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Agency for Healthcare Research Quality

Medical Decisionmaking

Authors: Luce BR, Zangwill KM, Palmer CS, et al.
Title: Cost-effectiveness analysis of an intranasal influenza vaccine for the prevention of influenza in healthy children.
Publication: Pediatrics 108(2):e24.
Date: 2001
Abstract: This study determined the potential cost-effectiveness of intranasal influenza vaccine among young, healthy children. The analysis included prospectively collected 2-year clinical trial data supplemented with data from the literature. Results indicated that routine use of intranasal influenza vaccine among healthy children may be cost-effective and cost-effectiveness may be maximized by using group-based vaccination approaches.

Authors: Palmer CS, Niparko JK, Wyatt JR, et al.
Title: A prospective study: cost-utility of the multichannel cochlear implant.
Publication: Archives of Otolaryngology 125(11):1221-28.
Date: 1999
Abstract: Cochlear implants can benefit individuals with advanced hearing loss insufficiently aided by hearing aids. This study determined the cost per QALY gained with implantation of a multichannel cochlear implant. Health utility and cost data were prospectively collected over 12 months in adults with severe to profound hearing loss. Results indicated a very favorable cost/QALY for those who received an implant compared with those who did not.

Authors: Halpern MT, Palmer CS, Seidlin M.
Title: Treatment patterns for otitis externa.
Publication: Journal of the American Board of Family Practitioners 12(1):1-7.
Date: 1999
Abstract: Data were analyzed from the 1993 National Ambulatory Medical Care Survey (NAMCS) and the 1993 National Hospital Ambulatory Medical Care Survey (NHAMCS) for adults and children treated for otitis externa. Data analyses included the reasons for physician visits, concomitant diagnoses, types of physicians seen, sources of payment, medical procedures administered, drugs prescribed, and patient disposition following a physician visit. Study results suggested that treatment patterns differ substantially for adults and children, as well as by physician specialty. Appropriate treatment of localized otitis externa with topical antibiotics should eliminate the need for systemic medications. Addition of systemic medications can unnecessarily increase treatment costs and the likelihood of side effects, and could reduce the likelihood of patient compliance.

Author: Friedman B, Steiner C.
Title: Does managed care affect the supply and use of ICU services?
Publication: Inquiry Spring(36):68-77.
Date: 1999
Abstract: In two States that differ greatly in hospital ownership and history of regulation, we find that the services per ICU user are less for managed care patients than for other privately insured. In Massachusetts, the differences across payers disappear for hospitals where the total supply of ICU is low in relation to expected demand. In both States, admission to ICU is not significantly different between managed care and other privately insured.
Availability: AHCPR Publication No. 99-R071 is available from the AHRQ Publications Clearinghouse.

Authors: Luce B, Elixhauser A.
Title: Documenting the value of your product—Outcomes research for medical devices.
Publication: Medical Devices and Diagnostic Imaging Jan 1999:159-68.
Date: 1999
Abstract: The market for medical technologies is changing. This market is more austere and more demanding, and new technologies are being scrutinized more closely than ever before. This article describes the new medical marketplace and helps device manufacturers become proactive in demonstrating the value of their products. Rather than trying to catch up when the demands for information are thrust upon them, a proactive approach helps smooth the way for product development, marketing, and acceptance.

Authors: Steiner C, Elixhauser A.
Title: Managed care, technology assessment and coverage of medical technology.
Publication: Today's Internist 39:22-7.
Date: 1998.
Abstract: This article summarizes the results of three surveys in which pharmaceutical directors, medical directors, and other decisionmakers in MCOs responded to questions about coverage of medical technology. Researchers conducted these surveys in the past several years and have published the results in several journals.
Availability: AHCPR Publication No. 98-R038 is available from the AHRQ Publications Clearinghouse.

Author: Brach C, ed.
Title: AHCPR research about managed care.
Publication: Rockville (MD): AHCPR.
Date: 1997
Abstract: This Program Note describes recent research projects supported by AHCPR, some with other agencies in the Department of Health and Human Services, or conducted by AHCPR researchers on managed care. Most research on managed care has been conducted in HMOs, the prototypic managed care organization. These studies are designed to produce information that, ultimately, will improve consumer choice, improve the quality and value of health care services, and support and improve the marketplace. The Program Note organizes the studies into these categories: Changes in Health Care Markets; Organization and Delivery of Services; Impact on Clinical Decisionmaking, Access, and Quality; Interventions that Improve Outcomes; Informing Consumers; Impact on Cost; Rural Studies; Tools; and Fostering Research.
Availability: AHCPR Publication No. 97-0023 is available from the AHRQ Publications Clearinghouse. Online version.

Authors: Elixhauser A, Luce B, Steiner C.
Title: Cost-effectiveness analysis, medical technology assessment, and managed care organizations.
Publication: In Policy Issues in Pharmaceutical Cost-Effectiveness Research: AEI Press.
Date: 1997
Abstract: Managed care organizations (MCOs) face an onslaught of criticism amid widespread concern that they deny access to potentially valuable but expensive medical technologies. Increasingly, technology assessment incorporates cost-effectiveness and cost-benefit analysis as an integral part of the assessment process, making the examination of the relationship between costs of the outcomes an important contributor to the evaluation of technologies. How do managed care organizations make decisions about which technologies to employ and which to reject and about appropriate use of specific technologies? What information is used in this decision that affects the health and well-being of patients and the costs of medical care? To what extent does formal technology assessment and cost-effectiveness analysis play a role in this decisionmaking process? Exploring these issues will help to identify what is known about the use of technology assessment and cost-effectiveness analysis in MCOs and how this use differs from other segments of the health care industry, and will help to identify gaps in the information base on medical technology.

Authors: Friedman B, Steiner C, Scott J.
Title: Rationing of an expensive technology in the U.S.: Hospital intensive care in two States, 1992.
Publication: In Governments and Health Systems: Implications of Differing Involvements, edited by Chinitz JCD. Sussex, England: John Wiley and Sons, Ltd.
Date: 1997
Abstract: A discussion of public and payer policies and descriptive review of variations in use of ICU services for adult, non-emergency, non-surgical patients. Once admitted to a hospital, most people with public and private insurance are protected against the extra out-of-pocket expense for the ICU. Therefore, some amount of rationing can be desirable if patients demand service that has very low benefit relative to the high resource costs of production. Many payers do give physicians and hospitals incentives to provide less ICU care than patients and ideal agents would demand. The variations in use suggest that rationing is more a function of hospital characteristics and performance variables than of patient characteristics.

Authors: Steiner C, Powe N, Anderson G, et al.
Title: Technology coverage decisions by health care plans and considerations used by medical directors for coverage decisions.
Publication: Med Care 35(5):1-18.
Date: 1997
Abstract: This study provides results from a national survey of indemnity and HMO payers regarding coverage decisions for new medical technology. The influence of payer type, size, and ownership on coverage of different laser technologies and types of considerations used to make decisions is examined. This article demonstrates variation in coverage across indemnity and HMO payers, and for-profit and indemnity plans covered more individual laser technologies.
Availability: AHCPR Publication No. 97-R068 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: The impact of financial incentives on physician behavior: A review of the evidence.
Publication: Med Care Res Rev 1996;53(3):294-314.
Date: 1996
Abstract: This study examines the relationship between the financial incentives confronting physicians in managed care plans and the utilization of services. The primary conclusion of this review is that the financial incentives confronting physicians are a key element in explaining the lower utilization rates of enrollees in managed care plans.
Availability: AHCPR Publication No. 98-R028 is available from the AHRQ Publications Clearinghouse.

Authors: Powe N, Steiner C, Anderson G, et al.
Title: Awareness of providers' use of new medical technology by private health care plans in the United States.
Publication: International Journal of Technology Assessment in Health Care 2:367-76.
Date: 1996
Abstract: In this study of 231 indemnity and HMO payers, the authors studied whether medical directors are aware when a new technology is getting used in procedures for which claims are submitted, the factors alerting them to such use, and the factors prompting them to make a specific coverage decision for the technology. The authors also examined the association between payer type, size and ownership, and each of those outcomes. The study demonstrates that payers overall are not aware when new technology is being used, although HMO payers demonstrate increased awareness as compared to indemnity payers. Payers are most often prompted to make a specific coverage decision if the technology is viewed as experimental.
Availability: AHCPR Publication No. 96-R118 is available from the AHRQ Publications Clearinghouse.

Authors: Steiner C, Powe N, Anderson G.
Title: Coverage decisions for medical technology by managed care: Relationship to organizational and physician payment characteristics.
Publication: American Journal of Managed Care 1996;2(10):1321-31.
Date: 1996
Abstract: This article presents results of a national survey of HMO medical directors regarding coverage decisions for new medical technology. This study investigates the influence of HMO organizational structure and method of physician payment on aspects of managed care plans' decisions to cover new medical technologies. The study demonstrates managed care plans use cost-effectiveness in decisionmaking, and plans' decreased use of cost considerations as financial risk-sharing with physicians increased.

Authors: Steiner C, Powe N, Anderson G, et al.
Title: The review process used by health care plans in the U.S. when evaluating new medical technology for coverage.
Publication: Journal of General Internal Medicine 5(11):294-302.
Date: 1996
Abstract: This study provides results from a national survey of indemnity and HMO payers regarding the process of establishing coverage for new medical technology. The study examines the actual review process, final decision authority, sources and evidence used for coverage decisions. The influence of payer type, size, and ownership on the coverage process is examined as well. Indemnity payers were likely to assert medical directors should be responsible for final decisionmaking. Barriers to optimal decisionmaking included lack of timely effectiveness and cost-effectiveness data.
Availability: AHCPR Publication No. 96-R120 is available from the AHRQ Publications Clearinghouse.

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