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Medicare savings from conservative management of low back pain. The American journal of managed care Garber, A. M., Azad, T. D., Dixit, A., Farid, M., Sung, E., Vail, D., Bhattacharya, J. 2018; 24 (10): e332?e337
Abstract

OBJECTIVES: Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. We estimated 1-year medical costs associated with early imaging of Medicare beneficiaries with idiopathic LBP.STUDY DESIGN: We used a 5% random sample of Medicare fee-for-service enrollees between 2006 and 2010 to determine 12-month costs following a diagnosis of idiopathic LBP. We analyzed costs of care and patient outcomes according to whether or not the patients had been referred for early imaging following their initial diagnosis.METHODS: We employed an instrumental variables analysis using risk-adjusted physician-level propensity to order imaging for patients without LBP as an instrument for imaging use among patients with LBP. We selected this approach to adjust for confounding by indication when estimating the relative costs of early imaging of LBP compared with conservative management.RESULTS: Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis. Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more.CONCLUSIONS: Medicare beneficiaries with low-risk LBP frequently receive early imaging studies. Early imaging was associated with greater long-term costs than a conservative diagnostic strategy; Medicare expenditures could be reduced by $362 million annually by managing newly diagnosed LBP in accordance with clinical guidelines.

View details for PubMedID 30325195
Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Freeman, J. V., Hutton, D. W., Barnes, G. D., Zhu, R. P., Owens, D. K., Garber, A. M., Go, A. S., Hlatky, M. A., Heidenreich, P. A., Wang, P. J., Al-Ahmad, A., Turakhia, M. P. 2016; 9 (6)
Abstract

Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data.We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios compared with warfarin and dabigatran were $20?486 and $23?422 per quality-adjusted life year, respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 quality-adjusted life years, respectively) and more costly. At a willingness-to-pay threshold of $50?000 per quality-adjusted life year, LAA closure was cost effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation.Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer-term trial results and postmarketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice.

View details for DOI 10.1161/CIRCEP.115.003407

View details for PubMedID 27307517
Health and Economic Benefits of Early Vaccination and Nonpharmaceutical Interventions for a Human Influenza A (H7N9) Pandemic ANNALS OF INTERNAL MEDICINE Khazeni, N., Hutton, D. W., Collins, C. I., Garber, A. M., Owens, D. K. 2014; 160 (10): 684-?
Abstract

Vaccination for the 2009 pandemic did not occur until late in the outbreak, which limited its benefits. Influenza A (H7N9) is causing increasing morbidity and mortality in China, and researchers have modified the A (H5N1) virus to transmit via aerosol, which again heightens concerns about pandemic influenza preparedness.To determine how quickly vaccination should be completed to reduce infections, deaths, and health care costs in a pandemic with characteristics similar to influenza A (H7N9) and A (H5N1).Dynamic transmission model to estimate health and economic consequences of a severe influenza pandemic in a large metropolitan city.Literature and expert opinion.Residents of a U.S. metropolitan city with characteristics similar to New York City.Lifetime.Societal.Vaccination of 30% of the population at 4 or 6 months.Infections and deaths averted and cost-effectiveness.In 12 months, 48�254 persons would die. Vaccinating at 9 months would avert 2365 of these deaths. Vaccinating at 6 months would save 5775 additional lives and $51 million at a city level. Accelerating delivery to 4 months would save an additional 5633 lives and $50 million.If vaccination were delayed for 9 months, reducing contacts by 8% through nonpharmaceutical interventions would yield a similar reduction in infections and deaths as vaccination at 4 months.The model is not designed to evaluate programs targeting specific populations, such as children or persons with comorbid conditions.Vaccination in an influenza A (H7N9) pandemic would need to be completed much faster than in 2009 to substantially reduce morbidity, mortality, and health care costs. Maximizing non-pharmaceutical interventions can substantially mitigate the pandemic until a matched vaccine becomes available.Agency for Healthcare Research and Quality, National Institutes of Health, and Department of Veterans Affairs.

View details for Web of Science ID 000337347100015

View details for PubMedCentralID PMC4053659
Health and Economic Benefits of Early Vaccination and Nonpharmaceutical Interventions for a Human Influenza A (H7N9) Pandemic: A Modeling Study. Annals of internal medicine Khazeni, N., Hutton, D. W., Collins, C. I., Garber, A. M., Owens, D. K. 2014; 160 (10): 684-694
Abstract

Vaccination for the 2009 pandemic did not occur until late in the outbreak, which limited its benefits. Influenza A (H7N9) is causing increasing morbidity and mortality in China, and researchers have modified the A (H5N1) virus to transmit via aerosol, which again heightens concerns about pandemic influenza preparedness.To determine how quickly vaccination should be completed to reduce infections, deaths, and health care costs in a pandemic with characteristics similar to influenza A (H7N9) and A (H5N1).Dynamic transmission model to estimate health and economic consequences of a severe influenza pandemic in a large metropolitan city.Literature and expert opinion.Residents of a U.S. metropolitan city with characteristics similar to New York City.Lifetime.Societal.Vaccination of 30% of the population at 4 or 6 months.Infections and deaths averted and cost-effectiveness.In 12 months, 48�254 persons would die. Vaccinating at 9 months would avert 2365 of these deaths. Vaccinating at 6 months would save 5775 additional lives and $51 million at a city level. Accelerating delivery to 4 months would save an additional 5633 lives and $50 million.If vaccination were delayed for 9 months, reducing contacts by 8% through nonpharmaceutical interventions would yield a similar reduction in infections and deaths as vaccination at 4 months.The model is not designed to evaluate programs targeting specific populations, such as children or persons with comorbid conditions.Vaccination in an influenza A (H7N9) pandemic would need to be completed much faster than in 2009 to substantially reduce morbidity, mortality, and health care costs. Maximizing non-pharmaceutical interventions can substantially mitigate the pandemic until a matched vaccine becomes available.Agency for Healthcare Research and Quality, National Institutes of Health, and Department of Veterans Affairs.

View details for DOI 10.7326/M13-2071

View details for PubMedID 24842415
Cost-Effectiveness of Genotype-Guided and Dual Antiplatelet Therapies in Acute Coronary Syndrome ANNALS OF INTERNAL MEDICINE Kazi, D. S., Garber, A. M., Shah, R. U., Dudley, R. A., Mell, M. W., Rhee, C., Moshkevich, S., Boothroyd, D. B., Owens, D. K., Hlatky, M. A. 2014; 160 (4): 221-232
Abstract

The choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available.To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.Decision-analytic model.Published literature, Medicare claims, and life tables.Patients having percutaneous coronary intervention for ACS.Lifetime.Societal.Five strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel.Direct medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs).The clopidogrel strategy produced$179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of $35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy($52 600 per QALY relative to genotyping with ticagrelor).Stronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor.No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings.

View details for Web of Science ID 000331666500002
Cost-effectiveness of genotype-guided and dual antiplatelet therapies in acute coronary syndrome. Annals of internal medicine Kazi, D. S., Garber, A. M., Shah, R. U., Dudley, R. A., Mell, M. W., Rhee, C., Moshkevich, S., Boothroyd, D. B., Owens, D. K., Hlatky, M. A. 2014; 160 (4): 221-232
Abstract

The choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available.To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.Decision-analytic model.Published literature, Medicare claims, and life tables.Patients having percutaneous coronary intervention for ACS.Lifetime.Societal.Five strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel.Direct medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs).The clopidogrel strategy produced$179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of $35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy($52 600 per QALY relative to genotyping with ticagrelor).Stronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor.No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings.

View details for PubMedID 24727840
Geographic differences in US health care spending--reply. JAMA Newhouse, J. P., Garber, A. M. 2014; 311 (6): 624-625
View details for DOI 10.1001/jama.2013.284333

View details for PubMedID 24519309
Transcatheter Aortic Valve Replacement in Nonsurgical Candidates With Severe, Symptomatic Aortic Stenosis: A Cost-Effectiveness Analysis CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Simons, C. T., Cipriano, L. E., Shah, R. U., Garber, A. M., Owens, D. K., Hlatky, M. A. 2013; 6 (4): 419-428
Abstract

Background- Transcatheter aortic valve replacement (TAVR) seems to improve the survival and quality of life of patients with aortic stenosis ineligible for surgical aortic valve replacement. Methods and Results- We used a decision analytic Markov model to estimate lifetime costs and benefits in a hypothetical cohort of patients with severe, symptomatic aortic stenosis who were ineligible for surgical aortic valve replacement. The model compared transfemoral TAVR with medical management and was calibrated to the Placement of Aortic Transcatheter Valves (PARTNER) trial. TAVR increased life expectancy from 2.08 to 2.93 years and quality-adjusted life expectancy from 1.19 to 1.93 years. TAVR also reduced subsequent hospitalizations by 1.40 but increased complications, particularly stroke (from 1% to 11% lifetime risk), and also increased lifetime costs from $83?600 to $1?69?100. The incremental cost-effectiveness of TAVR was $1?16?500 per quality-adjusted life-year gained ($99?900 per life-year gained). Results were robust to reasonable changes in individual variables but were sensitive to the level of annual healthcare costs caused by noncardiac diseases and to the projected life expectancy of medically treated patients. Conclusions- TAVR seems to be an effective but somewhat expensive alternative to medical management among patients with symptomatic aortic stenosis ineligible for surgery. TAVR is more cost-effective for patients with a lower burden of noncardiac disease.

View details for DOI 10.1161/CIRCOUTCOMES.113.000280

View details for Web of Science ID 000321898000009

View details for PubMedID 23838104
Three Large-Scale Changes To The Medicare Program Could Curb Its Costs But Also Reduce Enrollment HEALTH AFFAIRS Eibner, C., Goldman, D. P., Sullivan, J., Garber, A. M. 2013; 32 (5): 891-899
Abstract

With Medicare spending projected to increase to 24 percent of all federal spending and to equal 6 percent of the gross domestic product by 2037, policy makers are again considering ways to curb the program's spending growth. We used a microsimulation approach to estimate three scenarios: imposing a means-tested premium for Part A hospital insurance, introducing a premium support credit to purchase health insurance, and increasing the eligibility age to sixty-seven. We found that the scenarios would lead to reductions in cumulative Medicare spending in 2012-36 of 2.4-24.0 percent. However, the scenarios also would increase out-of-pocket spending for enrollees and, in some cases, cause millions of seniors not to enroll in the program and to be left without coverage. To achieve substantial cost savings without causing substantial lack of coverage among seniors, policy makers should consider benefit changes in combination with other options, such as some of those now being contemplated by the Obama administration and Congress.

View details for DOI 10.1377/hlthaff.2012.0147

View details for Web of Science ID 000319315000010

View details for PubMedID 23650322
Cost-Effectiveness of Statins for Primary Cardiovascular Prevention in Chronic Kidney Disease JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Erickson, K. F., Japa, S., Owens, D. K., Chertow, G. M., Garber, A. M., Goldhaber-Fiebert, J. D. 2013; 61 (12): 1250-1258
Abstract

The authors sought to evaluate the cost-effectiveness of statins for primary prevention of myocardial infarction (MI) and stroke in patients with chronic kidney disease (CKD).Patients with CKD have an elevated risk of MI and stroke. Although HMG Co-A reductase inhibitors (?statins?) may prevent cardiovascular events in patients with non?dialysis-requiring CKD, adverse drug effects and competing risks could materially influence net effects and clinical decision-making.We developed a decision-analytic model of CKD and cardiovascular disease (CVD) to determine the cost-effectiveness of low-cost generic statins for primary CVD prevention in men and women with hypertension and mild-to-moderate CKD. Outcomes included MI and stroke rates, discounted quality-adjusted life years (QALYs) and lifetime costs (2010 USD), and incremental cost-effectiveness ratios.For 65-year-old men with moderate hypertension and mild-to-moderate CKD, statins reduced the combined rate of MI and stroke, yielded 0.10 QALYs, and increased costs by $1,800 ($18,000 per QALY gained). For patients with lower baseline cardiovascular risks, health and economic benefits were smaller; for 65-year-old women, statins yielded 0.06 QALYs and increased costs by $1,900 ($33,400 per QALY gained). Results were sensitive to rates of rhabdomyolysis and drug costs. Statins are less cost-effective when obtained at average retail prices, particularly in patients at lower CVD risk.Although statins reduce absolute CVD risk in patients with CKD, the increased risk of rhabdomyolysis, and competing risks associated with progressive CKD, partly offset these gains. Low-cost generic statins appear cost-effective for primary prevention of CVD in patients with mild-to-moderate CKD and hypertension.

View details for DOI 10.1016/j.jacc.2012.12.034

View details for PubMedID 23500327
An economic analysis of conservative management versus active treatment for men with localized prostate cancer. Journal of the National Cancer Institute. Monographs Perlroth, D. J., Bhattacharya, J., Goldman, D. P., Garber, A. M. 2012; 2012 (45): 250-257
Abstract

Comparative effectiveness research suggests that conservative management (CM) strategies are no less effective than active initial treatment for many men with localized prostate cancer. We estimate longer-term costs of initial management strategies and potential US health expenditure savings by increased use of conservative management for men with localized prostate cancer. Five-year total health expenditures attributed to initial management strategies for localized prostate cancer were calculated using commercial claims data from 1998 to 2006, and savings were estimated from a US population health-care expenditure model. Our analysis finds that patients receiving combinations of active treatments have the highest additional costs over conservative management at $63 500, followed by $48 550 for intensity-modulated radiation therapy, $37 500 for primary androgen deprivation therapy, and $28 600 for brachytherapy. Radical prostatectomy ($15 200) and external beam radiation therapy ($18 900) were associated with the lowest costs. The population model estimated that US health expenditures could be lowered by 1) use of initial CM over all active treatment ($2.9-3.25 billion annual savings), 2) shifting patients receiving intensity-modulated radiation therapy to CM ($680-930 million), 3) foregoing primary androgen deprivation therapy($555 million), 4) reducing the use of adjuvant androgen deprivation in addition to local therapies ($630 million), and 5) using single treatments rather than combination local treatment ($620-655 million). In conclusion, we find that all active treatments are associated with higher longer-term costs than CM. Substantial savings, representing up to 30% of total costs, could be realized by adopting CM strategies, including active surveillance, for initial management of men with localized prostate cancer.

View details for DOI 10.1093/jncimonographs/lgs037

View details for PubMedID 23271781

View details for PubMedCentralID PMC3540871
Cost-Effectiveness of Early Colectomy With Ileal Pouch-Anal Anastamosis Versus Standard Medical Therapy in Severe Ulcerative Colitis ANNALS OF SURGERY Park, K. T., Tsai, R., Perez, F., Cipriano, L. E., Bass, D., Garber, A. M. 2012; 256 (1): 117-124
Abstract

Inflammatory bowel diseases are costly chronic gastrointestinal diseases. We aimed to determine whether immediate colectomy with ileal pouch-anal anastamosis (IPAA) after diagnosis of severe ulcerative colitis (UC) was cost-effective compared to the standard medical therapy.We created a Markov model simulating 2 cohorts of 21-year-old patients with severe UC, following them until 100 years of age or death, comparing early colectomy with IPAA strategy to the standard medical therapy strategy. Deterministic and probabilistic analyses were performed.Standard medical care accrued a discounted lifetime cost of $236,370 per patient. In contrast, early colectomy with IPAA accrued a discounted lifetime cost of $147,763 per patient. Lifetime quality-adjusted life-years gained (QALY-gained) for standard medical therapy was 20.78, while QALY-gained for early colectomy with IPAA was 20.72. The resulting incremental cost-effectiveness ratio (?costs/?QALY) was approximately $1.5 million per QALY-gained. Results were robust to one-way sensitivity analyses for all variables in the model. Quality-of-life after colectomy with IPAA was the most sensitive variable impacting cost-effectiveness. A low utility value of less than 0.7 after colectomy with IPAA was necessary for the colectomy with IPAA strategy to be cost-ineffective.Under the appropriate clinical settings, early colectomy with IPAA after diagnosis of severe UC reduces health care expenditures and provides comparable quality of life compared to exhaustive standard medical therapy.

View details for DOI 10.1097/SLA.0b013e3182445321

View details for Web of Science ID 000306083300020

View details for PubMedID 22270693
PANACEA OR PERSONALIZED MEDICINE? OPTIMIZING ANTIPLATELET THERAPY IN ACUTE CORONARY SYNDROME - A COST-EFFECTIVENESS ANALYSIS 61st Annual Scientific Session and Expo of the American-College-of-Cardiology (ACC)/Conference on ACC-i2 with TCT Kazi, D., Garber, A. M., Shah, R., Rhee, C., Moshkevich, S., Mell, M. W., Boothroyd, D., Owens, D. K., Hlatky, M. ELSEVIER SCIENCE INC. 2012: E348?E348
View details for Web of Science ID 000302326700349
Cost-effectiveness Analysis of Adjunct VSL#3 Therapy Versus Standard Medical Therapy in Pediatric Ulcerative Colitis JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Park, K. T., Perez, F., Tsai, R., Honkanen, A., Bass, D., Garber, A. 2011; 53 (5): 489-496
Abstract

Inflammatory bowel diseases (IBDs) are costly chronic gastrointestinal diseases, with pediatric IBD representing increased costs per patient compared to adult disease. Health care expenditures for ulcerative colitis (UC) are >$2 billion annually. It is not clear whether the addition of VSL#3 to standard medical therapy in UC induction and maintenance of remission is a cost-effective strategy.We performed a systematic review of the literature and created a Markov model simulating a cohort of 10-year-old patients with severe UC, studying them until 100 years of age or death. We compared 2 strategies: standard medical therapy versus medical therapy + VSL#3. For both strategies, we assumed that patients progressed through escalating therapies--mesalamine, azathioprine, and infliximab--before receiving a colectomy + ileal pouch anal anastamosis (IPAA) if the 3 medical therapy options were exhausted. The primary outcome measure was the incremental cost-effectiveness ratio (ICER), defined as the difference of costs between strategies for each quality-adjusted life-year (QALY) gained. One-way sensitivity analyses were performed on variables to determine the key variables affecting cost-effectiveness.Standard medical care accrued a lifetime cost of $203,317 per patient, compared to $212,582 per patient for medical therapy + VSL#3. Lifetime QALYs gained was comparable for standard medical therapy and medical therapy + VSL#3 at 24.93 versus 25.05, respectively. Using the definition of ICER <50,000/QALY as a cost-effective intervention, medical therapy + VSL#3 produced an ICER of $79,910 per QALY gained, making this strategy cost-ineffective. Sensitivity analyses showed that 4 key parameters could affect the cost-effectiveness of the 2 strategies: cost of colectomy + IPAA, maintenance cost after surgery, probability of developing pouchitis after surgery, and the quality of life after a colectomy + IPAA. High surgical and postsurgical costs, a high probability of developing pouchitis, and a low quality of life after a colectomy + IPAA could make adjunct VSL#3 use a cost-effective strategy.Given present data, adjunct VSL#3 use for pediatric UC induction and maintenance of remission is not cost-effective, although several key parameters could make this strategy cost-effective. The quality of life after an IPAA is the single most important variable predicting whether this procedure benefits patients over escalating standard medical therapy.

View details for DOI 10.1097/MPG.0b013e3182293a5e

View details for Web of Science ID 000296383000007

View details for PubMedID 21694634
Knowing Loved Ones' End-of-Life Health Care Wishes: Attachment Security Predicts Caregivers' Accuracy HEALTH PSYCHOLOGY Turan, B., Goldstein, M. K., Garber, A. M., Carstensen, L. L. 2011; 30 (6): 814-818
Abstract

At times, caregivers make life-and-death decisions for loved ones. Yet very little is known about the factors that make caregivers more or less accurate as surrogate decision makers for their loved ones. Previous research suggests that in low stress situations, individuals with high attachment-related anxiety are attentive to their relationship partners' wishes and concerns, but get overwhelmed by stressful situations. Individuals with high attachment-related avoidance are likely to avoid intimacy and stressful situations altogether. We hypothesized that both of these insecure attachment patterns limit surrogates' ability to process distressing information and should therefore be associated with lower accuracy in the stressful task of predicting their loved ones' end-of-life health care wishes.Older patients visiting a medical clinic stated their preferences toward end-of-life health care in different health contexts, and surrogate decision makers independently predicted those preferences. For comparison purposes, surrogates also predicted patients' perceptions of everyday living conditions so that surrogates' accuracy of their loved ones' perceptions in nonstressful situations could be assessed.Surrogates high on either type of insecure attachment dimension were less accurate in predicting their loved ones' end-of-life health care wishes. It is interesting to note that even though surrogates' attachment-related anxiety was associated with lower accuracy of end-of-life health care wishes of their loved ones, it was associated with higher accuracy in the nonstressful task of predicting their loved ones' everyday living conditions.Attachment orientation plays an important role in accuracy about loved ones' end-of-life health care wishes. Interventions may target emotion regulation strategies associated with insecure attachment orientations.

View details for DOI 10.1037/a0025664

View details for Web of Science ID 000297029200020

View details for PubMedID 22081941

View details for PubMedCentralID PMC3228368
Individualized Cost-Effectiveness Analysis PLOS MEDICINE Ioannidis, J. P., Garber, A. M. 2011; 8 (7)
View details for DOI 10.1371/journal.pmed.1001058

View details for PubMedID 21765810
Cost-Effectiveness Analysis of Nephron Sparing Options for the Management of Small Renal Masses JOURNAL OF UROLOGY Chang, S. L., Cipriano, L. E., Harshman, L. C., Garber, A. M., Chung, B. I. 2011; 185 (5): 1591-1597
Abstract

A recent increase in the detection of contrast enhancing renal masses 4 cm or smaller suspicious for malignancy has led to the widespread use of nephron sparing options. Limited data exist to help clinicians decide which of these competing nephron sparing therapies is most appropriate. We performed a cost-effectiveness analysis to evaluate the relative clinical and economic merits of commonly available nephron sparing strategies for small renal masses.We developed a decision analytic Markov model estimating the costs and health outcomes of treating a healthy 65-year-old patient with an asymptomatic unilateral small renal mass using competing nephron sparing options of immediate intervention (ie open and laparoscopic partial nephrectomy as well as laparoscopic and percutaneous ablation), active surveillance with possible delayed intervention and nonsurgical management with observation. Benefits were measured in quality adjusted life-years. We used a societal perspective, lifetime horizon and willingness to pay threshold of $50,000 per quality adjusted life-year gained. Model results were assessed with sensitivity analyses.In the base case scenario the least costly option was observation and the optimal option was immediate laparoscopic partial nephrectomy, which had an incremental cost-effectiveness ratio of $36,645 per quality adjusted life-year gained compared to surveillance with possible delayed percutaneous ablation. Results were sensitive to age at diagnosis, health status and tumor size.Immediate laparoscopic partial nephrectomy is the preferred nephron sparing option for healthy patients younger than 74 years old with a small renal mass. Surveillance with possible delayed percutaneous ablation is a cost-effective alternative for patients with advanced age or significant comorbidities. Observation maximizes quality adjusted life-years in patients who are poor surgical candidates or with limited life expectancy (less than 3 years).

View details for DOI 10.1016/j.juro.2010.12.100

View details for Web of Science ID 000289279600013

View details for PubMedID 21419445
How CER Could Pay for Itself - Insights from Vertebral Fracture Treatments NEW ENGLAND JOURNAL OF MEDICINE Elshaug, A. G., Garber, A. M. 2011; 364 (15): 1390-1393
View details for Web of Science ID 000289467200003

View details for PubMedID 21488762
Cost-Effectiveness of Dabigatran Compared With Warfarin for Stroke Prevention in Atrial Fibrillation ANNALS OF INTERNAL MEDICINE Freeman, J. V., Zhu, R. P., Owens, D. K., Garber, A. M., Hutton, D. W., Go, A. S., Wang, P. J., Turakhia, M. P. 2011; 154 (1): 1-U129
Abstract

Warfarin reduces the risk for ischemic stroke in patients with atrial fibrillation (AF) but increases the risk for hemorrhage. Dabigatran is a fixed-dose, oral direct thrombin inhibitor with similar or reduced rates of ischemic stroke and intracranial hemorrhage in patients with AF compared with those of warfarin.To estimate the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with adjusted-dose warfarin for preventing ischemic stroke in patients 65 years or older with nonvalvular AF.Markov decision model.The RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial and other published studies of anticoagulation. The cost of dabigatran was estimated on the basis of pricing in the United Kingdom.Patients aged 65 years or older with nonvalvular AF and risk factors for stroke (CHADS? score ?1 or equivalent) and no contraindications to anticoagulation.Lifetime.Societal.Warfarin anticoagulation (target international normalized ratio, 2.0 to 3.0); dabigatran, 110 mg twice daily (low dose); and dabigatran, 150 mg twice daily (high dose).Quality-adjusted life-years (QALYs), costs (in 2008 U.S. dollars), and incremental cost-effectiveness ratios.The quality-adjusted life expectancy was 10.28 QALYs with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Total costs were $143 193 for warfarin, $164 576 for low-dose dabigatran, and $168 398 for high-dose dabigatran. The incremental cost-effectiveness ratios compared with warfarin were $51 229 per QALY for low-dose dabigatran and $45 372 per QALY for high-dose dabigatran.The model was sensitive to the cost of dabigatran but was relatively insensitive to other model inputs. The incremental cost-effectiveness ratio increased to $50 000 per QALY at a cost of $13.70 per day for high-dose dabigatran but remained less than $85 000 per QALY over the full range of model inputs evaluated. The cost-effectiveness of high-dose dabigatran improved with increasing risk for stroke and intracranial hemorrhage.Event rates were largely derived from a single randomized clinical trial and extrapolated to a 35-year time frame from clinical trials with approximately 2-year follow-up.In patients aged 65 years or older with nonvalvular AF at increased risk for stroke (CHADS? score ?1 or equivalent), dabigatran may be a cost-effective alternative to warfarin depending on pricing in the United States.American Heart Association and Veterans Affairs Health Services Research & Development Service.

View details for PubMedID 21041570
The Role Of Costs In Comparative Effectiveness Research HEALTH AFFAIRS Garber, A. M., Sox, H. C. 2010; 29 (10): 1805-1811
Abstract

The major expansion of federal comparative effectiveness research launched in 2009 held the potential to supply the information needed to help slow health spending growth while improving the outcomes of care. However, when Congress passed the Patient Protection and Affordable Care Act one year later, it limited the role of cost analysis in the work sponsored by the Patient-Centered Outcomes Research Institute. Despite this restriction, cost-effectiveness analysis meets important needs and is likely to play a larger role in the future. Under the terms of the Affordable Care Act, the institute can avoid commissioning cost-effectiveness analyses and still provide information bearing on the use and costs of health care interventions. This information will enable others to investigate the comparative value of these interventions. We argue that doing so is necessary to decision makers who are attempting to raise the quality of care while reining in health spending.

View details for DOI 10.1377/hlthaff.2010.0647

View details for Web of Science ID 000282513600009

View details for PubMedID 20921479
Incidental Extracardiac Findings at Coronary CT: Clinical and Economic Impact AMERICAN JOURNAL OF ROENTGENOLOGY Lee, C. I., Tsai, E. B., Sigal, B. M., Plevritis, S. K., Garber, A. M., Rubin, G. D. 2010; 194 (6): 1531-1538
Abstract

The purpose of this study was to evaluate the prevalence of incidental extracardiac findings on coronary CT, to determine the associated downstream resource utilization, and to estimate additional costs per patient related to the associated diagnostic workup.This retrospective study examined incidental extracardiac findings in 151 consecutive adults (69.5% men and 30.5% women; mean age, 54 years) undergoing coronary CT during a 7-year period. Incidental findings were recorded, and medical records were reviewed for downstream diagnostic examinations for a follow-up period of 1 year (minimum) to 7 years (maximum). Costs of further workup were estimated using 2009 Medicare average reimbursement figures.There were 102 incidental extracardiac findings in 43% (65/151) of patients. Fifty-two percent (53/102) of findings were potentially clinically significant, and 81% (43/53) of these findings were newly discovered. The radiology reports made specific follow-up recommendations for 36% (19/53) of new significant findings. Only 4% (6/151) of patients actually underwent follow-up imaging or intervention for incidental findings. One patient was found to have a malignancy that was subsequently treated. The average direct costs of additional diagnostic workup were $17.42 per patient screened (95% CI, $2.84-$32.00) and $438.39 per patient with imaging follow-up (95% CI, $301.47-$575.31).Coronary CT frequently reveals potentially significant incidental extracardiac abnormalities, yet radiologists recommend further evaluation in only one-third of cases. An even smaller fraction of cases receive further workup. The failure to follow-up abnormal incidental findings may result in missed opportunities to detect early disease, but also limits the short-term attributable costs.

View details for DOI 10.2214/AJR.09.3587

View details for PubMedID 20489093
Population Strategies to Decrease Sodium Intake and the Burden of Cardiovascular Disease A Cost-Effectiveness Analysis ANNALS OF INTERNAL MEDICINE Smith-Spangler, C. M., Juusola, J. L., Enns, E. A., Owens, D. K., Garber, A. M. 2010; 152 (8): 481-U21
Abstract

Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake.To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax.A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke.Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data.U.S. adults aged 40 to 85 years.Lifetime.Societal.Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted.Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period.Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake.Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict.Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses.Department of Veterans Affairs, Stanford University, and National Science Foundation.

View details for Web of Science ID 000277054400001

View details for PubMedID 20194225
Modernizing Device Regulation. NEW ENGLAND JOURNAL OF MEDICINE Garber, A. M. 2010; 362 (13): 1161-1163
View details for DOI 10.1056/NEJMp1000447

View details for Web of Science ID 000276239500001

View details for PubMedID 20335575
A cost-benefit analysis of preimplantation genetic diagnosis for carrier couples of cystic fibrosis FERTILITY AND STERILITY Davis, L. B., Champion, S. J., Fair, S. O., Baker, V. L., Garber, A. M. 2010; 93 (6): 1793-1804
Abstract

To perform a cost-benefit analysis of preimplantation genetic diagnosis (PGD) for carrier couples of cystic fibrosis (CF) compared with the alternative of natural conception (NC) followed by prenatal testing and termination of affected pregnancies.Cost-benefit analysis using a decision analytic model.Outpatient reproductive health practices.A simulated cohort of 1,000 female patients.We calculated the net benefit of giving birth to a child as the present value of lifetime earnings minus lifetime medical costs.Net benefits in dollars.When used for women younger than 35 years of age, the net benefit of PGD over NC was $182,000 ($715,000 vs. $532,000, respectively). For women aged 35-40 years, the net benefit of PGD over NC was $114,000 ($634,000 vs. $520,000, respectively). For women older than 40 years, however, the net benefit of PGD over NC was -$148,000 ($302,000 vs. $450,000, respectively).Preimplantation genetic diagnosis provides net economic benefits when used by carrier couples of CF. Although there is an upper limit of maternal age at which economic benefit can be demonstrated, carrier couples of CF should be offered PGD for prevention of an affected child.

View details for DOI 10.1016/j.fertnstert.2008.12.053

View details for Web of Science ID 000276678100010

View details for PubMedID 19439290
Cost Effectiveness of Alternative Imaging Strategies for the Diagnosis of Small-Bowel Crohn's Disease CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Levesque, B. G., Cipriano, L. E., Chang, S. L., Lee, K. K., Owens, D. K., Garber, A. M. 2010; 8 (3): 261-267
Abstract

The cost effectiveness of alternative approaches to the diagnosis of small-bowel Crohn's disease is unknown. This study evaluates whether computed tomographic enterography (CTE) is a cost-effective alternative to small-bowel follow-through (SBFT) and whether capsule endoscopy is a cost-effective third test in patients in whom a high suspicion of disease remains after 2 previous negative tests.A decision-analytic model was developed to compare the lifetime costs and benefits of each diagnostic strategy. Patients were considered with low (20%) and high (75%) pretest probability of small-bowel Crohn's disease. Effectiveness was measured in quality-adjusted life-years (QALYs) gained. Parameter assumptions were tested with sensitivity analyses.With a moderate to high pretest probability of small-bowel Crohn's disease, and a higher likelihood of isolated jejunal disease, follow-up evaluation with CTE has an incremental cost-effectiveness ratio of less than $54,000/QALY-gained compared with SBFT. The addition of capsule endoscopy after ileocolonoscopy and negative CTE or SBFT costs greater than $500,000 per QALY-gained in all scenarios. Results were not sensitive to costs of tests or complications but were sensitive to test accuracies.The cost effectiveness of strategies depends critically on the pretest probability of Crohn's disease and if the terminal ileum is examined at ileocolonoscopy. CTE is a cost-effective alternative to SBFT in patients with moderate to high suspicion of small-bowel Crohn's disease. The addition of capsule endoscopy as a third test is not a cost-effective third test, even in patients with high pretest probability of disease.

View details for DOI 10.1016/j.cgh.2009.10.032

View details for PubMedID 19896559
Following Your Heart or Your Head: Focusing on Emotions Versus Information Differentially Influences the Decisions of Younger and Older Adults JOURNAL OF EXPERIMENTAL PSYCHOLOGY-APPLIED Mikels, J. A., Loeckenhoff, C. E., Maglio, S. J., Carstensen, L. L., Goldstein, M. K., Garber, A. 2010; 16 (1): 87-95
Abstract

Research on aging has indicated that whereas deliberative cognitive processes decline with age, emotional processes are relatively spared. To examine the implications of these divergent trajectories in the context of health care choices, we investigated whether instructional manipulations emphasizing a focus on feelings or details would have differential effects on decision quality among younger and older adults. We presented 60 younger and 60 older adults with health care choices that required them to hold in mind and consider multiple pieces of information. Instructional manipulations in the emotion-focus condition asked participants to focus on their emotional reactions to the options, report their feelings about the options, and then make a choice. In the information-focus condition, participants were instructed to focus on the specific attributes, report the details about the options, and then make a choice. In a control condition, no directives were given. Manipulation checks indicated that the instructions were successful in eliciting different modes of processing. Decision quality data indicate that younger adults performed better in the information-focus than in the control condition whereas older adults performed better in the emotion-focus and control conditions than in the information-focus condition. Findings support and extend extant theorizing on aging and decision making as well as suggest that interventions to improve decision-making quality should take the age of the decision maker into account.

View details for DOI 10.1037/a0018500

View details for Web of Science ID 000276369400007

View details for PubMedID 20350046
Health Outcomes and Costs of Community Mitigation Strategies for an Influenza Pandemic in the United States CLINICAL INFECTIOUS DISEASES Perlroth, D. J., Glass, R. J., Davey, V. J., Cannon, D., Garber, A. M., Owens, D. K. 2010; 50 (2): 165-174
Abstract

The optimal community-level approach to control pandemic influenza is unknown.We estimated the health outcomes and costs of combinations of 4 social distancing strategies and 2 antiviral medication strategies to mitigate an influenza pandemic for a demographically typical US community. We used a social network, agent-based model to estimate strategy effectiveness and an economic model to estimate health resource use and costs. We used data from the literature to estimate clinical outcomes and health care utilization.At 1% influenza mortality, moderate infectivity (R(o) of 2.1 or greater), and 60% population compliance, the preferred strategy is adult and child social distancing, school closure, and antiviral treatment and prophylaxis. This strategy reduces the prevalence of cases in the population from 35% to 10%, averts 2480 cases per 10,000 population, costs $2700 per case averted, and costs $31,300 per quality-adjusted life-year gained, compared with the same strategy without school closure. The addition of school closure to adult and child social distancing and antiviral treatment and prophylaxis, if available, is not cost-effective for viral strains with low infectivity (R(o) of 1.6 and below) and low case fatality rates (below 1%). High population compliance lowers costs to society substantially when the pandemic strain is severe (R(o) of 2.1 or greater).Multilayered mitigation strategies that include adult and child social distancing, use of antivirals, and school closure are cost-effective for a moderate to severe pandemic. Choice of strategy should be driven by the severity of the pandemic, as defined by the case fatality rate and infectivity.

View details for DOI 10.1086/649867

View details for Web of Science ID 000273069100003

View details for PubMedID 20021259
THE POTENTIAL IMPACT OF COMPARATIVE EFFECTIVENESS RESEARCH ON US HEALTH CARE EXPENDITURES DEMOGRAPHY Perlroth, D. J., Goldman, D. P., Garber, A. M. 2010; 47: S173-S190
Abstract

Comparative effectiveness research (CER) has the potential to slow health care spending growth by focusing resources on health interventions that provide the most value. In this article, we discuss issues surrounding CER and its implementation and apply these methods to a salient clinical example: treatment of prostate cancer. Physicians have several options for treating patients recently diagnosed with localized disease, including removal of the prostate (radical prostatectomy), treatment with radioactive seeds (brachytherapy), radiation therapy (IMRT), or--if none of these are pursued--active surveillance. Using a commercial health insurance claims database and after adjustment for comorbid conditions, we estimate that the additional cost of treatment with radical prostatectomy is $7,300, while other alternatives are more expensive--$19,000 for brachytherapy and $46,900 for IMRT. However a review of the clinical literature uncovers no evidence that justifies the use of these more expensive approaches. These results imply that if patient management strategies were shifted to those supported by CER-based criteria, an estimated $1.7 to $3.0 billion (2009 present value) could be saved each year.

View details for Web of Science ID 000284671700010

View details for PubMedID 21302424
Cost-Effectiveness of Dabigatran Compared With Warfarin for Stroke Prevention in Atrial Fibrillation Annals of Internal Medicine Freeman, J., Zhu, R., Owens, Douglas K., Garber, Alan M., Hutton, D., Go, A., Wang, P., Turakhia, M. 2010
Health outcomes and costs of community mitigation strategies for an influenza pandemic in the United States. Clinical Infectious Diseases Perlroth, D., RJ, G., VJ, D., D, C., Garber, Alan M., Owens, Douglas K. 2010; 50: 165-174
Effectiveness and Cost-Effectiveness of Vaccination Against Pandemic Influenza (H1N1) 2009 ANNALS OF INTERNAL MEDICINE Khazeni, N., Hutton, D. W., Garber, A. M., Hupert, N., Owens, D. K. 2009; 151 (12): 829-U2
Abstract

Decisions on the timing and extent of vaccination against pandemic (H1N1) 2009 virus are complex.To estimate the effectiveness and cost-effectiveness of pandemic influenza (H1N1) vaccination under different scenarios in October or November 2009.Compartmental epidemic model in conjunction with a Markov model of disease progression.Literature and expert opinion.Residents of a major U.S. metropolitan city with a population of 8.3 million.Lifetime.Societal.Vaccination in mid-October or mid-November 2009.Infections and deaths averted, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.Assuming each primary infection causes 1.5 secondary infections, vaccinating 40% of the population in October or November would be cost-saving. Vaccination in October would avert 2051 deaths, gain 69 679 QALYs, and save $469 million compared with no vaccination; vaccination in November would avert 1468 deaths, gain 49 422 QALYs, and save $302 million.Vaccination is even more cost-saving if longer incubation periods, lower rates of infectiousness, or increased implementation of nonpharmaceutical interventions delay time to the peak of the pandemic. Vaccination saves fewer lives and is less cost-effective if the epidemic peaks earlier than mid-October.The model assumed homogenous mixing of case-patients and contacts; heterogeneous mixing would result in faster initial spread, followed by slower spread. Additional costs and savings not included in the model would make vaccination more cost-saving.Earlier vaccination against pandemic (H1N1) 2009 prevents more deaths and is more cost-saving. Complete population coverage is not necessary to reduce the viral reproductive rate sufficiently to help shorten the pandemic.Agency for Healthcare Research and Quality and National Institute on Drug Abuse.

View details for PubMedID 20008759
Effectiveness and Cost-Effectiveness of Expanded Antiviral Prophylaxis and Adjuvanted Vaccination Strategies for an Influenza A (H5N1) Pandemic ANNALS OF INTERNAL MEDICINE Khazeni, N., Hutton, D. W., Garber, A. M., Owens, D. K. 2009; 151 (12): 840-U3
Abstract

The pandemic potential of influenza A (H5N1) virus is a prominent public health concern of the 21st century.To estimate the effectiveness and cost-effectiveness of alternative pandemic (H5N1) mitigation and response strategies.Compartmental epidemic model in conjunction with a Markov model of disease progression.Literature and expert opinion.Residents of a U.S. metropolitan city with a population of 8.3 million.Lifetime.Societal.3 scenarios: 1) vaccination and antiviral pharmacotherapy in quantities similar to those currently available in the U.S. stockpile (stockpiled strategy), 2) stockpiled strategy but with expanded distribution of antiviral agents (expanded prophylaxis strategy), and 3) stockpiled strategy but with adjuvanted vaccine (expanded vaccination strategy). All scenarios assumed standard nonpharmaceutical interventions.Infections and deaths averted, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.Expanded vaccination was the most effective and cost-effective of the 3 strategies, averting 68% of infections and deaths and gaining 404 030 QALYs at $10 844 per QALY gained relative to the stockpiled strategy.Expanded vaccination remained incrementally cost-effective over a wide range of assumptions.The model assumed homogenous mixing of cases and contacts; heterogeneous mixing would result in faster initial spread, followed by slower spread. We did not model interventions for children or older adults; the model is not designed to target interventions to specific groups.Expanded adjuvanted vaccination is an effective and cost-effective mitigation strategy for an influenza A (H5N1) pandemic. Expanded antiviral prophylaxis can help delay the pandemic while additional strategies are implemented.National Institutes of Health and Agency for Healthcare Research and Quality.

View details for PubMedID 20008760
The Confirmatory Trial in Comparative-Effectiveness Research NEW ENGLAND JOURNAL OF MEDICINE Garber, A. M., Hlatky, M. A. 2009; 361 (15): 1498-1499
View details for Web of Science ID 000270540000014

View details for PubMedID 19812407
Laparoscopy in women with unexplained infertility: a cost-effectiveness analysis FERTILITY AND STERILITY Moayeri, S. E., Lee, H. C., Lathi, R. B., Westphal, L. M., Milki, A. A., Garber, A. M. 2009; 92 (2): 471-480
Abstract

To evaluate the cost effectiveness of laparoscopy for unexplained infertility.We performed a cost-effectiveness analysis using a computer-generated decision analysis tree. Data used to construct the mathematical model were extracted from the literature or obtained from our practice. We compared outcomes following four treatment strategies: [1] no treatment, [2] standard infertility treatment algorithm (SITA), [3] laparoscopy with expectant management (LSC/EM), and [4] laparoscopy with infertility therapy (LSC/IT). The incremental cost-effectiveness ratio (ICER) was calculated, and one-way sensitivity analyses assessed the impact of varying base-case estimates.Academic in vitro fertilization practice.Computer-simulated patients assigned to one of four treatments.Fertility treatment or laparoscopy.Incremental cost-effectiveness ratios.Using base-case assumptions, LSC/EM was preferred (ICER =$128,400 per live-birth in U.S. dollars). Changing the following did not alter results: rates and costs of multiple gestations, penalty for high-order multiples, infertility treatment costs, and endometriosis prevalence. Outcomes were most affected by patient dropout from infertility treatments-SITA was preferred when dropout was less than 9% per cycle. Less important factors included surgical costs, acceptability of twins, and the effects of untreated endometriosis on fecundity.Laparoscopy is cost effective in the initial management of young women with infertility, particularly when infertility treatment dropout rates exceed 9% per cycle.

View details for DOI 10.1016/j.fertnstert.2008.05.074

View details for PubMedID 18722609
Toward a 21st-Century Health Care System: Recommendations for Health Care Reform ANNALS OF INTERNAL MEDICINE Arrow, K., Auerbach, A., Bertko, J., Brownlee, S., Casalino, L. P., Cooper, J., Crosson, F. J., Enthoven, A., Falcone, E., Feldman, R. C., Fuchs, V. R., Garber, A. M., Gold, M. R., Goldman, D., Hadfield, G. K., Hall, M. A., Horwitz, R. I., Hooven, M., Jacobson, P. D., Jost, T. S., Kotlikoff, L. J., Levin, J., Levine, S., Levy, R., Linscott, K., Luft, H. S., Mashal, R., McFadden, D., Mechanic, D., Meltzer, D., Newhouse, J. P., Noll, R. G., Pietzsch, J. B., Pizzo, P., Reischauer, R. D., Rosenbaum, S., Sage, W., Schaeffer, L. D., Sheen, E., Silber, M., Skinner, J., Shortell, S. M., Thier, S. O., Tunis, S., Wulsin, L., Yock, P., Bin Nun, G., Bryan, S., Luxenburg, O., van de Ven, W. P. 2009; 150 (7): 493-?
Abstract

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

View details for Web of Science ID 000265117600008

View details for PubMedID 19258550
THE DESALINIZATION OF THE AMERICAN DIET: THE COST-EFFECTIVENESS OF STRATEGIES TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE 32nd Annual National Meeting of the Society-for-General-Internal-Medicine Smith-Spangler, C. M., Juusola, J. L., Enns, E. A., Steele, K. M., Jaatma, I., Adler, S., Garber, A. M. SPRINGER. 2009: 182?182
View details for Web of Science ID 000265382000484
Effectiveness and Cost-Effectiveness of Expanded Antiviral Prophylaxis and Adjuvanted Vaccination Strategies for an Influenza A (H5N1) Pandemic Annals of Internal Medicine Khazeni, N., DW, H., Garber, Alan M., Owens, D. 2009; 151
Toward a 21st-Century Health Care System: Recommendations for Health Care Reform Annals of Internal Medicine Arrow, Kenneth J., A, A., J, B., S, B., LP, C., J, C., J, C., Enthoven, Alain C., E, F., RC, F., Fuchs, Victor R., Garber, Alan M., MR, G., D, G., GK, H., MA, H., RI, H., M, H., PD, J., T, S., LJ, K., J, L., S, L., R, L., K, L., Luft, Harold S., R, M., D, M., D, M., D, M., O, L., JP, N., RG, N., JB, P., P, P., RD, R., S, R., W, S., LD, S., E, S., BM, S., J, S., Shortell, Stephen M., SO, T., Tunis, Sean R., L, W., P, Y., GB, N., Bryan, S., van de Ven PMM 2009; 150
Effectiveness and Cost-Effectiveness of Vaccination Against Pandemic Influenza (H1N1) 2009 Annals of Internal Medicine Khazeni, N., DW, H., Garber, Alan M., N, H., Owens, D. 2009; 151
Simple counts of ADL dependencies do not adequately reflect older adults' preferences toward states of functional impairment JOURNAL OF CLINICAL EPIDEMIOLOGY Sims, T., Holmes, T. H., Bravata, D. M., Garber, A. M., Nelson, L. M., Goldstein, M. K. 2008; 61 (12): 1261-1270
Abstract

To use unweighted counts of dependencies in activities of daily living (ADLs) to assess the impact of functional impairment requires an assumption of equal preferences for each ADL dependency. To test this assumption, we analyzed standard gamble (SG) utilities of single and combination ADL dependencies among older adults.Four hundred older adults used multimedia software (FLAIR1) to report SG utilities for their current health and hypothetical health states of dependency in each of 7 ADLs and 8 of 30 combinations of ADL dependencies.Utilities for health states of multiple ADL dependencies were often greater than for states of single ADL dependencies. Dependence in eating, which is the ADL dependency with the lowest utility rating of the single ADL dependencies, ranked lower than 7 combination states. Similarly, some combination states with fewer ADL dependencies had lower utilities than those with more ADL dependencies. These findings were consistent across groups by gender, age, and education.Our results suggest that the count of ADL dependencies does not adequately represent the utility for a health state. Cost-effectiveness analyses and other evaluations of programs that prevent or treat functional dependency should apply utility weights rather than relying on simple ADL counts.

View details for DOI 10.1016/j.jclinepi.2008.05.001

View details for Web of Science ID 000261219700010

View details for PubMedID 18722749

View details for PubMedCentralID PMC2596888
Is American Health Care Uniquely Inefficient? JOURNAL OF ECONOMIC PERSPECTIVES Garber, A. A., Skinner, J. 2008; 22 (4): 27-50
View details for Web of Science ID 000261349700002

View details for PubMedID 19305645
Management of acute kidney injury in the intensive care unit - A cost-effectiveness analysis of daily vs alternate-day hemodialysis ARCHIVES OF INTERNAL MEDICINE Desai, A. A., Baras, J., Berk, B. B., Nakajima, A., Garber, A. M., Owens, D., Chertow, G. M. 2008; 168 (16): 1761-1767
Abstract

Although evidence suggests that a higher hemodialysis dose and/or frequency may be associated with improved outcomes, the cost-effectiveness of a daily hemodialysis strategy for critically ill patients with acute kidney injury (AKI) is unknown.We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of daily hemodialysis, compared with alternate-day hemodialysis, for patients with AKI in the intensive care unit (ICU). We employed a societal perspective with a lifetime analytic time horizon. We modeled the efficacy of daily hemodialysis as a reduction in the relative risk of death on the basis of data reported in the 2004 clinical trial published by Schiffl et al. We performed 1- and 2-way sensitivity analyses across cost, efficacy, and utility input variables. The main outcome measure was cost per quality-adjusted life-year (QALY).In the base case for a 60-year-old man, daily hemodialysis was projected to add 2.14 QALYs and $10,924 in cost. We found that the cost-effectiveness of daily hemodialysis compared with alternate-day hemodialysis was $5084 per QALY gained. The incremental cost-effectiveness ratio became less favorable (>$50,000 per QALY gained) when the maintenance hemodialysis rate of the daily hemodialysis group was varied to more than 27% and when the difference in 14-day postdischarge mortality between the alternatives was varied to less than 0.5%.Daily hemodialysis is a cost-effective strategy compared with alternate-day hemodialysis for patients with severe AKI in the ICU.

View details for PubMedID 18779463
Is Having More Preapproval Data The Best Way To Assure Drug Safety? HEALTH AFFAIRS Garber, A. M. 2008; 27 (5): W371-W373
Abstract

An intensified focus on drug safety often leads to demands for more data collection prior to drug approval. Other approaches can be used, such as enhanced postmarketing surveillance. Many drug benefits and adverse effects are unlikely to become apparent before wide distribution among diverse patients. The best balance of pre- and postapproval data collection may vary by drug. The consequences of alternative strategies are complex and not always immediately apparent, so formal modeling offers the best approach to determine which strategy is optimal in each case.

View details for DOI 10.1377/hlthaff.27.5.w371

View details for Web of Science ID 000259861700050

View details for PubMedID 18682442
Commentary: The impact of Medicare coverage policies on health care utilization HEALTH SERVICES RESEARCH Garber, A. M. 2008; 43 (4): 1302-1307
View details for DOI 10.1111/j.1475-6773.2008.00852.x

View details for Web of Science ID 000257756000011

View details for PubMedID 18479412
Future costs and the future of cost-effectiveness analysis JOURNAL OF HEALTH ECONOMICS Garber, A. M., Phelps, C. E. 2008; 27 (4): 819-821
View details for DOI 10.1016/j.jhealeco.2008.05.002

View details for Web of Science ID 000257591200002

View details for PubMedID 18539348

View details for PubMedCentralID PMC2574706
A menu without prices ANNALS OF INTERNAL MEDICINE Garber, A. M. 2008; 148 (12): 964-966
View details for Web of Science ID 000257425000009

View details for PubMedID 18483127
Systematic review: The effects of growth hormone on athletic performance ANNALS OF INTERNAL MEDICINE Liu, H., Bravata, D. M., Olkin, I., Friedlander, A., Liu, V., Roberts, B., Bendavid, E., Saynina, O., Salpeter, S. R., Garber, A. M., Hoffman, A. R. 2008; 148 (10): 747-U59
Abstract

Human growth hormone is reportedly used to enhance athletic performance, although its safety and efficacy for this purpose are poorly understood.To evaluate evidence about the effects of growth hormone on athletic performance in physically fit, young individuals.MEDLINE, EMBASE, SPORTDiscus, and Cochrane Collaboration databases were searched for English-language studies published between January 1966 and October 2007.Randomized, controlled trials that compared growth hormone treatment with no growth hormone treatment in community-dwelling healthy participants between 13 and 45 years of age.2 authors independently reviewed articles and abstracted data.44 articles describing 27 study samples met inclusion criteria; 303 participants received growth hormone, representing 13.3 person-years of treatment. Participants were young (mean age, 27 years [SD, 3]), lean (mean body mass index, 24 kg/m2 [SD, 2]), and physically fit (mean maximum oxygen uptake, 51 mL/kg of body weight per minute [SD, 8]). Growth hormone dosage (mean, 36 microg/kg per day [SD, 21]) and treatment duration (mean, 20 days [SD, 18] for studies giving growth hormone for >1 day) varied. Lean body mass increased in growth hormone recipients compared with participants who did not receive growth hormone (increase, 2.1 kg [95% CI, 1.3 to 2.9 kg]), but strength and exercise capacity did not seem to improve. Lactate levels during exercise were statistically significantly higher in 2 of 3 studies that evaluated this outcome. Growth hormone-treated participants more frequently experienced soft tissue edema and fatigue than did those not treated with growth hormone.Few studies evaluated athletic performance. Growth hormone protocols in the studies may not reflect real-world doses and regimens.Claims that growth hormone enhances physical performance are not supported by the scientific literature. Although the limited available evidence suggests that growth hormone increases lean body mass, it may not improve strength; in addition, it may worsen exercise capacity and increase adverse events. More research is needed to conclusively determine the effects of growth hormone on athletic performance.

View details for Web of Science ID 000256372200004

View details for PubMedID 18347346
Unsupervised method for automatic construction of a disease dictionary from a large free text collection. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Xu, R., Supekar, K., Morgan, A., Das, A., Garber, A. 2008: 820-824
Abstract

Concept specific lexicons (e.g. diseases, drugs, anatomy) are a critical source of background knowledge for many medical language-processing systems. However, the rapid pace of biomedical research and the lack of constraints on usage ensure that such dictionaries are incomplete. Focusing on disease terminology, we have developed an automated, unsupervised, iterative pattern learning approach for constructing a comprehensive medical dictionary of disease terms from randomized clinical trial (RCT) abstracts, and we compared different ranking methods for automatically extracting con-textual patterns and concept terms. When used to identify disease concepts from 100 randomly chosen, manually annotated clinical abstracts, our disease dictionary shows significant performance improvement (F1 increased by 35-88%) over available, manually created disease terminologies.

View details for PubMedID 18999169
Management of acute kidney injury in the intensive care unit: a cost-effectiveness analysis of daily vs alternate-day hemodialysis Arch Intern Med Desai, A., J, B., BB, B., A, N., Garber, Alan M., Owens, Douglas K., Chertow, Glenn M. 2008; 168: 1761-1767
Management of acute kidney injury in the intensive care unit: a cost-effectiveness analysis of daily vs alternate-day hemodialysis. Archives of Internal Medicine Desai, A., J, B., B, B., A, N., Garber, Alan M., Owens, Douglas K., Chertow, G. 2008; 168: 1761-1767
The promise of health care cost containment HEALTH AFFAIRS Garber, A., Goldman, D. P., Jena, A. B. 2007; 26 (6): 1545-1547
Abstract

Today the United States may be on the cusp of changing from a cost-unconscious health care system to one that seeks value. The consequences of adopting a value-based approach to coverage have not been well studied; however, several broad strands of the health literature suggest that spending could be reduced by as much as 30 percent without adversely affecting health.

View details for DOI 10.1377/hlthaff.26.6.1545

View details for Web of Science ID 000251146300010

View details for PubMedID 17978370
Rise of pay for performance: Implications for care of people with chronic kidney disease CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Desai, A. A., Garber, A. M., Chertow, G. M. 2007; 2 (5): 1087-1095
Abstract

Many health care providers and policy makers believe that health care financing systems fail to reward high-quality care. In recent years, federal and private payers have begun to promote pay for performance, or value-based purchasing, initiatives to raise the quality of care. This report describes conceptual issues in the design and implementation of pay for performance for chronic kidney disease and ESRD care. It also considers the implications of recent ESRD payment policy changes on the broader goals of pay for performance. Congressionally mandated bundle payment demonstration for dialysis, newly implemented case-mix adjustment of the composite rate, and G codes for the monthly capitation payment are important opportunities to understand facility and provider behavior with particular attention to patient selection and treatment practices. Well-designed payment systems will reward quality care for patients while maintaining appropriate accountability and fairness for health care providers.

View details for DOI 10.2215/CJN.00510107

View details for PubMedID 17702735
Influence of race on inpatient treatment intensity at the end of life JOURNAL OF GENERAL INTERNAL MEDICINE Barnato, A. E., Chang, C. H., Saynina, O., Garber, A. M. 2007; 22 (3): 338-345
Abstract

To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.United States, 1989-1999.Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than non-blacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99-1.03], p = .36; terminal hospitalization AOR 1.03 [1.0-1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08-1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20-1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91-0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70-0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital's black census was a strong predictor of inpatient end-of-life treatment intensity.Black decedents were treated more intensively during hospitalization than non-black decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital's black census. The causes and consequences of these hospital-level differences in intensity deserve further study.

View details for DOI 10.1007/s11606-006-0088-x

View details for Web of Science ID 000244718600009

View details for PubMedID 17356965
A cost-effectiveness analysis of adjuvant trastuzumab regimens in early HER2/neu-positive breast cancer JOURNAL OF CLINICAL ONCOLOGY Kurian, A. W., Newton Thompson, R., Gaw, A. F., Arai, S., Ortiz, R., Garber, A. M. 2007; 25 (6): 634-641
Abstract

One-year adjuvant trastuzumab (AT) therapy, with or without anthracyclines, increases disease-free and overall survival in early-stage HER2/neu-positive breast cancer. We sought to evaluate the cost effectiveness of these regimens, which are expensive and potentially toxic.We used a Markov health-state transition model to simulate three adjuvant therapy options for a cohort of 49-year-old women with HER2/neu-positive early-stage breast cancer: conventional chemotherapy without trastuzumab; anthracycline-based AT regimens used in the National Surgical Adjuvant Breast and Bowel Project B-31 and North Central Cancer Treatment Group N9831 trials; and the nonanthracycline AT regimen used in the Breast Cancer International Research group 006 trial. The base case used treatment efficacy measures reported in the randomized clinical trials of AT. We measured health outcomes in quality-adjusted life-years (QALYs) and costs in 2005 United States dollars (US dollars) and subjected results to probabilistic sensitivity analysis.In the base case, the anthracycline-based AT arm has an incremental cost-effectiveness ratio (ICER) of 39,982 dollars/QALY, whereas the nonanthracycline AT arm is more expensive and less effective; this result is insensitive to changes in recurrence rates, but if there is no benefit after 4 years, ICERs exceed 100,000 dollars/QALY for both AT arms. Results are moderately sensitive to variation in breast cancer survival rates and trastuzumab cost, and less sensitive to variations in cardiac toxicity.AT has an ICER comparable to those for other widely used interventions. Longer clinical follow-up is warranted to evaluate the long-term efficacy and toxicity of different AT regimens.

View details for DOI 10.1200/JCO.2006.06.3081

View details for Web of Science ID 000244384000006

View details for PubMedID 17308268
B type natriuretic peptide testing was more cost effective than conventional diagnosis in patients with acute dyspnoea. Evidence-based medicine Shetty, K., Garber, A. 2007; 12 (1): 28-?
View details for PubMedID 17264276
Systematic review: The safety and efficacy of growth hormone in the healthy elderly ANNALS OF INTERNAL MEDICINE Liu, H., Bravata, D. M., Olkin, I., Nayak, S., Roberts, B., Garber, A. M., Hoffman, A. R. 2007; 146 (2): 104-115
Abstract

Human growth hormone (GH) is widely used as an antiaging therapy, although its use for this purpose has not been approved by the U.S. Food and Drug Administration and its distribution as an antiaging agent is illegal in the United States.To evaluate the safety and efficacy of GH therapy in the healthy elderly.The authors searched MEDLINE and EMBASE databases for English-language studies published through 21 November 2005 by using such terms as growth hormone and aging.The authors included randomized, controlled trials that compared GH therapy with no GH therapy or GH and lifestyle interventions (exercise with or without diet) with lifestyle interventions alone. Included trials provided GH for 2 weeks or more to community-dwelling participants with a mean age of 50 years or more and a body mass index of 35 kg/m2 or less. The authors excluded studies that evaluated GH as treatment for a specific illness.Two authors independently reviewed articles and abstracted data.31 articles describing 18 unique study populations met the inclusion criteria. A total of 220 participants who received GH (107 person-years) completed their respective studies. Study participants were elderly (mean age, 69 years [SD, 6]) and overweight (mean body mass index, 28 kg/m2 [SD, 2]). Initial daily GH dose (mean, 14 microg per kg of body weight [SD, 7]) and treatment duration (mean, 27 weeks [SD, 16]) varied. In participants treated with GH compared with those not treated with GH, overall fat mass decreased (change in fat mass, -2.1 kg [95% CI, -2.8 to -1.35] and overall lean body mass increased (change in lean body mass, 2.1 kg [CI, 1.3 to 2.9]) (P < 0.001), and their weight did not change significantly (change in weight, 0.1 kg [CI, -0.7 to 0.8]; P = 0.87). Total cholesterol levels decreased (change in cholesterol, -0.29 mmol/L [-11.21 mg/dL]; P = 0.006), although not significantly after adjustment for body composition changes. Other outcomes, including bone density and other serum lipid levels, did not change. Persons treated with GH were significantly more likely to experience soft tissue edema, arthralgias, carpal tunnel syndrome, and gynecomastia and were somewhat more likely to experience the onset of diabetes mellitus and impaired fasting glucose.Some important outcomes were infrequently or heterogeneously measured and could not be synthesized. Most included studies had small sample sizes.The literature published on randomized, controlled trials evaluating GH therapy in the healthy elderly is limited but suggests that it is associated with small changes in body composition and increased rates of adverse events. On the basis of this evidence, GH cannot be recommended as an antiaging therapy.

View details for Web of Science ID 000243901000004

View details for PubMedID 17227934
Extracting Subject Demographic Information From Abstracts of Randomized Clinical Trial Reports 12th World Congress on Health (Medical) Informatics xu, r., Garten, Y., Supekar, K. S., Das, A. K., Altman, R. B., Garber, A. M. I O S PRESS. 2007: 550?554
Abstract

In order to make more informed healthcare decisions, consumers need information systems that deliver accurate and reliable information about their illnesses and potential treatments. Reports of randomized clinical trials (RCTs) provide reliable medical evidence about the efficacy of treatments. Current methods to access, search for, and retrieve RCTs are keyword-based, time-consuming, and suffer from poor precision. Personalized semantic search and medical evidence summarization aim to solve this problem. The performance of these approaches may improve if they have access to study subject descriptors (e.g. age, gender, and ethnicity), trial sizes, and diseases/symptoms studied. We have developed a novel method to automatically extract such subject demographic information from RCT abstracts. We used text classification augmented with a Hidden Markov Model to identify sentences containing subject demographics, and subsequently these sentences were parsed using Natural Language Processing techniques to extract relevant information. Our results show accuracy levels of 82.5%, 92.5%, and 92.0% for extraction of subject descriptors, trial sizes, and diseases/symptoms descriptors respectively.

View details for PubMedID 17911777
Influence of Race on Inpatient Treatment Intensity at the End of Life Journal of General Internal Medicine Garber, Alan M., Saynina, O., Chang, C., Barnato, A. 2007; 22: 338-345
Rise of Pay for Performance: Implications for Care of People with Chronic Kidney Disease Clinical Journal of the American Society of Nephrology Desai, A., Garber, Alan M., Chertow, G. 2007
The cost-effectiveness of therapy with Teriparatide and alendronate in women with severe osteoporosis ARCHIVES OF INTERNAL MEDICINE Liu, H., Michaud, K., Nayak, S., Karpf, D. B., Owens, D. K., Garber, A. M. 2006; 166 (11): 1209-1217
Abstract

Teriparatide is a promising new agent for the treatment of osteoporosis.The objective of this study was to evaluate the cost-effectiveness of teriparatide-based strategies compared with alendronate sodium for the first-line treatment of high-risk osteoporotic women. We developed a microsimulation with a societal perspective. Key data sources include the Study of Osteoporotic Fractures, the Fracture Intervention Trial, and the Fracture Prevention Trial. We evaluated postmenopausal white women with low bone density and prevalent vertebral fracture. The interventions were usual care (UC) (calcium or vitamin D supplementation) compared with 3 strategies: 5 years of alendronate therapy, 2 years of teriparatide therapy, and 2 years of teriparatide therapy followed by 5 years of alendronate therapy (sequential teriparatide/alendronate). The main outcome measure was cost per quality-adjusted life-year (QALY).For the base-case analysis, the cost of alendronate treatment was 11,600 dollars per QALY compared with UC. The cost of sequential teriparatide/alendronate therapy was 156,500 dollars per QALY compared with alendronate. Teriparatide treatment alone was more expensive and produced a smaller increase in QALYs than alendronate. For sensitivity analysis, teriparatide alone was less cost-effective than alendronate even if its efficacy lasted 15 years after treatment cessation. Sequential teriparatide/alendronate therapy was less cost-effective than alendronate even if fractures were eliminated during the alendronate phase, although its cost-effectiveness was less than 50,000 dollars per QALY if the price of teriparatide decreased 60%, if used in elderly women with T scores of -4.0 or less, or if 6 months of teriparatide therapy had comparable efficacy to 2 years of treatment.Alendronate compares favorably to interventions accepted as cost-effective. Therapy with teriparatide alone is more expensive and produces a smaller increase in QALYs than therapy with alendronate. Sequential teriparatide/alendronate therapy appear expensive but could become more cost-effective with reductions in teriparatide price, with restriction to use in exceptionally high-risk women, or if short courses of treatment have comparable efficacy to that observed in clinical trials.

View details for PubMedID 16772249
Cost-effectiveness of screening BRCA1/2 mutation carriers with breast magnetic resonance imaging JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Plevritis, S. K., Kurian, A. W., Sigal, B. M., Daniel, B. L., Ikeda, D. M., Stockdale, F. E., Garber, A. M. 2006; 295 (20): 2374-2384
Abstract

Women with inherited BRCA1/2 mutations are at high risk for breast cancer, which mammography often misses. Screening with contrast-enhanced breast magnetic resonance imaging (MRI) detects cancer earlier but increases costs and results in more false-positive scans.To evaluate the cost-effectiveness of screening BRCA1/2 mutation carriers with mammography plus breast MRI compared with mammography alone.A computer model that simulates the life histories of individual BRCA1/2 mutation carriers, incorporating the effects of mammographic and MRI screening was used. The accuracy of mammography and breast MRI was estimated from published data in high-risk women. Breast cancer survival in the absence of screening was based on the Surveillance, Epidemiology and End Results database of breast cancer patients diagnosed in the prescreening period (1975-1981), adjusted for the current use of adjuvant therapy. Utilization rates and costs of diagnostic and treatment interventions were based on a combination of published literature and Medicare payments for 2005.The survival benefit, incremental costs, and cost-effectiveness of MRI screening strategies, which varied by ages of starting and stopping MRI screening, were computed separately for BRCA1 and BRCA2 mutation carriers.Screening strategies that incorporate annual MRI as well as annual mammography have a cost per quality-adjusted life-year (QALY) gained ranging from less than 45,000 dollars to more than 700,000 dollars, depending on the ages selected for MRI screening and the specific BRCA mutation. Relative to screening with mammography alone, the cost per QALY gained by adding MRI from ages 35 to 54 years is 55,420 dollars for BRCA1 mutation carriers, 130,695 dollars for BRCA2 mutation carriers, and 98,454 dollars for BRCA2 mutation carriers who have mammographically dense breasts.Breast MRI screening is more cost-effective for BRCA1 than BRCA2 mutation carriers. The cost-effectiveness of adding MRI to mammography varies greatly by age.

View details for PubMedID 16720823
Racial differences in preferences toward states of functional dependence. Annual Meeting of the American-Geriatrics-Society Sims, T., Mather, M., Garber, A. M., Goldstein, M. K. WILEY-BLACKWELL. 2006: S195?S195
View details for Web of Science ID 000237069300568
Are patient preferences for functional independence and health care in the home stable over time? Annual Meeting of the American-Geriatrics-Society Sims, T., Garber, A. M., Calcagni, J., Goldstein, M. K. WILEY-BLACKWELL. 2006: S59?S59
View details for Web of Science ID 000237069300170
To use technology better HEALTH AFFAIRS Garber, A. M. 2006; 25 (2): W51-W53
Abstract

Although technological innovation can improve health outcomes, the precise magnitude of the contribution and its value are not easily measured. The findings reported by Jonathan Skinner and colleagues temper the favorable conclusions reached by observing correlations between improvement in heart attack outcomes over time with spending on medical products and services. Improvements in health care depend not only on producing better technologies, but also on using technology better.

View details for DOI 10.1377/hlthaff.25.w51

View details for Web of Science ID 000236094500063

View details for PubMedID 16464903
Combining text classification and Hidden Markov Modeling techniques for categorizing sentences in randomized clinical trial abstracts. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium xu, r., Supekar, K., Huang, Y., Das, A., Garber, A. 2006: 824-828
Abstract

Randomized clinical trials (RCT) papers provide reliable information about efficacy of medical interventions. Current keyword based search methods to retrieve medical evidence,overload users with irrelevant information as these methods often do not take in to consideration semantics encoded within abstracts and the search query. Personalized semantic search, intelligent clinical question answering and medical evidence summarization aim to solve this information overload problem. Most of these approaches will significantly benefit if the information available in the abstracts is structured into meaningful categories (e.g., background, objective, method, result and conclusion). While many journals use structured abstract format, majority of RCT abstracts still remain unstructured.We have developed a novel automated approach to structure RCT abstracts by combining text classification and Hidden Markov Modeling(HMM) techniques. Results (precision: 0.98, recall: 0.99) of our approach significantly outperform previously reported work on automated categorization of sentences in RCT abstracts.

View details for PubMedID 17238456
Effect of Geriatrics Evaluation and Management on Nursing Home Use and Health Care Costs: Results From a Randomized Trial Medical Care Phibbs, Ciaran S., Holty, J., Goldstein, Mary K., Garber, Alan M., Wang, Y., Feussner, J., Cohen, H. 2006; 44: 91-95
Biomedical Informatics: Computer Applications in Health Care and Biomedicine, 3rd edition Shortliffe, E., Cimino, J., Garber, Alan M., Owens, Douglas K., Singer, Sara J., Enthoven, Alain C. Springer. 2006
The effect of geriatrics evaluation and management on nursing home use and health care costs - Results from a randomized trial MEDICAL CARE Phibbs, C. S., Holty, J. E., Goldstein, M. K., Garber, A. M., Wang, Y. J., Feussner, J. R., Cohen, H. J. 2006; 44 (1): 91-95
Abstract

The Geriatric Evaluation and Management study was developed to assess the impact of a comprehensive geriatric assessment service on the care of the elderly.We sought to evaluate the cost and clinical impact of inpatient units and outpatient clinics for geriatric evaluation and management.We undertook a prospective, randomized, controlled trial using a 2x2 factorial design, with 1-year follow-up.A total of 1388 participants hospitalized on either a medical or surgical ward at 11 participating Veterans Affairs medical centers were randomized to receive either inpatient geriatric unit (GEMU) or usual inpatient care (UCIP), followed by either outpatient care from a geriatric clinic (GEMC) versus usual outpatient care (UCOP).We measured health care utilization and costs.Patients assigned to the GEMU had a significantly decreased rate of nursing home placement (odds ratio=0.65; P=0.001). Neither the GEMU nor GEMC had any statistically significant improvement effects on survival and only modest effects on health status. There were statistically insignificant mean cost savings of $1027 (P=0.29) per patient for the GEMU and $1665 (P=0.69) per patient for the GEMC.Inpatient or outpatient geriatric evaluation and management units didn't increase the costs of care. Although there was no effect on survival and only modest effects on SF-36 scores at 1-year follow-up, there was a statistically significant reduction in nursing home admissions for patients treated in the GEMU.

View details for Web of Science ID 000234342600013

View details for PubMedID 16365618
Consequences of health trends and medical innovation for the future elderly HEALTH AFFAIRS Goldman, D. P., Shang, B. P., Hattacharya, J., Garber, A. M., Hurd, M., Joyce, G. F., Lakdawalla, D. N., Panis, C., Shekelle, P. G. 2005; 24 (6): W5R5-W5R17
Abstract

Recent innovations in biomedicine seem poised to revolutionize medical practice. At the same time, disease and disability are increasing among younger populations. This paper considers how these confluent trends will affect the elderly's health status and health care spending over the next thirty years. Because healthier people live longer, cumulative Medicare spending varies little with a beneficiary's disease and disability status upon entering Medicare. On the other hand, ten of the most promising medical technologies are forecast to increase spending greatly. It is unlikely that a "silver bullet" will emerge to both improve health and dramatically reduce medical spending.

View details for Web of Science ID 000235033500053

View details for PubMedID 16186147
Effect of care-providing for functional dependence on estimates of quality of life Sims, T., Goldstein, M., Mahlow, P., Mather, M., Garber, A. OXFORD UNIV PRESS INC. 2005: 369?369
View details for Web of Science ID 000233615001080
Differences in utilities for long-term care settings among older adults with and without living children Garber, A., Sims, T., Goldstein, M. OXFORD UNIV PRESS INC. 2005: 105?105
View details for Web of Science ID 000233615000289
The cost-effectiveness of parathyroid hormone and alendronate in high-risk osteoporotic women. 27th Annual Meeting of the American-Society-for-Bone-and-Mineral-Research Liu, H., Michaud, K., Nayak, S., Karpf, D. B., Owens, D. K., Garber, A. M. WILEY-BLACKWELL. 2005: S409?S409
View details for Web of Science ID 000233503805169
The cost-effectiveness of parathyroid hormone and alendronate in high-risk osteoporotic women. 69th Annual Scientific Meeting of the American-College-of-Rheumatology/40th Annual Scientific Meeting of the Association-of-Rheumatology-Health-Professionals Michaud, K., Liu, H., Nayak, S., Owens, D. K., Garber, A. M. WILEY-BLACKWELL. 2005: S266?S266
View details for Web of Science ID 000232207801177
Cost-effectiveness of defending against bioterrorism: A comparison of vaccination and antibiotic prophylaxis against anthrax ANNALS OF INTERNAL MEDICINE Fowler, R. A., Sanders, G. D., Bravata, D. M., Nouri, B., Gastwirth, J. M., Peterson, D., Broker, A. G., Garber, A. M., Owens, D. K. 2005; 142 (8): 601-610
Abstract

Weaponized Bacillus anthracis is one of the few biological agents that can cause death and disease in sufficient numbers to devastate an urban setting.To evaluate the cost-effectiveness of strategies for prophylaxis and treatment of an aerosolized B. anthracis bioterror attack.Decision analytic model.We derived probabilities of anthrax exposure, vaccine and treatment characteristics, and their costs and associated clinical outcomes from the medical literature and bioterrorism-preparedness experts.Persons living and working in a large metropolitan U.S. city.Patient lifetime.Societal.We evaluated 4 postattack strategies: no prophylaxis, vaccination alone, antibiotic prophylaxis alone, or vaccination and antibiotic prophylaxis, as well as preattack vaccination versus no vaccination.Costs, quality-adjusted life-years, life-years, and incremental cost-effectiveness.If an aerosolized B. anthracis bioweapon attack occurs, postexposure prophylactic vaccination and antibiotic therapy for those potentially exposed is the most effective (0.33 life-year gained per person) and least costly (355 dollars saved per person) strategy, as compared with vaccination alone. At low baseline probabilities of attack and exposure, mass previous vaccination of a metropolitan population is more costly (815 million dollars for a city of 5 million people) and not more effective than no vaccination.If prophylactic antibiotics cannot be promptly distributed after exposure, previous vaccination may become cost-effective.The probability of exposure and disease critically depends on the probability and mechanism of bioweapon release.In the event of an aerosolized B. anthracis bioweapon attack over an unvaccinated metropolitan U.S. population, postattack prophylactic vaccination and antibiotic therapy is the most effective and least expensive strategy.

View details for Web of Science ID 000228410400002

View details for PubMedID 15838066
Attaining a diverse sample of older adults through internet-based surveys in the home. Annual Meeting of the American-Geriatrics-Society Bravata, D., Sims, T., Mahlow, P., Garber, A., Goldstein, M. K. WILEY-BLACKWELL. 2005: S81?S82
View details for Web of Science ID 000228450900231
Technology diffusion, hospital variation, and racial disparities among elderly Medicare beneficiaries 1989-2000 MEDICAL CARE Groeneveld, P. W., Laufer, S. B., Garber, A. M. 2005; 43 (4): 320-329
Abstract

Low rates of technology utilization in hospitals with high proportions of black inpatients may be a remediable cause of healthcare disparities.Our objective was to determine how differences in technology utilization among hospitals contributed to racial disparity and if temporal reduction in hospital procedure rate variation resulted in decreased racial disparity for these technologies.We identified 2,348,952 elderly Medicare beneficiaries potentially eligible for 1 of 5 emerging medical technologies from 1989-2000 and determined if these patients had received the indicated procedure within 90 days of their qualifying hospital admission. Initial multivariate regression models adjusted for age, race, sex, admission year, clinical comorbidity, community levels of education and income, and academic/urban hospital admission. The inpatient racial composition of each patient's admitting hospital and time-race interactions were added as covariates to subsequent models.Blacks had significantly lower adjusted rates (P < 0.001) compared with whites for tissue replacement of the aortic valve, internal mammary artery coronary bypass grafting, dual-chambered pacemaker implantation, and lumbar spinal fusion. Hospitals with > 20% black inpatients were less likely to perform these procedures on both white and black patients than hospitals with < 9% black inpatients, and racial disparity was greater in hospitals with larger black populations. There were no temporal reductions in racial disparities.Blacks may be disadvantaged in access to new procedures by receiving care at hospitals that have both lower procedure rates and greater racial disparity. Policies designed to ameliorate racial disparities in health care must address hospital variation in the provision of care.

View details for Web of Science ID 000227914000003

View details for PubMedID 15778635
Acceptability of multimedia survey instrument among older adults. Annual Meeting of the American-Geriatrics-Society Sims, T., Garber, A., Mahlow, P., Goldstein, M. K. WILEY-BLACKWELL. 2005: S81?S81
View details for Web of Science ID 000228450900230
Having IADL dependency does not prevent people from overestimating impact of ADL dependency. Annual Meeting of the American-Geriatrics-Society Sims, T., Mather, M., Mahlow, P., Nelson, L., Garber, A., Goldstein, M. WILEY-BLACKWELL. 2005: S2?S2
View details for Web of Science ID 000228450900006
Invariance and inconsistency in utility ratings 22nd Annual Meeting of the Society-for-Medical-Decision-Making Bravata, D. M., Nelson, L. M., Garber, A. M., Goldstein, M. K. SAGE PUBLICATIONS INC. 2005: 158?67
Abstract

To assess utilities of composite health states for dependence in activities of daily living (ADLs) for invariance (i.e., when subjects provide a utility of 1 for all health states) and order inconsistency (i.e., when subjects order their utilities such that their utility for a combination of ADL dependencies is greater than their utility for any subset of the combination).Each of the 400 subjects, age 65 y and older, enrolled in one of several regional medical centers of the Kaiser Permanente Medical Care Program of Northern California and provided standard-gamble utilities for single ADL dependencies (e.g., bathing, dressing, continence) and for dependence in 8 other combinations of ADL dependencies. For order-inconsistent responses, the authors calculated the maximum magnitude of inconsistency as the maximum difference between the utility for the combined ADL dependence health state and that of its inconsistent subset.A total of 76 subjects (19%) gave a utility of 1.0 for all health states presented to them; 19 (5%) gave the same utility other than 1.0 for all health states; 130 (33%) gave at least 1 utility < 1.0 and had no order inconsistencies; and 175 (44%) had at least 1 order inconsistency. Invariance was associated with a Mini-Mental Status Examination score < 28.6 (P = 0.01), with education < 12 y (P = 0.004), with race/ethnicity other than non-Hispanic White/Caucasian (P = 0.001), and with shorter time spent on the utility elicitation task (P < 0.0001). Among the inconsistent subjects, 69% had a maximal magnitude of inconsistency that was within 1 standard deviation of the mean utilities. The maximal magnitude of inconsistency was associated with longer time spent on the elicitation task (P < 0.0001) and race/ethnicity other than non-Hispanic White/Caucasian (P = 0.005). The mean (s) utility for dependence in continence among consistent subjects who were not invariant (0.88 [0.24]) was higher than among inconsistent subjects (0.80 [0.27]; P = 0.01).Invariance and order inconsistencies in utility ratings for complex health states occur frequently. Utilities of consistent subjects may differ from those of inconsistent subjects. Utility assessments should attempt to measure and report these patterns.

View details for DOI 10.1177/0272989X05275399

View details for Web of Science ID 000228014000004

View details for PubMedID 15800300
Trends in implantable cardioverter-defibrillator racial disparity - The importance of geography JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Groeneveld, P. W., Heidenreich, P. A., Garber, A. M. 2005; 45 (1): 72-78
Abstract

The study was designed to determine whether racial disparity in utilization of the implantable cardioverter-defibrillator (ICD) has improved over time, and whether small-area geographic variation in ICD utilization contributed to national levels of racial disparity.Although racial disparities in cardiac procedures have been well-documented, it is unknown whether there has been improvement over time. Low ICD utilization rates in predominantly black geographic areas may have exacerbated national levels of disparity.Discharge abstracts from elderly black and white Medicare beneficiaries hospitalized with ventricular arrhythmias from 1990 to 2000 were analyzed to determine if ICD implantation occurred within 90 days of initial hospitalization. Multivariate logistic regression models were constructed to assess the relationship between ICD implantation, year of admission, and the percentage of black inhabitants in each patient's county of hospitalization while controlling for clinical, hospital, and demographic characteristics.There was improvement in ICD implantation racial disparity: In the period 1990 to 1992, black patients had an odds ratio of 0.52 (95% confidence interval [CI] 0.42 to 0.64) for receiving an ICD compared with whites. However, by 1999 to 2000, the odds ratio for blacks had risen to 0.69 (95% CI 0.61 to 0.78) (test-for-trend p=0.01). Approximately 20% of this trend could be explained by reduction in geographic variation in ICD use between areas with larger black and predominantly white populations.Rates of ICD implants became more equal among whites and blacks during the 1990s, although persistent disparity remained at the decade's end. Geographic equalization in cardiovascular procedure rates may be an essential mechanism in rectifying disparities in health care.

View details for DOI 10.1016/j.jacc.2004.07.061

View details for Web of Science ID 000226012600014

View details for PubMedID 15629377
Multimedia quality of life assessment: advances with FLAIR. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Sims, T. L., Garber, A. M., Miller, D. E., Mahlow, P. T., Bravata, D. M., Goldstein, M. K. 2005: 694-698
Abstract

Assessing impact of functional dependency on quality of life (QOL) among older adults can provide an in-depth understanding of health preferences. Utilities as a measure of preferences are necessary in conducting cost-effectiveness evaluations of healthcare interventions designed to improve overall QOL. We describe further development of a multimedia utility elicitation instrument that is highly portable and easily accessible. An earlier version, FLAIR1, introduced features designed for older adult, computer inexperienced users. FLAIR2 includes modifications such as migration to a web-based platform, consistency checks, audio/visual updates, and more response methods. As compared with FLAIR1, more FLAIR2 respondents (n=318) preferred using the computer and found the computer program to be enjoyable, easy to use, and easily understood. There were also fewer inconsistencies among FLAIR2 respondents. FLAIR2 enhancements have increased portability, minimized invariance and inconsistency, and produced a more user friendly design.

View details for PubMedID 16779129
Consequences of health trends and medical innovation for the future elderly Health Affairs (Project Hope) Goldman, D.P., Shang, B., Bhattacharya, J., Garber, Alan M., Hurd, M., Joyce, G. F., DN, L., C, P., PG, S. 2005; 24 Suppl 2: W5R5-17
Trends in implantable cardioverter-defibrillator racial disparity: the importance of geography Journal of the American College of Cardiology Heidenreich, Paul A., Groeneveld, P., Garber, Alan M. 2005; 45: 72-78
Technology Diffusion, Hospital Variation, and Racial Disparities Among Elderly Medicare Beneficiaries: 1989-2000 Medical Care Groeneveld, Peter W., Laufer, Sara B., Garber, Alan M. 2005; 43: 320-329
Evidence-based guidelines as a foundation for performance incentives HEALTH AFFAIRS Garber, A. M. 2005; 24 (1): 174-179
Abstract

Clinical guidelines, which increasingly build upon impartial analysis of evidence from well-designed studies, have become highly credible sources of information about what forms of care are effective. Consequently, they are attractive as foundations for performance incentives. Unfortunately, they are often complex, and frequently it is infeasible to gather the information required to assess compliance with guidelines at reasonable cost. I discuss the problems in implementing evidence-based guidelines and steps that could be taken to make them more useful as a basis for performance measurement.

View details for DOI 10.1377/hlthaff.24.1.174

View details for Web of Science ID 000227835600023

View details for PubMedID 15647228
Health plans' coverage determinations for technology-based interventions: The case of electrical bone growth stimulation AMERICAN JOURNAL OF MANAGED CARE Huang, A. J., Gemperli, M. P., Bergthold, L., Singer, S. S., Garber, A. 2004; 10 (12): 957-962
Abstract

To determine (1) whether commercial health plans' coverage criteria for a costly technology-based medical intervention are consistent with recent clinical effectiveness evidence, (2) whether medical directors adhere to planwide coverage criteria when making coverage determinations for individual patients, and (3) if any organizational characteristics are associated with having more stringent coverage criteria or making more frequent coverage denials.Case-based survey of medical directors of US commercial health plans.A close-ended survey was mailed to 346 medical directors meeting eligibility criteria, asking about the criteria specified in their plans' coverage policies for electrical bone growth stimulation (EBGS) and whether they would cover this intervention for a hypothetical patient with abnormal union of long-bone fracture.Responses from 228 (66%) of the 346 directors indicated that approximately 72% of plans have a formal coverage policy for EBGS for long-bone fractures. More than 30% of plans specify that longer than 4 months must elapse before EBGS is attempted, although clinical studies do not support absolute waiting times. Directors of approximately 61% of plans with policies requiring extended waiting periods would nevertheless authorize EBGS for patients who did not meet this criterion.Health plans apply varied criteria in coverage policies for technology-based treatments such as EBGS, but do not always adhere to stated criteria when determining coverage for individual patients. For-profit status, accreditation status, geographic location, and size of plan are not associated with being more or less likely to authorize EBGS.

View details for Web of Science ID 000225627700007

View details for PubMedID 15617371
Impacts of informal caregiver availability on long-term care expenditures in OECD countries HEALTH SERVICES RESEARCH Yoo, B. K., Bhattacharya, J., McDonald, K. M., Garber, A. M. 2004; 39 (6): 1971-1995
Abstract

To quantify the effects of informal caregiver availability and public funding on formal long-term care (LTC) expenditures in developed countries.Secondary data were acquired for 15 Organization for Economic Cooperation and Development (OECD) countries from 1970 to 2000.Secondary data analysis, applying fixed- and random-effects models to time-series cross-sectional data. Outcome variables are inpatient or home heath LTC expenditures. Key explanatory variables are measures of the availability of informal caregivers, generosity in public funding for formal LTC, and the proportion of the elderly population in the total population.Aggregated macro data were obtained from OECD Health Data, United Nations Demographic Yearbooks, and U.S. Census Bureau International Data Base.Most of the 15 OECD countries experienced growth in LTC expenditures over the study period. The availability of a spouse caregiver, measured by male-to-female ratio among the elderly, is associated with a $28,840 (1995 U.S. dollars) annual reduction in formal LTC expenditure per additional elderly male. Availability of an adult child caregiver, measured by female labor force participation and full-time/part-time status shift, is associated with a reduction of $310 to $3,830 in LTC expenditures. These impacts on LTC expenditure vary across countries and across time within a country.The availability of an informal caregiver, particularly a spouse caregiver, is among the most important factors explaining variation in LTC expenditure growth. Long-term care policies should take into account behavioral responses: decreased public funding in LTC may lead working women to leave the labor force to provide more informal care.

View details for Web of Science ID 000226743500004

View details for PubMedID 15544640

View details for PubMedCentralID PMC1361108
Cost-effectiveness and evidence evaluation as criteria for coverage policy HEALTH AFFAIRS Garber, A. M. 2004; 23 (4): W284-W296
View details for DOI 10.1377/hlthaff.W4.284

View details for Web of Science ID 000222499600047
Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life HEALTH SERVICES RESEARCH Barnato, A. E., McClellan, M. B., Kagay, C. R., Garber, A. M. 2004; 39 (2): 363-375
Abstract

Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures.The 1985-1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files.We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services.Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission.Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred.

View details for Web of Science ID 000220100800009

View details for PubMedID 15032959
The costs of decedents in the Medicare program: Implications for payments to Medicare plus choice plans HEALTH SERVICES RESEARCH Buntin, M. B., Garber, A. M., McClellan, M., Newhouse, J. P. 2004; 39 (1): 111-130
Abstract

To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures.Medicare administrative claims for 1994 and 1995.We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters.The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors.Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments.More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.

View details for Web of Science ID 000188758000009

View details for PubMedID 14965080
Cost-effectiveness and evidence evaluation as criteria for coverage policy. Health affairs Garber, A. M. 2004: W4-284 96
Abstract

Private health plans and government health insurance programs in the United States base their coverage decisions on evidence criteria, rather than explicit cost-effectiveness criteria. As health spending continues to grow rapidly, however, approaches to coverage policy that ignore costs fail to meet the needs of consumers, employers, health plans, and federal and state governments. I describe the role of evidence-based criteria in formal coverage decision making and contrast the ways that these criteria differ from cost-effectiveness criteria. Finally, I discuss options for incorporating considerations of cost-effectiveness into coverage policy and other aspects of benefit design.

View details for PubMedID 15451997
The changing face of health care Conference on Coping with Methuselah - The Impact of Molecular Biology on Medicine and Society Garber, A. M., Goldman, D. P. BROOKINGS INST. 2004: 105?125
View details for Web of Science ID 000221625600004
Cost-effectiveness and evidence evaluation as criteria for coverage policy Health Affairs Garber, Alan M. 2004: 284-296
Impacts of informal caregiver availability on long-term care expenditures in OECD countries Health Services Research Yoo, B., Bhattacharya, J., McDonald, Kathryn M., Garber, Alan M. 2004; 39: 1971-1992
U.S. Physician Workforce: Serious Questions Raised, Answers Needed Annals of Internal Medicine Garber, Alan M., Sox, Harold S. 2004; 141: 732-734
Costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans, The Health Services Research MB, B., Garber, Alan M., McClellan, Mark B., JP, N. 2004; 39: 111-130
Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life Health Services Research Barnato, A., McClellan, Mark B., Kagay, C., Garber, Alan M. 2004; 39: 363-375
Cost-effectiveness of bypass surgery versus stenting in patients with multivessel coronary artery disease AMERICAN JOURNAL OF MEDICINE Yock, C. A., Boothroyd, D. B., Owens, D. K., Garber, A. M., Hlatky, M. A. 2003; 115 (5): 382-389
Abstract

To compare the cost-effectiveness of surgical and angioplasty-based coronary artery revascularization techniques, in particular, angioplasty with primary stenting.We used data from the Study of Economics and Quality of Life, a substudy of the Bypass Angioplasty Revascularization Investigation (BARI), to measure the outcomes and costs of angioplasty and bypass surgery in patients with multivessel coronary artery disease who had not undergone prior coronary artery revascularization. Using a Markov decision model, we updated the outcomes and costs to reflect technology changes since the time of enrollment in BARI, and projected the lifetime costs and quality-adjusted life-years (QALYs) for the two procedures from the time of initial treatment through death. We accounted for the effects of improved procedural safety and efficiency, and prolonged therapeutic effects of both surgery and stenting. This study was conducted from a societal perspective.Surgical revascularization was less costly and resulted in better outcomes than catheter-based intervention including stenting. It remained the preferred strategy after adjusting the stent outcomes to eliminate the costs and events associated with target lesion restenosis. Among angioplasty-based strategies, primary stent use cost an additional 189,000 US dollars per QALY gained compared with a strategy that reserved stent use for treatment of suboptimal balloon angioplasty results.Bypass surgery results in better outcomes than angioplasty in patients with multivessel disease, and at a lower cost.

View details for DOI 10.1016/S0002-9343(03)00296-1

View details for PubMedID 14553874
Cost-effectiveness of recombinant human activated protein C and the influence of severity of illness in the treatment of patients with severe sepsis JOURNAL OF CRITICAL CARE Fowler, R. A., Hill-Popper, M., Stasinos, J., Petrou, C., Sanders, G. D., Garber, A. M. 2003; 18 (3): 181-191
Abstract

To evaluate the cost-effectiveness of recombinant human activated protein C (rhAPC) compared with usual therapy for patients with severe sepsis, and also to determine the influence that severity of illness exerts on cost-effectiveness.We use a Markov model-based cost-effectiveness analysis of treatment strategies for patients with severe sepsis. Therapy includes treatment with either rhAPC and usual therapy, or usual therapy alone. Probabilities for clinical outcomes were obtained from a large randomized clinical trial comparing the use of rhAPC with placebo (PROWESS study) and from outcomes literature for patients with severe sepsis and its complications. Cost estimates were based on Medicare reimbursement rates, Health Care Financing Administration information and the literature. Outcome measures include life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.Compared with usual therapy alone, rhAPC treatment for patients with very severe sepsis (APACHE II score > or = 25) was associated with an incremental cost-effectiveness ratio of $13 493/QALY. Treatment of patients with less severe sepsis with rhAPC (APACHE II score < 25) had an incremental cost-effectiveness ratio of $403,000/QALY. For patients with very severe sepsis the incremental cost-effectiveness ratio for treatment with rhAPC remained under $30,000/QALY, over a broad range of variables, including costs of rhAPC, costs of acute care and costs and probabilities of complications of treatment. For patients with less severe sepsis, drug costs would need to fall well below current market price before achieving cost-effectiveness. A probabilistic sensitivity analysis comparing rhAPC treatment with usual therapy for patients with very severe sepsis showed that < 1% of Monte Carlo simulations had incremental cost-effectiveness ratios > $50,000/QALY.The use of rhAPC for the treatment of patients with very severe sepsis, as determined by APACHE II score > or = 25, appears cost-effective, while treatment of patients with APACHE II score < 25 is not cost-effective.

View details for DOI 10.1053/S0883-9441(03)00081-9

View details for Web of Science ID 000186426700009

View details for PubMedID 14595571
Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest CIRCULATION Groeneveld, P. W., Heidenreich, P. A., Garber, A. M. 2003; 108 (3): 286-291
Abstract

It is unknown whether white and black Medicare beneficiaries have different rates of cardiac procedure utilization or long-term survival after cardiac arrest.A total of 5948 elderly Medicare beneficiaries (5429 white and 519 black) were identified who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. Demographic, socioeconomic, and clinical information about these patients was obtained from Medicare administrative files, the US census, and the American Hospital Association's annual institutional survey. A Cox proportional hazard model that included demographic and clinical predictors indicated a hazard ratio for mortality of 1.30 (95% CI 1.09 to 1.55) for blacks aged 66 to 74 years compared with whites of the same age. The addition of cardiac procedures to this model lowered the hazard ratio for blacks to 1.23 (95% CI 1.03 to 1.46). In analyses stratified by race, implantable cardioverter-defibrillators (ICDs) had a mortality hazard ratio of 0.53 (95% CI 0.45 to 0.62) for white patients and 0.50 (95% CI 0.27 to 0.91) for black patients. Logistic regression models that compared procedure rates between races indicated odds ratios for blacks aged 66 to 74 years of 0.58 (95% CI 0.36 to 0.94) to receive an ICD and 0.50 (95% CI 0.34 to 0.75) to receive either revascularization or an ICD.There is racial disparity in long-term mortality among elderly cardiac arrest survivors. Both black and white patients benefited from ICD implantation, but blacks were less likely to undergo this potentially life-saving procedure. Lower rates of cardiac procedures may explain in part the lower survival rates among black patients.

View details for DOI 10.1161/01.CIR.0000079164.95019.5A

View details for Web of Science ID 000184282200012

View details for PubMedID 12835222
Cost-effectiveness of recombinant human activated protein C and the influence of severity of illness in the treatment of patients with severe sepsis Journal of Critical Care RA, F., M, H., C, P., J, S., Sanders, Gillian D., Garber, Alan M. 2003; 18: 181-191
Medical Innovation: Promise and Pitfalls Brookings Review Fuchs, Victor R., Garber, Alan M. 2003
Trends in hospital treatment of ventricular arrhythmias among Medicare beneficiaries, 1985 to 1995 AMERICAN HEART JOURNAL McDonald, K. M., Hlatky, M. A., Saynina, O., Geppert, J., Garber, A. M., McClellan, M. B. 2002; 144 (3): 413-421
Abstract

Treatment options for patients with ventricular arrhythmias have undergone major changes in the last 2 decades. Trends in use of invasive procedures, clinical outcomes, and expenditures have not been well documented.We used administrative databases of Medicare beneficiaries from 1985 to 1995 to identify patients hospitalized with ventricular arrhythmias. We created a longitudinal patient profile by linking the index admission with all earlier and subsequent admissions and with death records.Approximately 85,000 patients aged > or =65 years went to hospitals in the United States with ventricular arrhythmias each year, and about 20,000 lived to admission. From 1987 to 1995, the use of electrophysiology studies and implantable cardioverter defibrillators in patients who were hospitalized grew substantially, from 3% to 22% and from 1% to 13%, respectively. Hospital expenditures rose 8% per year, primarily because of the increased use of invasive procedures. Survival improved, particularly in the medium term, with 1-year survival rates increasing between 1987 and 1994 from 52.9% to 58.3%, or half a percentage point each year.Survival of patients who sustain a ventricular arrhythmia is poor, but improving. For patients who are admitted, more intensive treatment has been accompanied by increased hospital expenditures.

View details for DOI 10.1067/mhj.2002.125498

View details for Web of Science ID 000178086800008

View details for PubMedID 12228777
Perinatal screening for group B streptococci: Cost-benefit analysis of rapid polymerase chain reaction PEDIATRICS Haberland, C. A., Benitz, W. E., Sanders, G. D., Pietzsch, J. B., Yamada, S., Nguyen, L., Garber, A. M. 2002; 110 (3): 471-480
Abstract

To evaluate the costs and benefits of a group B streptococci screening strategy using a new, rapid polymerase chain reaction test in a hypothetical cohort of expectant mothers in the United States.Cost-benefit analysis using the human capital method. We developed a decision model to analyze the costs and benefits of a hypothetical group B streptococci screening strategy using a new, rapid polymerase chain reaction test as compared with the currently recommended group B streptococci screening guidelines-prenatal culture performed at 35 to 37 weeks or risk-factor-based strategy with subsequent intrapartum treatment of the expectant mothers with antibiotics to prevent early-onset group B streptococcal infections in their infants.A hypothetical cohort of pregnant women and their newborns.Screening strategies for group B streptococci using the new polymerase chain reaction technique, the 35- to 37-week culture, or maternal risk factors.Infant infections averted, infant deaths, infant disabilities, costs, and societal benefits of healthy infants.A screening strategy using the new polymerase chain reaction test generates a net benefit of $7 per birth when compared with the maternal risk-factor strategy. For every 1 million births, 80 700 more women would receive antibiotics, 884 fewer infants would become infected with early-onset group B streptococci, and 23 infants would be saved from death or disability. The polymerase chain reaction-based strategy generates a net benefit of $6 per birth when compared with the 35- to 37-week prenatal culture strategy and results in fewer maternal courses of antibiotics (64 080 per million births), fewer perinatal infections with early-onset group B streptococci (218/million), and a reduction in 6 infant deaths and severe infant disability per million births. The benefits hold over a wide range of assumptions regarding key factors in the analysis.Although additional clinical trials are needed to establish the accuracy of this new polymerase chain reaction test, initial studies suggest that strategies using this test will be superior to the other 2 strategies. Using the rapid polymerase chain reaction test becomes less attractive as the cost of the test increases. The test's greatest strengths lie in its ability to identify women and infants at risk at the time of labor, thereby decreasing the number of false-positives and false-negatives seen with the other 2 strategies and allowing for more accurate and effective intrapartum prophylaxis.

View details for PubMedID 12205247
Utilization and outcomes of the implantable cardioverter defibrillator, 1987 to 1995 AMERICAN HEART JOURNAL Hlatky, M. A., Saynina, O., McDonald, K. M., Garber, A. M., McClellan, M. B. 2002; 144 (3): 397-403
Abstract

The patterns of adoption of the implantable cardioverter defibrillator (ICD) and the outcomes of its use have not been well documented in general, unselected populations. The purpose of this study was to document the impact of the ICD in widespread clinical practice.We identified ICD recipients by use of the hospital discharge databases of Medicare beneficiaries for 1987 through 1995 and of California residents for 1991 through 1995. The index admission for each patient was linked to previous and subsequent admissions and to mortality files to create a longitudinal patient profile.The rate of ICD implantations increased >10-fold between 1987 and 1995, as both the number of hospitals performing the procedure and the volume of ICD implantations per hospital rose. Mortality rates within 30 days of ICD implantation decreased from 6.0% to 1.9%, and mortality rates within 1 year fell from 19.3% to 11.4%. Surgical interventions to revise or replace the ICD within the first year remained about 5%, however, and cumulative expenditures at 1 year ($46,000-$51,000) changed very little. ICD implantation rates varied >3-fold among different regions of the United States.ICD use has expanded markedly during the study period, with improved mortality rates, but medical expenditures and rates of surgical revision remain high for ICD recipients.

View details for DOI 10.1067/mhj.2002.125496

View details for Web of Science ID 000178086800006

View details for PubMedID 12228775
Quality of life assessment software for computer-inexperienced older adults: Multimedia utility elicitation for activities of daily living Annual Symposium of the American-Medical-Informatics-Association Goldstein, M. K., Miller, D. E., Davies, S., Garber, A. M. HANLEY & BELFUS INC MED PUBLISHERS. 2002: 295?299
Abstract

Functional status as measured by dependencies in the Activities of Daily Living (ADLs) is an important indicator of overall health for older adults. Methodologies for outcomes-based medical-decision-making for public policy, such as decision modeling and cost-effectiveness analysis, require utilities for outcome health states. Utilities have been reported for many disease states, but have not been indexed by functional status, which is a strong predictor of outcome in geriatrics. We describe here a utility elicitation program developed specifically for use with computer-inexperienced older adults: Functional Limitation And Independence Rating (FLAIR1). FLAIR1 design features address common physical problems of the aged and computer attitudes of inexperienced users that could impede computer acceptance. We interviewed 400 adults ages 65 years and older with FLAIR1. In exit interviews with 154 respondents, 118 (76%) found FLAIR1 easy to use. Design features in FLAIR1 can be applied to other software for older adults

View details for PubMedID 12463834
Trends in Hospital Treatment of Ventricular Arrhythmias among Medicare Beneficiaries, 1985-1995 American Heart Journal McDonald, Kathryn M., Hlatky, Mark A., Saynina, O., Geppert, Jeffrey J., Garber, Alan M., McClellan, Mark B. 2002; 144: 413-421
Proceedings of the American Medical Informatics Association's Annual Symposium 2002 Goldstein, M., Miller, David E., Davies, Sheryl M., Garber, Alan M. American Medical Informatics Association. 2002: 295?299
Perinatal Screening of Group B Streptococci: Cost-Benefit Analysis of Rapid Polymerase Chain Reaction Pediatrics Haberland, C., Benitz, W., Sanders, Gillian D., Pietzsch, J., Yamada, S., Nguyen, L., Garber, Alan M. 2002; 110: 471-480
Utilization and Outcomes of the Implantable Cardioverter Defibrillator: 1987-1995 American Heart Journal Hlatky, Mark A., Saynina, O., McDonald, Kathryn M., Garber, Alan M., McClellan, Mark B. 2002; 144
Cost-effectiveness of automated external defibrillators on airlines JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Groeneveld, P. W., Kwong, J. L., Liu, Y. Y., Rodriguez, A. J., Jones, M. P., Sanders, G. D., Garber, A. M. 2001; 286 (12): 1482-1489
Abstract

Installation of automated external defibrillators (AEDs) on passenger aircraft has been shown to improve survival of cardiac arrest in that setting, but the cost-effectiveness of such measures has not been proven.To examine the costs and effectiveness of several different options for AED deployment in the US commercial air transportation system.Decision and cost-effectiveness analysis of a strategy of full deployment on all aircraft as well as several strategies of partial deployment only on larger aircraft, compared with a baseline strategy of no AEDs on aircraft (but training flight attendants in basic life support) for a hypothetical cohort of persons experiencing cardiac arrest aboard US commercial aircraft. Estimates for costs and outcomes were obtained from the medical literature, the Federal Aviation Administration, the Air Transport Association of America, a population-based cohort of Medicare patients, AED manufacturers, and the Bureau of Labor Statistics.Quality-adjusted survival after cardiac arrest; costs of AED deployment on aircraft and of medical care for cardiac arrest survivors.Adding AEDs on passenger aircraft with more than 200 passengers would cost $35 300 per quality-adjusted life-year (QALY) gained. Additional AEDs on aircraft with capacities between 100 and 200 persons would cost an additional $40 800 per added QALY compared with deployment on large-capacity aircraft only, and full deployment on all passenger aircraft would cost an additional $94 700 per QALY gained compared with limited deployment on aircraft with capacity greater than 100. Sensitivity analyses indicated that the quality of life, annual mortality rate, and the effectiveness of AEDs in improving survival were the most influential factors in the model. In 85% of Monte Carlo simulations, AED placement on large-capacity aircraft produced cost-effectiveness ratios of less than $50 000 per QALY.The cost-effectiveness of placing AEDs on commercial aircraft compares favorably with the cost-effectiveness of widely accepted medical interventions and health policy regulations, but is critically dependent on the passenger capacity of the aircraft. Placing AEDs on most US commercial aircraft would meet conventional standards of cost-effectiveness.

View details for Web of Science ID 000171188600026

View details for PubMedID 11572741
Evidence-based coverage policy HEALTH AFFAIRS Garber, A. M. 2001; 20 (5): 62-82
Abstract

Many health plans apply evidence-based approaches to coverage decisions. The foundation of such approaches is the systematic review of information about the effectiveness of medical interventions. This paper discusses the principles underlying evidence-based coverage policy and how they are applied by two major programs: the Technology Evaluation Center of the Blue Cross Blue Shield Association and the Medicare Coverage Advisory Committee. Although such policies likely have limited effects on spending, they can help to direct medical resources toward effective care.

View details for Web of Science ID 000170862800007

View details for PubMedID 11558722
Current approaches to cervical-cancer screening. NEW ENGLAND JOURNAL OF MEDICINE Sawaya, G. F., Brown, A. D., Washington, A. E., Garber, A. M. 2001; 344 (21): 1603-1607
View details for Web of Science ID 000168829700007
Clinical practice. Current approaches to cervical-cancer screening. New England journal of medicine Sawaya, G. F., Brown, A. D., Washington, A. E., Garber, A. M. 2001; 344 (21): 1603-1607
View details for PubMedID 11372013
Frontiers in Health Policy Research Garber, Alan M. Cambridge, MA: MIT Press. 2001
Trends in the use of intensive procedures at the end of life 4th Frontiers in Health Policy Research Conference Barnato, A. E., Garber, A. M., Kagay, C. R., McClellan, M. C. M I T PRESS. 2001: 95?114
View details for Web of Science ID 000173562100004
Trends in the Use of Intensive Procedures at the End of Life Barnato, A., Garber, Alan M., Kagay, C., McClellan, Mark B. MIT Press In Garber, Alan (ed) "Frontiers in Health Policy Research". 2001
Current Approaches to Cervical Cancer Screening New England Journal of Medicine Sawaya, G., Brown, A., Washington, A., Garber, A. 2001
Issues in Health Care in the US and Japan Garber, Alan M., Ogura, S. University of Chicago Press. 2001
Covering America: Real Remedies for the Uninsured Singer, S., Garber, A., Enthoven, A. Washington DC: Economic and Social Research Institute. 2001: 155?172
Growth in Expenditures for Hospital Care for the Elderly: Cohort and Time Effects MaCurdy, Thomas E., Garber, Alan M. University of Chicago Press In "Issues in Health Care in the U.S. and Japan", Alan Garber and S. Ogura S, ed.. 2001
Cost-Effectiveness of Automated External Defibrillators on US Airlines, The Journal of the American Medical Association Groeneveld, P., Kwong, J., Liu, Y., Rodriguez, A., Jones, M., Sanders, G., Garber, A. 2001; 286: 1482-1489
Cost-effectiveness of androgen suppression therapies in advanced prostate cancer JOURNAL OF THE NATIONAL CANCER INSTITUTE Bayoumi, A. M., Brown, A. D., Garber, A. M. 2000; 92 (21): 1731-1739
Abstract

The costs and side effects of several antiandrogen therapies for advanced prostate cancer differ substantially. We estimated the cost-effectiveness of antiandrogen therapies for advanced prostate cancer.We performed a cost-effectiveness analysis using a Markov model based on a formal meta-analysis and literature review. The base case was assumed to be a 65-year-old man with a clinically evident, local recurrence of prostate cancer. The model used a societal perspective and a time horizon of 20 years. Six androgen suppression strategies were evaluated: diethylstilbestrol (DES), orchiectomy, a nonsteroidal antiandrogen (NSAA), a luteinizing hormone-releasing hormone (LHRH) agonist, and combinations of an NSAA with an LHRH agonist or orchiectomy. Outcome measures were survival, quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios.DES, the least expensive therapy, had a discounted lifetime cost of $3600 and the lowest quality-adjusted survival, 4.6 QALYs. At a cost of $7000, orchiectomy was associated with 5.1 QALYs, resulting in an incremental cost-effectiveness ratio of $7500/QALY relative to DES. All other strategies-LHRH agonists, NSAA, and both combined androgen blockade strategies-had higher costs and lower quality-adjusted survival than orchiectomy. These results were sensitive to the quality of life associated with orchiectomy and the efficacy of combined androgen blockade, and they changed little when prostate-specific antigen results were used to guide therapy. Under a wide range of other assumptions, the cost-effectiveness of orchiectomy relative to DES was consistently less than $20 000/QALY. Androgen suppression therapies were most cost-effective if initiated after patients became symptomatic from prostate metastases.For men who accept it, orchiectomy is likely to be the most cost-effective androgen suppression strategy. Combined androgen blockade is the least economically attractive option, yielding small health benefits at high relative costs.

View details for Web of Science ID 000090110800010

View details for PubMedID 11058616
A cost-effectiveness analysis of prescribing strategies in the management of gastroesophageal reflux disease AMERICAN JOURNAL OF GASTROENTEROLOGY Gerson, L. B., Robbins, A. S., Garber, A., Hornberger, J., Triadafilopoulos, G. 2000; 95 (2): 395-407
Abstract

Patients who have uncomplicated gastroesophageal-reflux disease (GERD) typically present with heartburn and acid regurgitation. We sought to determine the cost-effectiveness of H2-receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs) as first-line empiric therapy for patients with typical symptoms of GERD.Decision analysis comparing costs and benefits of empirical treatment with H2RAs and PPIs for patients presenting with typical GERD was employed. The six treatment arms in the model were: 1) Lifestyle therapy, including antacids; 2) H2RA therapy, with endoscopy performed if no response to H2RAs; 3) Step up (H2RA-PPI) Arm: H2RA followed by PPI therapy in the case of symptomatic failure; 4) Step down arm: PPI therapy followed by H2RA if symptomatic response to PPI, and antacid therapy if response to H2RA therapy; 5) PPI-on-demand therapy: 8 wk of treatment for symptomatic recurrence, with no more than three courses per year; and 6) PPI-continuous therapy. Measurements were lifetime costs, quality-adjusted life years (QALYs) gained, and incremental cost effectiveness.Initial therapy with PPIs followed by on-demand therapy was the most cost-effective approach, with a cost-effectiveness ratio of $20,934 per QALY gained for patients with moderate to severe GERD symptoms, and $37,923 for patients with mild GERD symptoms. This therapy was also associated with the greatest gain in discounted QALYs. The PPI-on-demand strategy was more effective and less costly than the H2RA followed by PPI strategy or the other treatment arms. The results were not highly sensitive to cost of therapy, QALY adjustment from GERD symptoms, or the success rate of the lifestyle arm. However, when the success rate of the PPI-on-demand arm was < or =59%, the H2RA-PPI arm was the preferred strategy.For patients with moderate to severe symptoms of GERD, initial treatment with PPIs followed by on-demand therapy is a cost-effective approach.

View details for Web of Science ID 000085334200019

View details for PubMedID 10685741
Using Cost-Effectiveness Analysis to Target Cholesterol Reduction Annals of Internal Medicine Garber, Alan M. 2000; 132: 1731-9
A concise review of the cost-effectiveness of coronary heart disease prevention MEDICAL CLINICS OF NORTH AMERICA Brown, A. I., Garber, A. M. 2000; 84 (1): 279-?
Abstract

Coronary heart disease is one of the largest sources of morbidity, mortality, and health care expenditure in the United States. This article reviews a number of studies that estimate the cost per unit of health benefits associated with different primary and secondary prevention strategies for coronary heart disease. Although prevention does not provide a panacea for rising health care spending, many preventive strategies are cost-effective when compared to other common clinical interventions. Prevention should be incorporated into regular clinical practice.

View details for Web of Science ID 000085136500017

View details for PubMedID 10685140
Medical Clinics of North America Brown, A.D., Garber, Alan M. 2000; 84: 279-297
Medical Informatics, Computer Application in Health Care, Second Edition Singer, Sara J., Enthoven, Alain C., Garber, Alan M. Springer-Verlag. 2000: 663?696
Cost-Effectiveness of Androgen Suppression Strategies in Advanced Prostate Cancer J Natl Cancer Inst Bayoumi, A.M., Brown, A.D., Garber, Alan M. 2000; 92: 397-403
Advances in Cost-Effectiveness Analysis of Health Interventions Garber, Alan M., Culyer, A., Newhouse, J. North-Holland, in "Handbook of Health Economics". 2000: 181?221
Cost-Effectiveness Analysis of Prescribing Strategies in Managing Gastroesophageal Reflux Disease, A American Journal of Gastroenterology Gerson, L., Robbins, A., Garber, A., Hornberger, J., Triadafilopoulos, G. 2000; 95: 833-835
Comments - Realistic rigor in cost-effectiveness methods MEDICAL DECISION MAKING Garber, A. M. 1999; 19 (4): 378-379
View details for Web of Science ID 000083056100002

View details for PubMedID 10520673
Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis - A cost-effectiveness analysis ANNALS OF INTERNAL MEDICINE Gould, M. K., Dembitzer, A. D., Sanders, G. D., Garber, A. M. 1999; 130 (10): 789-?
Abstract

Low-molecular-weight heparins are effective for treating venous thrombosis, but their cost-effectiveness has not been rigorously assessed.To evaluate the cost-effectiveness of low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis.Decision model.Probabilities for clinical outcomes were obtained from a meta-analysis of randomized trials. Cost estimates were derived from Medicare reimbursement and other sources.Two hypothetical cohorts of 60-year-old men with acute deep venous thrombosis.Patient lifetime.Societal.Fixed-dose low-molecular-weight heparin or adjusted-dose unfractionated heparin.Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. An in-patient hospital setting was used for the base-case analysis. Secondary analyses examined outpatient treatment with low-molecular-weight heparin.Total costs for inpatient treatment were $26,516 for low-molecular-weight heparin and $26,361 for unfractionated heparin. The cost of initial care was higher in patients who received low-molecular-weight heparin, but this was partly offset by reduced costs for early complications. Low-molecular-weight heparin treatment increased quality-adjusted life expectancy by approximately 0.02 years. The incremental cost-effectiveness of inpatient low-molecular-weight heparin treatment was $7820 per QALY gained. Treatment with low-molecular-weight heparin was cost saving when as few as 8% of patients were treated at home.When late complications were assumed to occur 25% less frequently in patients who received unfractionated heparin, the incremental cost-effectiveness ratio increased to almost $75,000 per QALY gained. When late complications were assumed to occur 25% less frequently in patients who received low-molecular-weight heparin, this treatment resulted in a net cost savings. Inpatient low-molecular-weight heparin treatment became cost saving when its pharmacy cost was reduced by 31% or more, when it reduced the yearly incidence of late complications by at least 7%, when as few as 8% of patients were treated entirely as outpatients, or when at least 13% of patients were eligible for early discharge.Low-molecular-weight heparins are highly cost-effective for inpatient management of venous thrombosis. This treatment reduces costs when small numbers of patients are eligible for outpatient management.

View details for Web of Science ID 000080305000001

View details for PubMedID 10366368
Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis - A meta-analysis of randomized, controlled trials ANNALS OF INTERNAL MEDICINE Gould, M. K., Dembitzer, A. D., Doyle, R. L., Hastie, T. J., Garber, A. M. 1999; 130 (10): 800-?
Abstract

Low-molecular-weight heparins may simplify the management of deep venous thrombosis. A critical clinical issue is whether this more convenient therapy is as safe and effective as treatment with unfractionated heparin.To compare the safety and efficacy of low-molecular-weight heparins with those of unfractionated heparin for treatment of acute deep venous thrombosis.Reviewers identified studies by searching MEDLINE, reviewing references from retrieved articles, scanning abstracts from conference proceedings, and contacting investigators and pharmaceutical companies.Randomized, controlled trials that compared a low-molecular-weight heparin preparation with unfractionated heparin for treatment of acute deep venous thrombosis.Two reviewers extracted data independently. Reviewers evaluated study quality using a validated four-item instrument.Eleven of 37 studies met inclusion criteria for three major outcomes. Most studies used proper randomization procedures, but only one was double-blinded. Compared with unfractionated heparin, low-molecular-weight heparins reduced mortality rates over 3 to 6 months of patient follow-up (odds ratio, 0.71 [95% CI, 0.53 to 0.94]; P = 0.02). For major bleeding complications, the odds ratio favored low-molecular-weight heparins (0.57 [CI, 0.33 to 0.99]; P = 0.047), but the absolute risk reduction was small and not statistically significant (0.61% [CI, -0.04% to 1.26%]; P = 0.07). For preventing thromboembolic recurrences, low-molecular-weight heparins seemed as effective as unfractionated heparin (odds ratio, 0.85 [CI, 0.63 to 1.14]; P > 0.2).Low-molecular-weight heparin treatment reduces mortality rates after acute deep venous thrombosis. These drugs seem to be as safe as unfractionated heparin with respect to major bleeding complications and appear to be as effective in preventing thromboembolic recurrences.

View details for Web of Science ID 000080305000002

View details for PubMedID 10366369
Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease ANNALS OF INTERNAL MEDICINE Garber, A. M., Solomon, N. A. 1999; 130 (9): 719-?
Abstract

The appropriate roles for several diagnostic tests for coronary disease are uncertain.To evaluate the cost-effectiveness of alternative approaches to diagnosis of coronary disease.Meta-analysis of the accuracy of alternative diagnostic tests plus decision analysis to assess the health outcomes and costs of alternative diagnostic strategies for patients at intermediate pretest risk for coronary disease.Studies of test accuracy that met inclusion criteria; published information on treatment effectiveness and disease prevalence.Men and women 45, 55, and 65 years of age with a 25% to 75% pretest risk for coronary disease.30 years.Societal.Diagnostic strategies were initial angiography and initial testing with one of five noninvasive tests--exercise treadmill testing, planar thallium imaging, single-photon emission computed tomography (SPECT), stress echocardiography, and positron emission tomography (PET)--followed by coronary angiography if noninvasive test results were positive. Testing was followed by observation, medical treatment, or revascularization.Life-years, quality-adjusted life-years (QALYs), costs, and costs per QALY.Life expectancy varied little with the initial diagnostic test; for a 55-year-old man, the best-performing test increased life expectancy by 7 more days than the worst-performing test. More sensitive tests increased QALYs more. Echocardiography improved health outcomes and reduced costs relative to stress testing and planar thallium imaging. The incremental cost-effectiveness ratio was $75,000/QALY for SPECT relative to echocardiography and was greater than $640,000 for PET relative to SPECT. Compared with SPECT, immediate angiography had an incremental cost-effectiveness ratio of $94,000/QALY.Qualitative findings varied little with age, sex, pretest probability of disease, or the test indeterminancy rate. Results varied most with sensitivity to severe coronary disease.Echocardiography, SPECT, and immediate angiography are cost-effective alternatives to PET and other diagnostic approaches. Test selection should reflect local variation in test accuracy.

View details for Web of Science ID 000080062300002

View details for PubMedID 10357690
Cost-effectiveness of 3 methods to enhance the sensitivity of Papanicolaou testing JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Brown, A. D., Garber, A. M. 1999; 281 (4): 347-353
Abstract

ThinPrep, AutoPap, and Papnet are 3 new technologies that increase the sensitivity and cost of cervical cancer screening.To estimate the cost-effectiveness of these technological enhancements to Papanicolaou (Pap) tests.We estimated the increase in sensitivity from using these technologies by combining results of 8 studies meeting defined criteria. We used published literature and additional sources for cost estimates. To estimate overall cost-effectiveness, we applied a 9-state time-varying transition state model to these data and information about specific populations.A hypothetical program serving a cohort of 20- to 65-year-old women who begin screening at the same age and are representative of the US population.The new technologies increased life expectancy by 5 hours to 1.6 days, varying with the technology and the frequency of screening. All 3 technologies also increased the cost per woman screened by $30 to $257 (1996 US dollars). AutoPap dominated ThinPrep in the base case. At each screening interval, AutoPap increased survival at the lowest cost. The cost per year of life saved rose from $7777 with quadrennial screening to $166000 with annual screening. Papnet produced more life-years at a higher cost per year of life saved. However, when used with triennial screening, each of them produced more life-years at lower cost than conventional Pap testing every 2 years. The cost-effectiveness ratio of each technology improved with increases in the prevalence of disease, decreases in the sensitivity of conventional Pap testing, and increases in the improvement in sensitivity produced by the technology.Technologies to increase the sensitivity of Pap testing are more cost-effective when incorporated into infrequent screening. Increases in sensitivity and decreases in cost may eventually make each technology more cost-effective.

View details for Web of Science ID 000078111300034

View details for PubMedID 9929088
Realistic Rigor in Cost-Effectiveness Methods Medical Decision Making Garber, Alan M. 1999; 19: 378-379
Aspects of Hypertension Management Brown, A.D., Garber, Alan M. Adis International Limited. 1999: 85?106
Low Molecular Weight Heparins Compared with Unfractionated Heparin for the Treatment of Acute Deep Vein Thrombosis: A Cost-Effectiveness Analysis Annals of Internal Medicine Gould, Michael K., Dembitzer, A., Sanders, Gillian D., Garber, Alan M. 1999; 130: 789-99
Cost-Effectiveness of Alternative Test Strategies for the Diagnosis of Coronary Artery Disease Annals of Internal Medicine Garber, Alan M., Solomon, N.A. 1999; 130: 719-728
Frontiers in Health Policy Research Garber, Alan M., MaCurdy, Thomas E., McClellan, Mark B. MIT Press. 1999
Cost-Effectiveness of Three Methods to Enhance the Sensitivity of Papanicolaou Testing Journal of the American Medical Association Brown, A., Garber, A. 1999; 281: 347-353
Cost-effectiveness and cost-benefit analysis of using methotrexate vs Goeckerman therapy for psoriasis - A pilot study ARCHIVES OF DERMATOLOGY Chen, S., Shaheen, A., Garber, A. 1998; 134 (12): 1602-1608
Abstract

To analyze the net benefit and cost-effectiveness of methotrexate use and Goeckerman therapy for psoriasis.Net benefit and cost-effectiveness depend on the costs, efficacy, and utilities of therapy. Utilities are quantitative measures of patient preferences. We obtained costs by using resource-based accounting techniques. Efficacy was estimated from literature reports. We surveyed patients with psoriasis, dermatologists, and healthy subjects using utility assessment methods. All assumptions were examined in a sensitivity analysis.For net benefit, if benefits out-weighed the costs, it was deemed worth providing. For the cost-effectiveness analysis, the ratio of costs-to-effectiveness of less than $35,000 was considered cost-effective.Using utilities from healthy nonexperts, the costs of both therapies exceeded the benefits in mild and moderate psoriasis. In severe psoriasis, only methotrexate demonstrates a net benefit. Both therapies were cost-effective compared with no therapy. Liquid methotrexate should be chosen over the tablet form since it was cheaper and had the same outcome. Goeckerman was cost-effective against liquid methotrexate in severe, but not mild or moderate psoriasis. There was a trend for therapies to be more cost-effective when using patient utilities and less with dermatologist utilities. The results were highly sensitive to efficacy and utilities.The results of this study need to be confirmed in other settings, but they demonstrate that the tools of cost-effectiveness and cost-benefit analysis have great potential value in dermatology. Once efficacy is better characterized and utilities better quantified, these types of analyses will be crucial for health care policy.

View details for Web of Science ID 000077622100017

View details for PubMedID 9875201
Cost effectiveness of coronary heart disease prevention strategies in adults PHARMACOECONOMICS Brown, A. D., Garber, A. M. 1998; 14 (1): 27-48
Abstract

Although risk-factor modification has gained wide acceptance as an effective approach to the prevention of coronary heart disease (CHD), health planners, physicians and patients confront considerable uncertainty over the most appropriate and efficient preventive strategies. Some preventive approaches are both inexpensive and effective; others are expensive while their effectiveness is slight or unproven. Effectiveness varies with an individual's age, gender and other risk factors. Information provided by a cost-effectiveness analysis can clarify the value of alternative strategies for CHD prevention in specific populations, thereby helping to choose among them. It does so by producing a standard measure of value--the cost per year of life saved (YLS) or cost per quality-adjusted life-year (QALY) saved--that reveals which of several alternative interventions provides the greatest health benefit from a given expenditure. This article summarises the extensive literature on the cost effectiveness of CHD prevention with an emphasis on primary prevention. Published work indicates that smoking-cessation programmes, particularly those that rely on counselling with or without nicotine supplements, are highly cost effective in many settings. Although the evidence is limited, exercise programmes also appear to be cost effective. The detection and treatment of hypertension is highly cost effective, particularly when inexpensive drugs with proven effectiveness, such as diuretics or beta-blockers, are used. Hormone-replacement therapy is a cost-effective approach to CHD prevention in most postmenopausal women, although direct clinical trial data are lacking and it is uncertain which hormone preparation is best. Cholesterol reduction is a cost-effective strategy for the prevention of CHD in individuals without other treatable risk factors who are at very high risk of developing CHD. For individuals with multiple CHD risk factors, the choice of risk-modification strategies is complex and depends upon the interactions of risk and the relative costs of treating each risk.

View details for Web of Science ID 000074792200004

View details for PubMedID 10182193
Persistence of Medicare expenditures among elderly beneficiaries Frontiers in Health Policy Research I, MIT Press Garber AM, MaCurdy TE, McClellan MA. 1998
Diagnosis and Medicare expenditures at the end of life Conference on Frontiers in the Economics of Aging Garber, A. M., MaCurdy, T., McClellan, M. UNIV CHICAGO PRESS. 1998: 247?273
View details for Web of Science ID 000078443200010
Persistence of Medicare expenditures among elderly beneficiaries Conference on Frontiers in Health Policy Research Garber, A. M., MACURDY, T. E., McClellan, M. B. M I T PRESS. 1998: 153?180
View details for Web of Science ID 000076033100005
Frontiers in Health Policy Research Garber, Alan M., MaCurdy, T., McClellan, Mark B. MIT Press. 1998: 739?740
Frontiers in the Economics of Aging McClellan, Mark B., Garber, Alan M., MaCurdy, Thomas E. University of Chicago Press. 1998
Effect of Search Procedures on Utility Elicitations Medical Decision Making Lenert, L., Cher, D., Goldstein, M., Bergen, M., Garber, A. 1998; 18: 915-920
Cost-Effectiveness and Cost Benefit Analysis of Using Methotrexate Vs. Goeckerman Therapy for Psoriasis Archives of Dermatology Chen, S., Shaheen, A., Garber, A. 1998; 134: 1602-1608
The Effect of Search Procedures on Utility Elicitations Medical Decision Making Lenert, L.A., Cher, D.J., Goldstein, M., Bergen, M., Garber, A. 1998; 18
Inquiries in the Economics of Aging Bhattacharya, J., Garber, Alan M., MaCurdy, T. University of Chicago Press. 1998: 311?324
The effect of search procedures on utility elicitations 18th Annual Meeting of the Society-for-Medical-Decision-Making Lenert, L. A., Cher, D. J., Goldstein, M. K., Bergen, M. R., Garber, A. SAGE PUBLICATIONS INC. 1998: 76?83
Abstract

Elicited preferences for health states vary among scaling methods, manners of describing health states, and other features of the elicitation process. The authors examined the effects of changing the search procedure for a subject's utility on mean utility values.A randomized controlled trial of two search procedures (titration and "ping-pong") using two otherwise identical computer programs that describe health states related to Gaucher's disease, then measuring subjects' preferences.Paid, healthy volunteers recruited from the community through advertisements.The mean time tradeoff (TTO) and standard gamble (SG) utility values for life with severe anemia and splenomegaly and life with chronic bone pain from Gaucher's disease were between 0.10 and 0.15 higher with the titration search procedure than with the ping-pong procedure. Effects of the search procedure were additive with variability due to scaling methods, resulting in mean differences in utility ratings for the same health state of as much as 0.28 among procedures and scaling methods. Effects of search procedures on utility values persisted on repeated testing at week 2 and week 3; there was no evidence of convergence to a single "true" utility value over time.The procedure used to search for subjects' utility values strongly influences the results of preference-assessment experiments. Effects of search procedures persist on repeated testing. The results suggest that utility values are heavily influenced by, if not created during, the process of elicitation. Thus, utility values elicited using different search procedures may not be directly comparable.

View details for Web of Science ID 000071405300015

View details for PubMedID 9456212
Measurement of the validity of utility elicitations performed by computerized interview MEDICAL CARE Lenert, L. A., Morss, S., Goldstein, M. K., Bergen, M. R., Faustman, W. O., Garber, A. M. 1997; 35 (9): 915-920
Abstract

The authors evaluate a measure of the validity of utility elicitations and study the potential effects of invalid elicitations on population utility values.The authors used a computerized survey to describe and measure preferences for three common side-effects of anti-psychotic drugs (tardive dyskinesia [TD], akathesia [AKA], pseudo-parkinsonism). The authors compared the validity of elicitations in 41 healthy volunteers to 22 schizophrenic patients. Preferences were measured using visual analog scale (VAS), pair-wise comparison (PWC), and the Standard Gamble (SG) methods. To assess the validity of each groups' responses, the authors compared the consistency of subjects' rank-order of the desirability of states across methods of preferences assessment (CAMPA).All healthy volunteers and 82% of patients completed the computer survey; of these subjects, 97% of healthy volunteers and 70% of patients indicated they thought they understood the task required of them. However, only 78% of healthy subjects and 44% of patients had a consistent rank ordering of preferences among VAS and PWC ratings; only 80% and 61%, respectively, had a consistent rank ordering preferences among SG and PWC ratings. For two of the three health states, inconsistent subjects had statistically higher SG utilities (for TD, 0.94 versus 0.87, and for AKA 0.92 versus 0.86; P < 0.05).The CAMPA test can identify potentially invalid preference ratings. Potentially invalid preference ratings may bias the "population" utilities for health states.

View details for PubMedID 9298080
Mortality, hospital admissions, and medical costs of end-stage renal disease in the United States and Manitoba, Canada MEDICAL CARE Hornberger, J. C., Garber, A. M., Jeffery, J. R. 1997; 35 (7): 686-700
Abstract

National registry data suggest that mortality rates among patients with end-stage renal disease are lower in Canada than in the United States. Casemix and treatment variables, although limited in such instances, do not explain this difference. Using a more complete set of casemix and treatment variables from clinical databases, this study assesses mortality, hospital admission, and the cost of medical care for patients with end-stage renal disease treated in Manitoba, Canada and the United States.Mortality rates were compared in patients with end-stage renal disease treated in the Province of Manitoba and a random sample of US patients enrolled in the US Renal Data System Casemix Severity Study. Hospital admission rates and costs of care were compared in Manitoba patients and in patients with end-stage renal disease in a large health care organization in Detroit, Michigan.Levels of serum creatinine, urea, and estimated glomerular filtration rate indicated more severe renal impairment at the outset of treatment in Manitoba than in the United States. Manitoba patients were more than twice as likely to receive kidney transplants as US Renal Data System patients. No patients in Manitoba used reprocessed dialyzers, compared with 57% of US Renal Data System patients. After adjustment for all casemix and treatment variables, the mortality rate was 47% higher in the United States. The hospital admission rate in Detroit was 41% lower than the hospital admission rate in Manitoba, which primarily reflects the doubled rate of transplantation in Manitoba. Adjusted total monthly costs were $503 higher in Detroit than in Manitoba.The higher mortality rates in the United States cannot be fully explained by adjustments for observable casemix or treatment variables. Further research is needed to identify factors that explain how Manitoba achieves a lower mortality rate while paying less for end-stage renal disease care than the United States.

View details for Web of Science ID A1997XJ68400003

View details for PubMedID 9219496
Polymerase chain reaction for diagnosis of HIV infection - Response ANNALS OF INTERNAL MEDICINE Owens, D. K., Holodniy, M., Garber, A. M. 1997; 126 (9): 740-740
View details for Web of Science ID A1997WW14700016
Cholesterol screening guidelines - Consensus, evidence, and common sense CIRCULATION Garber, A. M., Browner, W. S. 1997; 95 (6): 1642-1645
View details for Web of Science ID A1997WN57700042

View details for PubMedID 9118535
The effect of assessment method and respondent population on utilities elicited for Gaucher Disease Annual Meeting of the Society-for-Medical-Decision-Making Clarke, A. E., Goldstein, M. K., Michelson, D., Garber, A. M., Lenert, L. A. RAPID SCIENCE PUBLISHERS. 1997: 169?84
Abstract

Measured preferences have been reported to vary with the method of elicitation and respondent population surveyed. We elicited utilities for Gaucher disease using a multimedia implementation of the time trade-off, standard gamble, and a conceptually different, largely untested approach, the risk-risk trade-off, from those who are healthy, those with a chronic illness and those with Gaucher disease. The risk-risk trade-off produced significantly lower utilities than the other two preference assessment methods and had the poorest test-retest reliability. The respondent's self-rated current health state utility was the most important determinant of utility values elicited by the time trade-off and standard gamble for the hypothetical health states. Our results do not support the use of our implementation of the risk-risk trade-off method. In eliciting preferences for hypothetical health states from the general population, the subjective rating of a respondent's own health state should be considered in determining representative population groups.

View details for Web of Science ID A1997WW41600009

View details for PubMedID 9161117
Cost-effectiveness of screening for carotid stenosis in asymptomatic persons Society-of-General-Internal-Medicine Meeting Lee, T. T., Solomon, N. A., Heidenreich, P. A., Oehlert, J., Garber, A. M. AMER COLL PHYSICIANS. 1997: 337-?
Abstract

The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented.To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention.Cost-effectiveness analysis using published data from clinical trials.General population of asymptomatic 65-year-old men.Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done.Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios.When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found).Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.

View details for Web of Science ID A1997WL10400001

View details for PubMedID 9054277
Cholesterol screening should be targeted. American journal of medicine Garber, A. M. 1997; 102 (2A): 26-30
Abstract

For primary prevention of coronary heart disease (CHD), the American College of Physicians (ACP) has recommended that initial cholesterol screening be targeted to people who have other risk factors in addition to elevated cholesterol. This would include those with symptoms of heart disease, asymptomatic men 35-65 years old and women 45-65 years old, or younger people who have > or = 2 risk factors or who might benefit from treatment for high blood cholesterol. After the age of 75, cholesterol is no longer a risk factor, so there is no rationale for testing. In primary prevention, lipoprotein fractionation should be performed in men and women who have been identified as having elevated blood cholesterol levels, not as part of initial testing. In secondary prevention, some studies indicate that cholesterol reduction may be beneficial after age 65. In asymptomatic younger people without other risk factors, the low prevalence of CHD and rapid response to cholesterol reduction once it is initiated suggest that early screening and treatment are unnecessary. Everyone should adopt the lifestyle modifications conducive to cardiovascular health, but the ACP believes that, for primary prevention, universal screening is neither cost effective nor the best use of the patient's and physician's time.

View details for PubMedID 9217583
Economic foundations of cost-effectiveness analysis JOURNAL OF HEALTH ECONOMICS Garber, A. M., Phelps, C. E. 1997; 16 (1): 1-31
Abstract

To address controversies in the applications of cost-effectiveness analysis, we investigate the principles underlying the technique and discuss the implications for the evaluation of medical interventions. Using a standard von Neumann-Morgenstern utility framework, we show how a cost-effectiveness criterion can be derived to guide resource allocation decisions, and how it varies with age, gender, income level, and risk aversion. Although cost-effectiveness analysis can be a useful and powerful tool for resource allocation decisions, a uniform cost-effectiveness criterion that is applied to a heterogeneous population level is unlikely to yield Pareto-optimal resource allocations.

View details for Web of Science ID A1997WX30700001

View details for PubMedID 10167341
Health care productivity. Brookings Papers on Economic Activity Microeconomics Garber AM., Baily MN 1997: 143-202,
Productivity Costs, Time Costs and Health-Related Quality of Life: A Response to the Erasmus Group Health Economics Weinstein, M.C., Siegel, J.E., Garber, A., Lipscomb, J., Luce, B.R., Manning, W.G., Torrance, G.W. 1997; 6: 505-510
Cost-Effectiveness of Screening for Carotid Stenosis in Asymptomatic Individuals Annals of Internal Medicine Lee, T., Solomon, N., Heidenreich, P., Oehlert, J., Garber, A. 1997; 126: 337-46
Cholesterol Screening Should Be Targeted American Journal of Medicine Garber, Alan M. 1997; 102(2A): 26-30
Measurement of the Validity of Utility Elicitations Performed by Computerized Interview Medical Care Lenert, L., Morss, S., Bergen, M., Goldstein, M., Faustman, W., Garber, A. 1997; 35: 169-184
Cholesterol Screening Guidelines: Consensus, Evidence, and Common Sense Circulation Garber, Alan M., Browner, W.S. 1997; 95: 1642-1645
Polymerase Chain Reaction for the Diagnosis of HIV Infection in Adults Annals of Internal Medicine Owens, Douglas K., Holodniy, M., Garber, Alan M. 1997; 126: 1020-1030
Effect of Assessment Method and Respondent Population on Utilities Elicited for Gaucher Disease, The Quality of Life Research Clarke, A., Goldstein, M., Michelson, D., Garber, A., Lenert, L. 1997; 6
Willingness-to-pay utility assessment: Feasibility of use in normative patient decision support systems JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Flowers, C. R., Garber, A. M., Bergen, M. R., Lenert, L. A. 1997: 223-227
Abstract

The authors developed an automated patient interviewing tool to elicit individuals' willingness-to-pay (WTP) utilities under conditions of uncertainty and examined the reliability of this method and its potential usefulness in clinical decision support. We tested this method in 52 healthy volunteers using a computer-based interview that trained subjects in standard gamble (SG) and WTP methods, and elicited preferences for moderate Gaucher disease using WTP and SG. We assessed the validity of the WTP method by calculating the cost-effectiveness threshold implied by subjects' WTP and SG utilities; we also assessed subjects' understanding and comfort with using WTP for decision making by a questionnaire. The WTP method had good test-retest reliability (r = 0.796), and produced a cost-effectiveness ratio and ratings for understanding and clarity that support its validity. Moreover, many subjects felt that WTP was a reasonable (83%) method for therapeutic decision making and expressed comfort (62%) in using the method for their own health care decisions. These results suggest that a probabilistic method for WTP utility assessment is potentially useful for acquiring patient preferences for use in normative decision support systems.

View details for Web of Science ID 000171774300046

View details for PubMedID 9357621
Evaluating the federal role in financing health-related research Colloquium on Science, Technology, and the Economy Garber, A. M., Romer, P. M. NATL ACAD SCIENCES. 1996: 12717?24
Abstract

This paper considers the appropriate role for government in the support of scientific and technological progress in health care; the information the federal government needs to make well-informed decisions about its role; and the ways that federal policy toward research and development should respond to scientific advances, technology trends, and changes in the political and social environment. The principal justification for government support of research rests upon economic characteristics that lead private markets to provide inappropriate levels of research support or to supply inappropriate quantities of the products that result from research. The federal government has two basic tools for dealing with these problems: direct subsidies for research and strengthened property rights that can increase the revenues that companies receive for the products that result from research. In the coming years, the delivery system for health care will continue to undergo dramatic changes, new research opportunities will emerge at a rapid pace, and the pressure to limit discretionary federal spending will intensify. These forces make it increasingly important to improve the measurement of the costs and benefits of research and to recognize the tradeoffs among alternative policies for promoting innovation in health care.

View details for Web of Science ID A1996VT05400010

View details for PubMedID 8917484
The cost of VA-sponsored research ACADEMIC MEDICINE Barnett, P. G., Garber, A. M. 1996; 71 (10): 1074-1078
Abstract

Under pressures to reduce health care costs, clinical income is a shrinking source of support for research. Such pressures also threaten research at the medical centers of the Department of Veterans Affairs (VA). VA research is particularly vulnerable because medical care appropriations constitute a large, though unknown, source of support. This study measures the medical care component and the total of VA research funds.The incremental costs of VA research were estimated from a survey of 497 clinician investigators and data on payroll, facility costs, and research grants and appropriations.The incremental costs of VA research totaled $541.4 million in the 1992-93 fiscal year. This included $245.6 million in federal appropriations for VA research, $33.1 million in research grants administered by the VA, and $262.8 million in support from other VA appropriations. Research added as much as $219.8 million to VA patient care costs.The VA is adopting strategies to increase the internal payoff of its research. The fiscal constraints facing VA and other academic medical centers mean that they will be able to support research with their own funds only when it benefits them directly.

View details for Web of Science ID A1996VN42600021

View details for PubMedID 9177641
Polymerase chain reaction for the diagnosis of HIV infection in adults - A meta-analysis with recommendations for clinical practice and study design ANNALS OF INTERNAL MEDICINE Owens, D. K., Holodniy, M., Garber, A. M., Scott, J., Sonnad, S., Moses, L., Kinosian, B., Schwartz, J. S. 1996; 124 (9): 803-?
Abstract

To do a meta-analysis of studies that have evaluated the sensitivity and specificity of polymerase chain reaction (PCR) assay for the diagnosis of human immunodeficiency virus (HIV) infection in adults. Evaluating the performance of PCR is difficult because in certain clinical situations, the sensitivity or specificity of PCR may exceed those of the current reference standard tests (enzyme immunoassay followed by confirmatory Western blot analysis). Therefore, an additional goal was to develop recommendations for 1) the design of future evaluative studies of PCR and 2) the use of PCR in persons with suspected HIV infection.Studies published between 1988 and 1994 that were identified in a search of 17 computer databases, including MEDLINE, and abstracts identified from conference proceedings.Studies were included if DNA amplification by PCR was done on peripheral blood mononuclear cells from adults. Ninety-six studies met the inclusion criteria.Data were extracted independently by two reviewers. Study design was assessed independently by two investigators blinded to study results.Reported sensitivities for PCR range from 10% to 100%, and specificities range from 40% to 100%. A summary receiver-operating characteristic curve based on all 96 studies has a maximum joint sensitivity and specificity (upper left point on the curve, where sensitivity equals specificity) of 97.0% to 98.1%. If the threshold value that defines a positive PCR result is chosen so that sensitivity is higher than 98.1%, specificity will decrease to less than 98.1%. Conversely, if the threshold value that defines a positive PCR result is chosen so that specificity is greater than 98.1%, sensitivity will decrease to less than 98.1%. If sensitivity and specificity are chosen to be equal, the corresponding false-positive rate is 1.9% to 3.0%. At the maximum joint sensitivity and specificity, the positive predictive value of PCR ranges from 34% to 85% as the prevalence of HIV increases from 1.0% to 10%. We identified seven areas in which study design could be modified to 1) reduce susceptibility to bias in estimates of the sensitivity and specificity of PCR and 2) to increase the generalizability of the study results. These modifications will also help to overcome methodologic problems created by the lack of a reference standard test.The PCR assay is not sufficiently accurate to be used for the diagnosis of HIV infection without confirmation. Use of PCR for the diagnosis of HIV in adults should be limited to situations in which antibody tests are known to be insufficient. Future studies of PCR performance should be sufficiently large and should use adequate reference standard tests and standardized methods for the performance of PCR. Specimens should be evaluated by persons blinded to clinical status and to the results of other diagnostic tests for HIV infection.

View details for Web of Science ID A1996UG25400004

View details for PubMedID 8610949
27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 6. Cost effectiveness of assessment and management of risk factors. Journal of the American College of Cardiology Goldman, L., Garber, A. M., Grover, S. A., Hlatky, M. A. 1996; 27 (5): 1020-1030
View details for PubMedID 8609317
Task force 6. Cost effectiveness of assessment and management of risk factors JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Goldman, L., Garber, A. M., Grover, S. A., Hlatky, M. A. 1996; 27 (5): 1020-1030
View details for Web of Science ID A1996UD65100007
Cholesterol screening in asymptomatic adults, revisited ANNALS OF INTERNAL MEDICINE Garber, A. M., Browner, W. S., Hulley, S. B. 1996; 124 (5): 518-531
Abstract

To assess the role of serum lipid levels as screening tests in adults.Pooled analysis of clinical trials, supplemented by analysis of data from the Framingham Heart Study, to estimate the effect of cholesterol reduction in patient groups stratified by cardiac risk.Published randomized controlled trials of cholesterol reduction, meta-analyses of such trials, prospective cohort studies of the association between cholesterol levels and morbidity and death related to coronary heart disease, and cost-effectiveness analyses of cholesterol reduction.Two-stage logistic regression on cardiac risk factors and outcomes in the Framingham Heart Study. The first stage predicted the risk for death from coronary heart disease using standard risk factors but not cholesterol; the second stage predicted the risk for death from coronary heart disease and all causes as functions of age and cholesterol level, stratified by the risk predicted from the first stage.Randomized clinical trials show that cholesterol reduction confers survival benefits in patients with symptomatic coronary disease. In asymptomatic middle-aged men, who are at lower risk for death from coronary disease, cholesterol reduction prevents coronary disease but has not been shown to prolong life. The risk model based on analysis of the data from the Framingham Heart Study is consistent with the randomized trial data and shows that in the demographic groups excluded from trials, the hypothetical benefits of cholesterol reduction are greatest when the underlying risk for coronary disease is greatest.Screening with total cholesterol levels is most likely to be useful when done in populations at high short-term risk for dying of coronary heart disease, such as survivors of myocardial infarction and middle-aged men with multiple cardiac risk factors. In these populations, cholesterol reduction appears to be both effective and cost-effective. In other populations, the benefits of reduction are much smaller or are uncertain.

View details for Web of Science ID A1996TW77300013

View details for PubMedID 8602715
Guidelines for using serum cholesterol, high-density lipoprotein cholesterol, and triglyceride levels as screening tests for preventing coronary heart disease in adults ANNALS OF INTERNAL MEDICINE Garber, A. M., Browner, W. S., Mazzaferri, E. L., Feussner, J. R., Kerby, G. R., Friesinger, G. C., Marton, K. I., Mushlin, A. I., Palda, V. A., Thibault, G. E., Sox, H., Barker, J., Hart, I., Blonde, L., Mazzaferri, E. L., Carravallah, L., Noble, J., Duffy, D., Feinberg, A., Wallace, E., FRYHOFER, S., Waxman, H. 1996; 124 (5): 515-517
View details for Web of Science ID A1996TW77300012
Cost-Effectiveness in Health and Medicine Garber, Alan M., Weinstein, M.C., Torrance, G.W., Kamlet, M.S. Oxford University Press (New York). 1996: 25?53
Guidelines for Using Serum Cholesterol, High-Density Lipoprotein Cholesterol, and Triglycerides as Screening Tests for Preventing Coronary Heart Disease in Adults Annals of Internal Medicine Garber, Alan M., Browner, W.S. 1996; 124: 515-17
Cholesterol Screening in Asymptomatic Adults, Revisited Annals of Internal Medicine Garber, Alan M., Browner, W.S., Hulley, S.B. 1996; 124: 518-31
Polymerase Chain Reaction for the Diagnosis of HIV Infection in Adults: A Meta-Analysis with Recommendations for Clinical Practice and Study Design, The Annals of Internal Medicine Owens, Douglas K., Holodniy, M., Garber, A., Scott, J., Sonnad, S., Moses, L., Kinosian, B., Schwartz, J. 1996; 124: 76-83
Task Force 6: Cost Effectiveness of Assessment and Management of Risk Factors Journal of the American College of Cardiology Goldman, L., Garber, A., Grover, S.A., Hlatky, M. 1996; 27: 957-1047
Cost-Effectiveness Analysis as a Measure of Value Tecnologica. Garber, Alan M. 1996; 39: 1, 3-6, 9-10
Cost-Effectiveness of Assessment and Management of Risk Factors J Am Coll Cardiol Goldman, L., Garber, Alan M., Grover, S., Hlatky, Mark A. 1996; 27: 395-407
The Cost of VA Sponsored Research Academic Medicine Barnett, Paul G., Garber, Alan M. 1996; 71
Individual and Social Responsibility: Child Care, Education, Medical Care, and Long-Term Care in America Garber, Alan M. University of Chicago Press. 1996: 143?169
Problems with the Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents Archives of Pediatrics & Adolescent Medicine Newman, T., Garber, A., Holtzman, N., Hulley, S. 1995; 149: 241-247
Cost of VA Sponsored Research: Modified Cost Allocation Method Center for Health Care Evaluation, Department of Veterans Affairs Barnett, Paul G., Garber, Alan M. 1995
DEVELOPING AND TESTING A MULTIMEDIA PRESENTATION OF A HEALTH-STATE DESCRIPTION MEDICAL DECISION MAKING Goldstein, M. K., Clarke, A. E., Michelson, D., Garber, A. M., Bergen, M. R., Lenert, L. A. 1994; 14 (4): 336-344
Abstract

Quality-adjustment weights for health states are an essential component of cost-utility analysis (CUA). Quality-adjustment weights are obtained by presenting large numbers of subjects with multiattribute descriptions of health states for rating. Comprehending multiattribute health states is a difficult task for most respondents. The authors hypothesized that multimedia (MM) presentation using computers might facilitate this task better than would a paper-based text (Text). To test this hypothesis, they developed closely matched MM and Text descriptions of health states in the first-person narrative style, and developed a method of testing the presentation of a health state. Subjects were randomized to exposure to either MM or Text and subject recall of the health state and recognition of features of the health state were tested. How well defined the preferences of the subjects were after each presentation method was assessed by having the subjects mark on a double-anchored visual-analog scale the "best" and "worst" they believed the quality of life in the health state might be. MM subjects had better recall (11.85 vs 9.44 of a total of 24 meaning units, p = 0.098) and better recognition (4.71 vs 4.22, p = 0.08). The average interval between the "best" and "worst" ratings was shorter for the MM subjects (2.19 cm vs 3.26 cm, p = 0.12).(ABSTRACT TRUNCATED AT 250 WORDS)

View details for Web of Science ID A1994PL43300004

View details for PubMedID 7528868
PREDICTING HIGH-RISK CHOLESTEROL LEVELS INTERNATIONAL STATISTICAL REVIEW Garber, A. M., Olshen, R. A., Zhang, H. P., Venkatraman, E. S. 1994; 62 (2): 203-228
View details for Web of Science ID A1994PB04800003
Developing and Testing a Multimedia Presentation of a Health State Description Medical Decision Making Goldstein, M., Clark, A., Michelson, D., Garber, A., Bergen, M., Lenert, L. 1994; 14: 336-344
Alglucerase for Gaucher's Disease: Dose, Costs, and Benefits PharmacoEconomics Beutler, E., Garber, A. 1994; 5: 453-459
PAYING FOR EVALUATIVE RESEARCH 4th Workshop on Examining Coverage and Adoption Decisions about Medical Technologies Garber, A. M., Owens, D. K. NATL ACADEMY PRESS. 1994: 172?192
View details for Web of Science ID A1994BB97Z00013
Aging in the United States and Japan: Economic Trends Garber, Alan M. University of Chicago Press. 1994: 175?194
Studies in the Economics of Aging Garber, Alan M., MaCurdy, T. University of Chicago Press. 1994: 365?394.
Workshop J: Prevention Strategies, Economic Realities, and Identification of Prevention Research Needs Preventive Medicine Weinstein, M.C., Garber, A., Fryback, D.G. 1994; 23: 571-572
Can Technology Assessment Control Health Spending? Health Affairs Garber, Alan M. 1994; 13: 115-126
Benefits vs Profits: Has the Orphan Drug Act Gone Too Far? Pharmacoeconomics Garber, Alan M. 1994; 5: 88-92
NURSING-HOME DISCHARGES AND EXHAUSTION OF MEDICARE BENEFITS JOURNAL OF THE AMERICAN STATISTICAL ASSOCIATION Garber, A. M., MACURDY, T. E. 1993; 88 (423): 727-736
View details for Web of Science ID A1993LT93200002
BLOOD CHOLESTEROL MEASUREMENT IN YOUNG-ADULTS - REPLY JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hulley, S. B., Newman, T. B., Grady, D., Baron, R. B., Browner, W. S., Garber, A. M. 1993; 270 (8): 937-938
View details for Web of Science ID A1993LT56700013
SHOULD WE BE MEASURING BLOOD CHOLESTEROL LEVELS IN YOUNG-ADULTS JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hulley, S. B., Newman, T. B., Grady, D., Garber, A. M., Baron, R. B., Browner, W. S. 1993; 269 (11): 1416-1419
Abstract

Should we measure blood cholesterol levels in all adults, or only in those at high risk of coronary heart disease (CHD)? Most men under the age of 35 years and women under the age of 45 years--roughly half the adult population--are at very low short-term risk of CHD. One consequence is that drug treatment to lower high blood cholesterol levels in the average young adult is an extremely expensive means of prolonging life; the estimated $1 million to $10 million per year of life is 100 to 1000 times the cost of other approaches. Individualized dietary treatment is somewhat cheaper but relatively ineffective. Another consequence of the low CHD risk in young adults is the greater likelihood that intervention may have harmful effects that outweight the benefits. Meta-analysis of primary prevention trials in middle-aged men reveal an increase in non-CHD deaths among those randomized to cholesterol interventions, an unexpected finding that is more substantial than the decrease in CHD deaths. This raises the possibility that one or more of the cholesterol interventions could have very serious adverse effects among young adults, whose risk of non-CHD death is normally 100 times their risk of CHD death. We conclude that the policy of screening and treating high blood cholesterol levels in young adults is neither cost-effective, nor does it satisfy ethical standards requiring strong evidence that preventive interventions do more good than harm. Fortunately, cholesterol screening in young adults is also not necessary: most CHD events associated with high blood cholesterol levels in this population will not occur for decades and can be prevented by treatment that is begun in middle age. Cholesterol screening and treatment in young adults should be limited to individuals with known coronary disease or other unusual factors that place them at high short-term risk of CHD death.

View details for Web of Science ID A1993KQ85700038

View details for PubMedID 8441219
Is high-flux dialysis cost-effective? International journal of technology assessment in health care Hornberger, J. C., Garber, A. M., Chernew, M. E. 1993; 9 (1): 85-96
Abstract

High-flux dialysis is a new method for providing routine-maintenance hemodialysis to patients with end-stage renal disease. It promises to shorten the duration of the dialysis session, but poses potential clinical risks to patients and financial risks to dialysis centers because of the high unit cost of purchasing new dialysis equipment. We retrospectively evaluated the cost-effectiveness of high-flux dialysis compared to conventional dialysis in a hospital-based center. The center provided only conventional dialysis until March 1989, when it initiated high-flux dialysis. The estimated annual costs of treatment were US $31,249 (high-flux) and $32,562 (conventional). The rate of hospital admissions was almost identical in both groups (conventional, 1.29 admissions per year; high-flux, 1.24 admissions per year; p = 0.23). Predicted prolongation of life expectancy with high-flux dialysis was significantly higher after statistical adjustment for observable patient characteristics (1.8 to 4.5 years; p < 0.01). The cost-effectiveness ratio was $28,188 per life-year saved for high-flux compared to conventional dialysis. These findings suggest that the added capital expense of purchasing high-flux equipment can be justified from the perspective of its societal cost-effectiveness.

View details for PubMedID 8423119
Should We Be Measuring Blood Cholesterol Levels in Young Adults? Journal of the American Medical Association Hulley, S.B., Newman, T.B., Grady, D., Garber, A., Baron, R.B., Browner, W.S. 1993; 269: 1416-1419
Nursing Home Discharges and Exhaustion of Medicare Benefits Journal of the American Statistical Association Garber, Alan M., MaCurdy, Thomas E. 1993; 88: 727-736
Is High-Flux Dialysis Cost Effective? International Journal of Technology Assessment in Health Care Hornberger, J., Garber, A., Chernew, M. 1993; 9: 85-96
A MULTIVARIATE-ANALYSIS OF MORTALITY AND HOSPITAL ADMISSIONS WITH HIGH-FLUX DIALYSIS JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Hornberger, J. C., Chernew, M., Petersen, J., Garber, A. M. 1992; 3 (6): 1227-1237
Abstract

The use of high-flux dialysis in clinical practice increased rapidly despite an absence of reports on the clinical effectiveness of the technique. Mortality and hospital admission rates of patients treated with high-flux dialysis were evaluated and compared with those of patients treated with conventional dialysis in a hospital-based renal dialysis unit in northern California. By use of a retrospective, cross-over design, 253 patients enrolled in the dialysis unit from January 1987 to January 1991 were studied. During this period, 107 patients were treated with high-flux dialysis for at least 1 month, and all but 17 of them had received conventional dialysis before switching to high-flux dialysis. The remaining 146 patients were treated with only conventional dialysis. Of the 80 patients who died during the study period, 69 were receiving conventional dialysis and 11 were receiving high-flux dialysis. The multivariate analyses, adjusted for age, gender, ethnic background, type of renal failure, comorbid conditions, and duration of ESRD, showed that annual mortality was substantially less for patients treated with high-flux dialysis compared with that for patients treated with conventional dialysis (7 versus 20%; P < 0.001). The difference in the rate of hospital admissions was not statistically significant. In this nonexperimental study, methods were applied to control for selectivity bias and other factors that might confound the apparent treatment effect. The findings suggest that the potential benefits of high-flux dialysis are sufficient to justify further confirmation in a randomized, controlled trial.

View details for Web of Science ID A1992KD27000005

View details for PubMedID 1477318
Creating the costliest orphan. The Orphan Drug Act in the development of Ceredase. International journal of technology assessment in health care Goldman, D. P., Clarke, A. E., Garber, A. M. 1992; 8 (4): 583-597
Abstract

The FDA recently approved Ceredase, a new treatment for Gaucher's disease, under the provisions of the Orphan Drug Act. Ceredase is unusually expensive, but there are no satisfactory alternative therapies. It appears likely that Ceredase would not have become available without the protection of the Orphan Drug Act, but its expense and the lack of information about its long-term effects on health raise questions about whether the ODA provides appropriate incentives to develop cost-effective technologies.

View details for PubMedID 1464480
New Directions in the Economics of Aging Garber, Alan M., MaCurdy, Thomas E. University of Chicago Press. 1992: 803?815
PAYMENT SOURCE AND EPISODES OF INSTITUTIONALIZATION CONF ON ECONOMICS OF AGING Garber, A. M., MACURDY, T. E. UNIV CHICAGO PRESS. 1992: 249?274
View details for Web of Science ID A1992BW30F00009
Creating the Costliest Orphan: The Orphan Drug Act in the Development of Ceredase International Journal of Technology Assessment in Health Care Clarke, A., Goldman, D., Garber, A. 1992; 8: 583-597
Multivariate Analysis of Mortality and Hospital Admission Rates of High-Flux Dialysis, A Journal of the American Society of Nephrology Hornberger, J., Chernew, M., Petersen, J., Garber, A. 1992; 3: 1227-1237
PRACTICE GUIDELINES AND CHOLESTEROL POLICY HEALTH AFFAIRS Garber, A. M., Wagner, J. L. 1991; 10 (2): 52-66
View details for Web of Science ID A1991FV30100003

View details for PubMedID 1885147
COSTS AND HEALTH CONSEQUENCES OF CHOLESTEROL SCREENING FOR ASYMPTOMATIC OLDER AMERICANS ARCHIVES OF INTERNAL MEDICINE Garber, A. M., LITTENBERG, B., Sox, H. C., Wagner, J. L., Gluck, M. 1991; 151 (6): 1089-1095
Abstract

To predict the consequences of cholesterol screening among elderly Americans who do not have symptoms of heart disease, we explore the cost implications of a cholesterol screening program, evaluate evidence linking hypercholesterolemia to coronary heart disease and mortality in the elderly, and describe the likely effects of therapy of hypercholesterolemia. According to our calculations, if all Americans 65 years of age and older adhered to a cholesterol screening program similar to the one proposed by the National Cholesterol Education Program, minimum annual expenditures for screening and treatment would be between $1.6 billion and $16.8 billion, depending on the effectiveness of diet and the cost of the medications used to treat hypercholesterolemia. There is no direct evidence that this program would lessen overall morbidity or extend the lives of elderly Americans.

View details for Web of Science ID A1991FQ68100007

View details for PubMedID 1904212
COSTS AND BENEFITS OF PRENATAL SCREENING FOR CYSTIC-FIBROSIS MEDICAL CARE Garber, A. M., FENERTY, J. P. 1991; 29 (5): 473-489
Abstract

New tests promise to facilitate the prenatal detection of cystic fibrosis (CF), a fatal genetic disorder. This study examines the costs and benefits of prenatal screening and selective abortion using two types of tests: those based on restriction fragment-length polymorphisms (RFLPs), which can only be applied when genetic material is available from a CF-affected family member; and those based on probes for the newly discovered CF gene, which can be applied in the general population. When either type is applied in families of CF-affected children, even an expensive test produces substantial net benefits. Existing direct gene probe tests are not sensitive, although eventually they may become less expensive and more accurate than tests based on RFLPs. Even if these tests become highly accurate, the financial benefits of population-wide screening for CF are likely to be small or negative, particularly if testing does not lead to increases in the number of normal children as it decreases the number of births of CF-affected children. Because few children born in families without a history of CF have the disease, tests that are not perfectly specific will produce a large number of false-positive results, leading to the abortion of many normal fetuses.

View details for Web of Science ID A1991FK98700007

View details for PubMedID 1673488
Costs and Benefits of Prenatal Screening for Cystic Fibrosis Medical Care Garber, Alan M., Fenerty, J.P 1991; 29: 473-489
Stanford Law & Policy Review Garber, Alan M., Fuchs, Victor R. 1991; 3: 203-209
THE NEW TECHNOLOGY-ASSESSMENT NEW ENGLAND JOURNAL OF MEDICINE Fuchs, V. R., Garber, A. M. 1990; 323 (10): 673-677
View details for Web of Science ID A1990DW78700011

View details for PubMedID 2385272
SCREENING FOR HYPERTENSION ANNALS OF INTERNAL MEDICINE LITTENBERG, B., Garber, A. M., Sox, H. C. 1990; 112 (3): 192-202
Abstract

To review the evidence on four questions about screening asymptomatic adults for arterial hypertension: Is hypertension a significant health problem? Is it detectable at an early, presymptomatic stage? Is treatment available and effective? Do the benefits of screening outweigh the costs and risks?We did a computerized search of the MEDLARS data base to identify community-based trials of drug therapy for mild hypertension; other relevant citations are included when appropriate.We approached the preliminary questions in our analysis by narrative review and argument. The estimates of therapeutic efficacy are based on previously published meta-analyses. The cost-effectiveness of screening was addressed by formal mathematical modeling of the effect of screening on various U.S. populations. RESULTS OF ANALYSIS: Hypertension is clearly a significant health problem. It can be detected early, and effective treatment is available. Screening asymptomatic adults for hypertension has benefits that compare favorably to the risks and costs involved. According to our estimates, screening is most cost-effective for older adults compared with younger adults and for men compared with women and is highly sensitive to the cost of therapy for mild hypertension.We recommend hypertension screening for all adults. We also discuss the frequency and setting of screening activities. When a low-cost therapy is used, the cost-effectiveness of screening for hypertension compares favorably with other cardiovascular interventions.

View details for Web of Science ID A1990CK83900008

View details for PubMedID 2136982
New Technology Assessment, The New England Journal of Medicine Fuchs, Victor R., Garber, Alan M. 1990; 323: 673-677
Issues in the Economics of Aging Garber, Alan M., MaCurdy, Thomas E. University of Chicago Press. 1990: 173?200
Computer Program for Statistically-Based Decision Analysis, A Proceedings of the Symposium on Computer Applications in Medical Care Polaschek, J.X., Lenert, L.A., Garber, A. 1990: 795-99
WHERE TO DRAW THE LINE AGAINST CHOLESTEROL ANNALS OF INTERNAL MEDICINE Garber, A. M. 1989; 111 (8): 625-627
View details for Web of Science ID A1989AV75200001

View details for PubMedID 2802415
THE RESTING ELECTROCARDIOGRAM AS A SCREENING-TEST - A CLINICAL ANALYSIS ANNALS OF INTERNAL MEDICINE Sox, H. C., Garber, A. M., LITTENBERG, B. 1989; 111 (6): 489-502
Abstract

To review the evidence that a resting electrocardiogram (ECG) predicts cardiac disease in healthy persons and to discuss the role of this test in screening for coronary artery disease.A manual search of the English-language literature using Index Medicus (1970-1988) and a bibliographic review of identified articles.We found 40 articles that described long-term survival of healthy individuals who either had had an abnormal finding on a resting ECG or had not had an abnormal finding.We pooled the pertinent studies and calculated the relative risk for coronary artery disease if an ECG finding was present and the 95% confidence limits (CI) on the relative risk. RESULTS OF ANALYSIS: One reason for doing a screening SCG is to detect disease whose effects can be prevented by early treatment. In population studies of healthy middle-aged men, frequent ventricular premature beats, left axis deviation, left ventricular hypertrophy (ECG-LVH), and changes indicative of myocardial ischemia are all associated with a small but statistically significant increase in the risk of dying from coronary artery disease. There is no evidence that early detection of these findings leads to a clinical intervention that improves health outcomes. A screening ECG can also serve as a "baseline" tracing. Two studies have shown that the baseline tracing has little effect on decision making in the emergency room.The evidence does not support doing a screening ECG in men without evidence of cardiac disease or cardiovascular risk factors.

View details for Web of Science ID A1989AQ50700008

View details for PubMedID 2528311
A DISCRETE-TIME MODEL OF THE ACQUISITION OF ANTIBIOTIC-RESISTANT INFECTIONS IN HOSPITALIZED-PATIENTS BIOMETRICS Garber, A. M. 1989; 45 (3): 797-816
Abstract

Antibiotic use is thought to promote bacterial antibiotic resistance by selectively inhibiting the growth of sensitive strains. This study investigates the relation between antibiotic use and the propagation of antibiotic-resistant hospital-acquired infections due to gram-negative bacteria in a population of hospitalized patients. It treats infection spread and hospital mortality as a Markov process, in which the transition probabilities are logistic functions of a set of personal and hospital characteristics. Data from a university hospital are used to derive the parameters of the model.

View details for Web of Science ID A1989AQ54000007

View details for PubMedID 2790122
SCREENING ASYMPTOMATIC ADULTS FOR CARDIAC RISK-FACTORS - THE SERUM-CHOLESTEROL LEVEL ANNALS OF INTERNAL MEDICINE Garber, A. M., Sox, H. C., LITTENBERG, B. 1989; 110 (8): 622-639
Abstract

From our review of the epidemiologic and clinical literature, we have developed recommendations for using the serum cholesterol test as a component of strategies to prevent coronary heart disease in asymptomatic adults. Total cholesterol, high-density lipoprotein, and low-density lipoprotein levels are risk factors for coronary disease and early mortality in middle-aged men. Weaker evidence suggests that hypercholesterolemia increases the risk for coronary disease in women or elderly men, or that hypertriglyceridemia increases the risk in men or women. A reduction in cholesterol levels lowers the incidence of and the mortality from coronary disease in asymptomatic, hypercholesterolemic, middle-aged men, but has not been shown to reduce overall mortality. The efficacy of treatment in women and elderly persons has not been studied. Screening and treatment plans should be individualized; a 5-year period between tests is adequate for asymptomatic, low-risk men, whereas more frequent testing is appropriate for high-risk men. Screening is optional for women and elderly persons.

View details for Web of Science ID A1989U180100010

View details for PubMedID 2648923
THE ROLE OF EXERCISE TESTING IN SCREENING FOR CORONARY-ARTERY DISEASE ANNALS OF INTERNAL MEDICINE Sox, H. C., LITTENBERG, B., Garber, A. M. 1989; 110 (6): 456-469
Abstract

To predict the effects of using exercise testing to screen healthy persons for coronary artery disease.The publications of the Coronary Artery Surgery Study were the principal sources of data for the cost-effectiveness analysis; we also used data from the Veterans Administration Cooperative Study of stable angina and the publications of the European Coronary Surgery Study Group.We used studies that provided the data that our decision model required--life expectancy and probabilities of outcomes in persons who have or do not have coronary artery disease.We did not use a structured method for abstracting data. We tested the susceptibility of our conclusions to poor quality of data by substituting a wide range of values for a variable in the decision model, and by calculating life expectancy and costs if screening was used routinely or not used.We assumed that persons with an abnormal exercise test would have arteriography and that persons with severe coronary artery disease would have bypass surgery. When there were no suitable published data for the model, we made assumptions that favored screening. The model predicts that screening would increase the life expectancy of 60-year-old men at average risk by at most 12 days. Sixty-year-old men with no risk factors for coronary artery disease would derive less benefit, as would women and younger men.The effect of exercise testing is too small to justify doing this procedure routinely in healthy persons. If coronary bypass surgery is found to prolong life in asymptomatic persons as much as it does in angina pectoris, screening older men with risk factors for coronary artery disease may prove to be worthwhile.

View details for Web of Science ID A1989T721500009

View details for PubMedID 2493211
Screening Asymptomatic Adults for Cardiac Risk Factors: The Serum Cholesterol Level Annals of Internal Medicine, Reprinted in Eddy DM, editor, Common Screening Tests, 113-153. Philadelphia: American College of Physicians, 1991 Garber, Alan M., Sox, H.C., Littenberg, B. 1989; 110: 622-39
Role of Exercise Testing in Screening for Coronary Artery Disease, The Annals of Internal Medicine Sox, H.C., Littenberg, B., Garber, A. 1989; 110: 456-69
Discrete-Time Model of the Acquisition of Antibiotic-Resistant Infections in Hospitalized Patients, A Biometrics Garber, Alan M. 1989; 45: 797-816
Pathways to Health: the Role of Social Factors Garber, Alan M. Henry J. Kaiser Family Foundation. 1989: 271?315
The Economics of Aging Garber, Alan M. University of Chicago Press. 1989: 255?77
Where to Draw the Line against Cholesterol Annals of Internal Medicine Garber, Alan M. 1989; 111: 625-27
Resting Electrocardiogram as a Screening Test: A Clinical Analysis, The Annals of Internal Medicine Sox, H.C., Garber, A., Littenberg, B. 1989; 111: 489-502
COST-CONTAINMENT AND FINANCING THE LONG-TERM CARE OF THE ELDERLY JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Garber, A. M. 1988; 36 (4): 355-361
View details for Web of Science ID A1988N072800012

View details for PubMedID 3127455
ANTIBIOTIC EXPOSURE AND RESISTANCE IN MIXED BACTERIAL-POPULATIONS THEORETICAL POPULATION BIOLOGY Garber, A. M. 1987; 32 (3): 326-346
Abstract

Antibiotic use is often blamed for increases in the prevalence of infections due to antibiotic-resistance bacteria. This paper clarifies the effects of antibiotic exposure on bacterial antibiotic resistance by developing models that describe the growth of competing bacterial strains whose antibiotic sensitivities differ. The analysis generalizes logistic growth models to include first-order growth parameters that are arbitrary functions of antibiotic levels. It derives closed-form solutions for population size, composition, and average antibiotic sensitivities as functions of antibiotic exposure. Strategies to minimize the bacterial population size are analyzed in the context of the model. These heuristic models explore in formal terms the population dynamics thought to underlie resistance development.

View details for Web of Science ID A1987L357200002

View details for PubMedID 3433231
Costs and benefits of prenatal screening for cystic fibrosis. JAMA : the journal of the American Medical Association Fenerty, J. P., Garber, A. M. 1987; 261 (5): 786-?
View details for PubMedID 11652528
Antibiotic Exposure and Resistance in Mixed Bacterial Populations Theoretical Population Biology Garber, Alan M. 1987; 32: 326-346
Case Mix, Costs, and Outcomes: Differences between Faculty and Community Services in a University Hospital New England Journal of Medicine Garber, Alan M., Fuchs, Victor R., Silverman, J.F. 1984; 310: 1231-1237
CASE MIX, COSTS, AND OUTCOMES - DIFFERENCES BETWEEN FACULTY AND COMMUNITY-SERVICES IN A UNIVERSITY HOSPITAL NEW ENGLAND JOURNAL OF MEDICINE Garber, A. M., Fuchs, V. R., Silverman, J. F. 1984; 310 (19): 1231-1237
Abstract

To gain insight into the possible consequences of prospective payment for university hospitals, we studied 2025 admissions to the faculty and community services of a university hospital, measuring differences in case mix, costs, and mortality in the hospital. The faculty service had more of the patients with costly diagnoses, but even after adjustment for diagnosis-related groups (DRGs), costs were 11 per cent higher on the faculty service (95 per cent confidence limits, 4 to 18 per cent). The percentage differential was greatest for diagnostic costs. The differential was particularly large--70 per cent (95 per cent confidence limits, 33 to 107 per cent)--for patients with a predicted probability of death of 0.25 or greater. The in-hospital mortality rate was significantly lower on the faculty service after adjustment for case mix and patient characteristics (P less than 0.05); the difference was particularly large for patients in the high-death-risk category. Comparison of a matched sample of 51 pairs of admissions from the high-death-risk category confirmed the above results with respect to costs and in-hospital mortality, but follow-up revealed that the survival rates were equal for the two services at nine months after discharge. The effect of prospective payment on the cost of care will be closely watched; we conclude that is will also be important to monitor the effect on outcomes, including hospital mortality rates.

View details for Web of Science ID A1984SQ22900006

View details for PubMedID 6424018

Alan M. Garber

Henry J. Kaiser Jr. Professor and Professor of Medicine, Emeritus

Medicine - Primary Care Outcomes Research

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