Preventing diabetes: the time is now.
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Diabetes Mellitus↗
Biomedical subjects
Steven Teutsch
Publications and source records attributed to Steven Teutsch.
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↗
Challenges in systematic reviews of economic analyses.
Economic analyses can provide valuable information for health care decision makers. Systematic reviews of economic analyses can integrate information from multiple studies and provide important insights by systematically examining how differences between models lead to different results. We use our experience in developing and implementing systematic reviews of economic analyses for the U.S. Preventive Services T ask Force, particularly our systematic review of the cost-effectiveness of colorectal cancer screening, to illustrate key methodologic challenges and suggest a framework for other researchers in this area.
Colorectal Neoplasms↗
Cost-effectiveness analysis: from science to application.
This article proposes ways to improve the credibility and use of cost-effectiveness analysis (CEA) in healthcare decision-making. We argue that the major issue is not the credibility of CEA as a methodology; although there are methodologic challenges, they can be addressed. Two issues, however, will require effort on the part of stakeholders to achieve consensus. First, agreement must be reached regarding the standards of evidence required to support healthcare policy decisions. Second, and of greater importance, the process of healthcare resource allocation decision-making must be viewed as credible and legitimate. We believe that the legitimacy of policy decisions regarding healthcare resource allocation and the acceptance of CEA as a decision tool informing the decision process will require both broad-based stakeholder engagement and transparency throughout the process. For this to occur, stakeholder groups must come to consensus on how to address competing policy goals. Specifically, how should we balance the desires for equity, universal access to healthcare services and technology, and the right of individuals to secure the specific healthcare resources they want?
Cost-Benefit Analysis↗
Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the U.S. Preventive Services Task Force.
BACKGROUND: Lung cancer is the leading cause of cancer-related death in the United States and worldwide. No major professional organizations, including the U.S. Preventive Services Task Force (USPSTF), currently recommend screening for lung cancer. PURPOSE: To examine the evidence evaluating screening for lung cancer with chest radiography, sputum cytologic examination, and low-dose computed tomography (CT) to aid the USPSTF in updating its recommendation on lung cancer screening. DATA SOURCES: MEDLINE, the Cochrane Library, reviews, editorials, and experts. STUDY SELECTION: Studies that evaluated mass screening programs for lung cancer involving the tests of interest were selected. All studies were reviewed, but only studies with control groups were rated in quality since these would most directly influence the USPSTF screening recommendation. DATA EXTRACTION: Data were abstracted to data collection forms. Studies were graded according to criteria developed by the USPSTF. DATA SYNTHESIS: None of the 6 randomized trials of screening for lung cancer with chest radiography alone or in combination with sputum cytologic examination showed benefit among those screened. All studies were limited because some level of screening occurred in the control population. Five case-control studies from Japan suggested benefit to both high- and low-risk men and women. All studies were limited by potential healthy screenee bias. Six cohort studies showed that when CT was used to screen for lung cancer, lung cancer was diagnosed at an earlier stage than in usual clinical care. However, these studies did not have control groups, making mortality evaluation difficult. In addition, the studies demonstrated a high rate of false-positive findings. CONCLUSIONS: Current data do not support screening for lung cancer with any method. These data, however, are also insufficient to conclude that screening does not work, particularly in women. Two randomized trials of screening with chest radiography or low-dose CT are currently under way and will better inform lung cancer screening decisions.
Evidence-Based Medicine↗
Has the epidemiology of nosocomial candidemia changed?
OBJECTIVE: To assess changes in the epidemiology of nosocomial candidemia in the post-fluconazole era among hospitalized patients using a case-control study design. DESIGN: Candidemia case-patients were matched 1:1 on diagnosis, age, and length of stay with control-patients. Conditional logistic regression was used to determine predictors and outcomes of candidemia. Treatment regimens and compliance with national practice guidelines were compared among case-patients. SETTING: Barnes-Jewish Hospital, a 1,278-bed, tertiary-care center affiliated with Washington University School of Medicine, St. Louis, Missouri. PARTICIPANTS: Patients admitted from January 1 to December 31, 2000. Case-patients were identified through the hospital microbiological surveillance system and matched with control-patients. RESULTS: Predictors of candidemia included Hickman catheters (odds ratio [OR], 9.53; 95% confidence interval [CI95], 1.34 to 68.01), gastric acid suppressants (OR, 6.38; CI95, 2.33 to 17.43), nasogastric tubes (OR, 3.69; CI95, 1.27 to 10.78), antibiotics (OR, 1.46; CI95, 1.15 to 1.86), and admission to the intensive care unit (OR, 6.40; CI95, 2.12 to 19.31). The crude case-fatality rate was 40%. Seventeen (15%) of the case-patients received the recommended treatment regimen according to recently published practice guidelines. CONCLUSIONS: The epidemiology of candidemia has changed little at our hospital during the past decade and remains a significant cause of mortality. Further studies on the benefits of preventive therapy will be essential to improve the outcome of this infection.
Antifungal Agents↗
The burden of appendicitis-related hospitalizations in the United States in 1997.
BACKGROUND: Acute appendicitis is among the most frequent causes of surgical abdominal disease worldwide. METHODS: Data from the Nationwide Inpatient Sample of the Healthcare Utilization Project were used to estimate the prevalence and disease burden of appendicitis-related hospitalizations in the United States in 1997. The data are a representative sample of discharge records from community hospitals drawn from 22 states in the United States. RESULTS: In the United States in 1997, there were an estimated 252,682 (95% CI: 242,957-262,407) appendicitis-related hospitalizations. The mean length of stay and total charges for appendicitis-related hospitalizations were four days (95% CI: 3.4-4.6) and $11,645 (95% CI: $11,299-$11,992) per hospitalization, respectively. Appendicitis-related hospitalizations associated with post-operative infection, peritoneal abscess, or peritonitis had longer average lengths of stay and higher average costs when compared to hospitalizations associated with local appendicitis without post-operative infection. Appendicitis cases among very young and older patients were more likely to be associated with peritoneal abscess, peritonitis, or post-operative infection. CONCLUSIONS: In 1997, appendicitis-related hospitalizations accounted for 0.6% of all hospitalizations in the United States, resulting in approximately one million hospital days and $3 billion in hospital charges. Between 1984 and 1997, the rate of appendicitis hospitalizations in the U. S. population declined slightly, whereas the total number of hospital days remained unchanged.
Acute Disease↗
The cost-effectiveness of screening mammography beyond age 65 years: a systematic review for the U.S. Preventive Services Task Force.
PURPOSE: There are few data on the effects of disease biology and competing mortality on the effectiveness of screening women for breast cancer after age 65 years. The authors performed a review to determine the costs and benefits of mammography screening after age 65 years. DATA SOURCES: Cost-effectiveness articles published between January 1989 and March 2002. STUDY SELECTION: Studies were identified by using MEDLINE and the National Health Service Economic Evaluation Database. The authors included research on screening after age 65 years conducted from a societal or government perspective; reviews and analyses of other technologies were excluded. DATA SYNTHESIS: 115 studies were identified and 10 met inclusion criteria. One study modeled age-dependent assumptions of disease biology. No study fully captured the potential harms of screening, including anxiety associated with false-positive results, overdiagnosis, and previous knowledge of cancer or living longer with the consequences of treatment. Studies differed in the specific strategies compared and in analytic approaches. On average, extending biennial screening to age 75 or 80 years was estimated to cost 34 000 dollars to 88 000 dollars (2002 U.S. dollars) per life-year gained, compared with stopping screening at age 65 years. Two studies suggested that it was more cost-effective to target healthy women than those with several competing risks for death. CONCLUSIONS: Current estimates suggest that biennial breast cancer screening after age 65 years reduces mortality at reasonable costs for women without clinically significant comorbid conditions. More data are needed on disease biology and preferences for benefits and harms in older women.
Age Factors↗
The cost of preventing diabetes: what do we know and what do we need to know?
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Diabetes Mellitus↗
The cost-effectiveness of preventing diabetes.
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Cost-Benefit Analysis↗
Prescription drug use in the elderly: a descriptive analysis.
In the current policy debate, pharmaceutical use in the elderly has been characterized largely by its economic impact, with little discussion of what drugs the elderly are taking. Based on data from the Medicare Current Beneficiary Survey (MCBS), this study defines subgroups of the community-dwelling elderly using health and functional status, and provides a comprehensive description of the composition of prescription drug use in this population. Drugs are classified into 16 primary therapeutic classes, with further breakdown into secondary classes and characterization by chronic versus acute use. Utilization is reported by age and health status categories.
Activities of Daily Living↗