OBJECTIVE: This review builds on the innovative research synthesis of Holder and his colleagues, addresses some of the limitations of the box-score approach to assessing treatment effectiveness that they used and provides a second approximation of the cost-effectiveness of treatment for alcoholism.
METHOD: For each of 141 comparative treatment studies, we determined whether or not it found at least one statistically significant positive effect on a drinking-related outcome variable for each of the modalities examined in a paired contrast with one other condition. We next calculated the predicted probability of each study yielding at least one statistically significant treatment effect, based on the number of tests for treatment effects conducted. Following that, for each study of a particular treatment modality, the strength of the "weakest competitor" against which the modality had been compared was determined. For each modality, we used the average predicted probability of the relevant studies finding a significant effect and the average effectiveness of the weakest competitor to predict the modality's effectiveness.
RESULTS: We calculated an Adjusted Effectiveness Index (AEIn) for each modality, which was the difference between its predicted and actual effectiveness score. Our AEIn results were consistent with those of Holder et al. in suggesting that some of the same modalities appear to be effective or ineffective. Our results differed from their findings with respect to other modalities, however. Using data presented by Holder and his colleagues on the minimum estimated cost of providing different modalities, we offer a second approximation of the modalities' cost-effectiveness.
CONCLUSIONS: Overall, we found a smaller range of effectiveness across modalities than did Holder and his colleagues and a nonsignificant relationship between cost and effectiveness. Like Holder et al., we do not believe major treatment provision or funding decisions should be based solely on this type of review.
Because medical technology is the most important controllable component of health spending growth, the success of strategies for limiting spending growth depends upon their impact on technology dissemination. Technology assessment is fundamental to any strategy for controlling the adoption of medical technologies. Cost-effectiveness analysis holds particular promise as a method for evaluating alternative health care technologies because it explicitly incorporates costs. This paper describes how the widespread adoption of health insurance promoted the dissemination of medical technologies and how technology dissemination fueled spending growth. It then describes approaches to technology assessment and the ways in which technology assessment, in the form of cost-effectiveness analysis, can be applied to help control spending growth.
Objective: To examine the cost effects of a single dose (5 ml/kg) of a protein-free synthetic surfactant (Exosurf) as therapy for neonatal respiratory distress syndrome, for both rescue and prophylactic therapy.
Research Design: Nonblinded, randomized clinical trials of both rescue and prophylactic therapy. Regression analyses were used to control for the independent effects of sex, multiple birth, delivery method, birth weight, and surfactant therapy.
Setting: The prophylactic trial was conducted at a university medical center only; the rescue trial also included a tertiary community hospital.
Patients: Prophylaxis was administered immediately after birth to 36 infants (38 control subjects) with birth weights between 700 and 1350 gm. Rescue therapy was administered at 4 to 24 hours of age to 53 infants (51 control subjects) with established respiratory distress syndrome and birth weights > or = 650 gm (no upper limit). Infants in the prophylactic trial were not eligible for the rescue trial.
Results: For the rescue trial, there was a $16,600 reduction in average hospital costs (p = 0.18), which was larger than the cost of the surfactant ($450 to $900), yielding a probable net savings. For the prophylactic trial, hospital costs were larger for treated infants versus control subjects who weighed less than about 1100 gm at birth and lower for treated infants versus control subjects who weighed more than 1100 gm at birth (p 0.05). For the prophylactic sample, the result was an average cost per life saved of $71,500.
Conclusions: Single-dose rescue surfactant therapy is probably a cost-effective therapy because it produced a lower mortality rate for the same (and probably lower) expenditure. Single-dose prophylactic therapy for smaller infants ( or = 1350 gm) appeared to yield a reduction in mortality rate for a small additional cost. The use of multiple-dose therapy in infants who do not respond to initial therapy may alter the effects described above to either increase or decrease the observed cost-effectiveness of surfactant therapy. Regardless, surfactant therapy will remain a cost-effective method of reducing mortality rates, relative to other commonly used health care interventions.