KEY ARTICLES ...

Culyer AJ The morality of efficiency in health care--some uncomfortable implications. Health Econ 1992;1:7-18

There are some general considerations which have implications for the delivery and finance of health care in all countries, not only Canada and the USA. Beginning with two propositions: that access to health care is a right of citizenship, which should not depend on individual income and wealth; and that the objective of health services is to maximise the impact on the nation's health of the resources available; the paper examines the ethical justification for pursuing efficiency in health care provision. The different meanings of efficiency are discussed in detail, and the use of quantitative indicators of health benefit, such as the QALY, placed in context. It is argued that the determination of health care resource allocations should take account of costs at both the macro planning level and the micro level of the individual doctor-patient relationship. Given the starting points the overall conclusion is that it is ethical to be efficient, since to be inefficient implies failure to achieve the ethical objective of maximising health benefits from available resources.

Williams A The role of health economics in clinical decision-making: is it ethical? Respir Med 1991;85:3-5

With health care resources inevitably limited, we must ensure that they are used where they will do the most good. Doing good means improving people's life expectancy and quality of life, two characteristics which are combined in the Quality-Adjusted-Life-Year, or QALY. Even with effectiveness measured in this humanitarian way some people think it is unethical to let cost-effectiveness notions guide health care priorities. But costs represent sacrifices of health imposed on others, and it cannot be ethical to ignore such sacrifices. Indeed the reverse is true, it is unethical to ignore costs, and not to seek to become more efficient.

Uther JF The automatic implantable defibrillator is the most realistic and cost-effective way of preventing sudden cardiac death. Aust N Z J Med 1992;22:636-8

Judgement about cost-effectiveness of medical treatments depends upon the criteria used to define effectiveness. The most rational single criterion is the Quality Adjusted Life Year gained (QALY). Comparisons of cost-effectiveness of treatments may be made by comparing the dollar costs per QALY. Both the dollar and the QALY comparisons are subject to all errors of biological variable measurement and bias introduced by experimental design seen in other biological experiments. The proper methodology for comparison is the prospective randomised controlled clinical trial. Such trials using the automatic implantable defibrillator (AICD) as prophylaxis against sudden cardiac death (SCD) have not yet been performed. The major underlying cause of SCD is coronary artery disease with previous myocardial infarction (MI) and provocative tests for ventricular arrhythmias are the most powerful predictors of SCD in infarction survivors. AICD implantation carriers a mortality of about 2%, and survival after successful implantation is about 89% at one, and 84% at two years. By comparison, infarction survivors with left ventricular ejection fraction 0.4 and inducible slow monomorphic ventricular tachycardia have a survival rate of 70% at one, and 54% at two years. Antiarrhythmic drugs have not proven effective. There is an urgent need to confirm the advantage of the AICD by proper randomised controlled trial.

Horn J, Geier HJ, Seefried G, Platt D [Intensive care medicine in advanced age from the viewpoint of the internist] [Intensivmedizin im hoheren Alter aus der Sicht des Internis TT ;TT:TT - [Int

BASIC REMARKS: The percentage of elderly patients in ICUs has doubled over the last 20 years; in the case of the over-seventy-year-olds it is at present about 30%. MAJOR DISCUSSION POINTS: The mean length of stay in the ICU and hospital, and the average costs incurred, are not significantly higher in the case of the elderly. With increasing age, mortality rises steadily, being about 20% for geriatric patients in the ICU, 37% in hospital, and 52, cumulative, after one year. Nevertheless, elderly patients benefit in particular from intensive care. Their relative mortality rate in comparison with the general population of the same age is only slightly elevated. In view of the very high mortality following cardiopulmonary resuscitation of geriatric patients, it would make good sense to limit the indication in particular cases. Quality of life after discharge from ICU care and thereafter is appreciably lower in comparison with younger patients, but acceptance of intensive care is very good among elderly patients, too. As a study we carried out in our "toxicological" ICU showed, prognostic scoring systems for the elderly are not particularly reliable, and the geriatric skills and the knowledge of the physician weigh heavier. CONCLUSIONS: We consider intensive care in the elderly to be both beneficial and efficient, for despite an increase in the mortality rate, a satisfactory quality of life is achieved.

Beard ME, Inder AB, Allen JR, Hart DN, Heaton DC, Spearing RL The costs and benefits of bone marrow transplantation. N Z Med J 1991;104:303-5

The average direct costs of performing a bone marrow transplant (BMT), including the subsequent year, was found to be NZ$27,074 for 43 consecutive transplants. In 29 BMTs a full two year period of follow up was available and a quality of life analysis was carried out on these patients. It was calculated that 59 quality adjusted life years (QALYs) had been gained by the BMT procedure at the time of analysis. By combining these two analyses the cost of each QALY gained by BMT is NZ$13,272. The relatively low cost of BMT is partly due to the extremely low annual costs in second and subsequent years post BMT. In our patients this cost amounted to $195 per year. The costs and benefits of BMT compare very favourably with other complex medical procedures.

Truog RD Triage in the ICU. Hastings Cent Rep 1992;22:13-7

Some patients in intensive care units are too sick to derive much benefit from being there, while others are too well to require the technology and skills offered. When ICU resources are scarce, they may ethically be withdrawn from either sort of patient in favor of one more likely to benefit from the care.

Laupacis A, Feeny D, Detsky AS, Tugwell PX How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations [see comments] Comment in: Can Med Assoc J 1993;148:Can Med As

Because economic evaluations of health care services are being published with increasing frequency it is important to (a) evaluate them rigorously and (b) compare the net benefit of the application of one technology with that of others. Four "levels of evidence" that rate economic evaluations on the basis of their methodologic rigour are proposed. They are based on the quality of the methods used to estimate clinical effectiveness, quality of life and costs. With the use of the magnitude of the incremental net benefit of a technology, therapies can also be classified into five "grades of recommendation." A grade A technology is both more effective and cheaper than the existing one, whereas a grade E technology is less or equally effective and more costly. Those of grades B through D are more effective and more costly. A grade B technology costs less than $20,000 per quality-adjusted life-year (QALY), a grade C one $20,000 to $100,000/QALY and a grade D one more than $100,000/QALY. Many issues other than cost effectiveness, such as ethical and political considerations, affect the implementation of a new technology. However, it is hoped that these guidelines will provide a framework with which to interpret economic evaluations and to identify additional information that will be useful in making sound decisions on the adoption and utilization of health care services.

Kawachi I, Malcolm LA The cost-effectiveness of treating mild-to-moderate hypertension: a reappraisal. J Hypertens 1991;9:199-208

The cost-effectiveness of treating mild-to-moderate hypertension (diastolic blood pressures, 90-114 mmHg) was evaluated using the latest available information on both costs and benefits. The net health care costs of lifelong treatment for hypertension, at a 5% discount rate, ranged from 1491 pounds to 2752 pounds in men and from 1568 pounds to 2850 pounds in women in New Zealand in 1988 (1.00 pounds = $NZ 2.81). These figures take into account the savings in health care costs arising from stroke prevention. The net health care benefits, measured in quality-adjusted life years (QALYs) discounted at 5%, ranged from--2 days (a net negative effect of treatment) to 64 days in men and from--18 days to 35 days in women. The cost-effectiveness of antihypertensive therapy discounted at 5% (excluding categories of patients for whom the ratio was undefined due to a net negative effect of treatment on QALYs) ranged from 11,058 pounds to 63,760 pounds per QALY gained in men and from 22,060 pounds to 194,989 pounds per QALY gained in women. Treatment was more cost-effective in men than in women, in older age groups and at higher levels of pretreatment diastolic blood pressure. The cost-effectiveness ratios were highly sensitive to the discount rate used (with the majority of ratios in women being undefined at a 10% discount rate) and the costs of the regimen used (diuretic monotherapy being the most cost-effective, followed by beta-blockers, then angiotensin-converting enzyme inhibitors), as well as to the assumptions made about the impact of medication side effects on patient quality of life. These results call for a re-examination of resource allocation to antihypertensive treatment and point to the need to make assessments of the cost-effectiveness of alternative, non-pharmacological approaches to stroke prevention.

Coast J Reprocessing data to form QALYs [see comments] Comment in: BMJ 1992;305:BMJ 1992 A

OBJECTIVES--To determine whether reprocessing data from published sources into quality adjusted life years (QALYs), as recommended in The QALY Toolkit, is a useful method of helping purchasing authorities to determine the most cost effective pattern of care to buy for their populations. SETTING--United Kingdom. DESIGN--The method was tested for six elective surgical conditions; data from published studies were reprocessed into the Rosser index, to obtain values for change in quality of life. These were then used to form QALYs. A small validation exercise was carried out. MAIN OUTCOME MEASURES--QALYs formed from the Rosser index. RESULTS--Published data could not be found for three interventions (cataract surgery, inguinal hernia repair, varicose vein surgery). For the remainder (prostatectomy, hip replacement, and knee replacement) data were found which could be reprocessed to form QALYs, though it was often hard to compare data from different studies and many assumptions had to be made. CONCLUSION--The value of QALY results obtained by this method is questionable, given the large number of assumptions which had to be made. For many interventions published data are unlikely to be available.

Barnett DB Assessment of quality of life. Am J Cardiol 1991;67:41C-44C

Assessment of quality of life has emerged in recent years as an important part of the overall evaluation of drug therapy and health care in general. Measurement techniques for this difficult assessment range from simple unqualified questions on patient well-being to complex statistical analyses of a wide range of lifestyle and activity variables. The factors that influence quality of life during chronic drug therapy differ in the treatment of symptomatic (e.g, heart failure) vs asymptomatic (e.g, hypertension) disease, and include drug side effects, relief of symptoms, improved prognosis, return to work, physical activity and the need for further hospital treatments. The manifestation of quality of life varies for different people leading to lack of agreement on the precise definition. The absence of standardization of methods of measurement also contributes to this and leads to lack of comparability of studies and unreasonable claims by some drug manufacturers. Further complicating issues in multicenter trials across countries include language problems and interethnic differences in "sickness" behavior. The recently introduced quality-adjusted life year (QALY) index, designed to take account of both the quality and duration of life in assessing the outcome of treatments, may avoid some of these problems. By classifying illness states (the Rosser index) on the basis of disability and distress, and comparing outcomes in terms of improved prognosis, QALYs have already been used for cost/benefit analyses of a number of new and expensive therapies. Like other methods, QALYs have problems related to variability in individual appreciation of life values. To date, a perfect method of quality of life assessment remains elusive.

Carr-Hill RA Allocating resources to health care: is the QALY (Quality Adjusted Life Year) a technical solution to a political problem? [see comments] Comment in: Int J Health Serv 1991;21:Int J Heal

The allocation of health care resources has always been and will remain a contentious issue. Classically, the arguments have been posed in terms of the "need" for health care and/or the "right" to treatment. More recently, there have been attempts to shape the debate in consequentialist terms, by introducing a composite outcome measure. In the United Kingdom, the QALY (Quality Adjusted Life Year) has been promoted enthusiastically. But, like many other such proposals, it is a dodo, and one that is potentially politically dangerous.

Eddy DM Oregon's methods. Did cost-effectiveness analysis fail? [see comments] Comment in: JAMA 1992;267:JAMA 1992

Zoloth-Dorfman L, Carney B The AIDS patient and the last ICU bed: scarcity, medical futility, and ethics. QRB Qual Rev Bull 1991;17:175-81

Hulsebos RG, Beltman FW, dos Reis Miranda D, Spangenberg JF Measuring quality of life with the sickness impact profile: a pilot study. Intensive Care Med 1991;17:285-8

A pilot-study was done to investigate the applicability of the sickness impact profile (SIP) in ex-ICU patients. For this study 221 consecutively admitted patients were reviewed retrospectively after excluding children, deceased patients and readmissions. SIP was assessed in these patients by either interview or questionnaire. These were divided into three groups: i) Patients interviewed at home (n = 26). ii) Patients receiving the SIP-questionnaire by mail (n = 93). iii) As for group ii, but after receiving a telephone invitation to participate (n = 102). Highest mean SIP-score was found in group i (16.3). Groups ii and iii scored 10.2 and 7.9 respectively. Analysis of variance demonstrated overall SIP-scores of these groups to be significantly different. The response in group iii (77%) was significantly higher compared to group ii (56%). Data collection in Group i appeared to be most expensive costing $13.20 per patient, followed by group iii ($3.79) and group ii ($2.56). It is concluded that the self-administered SIP is suitable for measuring outcome in ICU-patients and is much cheaper than the direct interview technique. The 3 different approaches should be considered as independent methods of which individual results cannot be compared. The response can be improved significantly by calling the patients before sending the questionnaire.

Chelluri L, Pinsky MR, Grenvik AN Outcome of intensive care of the "oldest-old" critically ill patients. Crit Care Med 1992;20:757-61

OBJECTIVE: To determine the short-term and long-term outcome of critically ill "oldest-old" (greater than or equal to 85 yrs) patients. DESIGN: Retrospective chart review and follow-up telephone interview. SETTING: ICUs at a tertiary care hospital. METHODS: The medical records of all patients greater than or equal to 85 yrs of age admitted to the ICUs during 1988 were reviewed. Demographic information, severity of illness, major interventions, mortality rate, and hospital charges were examined. A follow-up telephone interview was conducted to determine the quality of life and mortality rate after discharge. RESULTS: Of 34 patients greater than or equal to 85 yrs of age admitted to the ICU, 21 (62%) survived to discharge from the hospital, and 13 (62%) of these 21 patients were discharged to home. Mean +/- SD hospital charges were $34,738 +/- 34,366. Seventeen of the 21 patients were contacted for long-term follow-up, and ten of these patients were alive at a mean follow-up time of 18 +/- 10 months (range 1 to 32). Eight of the ten patients described their quality of life as fair or good. CONCLUSION: These findings suggest that age alone may be an inappropriate criterion for allocation of ICU resources.

O'Brien MS, Ricotta JJ Conserving resources after carotid endarterectomy: selective use of the intensive care unit. J Vasc Surg 1991;14:796-800; d

A retrospective review was undertaken of a random sample (N = 73) comprising 50% of carotid endarterectomies performed during 1986 to evaluate the necessity of routine postoperative intensive care unit (ICU) admission after carotid endarterectomy. Severity of illness was determined with use of the Acute Physiology Score of the APACHE II system. The Therapeutic Index Scoring System was used to quantify postoperative services used. Postoperative morbidity was analyzed. Financial impact was extrapolated with use of 1990 billing data. Length of ICU stay was 24.5 hours. Only 13 of 73 patients (18%) required ICU services. In 10 (77%) of these patients therapy was initiated in the recovery room and discontinued in six patients within 3 hours of ICU admission. Only two patients required ICU services for 16 hours after surgery. The mean Acute Physiology Score was low (4.96) and could not identify patients who required unique ICU services. Neurologic deficits were seen in five patients (6.9%). In three cases deficits were recognized in the recovery room; deficits developed in two patients after discharge from the ICU. Observation in the recovery room with transfer of stable patients would have eliminated ICU admission in 60 patients (82%). In 1990 the incremental ICU charge was $720/patient day. This represents 12.5% of the hospital charges for carotid endarterectomy. The ICU is an expensive and highly used hospital resource. Only a few patients need unique ICU services after carotid endarterectomy, and this is usually apparent within 2 hours of surgery.(ABSTRACT TRUNCATED AT 250 WORDS).

Eddy DM What care is 'essential'? What services are 'basic'? JAMA 1991;265:782, 786-8

Vazquez Mata G, Rivera Fernandez R, Gonzalez Carmona A, Delgado-Rodriguez M, Tor Factors related to quality of life 12 months after discharge from an intensive care unit. Crit Care Med 1992;20:1257-62

OBJECTIVE: To perform an analysis of the quality of life of survivors after ICU discharge. DESIGN: Prospective study. SETTING: Medical-surgical ICU of a Spanish reference hospital. PATIENTS: Patients (n = 606) admitted in a 6-month period. METHOD: A questionnaire regarding quality of life issues was completed at the time of admission by patients or surrogates (n = 606). The questionnaire was given again 12 months after ICU discharge to 444 surviving patients. Both questionnaires evaluated the patient's ability to function and communicate for the previous 3 months. A Quality of Life score of 0 corresponded to no limitations. An increasing score indicated a reduction in function. A score of greater than 10 points implied a severe physical handicap. Information was also collected on the severity of illness and the diagnosis that prompted ICU admission. RESULTS: The mean Quality of Life score of all survivors worsened from a mean of 4.62 at the time of ICU admission to a mean of 6.11 at 12 months after ICU discharge (p less than .01) and was most evident for patients greater than 75 yrs of age (from a mean of 6.33 to a mean of 9.54). However, patients with the highest initial Quality of Life scores had a significant improvement at 12 months (14.61 +/- 0.50 to 12.48 +/- 0.78 points [p less than .05]). A higher severity of illness score corresponded to a higher Quality of Life score, but a multivariate analysis indicated that the factors with the greatest influence on the post-discharge Quality of Life score were the initial Quality of Life score and age. CONCLUSIONS: Twelve months after discharge from the ICU, a patient's functional status, as measured by the Quality of Life score, is influenced most by age and their Quality of Life score at the time of ICU admission. While there is an overall decrease in the Quality of Life score for survivors, admission and treatment in an ICU do not always result in deterioration of the Quality of Life score. This study indicates that Quality of Life scores could become a routine part of patient evaluation.

Byrick RJ, Caskennette GM Audit of critical care: aims, uses, costs and limitations of a Canadian system [see comments] Comment in: Can J Anaesth 1992;39:Can J Anae

We describe an audit system used in our Medical/Surgical Intensive Care Unit (ICU) during 1989-90. The system emphasizes the integration of data acquisition (database function) with the analysis and use of data (decision function). Resource input (human and technological) included patient demographics, diagnoses, complications, procedures, severity of illness (Apache II), therapeutic interventions (TISS), and nursing workload (GRASP and TISS). The output was assessed by survival, length of stay and ability to return home. The annual operating cost for 277 admissions (249 patients) to this ICU was $7,333. The implementation costs were $58,261 including program development and computer purchases. Non-survivors of ICU and hospital had higher Apache II scores on admission (P less than 0.0001) and longer ICU length of stay (P less than 0.05) than survivors. The nursing workload (both TISS and GRASP) on the day of admission and the last day in ICU were greater in non-survivors (P less than 0.0001) than survivors. Limitations of this audit system included the delay (6-9 mos) from ICU admission until data entry, the large number of diagnostic groups in the ICD.9.CM classification, and lack of a documented cause/effect relationship between interventions and complications. This audit system was more useful for utilization management than for quality assurance purposes.

Jessop EG Doctors and priorities. Lancet 1991;337:1464

Mahul P, Perrot D, Tempelhoff G, Gaussorgues P, Jospe R, Ducreux JC, Dumont A, M Short- and long-term prognosis, functional outcome following ICU for elderly. Intensive Care Med 1991;17:7-10

Among 1532 ICU patients we analysed 295 elderly patients (19%) aged more than 70-years-old. We determined prospectively the immediate and subsequent one-year outcome with a study of the predictive value of their ICU admission parameters. Then we followed the ICU survivors over the year after discharge (1, 6, 12 months) by quality of life questionnaires. ICU mortality was 26.7%; SAPS was the only predictor of short term mortality. On ICU discharge, 216 elderly were followed at 1, 6, 12 months; the one-year cumulative mortality was 49% from ICU discharge, majority of deaths occurring over the first month. Age, previous health status and SAPS had a predictor value of one-year mortality for ICU survivors. 103 patients were alive at one year: 88% returned to home, 72% had a relatively good functional status allowing an independent life, and 82% had the same or improved functional status.

Swenson MD Scarcity in the intensive care unit: principles of justice for rationing ICU beds. Am J Med 1992;92:551-5

Difficult dilemmas arise when resources become scarce in intensive care units (ICUs). When there are fewer beds available than patients who need them, how are those beds to be distributed? In this report, I discuss such rationing dilemmas from the context of John Rawls' theory of justice. Principles of justice can be chosen by clinicians and used to set priorities in the distribution of scarce ICU beds. These principles consist of a ranking of patients based on available prognostic data. Such a ranking would be the most fair way of distributing scarce ICU beds within a Rawlsian conception of justice. It is a ranking that would be chosen by the patients themselves, were they able to consider the matter from a rational and impartial perspective.

Rineberg BA Health care rationing: a quality of life issue. Orthopedics 1991;14:815

Peterson MW, Geist LJ, Schwartz DA, Konicek S, Moseley PL Outcome after cardiopulmonary resuscitation in a medical intensive care unit. Chest 1991;100:168-74

Cardiopulmonary resuscitation (CPR) is often performed in modern critical care units, but its efficacy has not been evaluated in this setting. It is important to evaluate CPR in critical care units because these patients often have multisystem disorders and suffer from diseases reported to carry a poor outcome after CPR. Inappropriate resuscitation of patients in this setting results in increased cost of care (both financial and emotional), with little tangible benefit. To address the question of successful resuscitation in the medical intensive care unit (MICU), we retrospectively reviewed the records of 114 patients who underwent CPR in our MICU over a three-year period. Eighty patients (70 percent) were not successfully resuscitated, 21 patients (18 percent) were successfully resuscitated but died before discharge, and 13 patients (11 percent) survived to leave the hospital. We evaluated a number of prearrest conditions (diagnoses, age, sex, duration of hospitalization, length of ICU stay, and severity of illness as measured by APACHE 2 scores) and arrest conditions (the initial cardiac rhythm and duration of CPR) to determine if the outcome after CPR was influenced by any of these parameters. Among the prearrest conditions, only a diagnosis of hypotension or sepsis and an elevated APACHE 2 acute physiology score were independently associated with a poor outcome after CPR. The only arrest condition found to be independently associated with outcome following CPR was the duration of resuscitative effort (p less than 0.01). The patients who were successfully resuscitated but died before discharge were not different from the patients who were not successfully resuscitated in any parameter that we evaluated. These results demonstrate that CPR can be successful in the MICU and that there are prearrest and arrest parameters which are useful in identifying those patients most likely to benefit from CPR in the

Hadorn DC Setting health care priorities in Oregon. Cost-effectiveness meets the rule of rescue [see comments] Comment in: JAMA 1991;265:JAMA 1991

The Oregon Health Services Commission recently completed work on its principal charge: creation of a prioritized list of health care services, ranging from the most important to the least important. Oregon's draft priority list was criticized because it seemed to favor minor treatments over lifesaving ones. This reaction reflects a fundamental and irreconcilable conflict between cost-effectiveness analysis and the powerful human proclivity to rescue endangered life: the "Rule of Rescue." Oregon's final priority list was generated without reference to costs and is, therefore, more intuitively sensible than the initial list. However, the utility of the final list is limited by its lack of specificity with regard to conditions and treatments. An alternative approach for setting health care priorities would circumvent the Rule of Rescue by carefully defining necessary indications for treatment. Such an approach might be applied to Oregon's final list in order to achieve better specificity.

Spiegelhalter DJ, Gore SM, Fitzpatrick R, Fletcher AE, Jones DR, Cox DR Quality of life measures in health care. III: Resource allocation [see comments] Comment in: BMJ 1993;306:BMJ 1993 F

Williams RM Public policy and quality assurance. Emerg Med Clin North Am 1992;10:493-506

The definition of quality varies widely among different key players in the American health care system. It is important for physicians and other providers to have an understanding of the public policy approach to quality assessment and assurance. Policy analysts use a number of techniques and methods in an attempt to define and balance the interests of individual patients with that of society as a whole. Benefit-cost, cost-effectiveness, and evaluation synthesis methods are used by public policy makers to arrive at rational consideration of the implications of allocation of scarce health care resources. Emergency medicine is on the forefront of many key policy decisions relative to the health care system. As the nation's health safety net, emergency medicine plays an integral and pivotal role in the definition, structure, and function of the health care system. In this regard, it is essential that emergency physicians and emergency medicine organizations play an active and formative role in the rapidly changing health care environment. Understanding conceptual approaches to the public policy approach to the health care system is an important endeavor for leadership in emergency medicine.

Oye RK, Bellamy PE Patterns of resource consumption in medical intensive care [see comments] Comment in: Chest 1991;99:Chest 1991

Intensive care is being scrutinized as a major factor in increasing health care costs. We examined 404 consecutive admissions to the medical ICUs at a university medical center to study patterns of consumption of ICU resources and the proportion of resources used by patients admitted for monitoring only. We found a skewed distribution of ICU resource consumption, with the "high-cost" 8 percent using as many ICU resources as the "low-cost" 92 percent. Forty-one percent of admissions did not receive acute ICU treatments, but these admissions consumed less than 10 percent of ICU resources. Reducing the number of patients admitted for monitoring will have a relatively small impact on hospital charges. Since over 70 percent of the high-cost patients died, improved understanding of prognosis and better physician-patient communication may substantially reduce the proportion of critical care resources expended on futile treatment.

Malstam J, Lind L Therapeutic intervention scoring system (TISS)--a method for measuring workload and calculating costs in the ICU. Acta Anaesthesiol Scand 1992;36:758-63

The Therapeutic Intervention Scoring System (TISS) is an easily applicable method for measurement of workload in the intensive care unit (ICU). In the present study a modified TISS-scoring (mTISS) was performed daily during 1988-1989 on 2693 patients in a general ICU. Of these, 900 could be classified as 'true' ICU-patients (ICU-stay or = 24 h or TISS or = 20 points), whereas the rest were postoperative. In ICU-patients the average length of stay was 4.5 +/- 8.9 days and the average workload 114 +/- 218 mTISS-points. The workload was not significantly related to age or type of admission (scheduled vs unscheduled). Hospital non-survivors (13.6%) showed a significantly increased mean total mTISS-score (239 +/- 364, P 0.001). Critically ill (TISS Class IV) patients (14% of the sample), with an average workload of 437 +/- 401 mTISS-points, consumed 53% of the total resources. Patients categorized (ICD-9) to respiratory and infectious diseases showed the greatest average workload (207 +/- 315 and 208 +/- 355 mTISS-points, respectively). A workload-index was also developed relating the actual workload to the ICU personnel. The cost of each mTISS-point was calculated. In conclusion, the present study showed that mTISS is a valuable tool when evaluating resource utilization in the ICU. Together with the proposed workload-index and calculation of costs, mTISS could be used for ICU management control.

Charny MC, Lewis PA, Farrow SC Choosing who shall not be treated in the NHS. Soc Sci Med 1989;28:1331-8

In the face of severe resource constraints, health care systems are seeking both to control costs and to ensure maximum benefits for the resources consumed. The use of Quality Adjusted Life Years (QALYs) is becoming more widely advocated as a decision aid in the solution of resource allocation problems. The QALY combines two dimensions of health outcome--the quantity of life and its quality--in such a way that choices between different services with different purposes can be made using comparisons based on common units of measurement. The combination of these two dimensions allows comparisons between services with different objectives, such as curing and caring services. The QALY, however, lacks a third dimension which is vital to the decision-making process to which it is intended to contribute: the worth of a specific life relative to others. This paper presents results based on interviews of 719 residents of Cardiff drawn at random from the electoral register. The results suggest that further development of the novel methodology used to establish the relative value placed on various human lives is worthwhile. Evidence is given which indicates that the public consider lives to be of unequal worth. The results also show that these values are consistent for different types of choices phrased in different ways on a large number of control variables, implying the existence of a cultural stable value system which is a necessary prerequisite if consensus values of human life are to be used to assist decision-making in non-private health care systems.(ABSTRACT TRUNCATED AT 250 WORDS).

Muakkassa FF, Fakhry SM, Rutledge R, Hsu H, Meyer AA Cost-effective use of microcomputers for quality assurance and resource utilization in the surgical intensive care unit. Crit Care Med 1990;18:1243-7

Need for organ system support, severity of illness, and the risk of life-threatening complications are major factors in determining the need for ICU care and directly affect ICU costs. Using a microcomputer and a relational database program, an ICU database was developed to study ICU utilization. The following information was collected for each ICU patient on admission, then daily, and on ICU discharge: demographic data, procedures, monitors used, laboratory tests, complications, outcome, and Acute Physiology and Chronic Health Evaluation (APACHE II) score as a measure of acuity. In our study, this information was used as a first step in an attempt to define categories of patients who might benefit most from intensive care and those who would not. From September 1, 1987 to March 1, 1989, 1,062 patients were admitted to the surgical ICU (SICU). Otorhinolaryngology (ENT) patients with major head and neck resections, routinely admitted to the SICU, were compared with those from other surgical services. The ENT patients had the lowest mean admission APACHE II (6.8 +/- 0.4 vs. 11.4 +/- 0.3), lowest mean daily APACHE II (7.8 +/- 0.4 vs. 13.2 +/- 0.1), lowest percent of ventilated patients (7.6% vs. 39.4%) and ventilator days (18.9% vs. 64.6%), and had the least monitoring by central venous catheters (20.9% vs. 57.1%) or pulmonary artery catheters (0.9% vs. 29.8%) (p less than .0001 for all of above). They also had the shortest mean ICU stay (1.2 +/- 0.1 vs. 3.3 +/- 0.2 days, p less than .05). The only complication in 105 ENT patients was one uncomplicated myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS).

Cohen DR Introducing quality into cost effectiveness. Qual Assur Health Care 1990;2:313-9

The objective of this study is to explore the problems which can arise when quality issues are introduced without proper analysis of the nature and objectives of health care. The principles of economics are used to explain why the primary output of health care should be perceived in terms of health gained (or maintained). Cost Effectiveness Analysis (CEA) is concerned with achieving a given output at lowest cost. The problems of measuring and valuing health gains, as well as problems arising when a quality dimension is introduced, are discussed with reference to the Quality Adjusted Life Year (QALY) as a measure of health gain. Quality of service provision is normally achieved at an increased cost per QALY. This need not make high quality services inefficient provided care is taken in use of terms and Cost Benefit Analysis (CBA) is used to highlight the value placed on consumer satisfaction.

Jonsson B Quality of life--economic aspects. Scand J Prim Health Care Suppl 1990;1:93-6

The interest for quality of life assessments in health care has grown during recent years. From the economist's point of view, quality of life is an appropriate outcome measure in economic assessments of health care as a tool in priority settings. In quality adjusted life-years (QALYs) improvements in the length of life and in its quality are amalgamated into one single index. Different types of medical interventions can be compared by calculations of costs per gained QALY. Unsolved problems still remain with QALYs but with scarce resources within the health care sector measures like QALYs provide a powerful guidance in priority settings.

Pickard JD, Bailey S, Sanderson H, Rees M, Garfield JS Steps towards cost-benefit analysis of regional neurosurgical care [see comments] Comment in: BMJ 1990;301:BMJ 1990 N

OBJECTIVE--To determine the cost of averting death or severe disability by neurosurgical intervention. DESIGN--Retrospective analysis of one year's admissions for neurosurgery; comparison of outcome with expected outcome in the absence of neurosurgical intervention and with the cost of neurosurgery. SETTING--Wessex Neurological Centre. PATIENTS--1026 Patients were admitted to the neurosurgical service in 1984. Of 1185 admissions, 978 case records were available and outcome was known in 919. MAIN OUTCOME MEASURES--Outcome was assessed with the Glasgow outcome scale, modified as necessary, from the case notes, or by letter follow up to the general practitioner. Expected outcomes for each of the 54 diagnoses were derived from both published reports where available and an expert panel of 18 consultant neurosurgeons. The cost of the neurosurgical service for 1983-4 was known from a separate study and the cost per patient was calculated using the length of stay. RESULTS--The cost of neurosurgery in 1983-4 was 1.8 million pounds. In all, 243 deaths or severe disabilities were estimated to have been averted at an average cost of 7325 pounds (range 5000 pounds to 70,000 pounds). The overall cost per quality adjusted life year (QALY) was 350 pounds (range 34 pounds to greater than 400,000 pounds). The cost of long term care for severely disabled survivors is at least 18-fold greater than the cost of neurosurgical intervention to avert such disability. CONCLUSIONS--In Britain neurosurgery is not expensive in comparison with the costs and benefits of other areas of medicine, and the cost per QALY is unexpectedly low except for severe diffuse head injury, malignant brain tumors, and cerebral metastases. The neurosurgical budget should be assessed in the context of managing a patient in hospital and subsequently in the community.

Jacobs CJ, van der Vliet JA, van Roozendaal MT, van der Linden CJ Mortality and quality of life after intensive care for critical illness. Intensive Care Med 1988;14:217-20

Early and late mortality of 313 ICU patients and the quality of life of 118 long term ICU survivors was studied to assess the effectiveness of intensive care for critically ill patients. The survival rate at discharge from the ICU was 76%, falling to 61% at 6 months and to 58% at 1 year. A simplified acute physiology score (SAPS) was recorded on ICU admission, as well as age, length of ICU-stay and the number of complications during intensive care. Information on housing, drug use, hospital admissions, physical condition and functional status 2 years after ICU discharge was collected by means of a questionnaire. No changes in housing occurred, but drug use and the number of hospital admissions were significantly increased. In 21% of the patients a deteriorated physical condition was found, 77% remained unchanged and 2% were improved 2 years after ICU discharge, compared to their condition prior to the acute illness. Major functional impairment was found in 38% of the patients. Although the longterm physical condition and functional status correlated with SAPS and age on ICU admission, the best indicator for quality of life after intensive care proved to be the health status prior to the acute illness.

Schechter CB, Rose DN, Fahs MC, Silver AL Tuberculin screening: cost-effectiveness analysis of various testing schedules. Am J Prev Med 1990;6:167-75

Because there is no tuberculin screening schedule currently recommended for adults, we used a Markov process in a cost-effectiveness analysis to determine an optimal strategy. We simulated the prognosis of a cohort of black 20-year-olds to evaluate the effects of various screening schedules with intradermal tuberculin and administration of isoniazid prophylaxis to those with positive results. The schedule with the lowest cost-effectiveness ratio is a single screening at 50 years of age, which costs $41,672 per quality-adjusted life year (QALY) gained. The cost-effectiveness ratio is nearly the same for all schedules involving a single screening between 30 and 70 years of age. Repeated screening strategies are less cost effective. Sensitivity analysis shows that the range of acceptable screening strategies changes significantly under alternate assumptions about the mortality from isoniazid hepatitis. However, screening at 50 years of age remains nearly optimal under the alternatives considered. Altering the values of other parameters generally produced only small changes. Tuberculin screening at 50 years of age should be added to primary care preventive practices because the strategy is as cost effective as standard health interventions and is robust to alternative assumptions. If further research confirms the base case assumptions about isoniazid toxicity, consideration should be given to increasing screening to every 10 years, which would produce a larger health benefit, albeit at substantially higher cost.

Civetta JM, Hudson-Civetta JA, Nelson LD Evaluation of APACHE II for cost containment and quality assurance. Ann Surg 1990;212:266-74; di

APACHE II (an acronym formed from acute physiology score and chronic health evaluation) has been proposed to limit intensive care unit (ICU) admissions ('cost containment') and to judge outcome ('quality assurance') of surgical patients. To judge its performance, a 6-month study of 372 surgical ICU patients was performed. When patients were divided by mean duration of stay, mortality rates rose from 1% (short stay) to 19% (long stay) (p less than 0.001) for patients with APACHE II scores less than 10, but decreased from 94% (short stay) to 60% (long stay) (p less than 0.01) for patients with APACHE II scores more than 24. Exclusion of patients by high or low APACHE scores would 'save' 6% of ICU days but risk increasing morbidity, hospital costs, and deaths. Grouped APACHE II scores did not correlate with total hospital charges (r = 0.05, p = 0.89) or ICU days used (r = 0.42, p = 0.17). Grouping by APACHE II score and duration of ICU stay showed neither symmetry nor uniformity of mortality rates. Surgical patients would not be well served by APACHE II for quality assurance or cost containment.

O'Brien B, Rushby J Outcome assessment in cardiovascular cost-benefit studies. Am Heart J 1990;119:740-7; dis

The scarcity of health resources and development of new treatments have introduced a need to assess health care interventions in the areas of both costs and benefits. Information on costs and benefits of one treatment program relative to another can assist decisions about resource allocation by indicating which interventions offer the greatest benefit at the least cost. Economic evaluation is dependent on accurate definition and appropriate measurement of outcome or benefit. This article reviews a number of evaluation techniques and cost-benefit studies associated with cardiovascular medicine. The focus is on health-related quality of life, the methodology, and the problems encountered therein. Methods for combining quantity and quality of life are discussed with reference to a composite measure of health outcome, quality-adjusted life years.

Weil MH, Weil CJ, Rackow EC Guide to ethical decision-making for the critically ill: the three R's and Q.C. Crit Care Med 1988;16:636-41

Ethical decision-making for the care of the critically ill and injured has never been more difficult than it is today. Major technologic advances prolong life but often provide questionable benefit in human terms. Both the ethical commitment to the individual patient and the competition for access to expensive and scarce health resources prompt the search for clinically useful and operationally appropriate criteria for decision-making. The mnemonic 3 R's and Q.C. was evolved as a practical tool by which the ethical basis for interventions may be tested. The first tier, the 3 R's, is likely to resolve the vast majority of ethical issues. These are appropriately addressed at the bedside by clinicians who determine whether a proposed intervention is Rational, Redeeming, and Respectful. When the ethical issues cannot be resolved at the bedside on the basis of the 3 R's, a second tier of testing of Quality of Life and Cost (Q.C.) is triggered. This addresses decision-making which is not exclusively or even primarily in the skill domain or authority of most physicians. It calls for assistance by those who represent a broader base of societal involvement including multidisciplinary experts in ethics and law who serve as consultants or who are organized into medical center-wide ethics committees.

Bulpitt CJ, Fletcher AE Measuring costs and financial benefits in randomized controlled trials. Am Heart J 1990;119:766-70; di

Economic assessment can be incorporated into clinical trials to evaluate and compare the costs and benefits of different health care programs. In this article the three main types of evaluation are discussed: cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. The measurement of direct and indirect costs is described and specific examples are quoted. Full economic analyses are given for the use of naftidrofuryl in the treatment of acute cerebral hemisphere infarction and the use of auranofin in the treatment of rheumatoid arthritis. Economic evaluation is seen to be justified whenever a more expensive treatment is expected to produce greater benefit. Such analyses should consider quality of life and health status, as well as the more easily identifiable outcomes.

Sporken P [Ethical aspects of therapeutic borderline situations in intensive care] [Ethische Aspekte therapeutischer Grenzsituationen in der In TT ;TT:TT - [Eth

Munoz E, Josephson J, Tenenbaum N, Goldstein J, Shears AM, Wise L Diagnosis-related groups, costs, and outcome for patients in the intensive care unit. Heart Lung 1989;18:627-33

Our purpose was to analyze hospital cost, resource utilization, and outcome by age for a large group of patients who required intensive care unit (ICU) services. Patients in the ICU (N = 6331) were stratified by age groups. Mean hospital cost per patient generally increased with age. Older patients (65 years of age and older) who were treated in the ICU had longer hospital lengths of stay, higher mortality rates, and a greater percentage of outlier patients, as compared with younger patients (under 65 years of age). Patients in the ICU would have produced a substantial loss for our medical center under a diagnosis-related group (DRG) all payer prospective payment scheme. Although higher mean costs were associated with older patients, every age group of patients in the ICU that we examined demonstrated a loss under DRGs. As a whole for the 3-year period, patients in the ICU would have generated more than +30 million in losses for our medical center. These losses were a result of a variety of factors, including a greater severity of illness and greater hospital resource utilization. The current DRG hospital payment system appears to be inequitable for the patient who receives treatment in the ICU during the hospital stay. As hospital operating margins continue to decline because of federal and state DRG hospital payment systems, additional pressures may be applied for physicians, nurses, and health care professionals to cut expenses for these patients. In this effort to watch the bottom line, physicians and nurses must not sacrifice the quality of or the access to care for patients who require ICU services.

Murphy DJ, Matchar DB Life-sustaining therapy. A model for appropriate use [see comments] Comment in: JAMA 1990;264:JAMA 1990

New strategies are needed to curb the proliferation of life-sustaining therapies that rarely benefit patients. We propose a model for appropriate use of such therapies that incorporates effectiveness, utility, and marginal costs. If a therapy is rarely effective and rarely desirable, it is considered medically inappropriate. If the marginal cost-effectiveness ratio is inordinately high, it is considered economically inappropriate. If a therapy is either medically or economically inappropriate, it should not be automatically offered. The model provides an operational definition of futility and is illustrated with an analysis of out-of-hospital cardiopulmonary resuscitation for chronically ill older people. Advance directives, explicit health care rationing, and defining futile therapy based on survival predictions are alternatives to the appropriate care model, but are insufficient strategies to solve the problem of inappropriate life-sustaining care.

Rhodes M, Sacco W, Smith S, Boorse D Cost effectiveness of trauma quality assurance audit filters. J Trauma 1990;30:724-7

The American College of Surgeons Committee on Trauma (ACSCOT) has published recommended minimal audit filters for trauma quality assurance. In this study ten filters were assessed through variable sample sizes over a 1-year period for cost and efficiency. Each filtered case was screened by trauma nurse coordinators. The trauma director reviewed possible deviations from standard and presented cases at peer review conferences for consensus on problem identification. While several filters had reasonable yield, most filters had minimal or no yield. Ten de novo problems were identified at a cost of +1,000 per de novo problem. Six filters were modified based on common reasons for overfiltration, resulting in a substantial reduction in filtration rate without losing problem identification. We conclude that ACSCOT audit filters 1 (unexpected deaths), 4 (ICU LOS greater than twice the average), 5 (trauma surgeon response), and 9 (major surgery greater than 24 hours) have a reasonable yield. Filters 2, 3, 7, 8, 11, and 12 have limited value to an established suburban trauma center and are not cost effective. Modifications of these filters can reduce cost without obvious impact on effectiveness. Specific audit filters recommended for future study are presented.

Zaren B, Bergstrom R Survival compared to the general population and changes in health status among intensive care patients. Acta Anaesthesiol Scand 1989;33:6-12

In order to evaluate intensive care, all adult patients (980) admitted to a multidisciplinary intensive care unit (ICU) during 1 year were followed prospectively. The ICU mortality was 9.6%. One year after admission the survival was 73.6%. By that time the surviving patients had a further survival that was 96% of that of the general population. Of the 1-year survivors, 22.3% had deteriorated in health status compared to 3 months before the stay in ICU. In the admission groups with high mortality the survivors had a more pronounced deterioration in health status. Increased age and length of stay in the ICU were associated with higher mortality but not with changes in health status. We conclude that the outcome of intensive care can be evaluated by studying only the survival, since the survival rate is correlated to changes in health status among survivors in the different admission groups. One year after admission most of the surviving patients had regained their previous health status and their further survival was almost the same as that of the general population.

Jacobs P, Noseworthy TW National estimates of intensive care utilization and costs: Canada and the United States. Crit Care Med 1990;18:1282-6

Although ICUs generate attention as consumers of resources, no national data on utilization and costs were available in Canada. U.S. estimates are too old for current comparison. Based on national hospital survey data from Statistics Canada, we calculated the utilization of ICUs in all Canadian general hospitals from 1969 to 1986 and estimated costs for 1986. Using the American Hospital Association's Annual Survey, we estimated comparable trend data from U.S. hospitals for the period of 1979 to 1986, and national ICU costs for 1986. The results demonstrated steady growth in Canadian utilization from 1969 to 1986, with increased ICU patient days (17 to 42 days/1000 population). National costs for 1986 were estimated at $1.03 billion (Canadian), which was roughly 8% of total inpatient costs and 0.2% of Canada's gross national product (GNP). Utilization trend data for the United States showed a rapid increase from 1979 through 1982 with slower growth after that. In the United States, ICU utilization in 1986 was estimated at 108 patient days/1000 population. Total ICU costs were estimated at $33.9 billion (U.S.), which is 20% of all inpatient hospital costs and accounts for 0.8% of the GNP. ICU utilization in the United States is 2.5 times that of Canada.

O'Kelly TJ, Westaby S Trauma centres and the efficient use of financial resources [see comments] Comment in: Br J Surg 1991;78:Br J Surg

The economic aspects of trauma centres were examined using published results and local financial data to discover if such institutions are an efficient use of resources. The cost of trauma centre care depends upon the number of centres built. An 'ideal' system in the UK of eight centres will cost 31.268 pounds per life saved compared with 45.661 pounds for the system proposed by the Royal College of Surgeons of England. Trauma centre care will be expensive but will generate benefits in return. Survivors will be young (mean age 30 years) and most (70-80 per cent) will regain their pre-injury functional/work status. When considered in terms of Quality Adjusted Life Years (QUALYs), trauma centres are a relatively efficient use of resources. An expected cost per QUALY of 942-1376 pounds is inexpensive compared with many health pursuits currently funded within the UK National Health Service.

Fisher MM, Raper RF Withdrawing and withholding treatment in intensive care. Part 1. Social and ethical dimensions [see comments] Comment in: Med J Aust 1990;153:Med J Aust

Intensive care is an expensive resource. The medical profession has been criticised for applying technology indiscriminately and at vast expense to a relatively small group of patients. The desire of governments to reduce the cost of health care has made rationing of health services a topic of open discussion rather than an implicit activity as it has been in the past. The appropriate response of doctors to these problems is to provide leadership in promoting public awareness and debate of the effects of rationing, and to provide rational allocation of therapy to individual patients. The major issues involving resource allocation in society and to individuals are discussed.

Weingarten S, Ermann B, Bolus R, Riedinger MS, Rubin H, Green A, Karns K, Ellrod Early "step-down" transfer of low-risk patients with chest pain. A controlled interventional trial. Ann Intern Med 1990;113:283-9

OBJECTIVE: To determine whether providing private practitioners with triage criteria for their low-risk chest pain patients would safely enhance bed utilization efficiency in coronary and intermediate care units. DESIGN: Prospective, controlled, interventional trial using an alternate month study design. SETTING: A large teaching community hospital. PATIENTS: Cohort of 404 low-risk patients with chest pain for whom a diagnosis of myocardial infarction has been excluded and who have not sustained complications, required interventions, or developed unstable comorbidity. INTERVENTIONS: During intervention months, private practitioners caring for low-risk patients in the coronary and intermediate care units were contacted 24 hours after admission. Physicians were informed that the transfer of low-risk patients to nonmonitored beds could probably be done safely, based on the results of a pilot study. The practitioner had the option of agreeing to or deferring patient transfer. During control months, physicians were not contacted in this way. MEASUREMENTS AND MAIN RESULTS: Use of the triage criteria by private practitioners reduced lengths of stay in the intermediate and coronary care units by 36% and 53%, respectively. Bed availability increased by 744 intermediate and 372 coronary care unit bed-days per year. Charges decreased by $2.6 million per year and profits improved by $390,000 per year. There were not significant differences in complications between control and intervention patients and in no case (95% CI, 0% to 1.6%) did the triage criteria adversely affect quality of care. CONCLUSIONS: The early transfer triage criteria may be a safe and efficacious decision aid for improving bed utilization in intermediate and coronary care units. In addition, this study shows the feasibility of and potential benefits from applying practice guidelines at a community hospital.

Fisher MM, Raper RF Withdrawing and withholding treatment in intensive care. Part 2. Patient assessment [see comments] Comment in: Med J Aust 1990;153:Med J Aust

In order to allocate resources fairly in intensive care units, and to avoid treatment which only prolongs dying, accurate prediction of outcome is necessary. Most systems that have been developed to predict the outcome of treatment are flawed and are little better than the guesses of experienced medical and nursing staff. The likelihood of survival must then be weighed against a subjective assessment of quality of life. The perception that intensive care wastes resources on patients who have little chance of survival should be reassessed in the light of our limited ability to detect hopelessly ill patients before embarking upon treatment.

Maynard A The design of future cost-benefit studies. Am Heart J 1990;119:761-5

An economic evaluation is designed to prioritize expenditure, aid decision making, and inform medical audit. A good economic evaluation is explicit and clearly describes the alternative therapies to be evaluated. The evaluation takes into consideration the cost of each component and measures outcome in economic benefit and physical, social, and psychologic well-being. A variety of approaches can be used to assess quality of life, and a good economic evaluation will use a range of measures. Costs and outcomes of health care interventions typically accrue across time periods, and the analysis must allow for this. Similarly, data must answer the question; how much does it cost to identify one additional unit of benefit? Because all evaluations are imprecise both in cost and outcome, sensitivity analysis is needed to determine the effect that different assumptions have on the results.

Soumerai SB, Avorn J Principles of educational outreach ('academic detailing') to improve clinical decision making. JAMA 1990;263:549-56

With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior changes can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health

Loomes G, McKenzie L The use of QALYs in health care decision making. Soc Sci Med 1989;28:299-308

This paper seeks to highlight some of the critical issues concerning the use of the Quality Adjusted Life Years (QALYs) to measure the outcome of health care choices, in decisions related to both individual patient care and social resource allocation. Much of the support for the QALY is based on its simplicity as a tool for resolving complex choices. However, it may be the case that the QALY is not sufficiently refined or robust, failing perhaps to take into account some of the critical factors which affect preferences over different health care scenarios.

Scitovsky AA Medical care in the last twelve months of life: the relation between age, functional status, and medical care expenditures. Milbank Q 1988;66:640-60

Medical care expenditures of a group of decedents during their last year of life suggest that high-technology medical services may be allocated most rationally than is generally assumed. Patients who received intensive hospital and physician services were largely the "young old," aged 65 to 79 years with good functional status, while the frail "older old," aged 80 years and over, received largely supportive care. Total care expenses of the older old were only slightly below those of the most expensive decedents, however, as expenses for nursing home and home health care more than offset lower medical service expenses. Further studies are needed before concluding that the major cause of high costs at teh end of life is the inappropriate use of high-technology care.