The different clinical guideline standards in Brazil: High cost treatment diseases versus poverty-related diseases

Each year, evidence-based clinical guidelines gain more space in the health professionals' practice and in services organization. Due to the scarcity of scientific publications focused on diseases of poverty, the development of well-founded clinical guidelines becomes more and more important. In view of that, this paper aims to evaluate the quality of Brazilian guidelines for those diseases. The AGREE II method was used to evaluate 16 guidelines for poverty-related diseases (PRD) and 16 guidelines for global diseases whose treatment require high-cost technologies (HCD), with the ultimate aim of comparing the results. It was found that, in general, the guideline development quality standard is higher for the HCD guidelines than for the PRD guidelines, with emphasis on the "rigour of development" (48% and 7%) and "editorial independence" (43% and 1%) domains, respectively, which had the greatest discrepancies. The HCD guidelines showed results close to or above international averages, whereas the PRD guidelines showed lower results in the 6 domains evaluated. It can be concluded that clinical protocol development priorities need some redirecting in order to qualify the guidelines that define the healthcare organization and the care of vulnerable populations.

Surviving niche busters: Main strategies employed by Canadian private insurers facing the arrival of high cost specialty drugs

The Canadian patchwork system of prescription drug coverage and the employer sponsored private health benefits group plans appear vulnerable to cost growth due to insufficient balance of power between fragmented public and private buyers, and pharmaceutical manufacturers. The emergence of "bad" insurance risks caused by new and very expensive treatments featuring high cost specialty medicines - also known as niche buster drugs - exposes this vulnerability. This study fills a gap in knowledge by seeking to better understanding how Canadian private insurers face the arrival of specialty pharmaceuticals. It completes an overview of a body of grey literature composed of publicly available online articles from the employment benefits and group insurance consulting and administration industry; online documents from group benefits sector conferences; and online or on demand materials from Canadian life and health insurers. Claims for high cost specialty drugs generate new bad insurance risks that Canadian health insurers attempt to mitigate through isolated corporate initiatives, industry-wide strategies and calls for universal, public catastrophic coverage. The outcomes of these strategies are limited cost-control measures as well as risk and cost transfers onto plan sponsors, patients and provincial public programs.

Mobile Health Devices as Tools for Worldwide Cardiovascular Risk Reduction and Disease Management

We examined evidence on whether mobile health (mHealth) tools, including interactive voice response calls, short message service, or text messaging, and smartphones, can improve lifestyle behaviors and management related to cardiovascular diseases throughout the world. We conducted a state-of-the-art review and literature synthesis of peer-reviewed and gray literature published since 2004. The review prioritized randomized trials and studies focused on cardiovascular diseases and risk factors, but included other reports when they represented the best available evidence. The search emphasized reports on the potential benefits of mHealth interventions implemented in low- and middle-income countries. Interactive voice response and short message service interventions can improve cardiovascular preventive care in developed countries by addressing risk factors including weight, smoking, and physical activity. Interactive voice response and short message service-based interventions for cardiovascular disease management also have shown benefits with respect to hypertension management, hospital readmissions, and diabetic glycemic control. Multimodal interventions including Web-based communication with clinicians and mHealth-enabled clinical monitoring with feedback also have shown benefits. The evidence regarding the potential benefits of interventions using smartphones and social media is still developing. Studies of mHealth interventions have been conducted in >30 low- and middle-income countries, and evidence to date suggests that programs are feasible and may improve medication adherence and disease outcomes. Emerging evidence suggests that mHealth interventions may improve cardiovascular-related lifestyle behaviors and disease management. Next-generation mHealth programs developed worldwide should be based on evidence-based behavioral theories and incorporate advances in artificial intelligence for adapting systems automatically to patients' unique and changing needs.

[Clinical and economical comparison between in-house (Make) and outsourcing (Buy) management of the cardiac catheterization laboratory from two high-volume diagnostic and interventional centers: immediate and 6-month results]

BACKGROUND

Percutaneous coronary interventions (PCI) are widespread procedures in the Italian Healthcare System, but concerns are raised about their economic sustainability. In the last decade, public hospitals have outsourced the PCI services (building and maintaining the technological instruments and the personnel) "buying" them from private companies (Buy) rather than building and maintaining them through public expenditure (Make). The aim of this study was to compare the economic and clinical impact of these two management solutions (Buy and Make) in two community hospitals located in the Turin metropolitan area (Italy).

METHODS

We conducted: 1) a quantitative assessment in order to compare differences in the economic impact between Buy and Make for providing PCI; 2) a qualitative assessment comparing the clinical characteristics of two inpatient populations undergoing PCI and then analyzing the efficacy of the procedure in-hospital and at 6-month follow-up.

RESULTS

Between January and June 2010, a total of 332 patients underwent PCI at the "degli Infermi" Hospital in Rivoli and 340 at the "Maria Vittoria" Hospital in Turin (Italy). There were no significant differences between the two populations neither about the clinical characteristics nor in procedural efficacy (either immediate or at follow-up). For 600 units of diagnostic-therapeutic pathway, the net present value at a discount rate of 3.5% of the Make project is higher than that of the Buy by €278.402,25, and is therefore the less convenient of the two solutions. The Buy solution is still the more convenient of the two at volumes <700 units.

CONCLUSIONS

Our findings show that the Buy solution, if tailored to the specific local needs, provides access to sophisticated technology without making worse quality of services and may save capital expenditure below 700 PCI/years.

Navigating time and uncertainty in health technology appraisal: would a map help?

Healthcare systems are increasingly under pressure to provide funding for innovative technologies. These technologies tend to be characterized by their potential to make valued contributions to patient health in areas of relative unmet need, and have high acquisition costs and uncertainty within the evidence base on their actual impact on health. Decision makers are increasingly interested in linking reimbursement strategies to the degree of uncertainty in the evidence base and, as a result, reimbursement for innovative technologies is frequently linked to some form of patient access or risk-sharing scheme. As the dominant methods of economic evaluation report final outcomes only at the time horizon of the analysis, they present only aggregated information. This omits much of the information available on how net benefit is distributed within the time horizon. In this article, we introduce the Net Benefit Probability Map (NBPM), which maps net health benefit versus time to identify how certain decision makers can be about the benefit of technologies at multiple time points. Using an illustrative example, we show how the NBPM can inform decision makers about how long it will take for innovative technologies to 'pay off', how methodological choices on discount rates affect results and how alternative payment mechanisms can reduce the risk for decision makers facing innovative technologies.

Does advanced medical technology encourage hospitalist use and their direct employment by hospitals?

In the United States, inpatient medical care increasingly encompasses the use of expensive medical technology and, at the same time, is coordinated and supervised more and more by a rapidly growing number of inpatient-dedicated physicians (hospitalists). In the production of inpatient care services, Hospitalist services can be viewed as complementary to sophisticated and expensive medical equipment in the provision of inpatient medical care. We investigate the causal relationship between a hospital's access to three types of sophisticated diagnostic and therapeutic medical equipment - intensity-modulated radiation therapy, gamma knife, and multi-slice computed tomography - and its likelihood of using hospitalists. To rule out omitted variables bias and reverse causality, we use technology-specific Certificate of Need regulation to predict technology use. We find a strong positive association, yet no causal link between access to medical technology and hospitalist use. We also study the choice of employment modality among hospitals that use hospitalists, and find that access to expensive medical technology reduces the hospital's propensity to employ hospitalists directly.

[A method for reassessment of cost-intensive cases in visceral surgery. Results of project by the German Society for Visceral Surgery]

Since the introduction of diagnosis-related groups (DRGs) many surgical departments report inappropriate reimbursement for complex cases and a shift in costly cases. To evaluate this situation, the German Society for Visceral Surgery inaugurated the present cost calculation project. In three university hospitals for 50 cases each, we depicted possible cost separators and utilized the complete cost calculation data (so-called Paragraph 21 data set) to test these separators. We identified "admission from another hospital", "severe surgically relevant concomitant disease", and "reoperation during the same hospital admission". The last was considered the economically most significant and medically most valid factor and was submitted as a possible modification to the german DRG system. The proposed cost separator "reoperation during the same hospital admission" was introduced into the DRG system after validation and leads to better allocation of reimbursements to complex and costly cases.

Case studies in medical futility

Technology has provided means to sustain life and provide care regardless of whether the treatment is appropriate and compassionate given the condition of the patient. This study presents two case histories, compiled from historical patient charts, staff notes and observations, that illustrate the variety of ethical issues involved and the role culture plays in the decision making process related to possible futile medical treatment. Ethical and cultural issues related to the cases are discussed and processes are presented that can help hospitals to avoid, or decrease the level of, medically futile care, and improve the cultural appropriateness of medical care and relationships with patients.

Physicians perceived usefulness of high-cost diagnostic imaging studies: results of a referral study in a German medical quality network

Background

Medical and technological progress has led to increased numbers of diagnostic tests, some of them inducing high financial costs. In Germany, high-cost diagnostic imaging is performed by a medical specialist after referral by a general practitioner (GP) or specialist in primary care. The aim of this study was to evaluate the physicians' perceived usefulness of high-cost diagnostic imaging in patients with different clinical conditions.

Methods

Thirty-four GPs, one neurologist and one orthopaedic specialist in ambulatory care from a Medical Quality Network documented 234 referrals concerning 97 MRIs, 96 CTs-scan and 41 intracardiac catheters in a three month period. After having received the test results, they indicated if these were useful for diagnosis and treatment of the patient.

Results

The physicians' perceived usefulness of tests was lowest in suspected cerebral disease (40% of test results were seen as useful), cervical spine problems (64%) and unexplained abdominal complaints (67%). The perceived usefulness was highest in musculoskeletal symptoms (94%) and second best in cardiological diseases (82%).

Conclusion

The perceived usefulness of high-cost diagnostic imaging was lower in unexplained complaints than in specific diseases. Interventions to improve the effectiveness and efficiency of test ordering should focus on clinical decision making in conditions where GPs perceived low usefulness.

High and rising health care costs. Part 2: technologic innovation

Technologic innovation, in combination with weak cost-containment measures, is a major factor in high and rising health care costs. Evidence suggests that improved health care technologies generally increase rather than reduce health care expenditures. Greater availability of such technologies as magnetic resonance imaging, computed tomography, coronary artery bypass graft, angioplasty, cardiac and neonatal intensive care units, positron emission tomography, and radiation oncology facilities is associated with greater per capita use and higher spending on these services. Because the spread of new technologies is relatively unrestrained in the United States, many of these technologies are used to a greater extent than in other nations, and the United States thereby incurs higher health care costs. Nations with a greater degree of health system integration have relied on expenditure controls and global budgets to control costs. Although diffusion of technology takes place more slowly in more tightly budgeted systems, the use of innovative technologies in those systems tends to catch up over time.

Cost-effectiveness Analysis in the Assessment of Diagnostic Imaging Technologies

In many ways, diagnostic technologies differ from therapeutic medical technologies. Perhaps most important, diagnostic technologies do not generally directly affect long-term patient outcomes. Instead, the results of diagnostic tests can influence the care of patients; in that way, diagnostic tests may affect long-term outcomes. Because of this, the benefits associated with the use of a specific diagnostic technology will depend on the performance characteristics (eg, sensitivity and specificity) of the test, as well as other factors, such as prevalence of disease and effectiveness of available treatments for the disease in question. The fact that diagnostic tests affect short-term, or "surrogate," outcomes, rather than long-term patient outcomes makes evaluation of these tests more complicated than the evaluation of therapeutic technologies. This article will trace the history of technology assessment in medicine, address the role of cost-effectiveness and decision analysis in health technology assessment, and describe unique features and approaches to assessing diagnostic technologies. The article will then conclude with a consideration of the limits of medical technology assessment.

Three new tools for parathyroid surgery: expensive and unnecessary?

BACKGROUND

The intraoperative quick parathyroid hormone assay, the intraoperative gamma probe, and endoscopic parathyroidectomy are three very new techniques developed to facilitate parathyroid surgery. Some hospitals do not have the necessary equipment, and many, like ours, continue to operate in the time-honored way.

STUDY DESIGN

We performed a retrospective chart review of 34 such operations, done with the use of Sestamibi scans, but entirely without the newer modalities.

RESULTS

Four-gland exploration was carried out on all patients. Operative times ranged from 15 to 165 minutes, with a mean of 47 minutes, and incision lengths ranged from 2 to 3 cm, with a mean of 2.8 cm. There was no mortality, no reoperation, and no vocal cord or recurrent laryngeal nerve injury. Our cure rate was 100%, as determined by a fall in postoperative calcium and parathormone levels.

CONCLUSIONS

In our view, the intraoperative parathyroid hormone assay, gamma probe, and endoscopic parathyroidectomy add an entirely unnecessary cost to an operation that can be completed satisfactorily with a preoperative Sestamibi scan and a thorough four-gland exploration.

Learning new lines. New 'playbook' advises hospitals how to win bigger reimbursement for medical procedures that use expensive advanced technology

If hospitals' tough negotiating tactics with managed care often seem to be taken from an instruction manual, then that perception would be correct. Profiting From Innovation is a research group's latest report to its hospital clients, telling them just how to get managed-care plans to pay for pricey medical technology.

Resource allocation and bioethics: the Patti Hearst dilemma

Abstract Medicine has entered an era of high technology, accompanied by expensive investigation and management. Simultaneously, there is increasing recognition of the gap between the costs of medical technology and society's willingness to pay. It is debatable whether medicine recognizes that it is a hostage in thrall to the medical-industrial complex or whether it has wittingly entered the compact to pursue the high-cost, high-technology course. The situation is reminiscent of the events surrounding the kidnap of Patti Hearst - a wealthy heiress who was much later arrested with the gang of robbers. Whether she was hostage or willing accomplice still remains obscure. It is necessary that a body, such as the Cochrane Collaboration, pursues these issues in medicine.

Negotiating payment for new technology purchases

The use of new technology in an existing healthcare service can have a far-reaching impact on a hospital's financial health. An understanding of the financial impact of a service before new technology is added is helpful in preparing to negotiate for appropriate payment for the new technology. The indirect financial impact of new technology on related and unrelated healthcare services should be projected for use in managed care negotiations. Managed care payers seek proof of immediate savings when deciding on payment increases for new technology.

Diffusion and utilization of magnetic resonance imaging in Asia

OBJECTIVES

An assessment of the current status of magnetic resonance imaging (MRI) was undertaken to provide input for future government decisions on the introduction of new technologies in Asia. The objective of the study is to describe and explain the diffusion pattern of this costly technology in several Asian settings.

METHODS

Data on the diffusion pattern of MRI for different Asian countries (the Republic of Korea, Malaysia, Indonesia, the Philippines and Thailand) and regions (the cities of Shanghai and Hong Kong in China and the state of Tamil Nadu in India) were obtained from national representatives of professional bodies by using standardized questionnaires for the year 1997-98. In addition, utilization data were collected at the hospital level in three countries before and after the economic crisis in the region. For four countries plus Hong Kong, background information on the legal framework for "big ticket" technologies was collected.

RESULTS

Since the introduction of the first MRI in the region in 1987, the number of MRIs has gradually increased both in public and private facilities in Asia. In 1998 the average number of MRI machines installed varied from less than 0.5 machine per million population to more than 5 machines per million population. The maintenance and operating costs, and not the absence of regulation, account for the low number of MRIs in the Philippines and Malaysia. Overall, installed MRIs have low magnetic field strength, vary with respect to brand and type, and are mostly in the private sector and in the urban areas of the region. The diffusion pattern of MRIs in countries of the Asian region appears to follow two types of patterns of diffusion: one set of countries seems to be composed of mostly early adopters and another set of countries appears to be composed mostly of late adopters.

CONCLUSIONS

Total number of MRIs per population in this region, though quite small compared to most OECD countries, reflects a higher share of the country's health-resource devoted to expensive high-technology devices. It is difficult to state the appropriate number of MRIs for each country; however, the study shows that there are observable problems in terms of efficiency, equity, and quality of MRI services. The research team proposes a few key recommendations to counteract these problems. Purchasing and regulatory bodies must be empowered with skill and knowledge of health technology assessment. Likewise, the fundamental problems resulting from inefficient and unfair health financing should not be overlooked, so that there is more equitable use of the technology.

When does regionalization of expensive medical care save money?

Regionalization of expensive, high-technology medical care is often proposed as a way to reduce medical costs. Most empirical estimates of the cost implications of regionalization suffer from methodological shortcomings. Here, we discuss all the factors that must be taken into account to produce an accurate assessment of how regionalization changes costs. These factors include the following: (1) The extent of resource sharing among different services; (2) The extent of unused capacity; (3) Whether regionalized facilities have high, low or average costs; (4) Costs of a regionalized system, including transporting patients to the regionalized facilities, coordinating care between the referring and regionalized providers, and out-of network care; (5) The effect of regionalization on the volume of care; and (6) whether a short- or long-term view is taken.

The future of plasma derivatives

In the early 1980s, the advent of recombinant DNA technology provided the perspective of an unlimited supply of recombinant plasma proteins. However, the cost of mammalian cell expression, downstream processing, and the development time of biotechnological pharmaceuticals have generally been underestimated. Despite the initial optimism that plasma derivatives would soon become obsolete, no more than three plasma proteins have been licensed for therapeutic use since that time. The current situation favours a reappraisal of plasma derivatives, which nowadays can meet safety standards similar to those of recombinant products. In terms of cost, human blood has the further advantage over biotechnological sources in that it allows the production of multiple pharmaceutical proteins from one single material. This provides a favourable starting point for exploring the therapeutic potential of the numerous plasma proteins that have remained unused so far.

[Rapid assessments"--quick evaluation of medical technology]

Assessing the clinical, economical and other consequences of medical technologies (health technology assessment, HTA) is an important instrument to support decisions in many health care systems. A comprehensive HTA, however, is time-consuming and costly while, on the other hand, decisions have to be made quickly. A number of international HTA programmes established rapid assessment tracks although they are variable in scope and methods. In the first part of this paper, these programmes were compared with respect to scope, methods and time to complete assessments. It can be shown from this comparison that there is no common definition of "rapid assessments". In the second part of the paper, a model for processing rapid assessment in the German context is introduced and discussed. The model aims at rapid assessments serving the needs of German decision-makers and ensuring high scientific quality at the same time. The model consists of a modular system that is tailored to the actual demand of the decision-maker. Modules are obligatory (such as a systematic literature search) or optional (such as meta-analysis). All modules are subject to standardisation as far as possible. However, it should be kept in mind that a close collaboration between commissioners and executives of an HTA is necessary to focus on the question and work out the HTA accordingly.

[Rationing in surgery and high-tech medicine]

There has been much debate about cost-cutting in health care. In this context, the term rationing means that acceptable services and measures with proven benefit are subject to limited allocation (or complete refusal thereof) due to a shortage of resources. After an introductory discussion about the "terminology" of rationing, achievements in premium health care will be critically elucidated in this regard. Chapter 2 focuses on the question of whether age is a valid criterion for the rationing of surgical care. Chapter 3 critically analyses the "societal solution" to the rationing problem. The way to solve society's tendency to become insatiable (pleonexia) is the same as the way to solve the shortage of resources, i.e. by "circumspection" or "moderation" on the part of each individual (sophrosyne).

Preventative maintenance and unscheduled downtime from an economic perspective

A spreadsheet-based model for economically characterizing the operation of a radiation treatment program has been used to perform a quantitative financial analysis of scheduled and unscheduled downtime. The incremental cost of downtime is broken down into three categories: remuneration of in-house or third party service technologists, decreased patient capacity, and local operating procedures for dealing with downtime. Different service arrangements and operating procedures are simulated to demonstrate the financial cost of treatment machine unavailability due to either preventative maintenance or unexpected breakdown. Depending on the service arrangement and operating policies for accommodating downtime, the combined cost of scheduled and unscheduled downtime (at 5%) can exceed 10% of the total cost of the radiation treatment program. It has also been demonstrated that the greatest cost component of downtime is decreased patient capacity, which can exceed $400,000 (CAN) when unscheduled downtime reaches 5%. The interpretation of this cost depends on the funding environment. Although the emphasis of this study has been the financial consequences of downtime, there are other factors which must be considered when developing policies and procedures for accommodating downtime such as effects on treatment, patient convenience and quality of life for staff. Even though the numerical results are strictly valid only within the context of the simulations performed, they do provide a broad framework within which medical physicists can make recommendations regarding service support and downtime.