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Biomedical subjects

M H Eckman

Publications and source records attributed to M H Eckman.

At least 19 recordsLinked to original sources
PubMed1995

Foot infections in diabetic patients. Decision and cost-effectiveness analyses.

OBJECTIVE: To examine the cost-effectiveness of approaches to the diagnosis and treatment of patients with type II (non-insulin-dependent) diabetes mellitus (NIDDM) who have foot infections and suspected osteomyelitis. DESIGN: Decision and cost-effectiveness analyses were performed using a Markov model. We examined the prevalence of osteomyelitis, the major complications and efficacies of long-term antibiotic therapy and surgery, and the performance characteristics of four diagnostic tests (roentgenography, technetium Tc 99m bone scanning, indium in 111-labeled white blood cell scanning, and magnetic resonance imaging). Data were drawn from the English-language literature using MEDLINE searches and bibliographies from selected articles. SETTING: Primary care. PATIENTS: Patients with NIDDM who had foot infections and suspected osteomyelitis but no signs of systemic toxicity. INTERVENTIONS: Following hospitalization for surgical débridement and intravenous antibiotic therapy: (1) treatment for presumed soft-tissue infection, (2) culture-guided empiric treatment for presumed osteomyelitis, (3) 71 combinations of diagnostic tests preceding antibiotic therapy for osteomyelitis, (4) 71 combinations of tests preceding amputation, and (5) immediate amputation. MAIN OUTCOME MEASURES: Quality-adjusted life expectancy, average costs. RESULTS: Culture-guided empiric treatment for osteomyelitis with 10 weeks of oral antibiotic therapy has similar effectiveness to testing followed by a long course of antibiotic therapy if any test result is positive. However, empiric treatment is the least expensive strategy. CONCLUSIONS: Noninvasive testing adds significant expense to the treatment of patients with NIDDM in whom pedal osteomyelitis is suspected, and such testing may result in little improvement in health outcomes. In patients without systemic toxicity, a 10-week course of culture-guided oral antibiotic therapy following surgical débridement may be as effective as and less costly than other approaches.

Amputation, Surgical↗
PubMed1994

Screening for prostate cancer. A decision analytic view.

OBJECTIVE: To determine the clinical and economic effects of screening for prostate cancer with prostate-specific antigen (PSA), transrectal ultrasound (TRUS), and digital rectal examination (DRE). DESIGN: Decision analytic cost-utility analysis comparing four screening strategies with a strategy of not screening. We assumed that the cancer detection rate and stage distribution were predicted by each combination of tests and that localized cancer was treated with radical prostatectomy. For each strategy, we calculated life expectancy, quality-adjusted life expectancy (QALE), and cost-utility ratios for unselected and high-prevalence populations. DATA: Probabilities and rates for clinical events were gathered from published data. We assessed utilities by the time-trade-off method using urologists, radiation oncologists, and internists as subjects. The Clinical Cost Manager at the New England Medical Center provided cost data. RESULTS: In unselected men between the ages of 50 and 70 years, screening with PSA or TRUS prolonged unadjusted life expectancy but diminished QALE. Screening with DRE alone yielded no reduction in mortality at any age. All programs increased costs. Results were sensitive only to assumptions about the efficacy of treatment. In high-prevalence populations, screening produced a similar pattern: gains in unadjusted life expectancy, losses in QALE, and increased costs. CONCLUSIONS: Our analysis does not support using PSA, TRUS, or DRE to screen asymptomatic men for prostatic cancer. Screening may result in poorer health outcomes and will increase costs dramatically. Assessment of comorbidity, risk attitude, and valuation of sexual function may identify individuals who will benefit from screening, but selecting high-prevalence populations will not improve the benefit of screening.

Aged↗
PubMed1993

Effect of laboratory variation in the prothrombin-time ratio on the results of oral anticoagulant therapy.

BACKGROUND: Patients receiving long-term anticoagulant therapy may be subject to unnecessary risks of bleeding or thromboembolism because of variability in the commercial thromboplastins used to determine prothrombin time and consequent uncertainty about the actual intensity of anticoagulation. METHODS: We explored the effect of this uncertainty on the benefits and risks of anticoagulation in patients with prosthetic heart valves, using models of thromboembolic and hemorrhagic complications as a function of the intensity of anticoagulation, with quality-adjusted life expectancy and average variable costs used to describe outcomes. RESULTS: Anticoagulation provides a striking benefit for patients whose treatment is conducted within the recommended range of the international normalized ratio (INR)--i.e., 2.5 to 3.5--but if uncertainty about the laboratory results causes the intensity of anticoagulation to fall outside this range, the gain becomes smaller. Uncertainty about the true intensity of anticoagulation may reduce the potential gain in life expectancy, adjusted for quality of life, by more than half and may increase the ratio of costs to effectiveness to almost five times the optimal value. Variability in the intensity of anticoagulation is even greater if older recommendations advocating a higher level of anticoagulation are followed. CONCLUSIONS: Uncertainty about the sensitivities of the commercially available thromboplastins used in the United States can have important clinical and economic effects. This problem could be eliminated if clinical laboratories uniformly reported the intensity of anticoagulation as the INR, by adjusting prothrombin-time ratios for variability in thromboplastins.

Cost-Benefit Analysis↗
PubMed1992

Direct angioplasty for acute myocardial infarction. A review of outcomes in clinical subsets.

PURPOSE: To review the usefulness of angioplasty done early in the course of an acute myocardial infarction without preceding thrombolytic therapy. DATA SOURCES: The English-language literature was searched from 1983 through October 1991 using MEDLINE; bibliographies from selected articles were searched by hand. STUDY SELECTION: Series reporting results for direct angioplasty without preceding thrombolytic therapy were reviewed. Twenty-three articles describing a total of 4368 patients were found. DATA EXTRACTION: After duplicate patient series were eliminated, weighted average short- and long-term mortality rates were calculated for the remaining 2073 patients in 10 series and for selected clinical subsets. RESULTS OF DATA SYNTHESIS: Average hospital mortality for patients with acute myocardial infarction having direct angioplasty was 8.3% (95% Cl, 7.1% to 9.5%). Patients in cardiogenic shock had the highest mortality (44.2%; Cl, 35.9% to 52.5%); patients with one-vessel disease had the lowest (1%; Cl, 0% to 2.3%). For patients in cardiogenic shock, data on direct angioplasty appeared superior to data for similar patients receiving thrombolytic therapy. Although few data exist, a survival advantage was also suggested for patients with a history of previous bypass surgery (hospital mortality, 11.1% [Cl, 4.4% to 17.8%]). CONCLUSIONS: Direct angioplasty has an overall mortality similar to that of thrombolytic therapy. Patients who may benefit more from mechanical revascularization than from thrombolytic therapy include those at increased risk for thrombolytic therapy (uncontrolled hypertension, recent major surgery, cerebrovascular accident, prolonged cardiopulmonary resuscitation, or bleeding diathesis), and those with cardiogenic shock. The efficacy in several other patient subsets (age greater than 65 years, previous coronary artery bypass grafting, prolonged delay before reperfusion) warrants further study.

Angioplasty, Balloon, Coronary↗
PubMed1992

Prophylactic use of the intra-aortic balloon pump in high-risk cardiac patients undergoing noncardiac surgery: a decision analytic view.

OBJECTIVE: As the indications for the intra-aortic balloon pump (IABP) continue to evolve, a potential new use may be the prophylactic preoperative insertion of the IABP in the high-risk cardiac patient undergoing noncardiac surgery. Our objective is to present a general approach to the high-risk cardiac patient who may benefit from the prophylactic insertion of the IABP. DESIGN: Case reports and a decision analysis. METHODS: A decision model was constructed that weighs the risk of life-threatening postoperative complications against the risk of vascular complications, including surgery and possible amputation, from IABP insertion. RESULTS AND CONCLUSIONS: A review of the literature identified 10 patients who underwent IABP placement prior to noncardiac surgery. These patients, along with our three cases, define a population of patients for whom the prophylactic IABP may be useful. This population includes patients with coronary artery disease (CAD) for whom bypass grafting is not an option due to: (1) inoperable CAD; (2) a severe coexisting disease process (such as a malignancy); or (3) the emergent nature of the noncardiac procedure. The decision analysis suggests that patients whose preoperative assessment places them at very high risk for postoperative complications (Goldman class IV or Detsky class III undergoing major surgery) may benefit the most from prophylactic placement of an IABP prior to noncardiac surgery.

Aged↗
PubMed1990

Anticoagulation for noncardiac procedures in patients with prosthetic heart valves. Does low risk mean high cost?

Hospitalizations for patients with prosthetic heart valves undergoing noncardiac surgery are frequently prolonged for intravenous heparin therapy to decrease the incidence of thromboembolism while patients are not taking oral anticoagulant agents. Because the rate of thromboembolic events is quite low and the period of increased risk is very short, the cost of preventing these rare events can be great. We performed cost-effectiveness analyses addressing these issues. We calculated the marginal cost per additional quality-adjusted year of life gained per thromboembolic event averted and per death averted. We conclude that the marginal cost of prolonging hospitalization to administer heparin is prohibitively high compared with most contemporary therapies, except when the patient has the most thrombogenic of valves. We also discuss the ethical and legal ramifications of integrating the results of cost-effectiveness analyses into clinical practice.

Anticoagulants↗
PubMed1989

Bone marrow donor registries: the relation between registry size and probability of finding complete and partial matches.

In a registry of volunteer bone marrow donors, the relation between registry size and probability of finding an exact or partial match for a random recipient cannot be theoretically derived because it depends on specifics of the human leukocyte antigen (HLA) haplotype frequencies in the donor and recipient populations. The relation must be explicitly calculated using empirically determined HLA haplotype frequency data for all possible pairings between a donor and a recipient population. This report describes a general solution to this problem. The method shows that the relation of the probability of matching to registry size is sigmoidal, with small increases in probability at the extremes of registry size and a middle range of registry size within which the probability of matching increases most sharply. This range determines the approximate size of the most cost-effective registry. In addition, for any pairing of donor and recipient populations, there is a maximum probability of identifying a match of a given quality for a random recipient, which cannot be exceeded even if registry size were infinite. This upper limit is a function of the frequency of blank (or unknown) alleles in the donor and recipient populations; the higher that frequency, the lower the maximum probability of achieving any given quality of match. The determinants of the probability of achieving a given quality of match with a given registry size are (1) the genetic heterogeneity within the recipient and donor populations, which increases the registry size required to achieve a given probability of matching, and (2) the degree of genetic homology between the donor and recipient populations, which increases the maximum probability of matching and also lowers registry size requirements. The method described here can be used to estimate donor pool size requirements using any donor and recipient populations for which HLA frequency data are available.

Bone Marrow Transplantation↗