubMed1986

Postmenopausal estrogens in prevention of osteoporosis. Benefit virtually without risk if cardiovascular effects are considered.

Postmenopausal estrogens can delay or prevent osteoporosis and decrease the frequency of fractures, but they also increase the risk of endometrial cancer. A decision analytic model was developed using a Markov process with 18 different states to estimate quality-adjusted life expectancy with and without estrogen therapy. The model considered fractures of the hip, wrist, pelvis, humerus and spine with potential outcomes of short-term morbidity, long-term disability, nursing home placement, and death. Quality adjustments were based on expert opinions. In sensitivity analyses, various risks of endometrial cancer and hysterectomy due to estrogens were examined. The effect of estrogen therapy on cardiac mortality also was considered. For a cohort of 50-year-old white women who would take estrogens for 15 years, the analysis showed a benefit of 0.47 years but 0.67 quality-adjusted years. For every five-fold increase in the relative risk of endometrial cancer, the benefit decreases by 0.07 quality years. The benefit would increase by 0.17 quality years for each 10 percent decrease in the fracture rate and 0.32 for each 10 percent decrease in cardiovascular mortality rate. Thus, estrogen therapy provides a significant gain in quality-adjusted life expectancy. In considering the efficacy of any drug, all the benefits of the drug as well as all its risks must be included. If the beneficial effect of estrogens on cardiovascular mortality is confirmed, it will overshadow all other effects. Any recommendation about postmenopausal estrogens with respect to osteoporosis that excludes their cardiovascular effects markedly underestimates the potential gains from therapy.

Cardiovascular Diseases↗
PubMedDate not supplied

What a difference a day makes: a decision analysis of adult streptococcal pharyngitis.

With the availability of group A beta-hemolytic streptococcal (GABHS) antigen detection tests, the management of adult pharyngitis is being reassessed. A decision analytic model was developed which considered four strategies: immediate treatment, no treatment, performing a rapid antigen test, or obtaining a bacterial culture. Patient outcomes were expressed in "well" days, which were reduced by the "sick" days associated with adverse reactions to treatment or complications of GABHS infection. When immediate test results are available, testing is the optimal strategy for probabilities of GABHS between 1 and 49 per cent. This range includes almost all patients, using probability estimates based on clinical criteria. The absolute benefit of testing was 0.1 days. The major advantage of a rapid test is the avoidance of penicillin reactions. Variations in the symptomatic benefits of treatment had minimal effects on the analysis. The analysis supports the use of an antigen test for adult patients with pharyngitis.

Acute Disease↗