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Biomedical subjects

Scott D Ramsey

Publications and source records attributed to Scott D Ramsey.

At least 19 recordsLinked to original sources
PubMed2006

Why do men choose one treatment over another?: a review of patient decision making for localized prostate cancer.

Treatment choices for localized prostate cancer appear to vary widely, although it is unclear whether this variation is a result of patient values or other factors. The authors conducted a systematic review of the literature, identifying 70 articles that focused on prostate cancer decision making. Studies suggest that men consider several issues when making treatment decisions. The authors found conflicting evidence regarding the importance that men place on cancer eradication, with considerable variation in how patients interpret evidence regarding treatment efficacy. The number of physicians that men see and the importance of the physician recommendation were found to vary considerably. Although men stated that side effects are important, few patients reported that side effect factors ultimately influenced their treatment choice. To the authors' knowledge, there is little research regarding how patients' personal values shape and influence their decision, or the role of race/ethnicity or socioeconomic status in preferences for treatment. The authors conclude that variations in treatment decisions may be more indicative of differences in the information patients receive rather than truly reflective of underlying patient preferences. Considerable progress is needed in helping patients fully understand how to balance the complex issues surrounding prostate cancer treatment decision making.

Culture↗
PubMed2006

Population-based study of the prevalence of family history of cancer: implications for cancer screening and prevention.

PURPOSE: Family history assessment is gaining importance as a potential public health tool to help determine susceptibility to common cancers. Population-based data on the prevalence of having a family history of common cancers are scant. METHODS: We queried survey questions from the National Health Interview Survey, an annual nationwide survey of approximately 36,000 households in the United States, to determine the prevalence of persons reporting one or more first-degree relatives with breast, colorectal, lung, prostate, or ovarian cancer. RESULTS: Breast cancer was the most common condition noted for family members (7.74% of respondents), followed by lung cancer (7.10%), colorectal cancer (4.96%), prostate cancer (4.68%), and ovarian cancer (1.79%). A family history of cancer was more commonly reported by older persons, whites, women, and high-income groups. CONCLUSION: A substantial proportion of persons in the United States report having a close family member with cancer, and thus may be eligible for earlier or more aggressive cancer screening services.

Adult↗
PubMed2006

Chronic obstructive pulmonary disease, risk factors, and outcome trials: comparisons with cardiovascular disease.

Chronic obstructive pulmonary disease (COPD) is a major health problem and now ranks fifth in terms of the global burden of disease. Although COPD is a disease that is characterized by progressive respiratory symptoms and functional decline, exacerbations pose the greatest risk for morbidity and early mortality, have a dramatic effect on quality of life, and are the most significant source of health care expenditure. To improve survival and reduce costs, it is critical to develop effective programs designed to reduce the frequency and severity of exacerbations for these patients. With limited health care resources, efficient and effective management of COPD ideally involves identifying and focusing efforts on individuals at particular risk. In the development of an appropriate multimodal strategy, lessons could be learned from the evolution of guidelines and management of cardiovascular disease, in particular heart failure, which has many parallels with COPD in terms of prevalence, prognosis, and impact on patient quality of life. There is a need for large prospective trials in COPD, based on hard clinical outcomes such as death, which, together with physician and patient education, will help to drive improvements in clinical management.

Cardiovascular Diseases↗
PubMed2006

Toward evidence-based assessment for coverage and reimbursement of laboratory-based diagnostic and genetic tests.

Despite the pervasiveness of laboratory tests and their importance to medicine, evidence for their appropriate use often is very limited. In this article, we argue for a fundamental restructuring of the process by which laboratory tests are evaluated and reimbursed. We present an approach that would promote more evidence- based appraisals for laboratory tests. In addition, we urge that coverage and reimbursement for laboratory tests move toward an evidence- and value-based approach, using the tools that largely have been adopted for pharmaceuticals by many US healthcare payers. To address this information gap for laboratory tests, we note several potential strategies to encourage manufacturers, laboratory service providers, and payers to collect outcome and cost data that will better support effective use of new laboratory tests. Integral to increasing appropriate use and reimbursement will be the development of a common language and format for dialogue--facilitating the development, review, and delivery of evidence-based tests by manufacturers, clinical laboratories, and healthcare payers.

Clinical Laboratory Techniques↗
PubMed2005

The cost of adjuvant chemotherapy in patients with early-stage breast carcinoma.

BACKGROUND: In the U.S., the majority of premenopausal patients with early-stage breast carcinoma are treated with adjuvant chemotherapy. However, to the authors' knowledge, there have been few formal analyses of adjuvant chemotherapy cost performed to date, especially in premenopausal women. The objective of the current study was to evaluate the direct medical cost of adjuvant chemotherapy in women with early-stage breast carcinoma. METHODS: The attributable cost of adjuvant chemotherapy was evaluated by comparing the total cost of care for patients with breast carcinoma (cases) during the period from diagnosis to 9 months subsequent with the cost for age-matched and gender-matched control patients without breast carcinoma over an equivalent time period. The authors identified cases from a linked database of claims records from a managed care organization, and the Cancer Surveillance System registry. Controls were identified from the managed care organization from which the cases originated. Resource prices were based on reimbursements from the managed care organization. RESULTS: The attributable cost of adjuvant chemotherapy was estimated to be dollar 23,019 (95% confidence interval, dollar 19,596-dollar 26,441), based on 1239 women. The cost appeared to decrease with increasing age at diagnosis, with total costs of dollar 26,834, dollar 19,889, and dollar 17,098 for women < 50, 50-59, and > or = 60 years, respectively. Also, costs were higher for regional versus local disease (dollar 36,076 vs. dollar 12,659), for women who had a mastectomy versus breast-conserving surgery (dollar 31,075 vs. dollar 17,889), and for women who had no comorbidities versus > or = 1 comorbidity (dollar 23,606 vs. dollar 21,340). Contributors to high chemotherapy cost included use of chemotherapy agents not included in clinical guidelines during the study period, use of supportive care agents, and hospitalizations. CONCLUSIONS: The attributable cost of adjuvant chemotherapy in patients with early-stage breast carcinoma is significant. The integration of managed care claims data with clinical data from the Cancer Surveillance System registry offered a unique opportunity to derive more informative and accurate disease burden estimates in oncology.

Adult↗
PubMed2005

Genetic services for familial cancer patients: a follow-up survey of National Cancer Institute Cancer Centers.

PURPOSE: Anecdotal reports suggest that the volume of services offered to individuals concerned with hereditary cancer risk has increased substantially in recent years. As a follow-up to our 1993 survey, we sought to determine how the scope and volume of genetic services has changed between 1993 and 2002. METHODS: We surveyed the 61 National Cancer Institute-designated cancer centers in operation in 2002 using an updated version of the questionnaire from 1993. Analysis included frequencies and summary statistics. RESULTS: The majority of cancer centers responding (46 of 56 centers; 82.1%) provided some genetic services for evaluation of familial cancer, which is a higher proportion than in 1993 (50%; P < .01). Almost all centers (42 of 46 centers; 91.3%) provided services not only to cancer patients and their families, but also to individuals concerned with risk, which is a change (P = .01) from 1993, when 64.7% of centers offered such services. In addition, increases have been found for most other measures of services rendered for familial genetic services. CONCLUSION: As public awareness of cancer susceptibility genes has grown markedly in recent years, the demand has also grown for genetic services to assess familial cancer risk. Major deleterious genetic mutations are rare, and much of the current research in genetic variation focuses on higher prevalence variants that carry lower risks. This may suggest that testing for mutations will move from genetics clinics to primary care and specialty practices. Thus, it is unclear whether the scope and volume of cancer center genetics services will continue to grow as rapidly as they have over the last decade.

Cancer Care Facilities↗
PubMed2005

Lifetime implications and cost-effectiveness of using finasteride to prevent prostate cancer.

PURPOSE: We estimate the lifetime implications of daily treatment with finasteride following the results of the Prostate Cancer Prevention Trial (PCPT). In this trial, prostate cancer prevalence was reduced by 25%; however, an increase in the number of high-grade tumors among the treatment group necessitates the long-term projection of the likely benefits and costs. METHODS: We use a Markov decision analysis model with data from the trial, the SEER program, and published literature. The model measures the cost per life-year and cost per quality-adjusted life-year (QALY) gained for a cohort of men age 55 years who initiate preventive treatment with finasteride. RESULTS: Finasteride is associated with a gain of 6 life-years per 1000 men treated at an incremental cost of 1660000 dollars per life-year gained. The quality-adjusted analysis results in 46 QALYs gained per 1000 men treated at an incremental cost of 200000 dollars per QALY gained, due primarily to the favorable effects of finasteride on benign prostatic hyperplasia. Under the assumption that the increase in high-grade tumors observed among finasteride treated men is a pathologic artifact, the incremental costs are 290000 dollars per life-year gained and 130000 dollars per QALY gained. CONCLUSIONS: The cost burden associated with finasteride is substantial, while its survival benefit is small and only realized many years after initiating treatment. To achieve an incremental cost below 100000 dollars per QALY gained, the price of finasteride must be reduced by 50% from its current average wholesale price and finasteride must be shown to prevent high-grade as well as low-grade disease.

Aged↗
PubMed2005

Economic analyses of human genetics services: a systematic review.

PURPOSE: The study's purpose was to conduct a structured review of economic analyses of genetic services. These will be increasingly valuable tools for assessing the clinical and economic outcomes of new medical technologies. METHODS: We searched for economic studies published between January 1990 and August 2004 from a variety of publicly available databases. Articles were first reviewed to determine whether they were original studies, and second to determine whether they were formal cost-effectiveness analyses by established criteria. Articles meeting these criteria were graded using a validated rating scale. RESULTS: Of 149 articles, 63 met established criteria for cost-effectiveness analyses. The majority (87%) were published since 1996. The majority of studies considered adult (31) or prenatal (25) conditions with the remainder considering preconception or pediatric conditions. More than half used life years gained or an ad hoc measure of outcome (e.g., cases detected). Twenty-five percent measured outcome as quality-adjusted life years. The disease areas most considered were cancer (21%) and aneuploidies (18%). The average quality ranking was 87 of 100 possible (range 48-100). Common shortcomings included lack of statement of perspective, lack of discussion of potential bias, and lack of disclosure of funding sources. CONCLUSIONS: Relatively few economic evaluations are available for genetic services, and most are clustered in specific disease areas. Overall quality was high, but varied widely. Most shortcomings that would improve study quality are easy to address. To improve the relevance of these studies, researchers need to incorporate measures of outcome that are familiar to decision makers, including quality-adjusted life years.

Adult↗
PubMed2005

Costs and survival of patients with colorectal cancer in a health maintenance organization and a preferred provider organization.

BACKGROUND: Colorectal cancer is relatively frequent among adults of working age, yet few studies have examined treatment, outcomes, and costs for people under 65 years of age with this disease. OBJECTIVE: The objective of this study was to compare the initial treatments, survival, cancer-related medical costs, and overall medical costs for working-aged persons with colorectal cancer in 2 large health insurance plans in Washington State, one a preferred provider organization (PPO) and the other a group model health maintenance organization (HMO). STUDY POPULATION: This study consisted of patients, aged 20-64 years, diagnosed with colorectal cancer in both health plans from 1996 to 1998. For each cancer case, up to 5 control subjects, matched on age and sex, were selected for the analysis. METHODS: We calculated unadjusted, attributable, and overall medical costs using the Kaplan-Meier sample average estimator. We calculated relative mortality rates using Cox regression. We used propensity scores to adjust overall costs and survival for potential confounding factors. RESULTS: Two hundred ten persons in the PPO and 136 persons in the HMO, aged 20-64 years, were diagnosed with cancer over the observation period and included in this study. Patients in the PPO were more likely to have local excision of their tumor (16% compared with 11%) and were less likely to receive chemotherapy (48% compared with 60%). The overall medical costs for the cancer cases were $46,000 in the HMO and $46,400 in the PPO (95% confidence interval for the difference: -$19,300 to 20,100). The cancer-attributable medical costs over 2 years were $40,400 in the HMO and $44,300 in the PPO (95% confidence interval for the difference: -$17,400 to 25,200). Survival was similar in the 2 health plans: the hazard ratio was 0.89 for those enrolled in the PPO (95% confidence interval: 0.50 to 1.59). Adjustment for potential confounding factors altered the results little. CONCLUSIONS: There were differences in the initial treatment of the patients in each health plan, but costs and survival were not significantly different between the 2 plans.

Adult↗
PubMed2005

Family history assessment to detect increased risk for colorectal cancer: conceptual considerations and a preliminary economic analysis.

BACKGROUND: Although the rationale for earlier screening of persons with a family history of colorectal cancer is plausible, there is no direct evidence that earlier assessment is either effective or cost-effective. OBJECTIVE: To estimate the clinical and economic effect of using family history assessment to identify persons for colorectal cancer screening before age 50. METHODS: We developed a decision model to compare costs and outcomes for two scenarios: (a) standard population screening starting at age 50; (b) family history assessment at age 40, followed by screening colonoscopy at age 40 for those with a suggestive family history of colorectal cancer. The analysis was conducted using the health insurer perspective. RESULTS: Using U.S. population estimates, 22 million would be eligible for family history assessment, and one million would be eligible for early colonoscopy; 2,834 invasive cancers would be detected, and 29,331 life years would be gained. The initial program cost would be USD $900 million. The discounted cost per life year gained of family history assessment versus no assessment equals USD $58,228. The results were most sensitive to the life expectancy benefit from earlier screening, the cost of colonoscopy, and the relative risk of colon cancer in those with a family history. CONCLUSIONS: The cost-effectiveness of family history assessment for colorectal cancer approaches that of other widely accepted technologies; yet, the results are sensitive to several assumptions where better data are needed. Because of the relatively high prevalence of family history in the population, careful analysis and empirical data are needed.

Adult↗
PubMed2004

Chronic obstructive pulmonary disease: is there a case for early intervention?

Chronic obstructive pulmonary disease (COPD) is a highly prevalent condition that represents a significant economic burden to society. Early diagnosis of COPD offers the best opportunity to slow the progression of the disease through smoking cessation. Aggressive medical management of COPD for patients diagnosed at a moderate or severe stage is likely to be attractive from an economic standpoint, although prospective studies are needed to validate current evidence. Poor adherence to smoking cessation and pharmacologic therapy suggests that patient education is critical to successful intervention at all stages of illness. The economic value of aggressive pharmacotherapy for early-stage COPD is less certain, but the burden of illness and potential pharmacoeconomic benefits in such patients is a strong rationale for combined clinical and economic trials.

Economics, Pharmaceutical↗
PubMed2004

Chemotherapy use, outcomes, and costs for older persons with advanced non-small-cell lung cancer: evidence from surveillance, epidemiology and end results-Medicare.

PURPOSE: There is limited published documentation regarding US community patterns of care for older patients with advanced non-small-cell lung cancer (NSCLC). Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we examined community treatment patterns for advanced NSCLC, focusing on chemotherapy. METHODS: Patients with locally advanced or metastatic (TNM system stages IIIb and IV) NSCLC diagnosed between January 1, 1994, and December 31, 1999, were stratified based on chemotherapy agents received during the first 3 months following diagnosis. Cox proportional hazards models were used to compare survival, controlling for age, sex, race, noncancer comorbidity, stage at diagnosis, SEER region, and receipt of cancer-related surgery or radiation therapy in the first 3 months following diagnosis. Lifetime medical costs were calculated for each group. RESULTS: 14,875 patients met inclusion criteria: 7,411 (49.8%) stage III and 7,464 (50.2%) stage IV at diagnosis. Thirty-one percent received chemotherapy, 8% received surgery, and 53% received radiation therapy either as initial or adjuvant treatment. Persons > or = 75 years of age, females, African Americans, and those with more than one comorbidity were significantly less likely to receive chemotherapy (P < .01). Survival was inferior for those who did not receive a platinum-containing agent (P < .01). Lifetime costs were highest for those receiving platinum + taxane combinations, exceeding other regimens by more than $10,000 USD per patient. CONCLUSION: Chemotherapy prolongs survival in community settings, but is underutilized for persons with advanced NSCLC. Reasons for lower use in minorities and variation across regions deserve further study.

Age Factors↗
PubMed2004

Revised Bethesda Guidelines for hereditary nonpolyposis colorectal cancer (Lynch syndrome) and microsatellite instability.

Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome, is a common autosomal dominant syndrome characterized by early age at onset, neoplastic lesions, and microsatellite instability (MSI). Because cancers with MSI account for approximately 15% of all colorectal cancers and because of the need for a better understanding of the clinical and histologic manifestations of HNPCC, the National Cancer Institute hosted an international workshop on HNPCC in 1996, which led to the development of the Bethesda Guidelines for the identification of individuals with HNPCC who should be tested for MSI. To consider revision and improvement of the Bethesda Guidelines, another HNPCC workshop was held at the National Cancer Institute in Bethesda, MD, in 2002. In this commentary, we summarize the Workshop presentations on HNPCC and MSI testing; present the issues relating to the performance, sensitivity, and specificity of the Bethesda Guidelines; outline the revised Bethesda Guidelines for identifying individuals at risk for HNPCC; and recommend criteria for MSI testing.

Adaptor Proteins, Signal Transducing↗
PubMed2004

Racial disparity in primary and adjuvant treatment for nonmetastatic prostate cancer: SEER-Medicare trends 1991 to 1999.

OBJECTIVES: To assess trends in the initial care of nonmetastatic prostate cancer, including the use of primary and adjuvant androgen deprivation therapy (ADT), using population-based treatment claims from 1991 to 1999. METHODS: We used a database linking the Surveillance, Epidemiology, and End Results (SEER) registry with Medicare claims to extract treatment information for 90,128 men aged 65 years and older, who were newly diagnosed with nonmetastatic prostate cancer. RESULTS: The use of aggressive therapy has increased among white men over time; but aggressive therapy has recently declined among African-American men. Accounting for age, grade, socioeconomic status, and comorbidity, African-American men were 26% less likely to receive aggressive therapy than white men (odds ratio 0.74; 95% confidence interval 0.70 to 0.79). The use of ADT has increased substantially in both the primary and the adjuvant settings. By 1999, 45.6% of white men and 35.8% of African-American men who selected conservative management received primary ADT; among men treated with external beam radiotherapy, the proportion receiving adjuvant ADT was 53.7% for white men and 42.4% for African-American men (P <0.001). CONCLUSIONS: Racial differences in the use of aggressive and conservative therapies are increasing. ADT is becoming a widely adopted component of initial treatment for localized prostate cancer. It is crucial to understand the impact of treatment patterns, including the increased use of ADT, on patient survival, morbidity, and costs of care.

Aged↗
PubMed2004

Quantifying losses to the donated blood supply due to donor deferral and miscollection.

BACKGROUND: Donors are deferred for multiple reasons. Losses related to disease marker rates are well established. Donor and donation losses for other reasons, however, have not been extensively quantified. STUDY DESIGN AND METHODS: To quantify these losses, three data sets from the Blood Centers of the Pacific were combined, permitting detailed analysis of year 2000 allogeneic whole-blood donations. RESULTS: During 2000, 13.6 percent of 116,165 persons who presented for donation were deferred at presentation. Short-term deferral accounted for 68.5 percent (hematocrit was most common at 60%); long-term deferral accounted for 21 percent (travel to a malarial area and tattoo or other nonintravenous drug use needle exposure were most common at 59 and 29%, respectively); and multiple-year or permanent deferral accounted for 10.5 percent (UK travel [variant Creutzfeldt-Jakob disease] risk and emigration from a malarial area were most common at 38 and 11%, respectively). Disease-marker-reactive donations represented 0.9 percent of donor outcomes. The prevalence of deferral and also miscollection (under- and overweight units) varied by age, sex, and first-time versus repeat donor status. Overall, miscollection led to a loss of 3.8 percent of 100,141 collections, ranging from 1.9 percent in repeat male donors 40 to 54 years of age to 10.7 percent in first-time female donors 16 to 24 years of age. CONCLUSION: Loss of units from both first-time and repeat donors due to temporary deferral and loss of units from miscollection are more common events than losses due to disease marker testing. Some of these losses may be avoidable and could increase the blood supply without having to recruit new donors.

Adolescent↗
PubMed2004

Genetic testing and pharmacogenomics: issues for determining the impact to healthcare delivery and costs.

OBJECTIVES: To determine the potential impact of genetic testing and pharmacogenomics on healthcare delivery and costs. STUDY DESIGN: Literature review. METHODS: We examined 3 examples: (1) BRCA1/2 testing for breast cancer risk, (2) HER2/neu overexpression testing to guide drug treatment in women with breast cancer, and (3) CYP2C9 testing before the use of the anticoagulant warfarin. We discussed each genetic testing example from the perspective of the patient, provider, insurer, industry, government, and society. RESULTS: The expanded use of genetic information offers many potential clinical benefits, but also many economic challenges. One of those challenges will be managing the impact of genetic testing on healthcare delivery and costs. CONCLUSIONS: Systematic, evidence-based technology assessments and economic evaluations will have to be used to guide the incorporation of genomics into clinical practice. More research also will be needed to assess patient preferences and willingness to pay for genomic technologies; how providers can assess and use genomic technologies; and how the industry, insurers, and government can best balance the relevant costs and benefits.

Breast Neoplasms↗
PubMed2003

Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema.

BACKGROUND: The National Emphysema Treatment Trial, a randomized clinical trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema, included a prospective economic analysis. METHODS: After pulmonary rehabilitation, 1218 patients at 17 medical centers were randomly assigned to lung-volume-reduction surgery or continued medical treatment. Costs for the use of medical care, medications, transportation, and time spent receiving treatment were derived from Medicare claims and data from the trial. Cost effectiveness was calculated over the duration of the trial and was estimated for 10 years of follow-up with the use of modeling based on observed trends in survival, cost, and quality of life. RESULTS: Interim analyses identified a group of patients with excess mortality and little chance of improved functional status after surgery. When these patients were excluded, the cost-effectiveness ratio for lung-volume-reduction surgery as compared with medical therapy was 190,000 dollars per quality-adjusted life-year gained at 3 years and 53,000 dollars per quality-adjusted life-year gained at 10 years. Subgroup analyses identified patients with predominantly upper-lobe emphysema and low exercise capacity after pulmonary rehabilitation who had lower mortality and better functional status than patients who received medical therapy. The cost-effectiveness ratio in this subgroup was 98,000 dollars per quality-adjusted life-year gained at 3 years and 21,000 dollars at 10 years. Bootstrap analysis revealed substantial uncertainty for the subgroup and 10-year estimates. CONCLUSIONS: Given its cost and benefits over three years of follow-up, lung-volume-reduction surgery is costly relative to medical therapy. Although the predictions are subject to substantial uncertainty, the procedure may be cost effective if benefits can be maintained over time.

Cost-Benefit Analysis↗