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Swisher-McClure S, Bekelman JE. It's the Team, Not the Beam. Int J Radiat Oncol Biol Phys 2019; 104:734-736. [PMID: 31204658 DOI: 10.1016/j.ijrobp.2019.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/01/2019] [Accepted: 02/06/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Samuel Swisher-McClure
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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2
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Martinho AM, Turner L. Stem cells in court: historical trends in US legal cases related to stem cells. Regen Med 2017. [DOI: 10.2217/rme-2017-0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Using two legal research platforms, we identified 193 stem-cell-related legal cases that were decided in US courts. Classifying the cases by category, we examined historical trends in the types of legal cases related to stem cells. Major types of cases involved plaintiffs seeking to overturn denial of health insurance coverage decisions, disputes related to intellectual property, false advertising, breaches of contract, exposure to hazardous agents, regulatory decisions, stem cell procedures and professional standard of care, use of stems cells in research, and public funding of embryonic stem cell research. Analysis of court decisions provides insight into contemporary and historical legal issues related to stem cells and reveals the breadth of stem-cell-related cases now being decided by US courts.
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Affiliation(s)
| | - Leigh Turner
- CVS Health, 2211 Sanders Rd, Northbrook, IL 60062, USA
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3
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Droste S, Herrmann-Frank A, Scheibler F, Krones T. Ethical issues in autologous stem cell transplantation (ASCT) in advanced breast cancer: a systematic literature review. BMC Med Ethics 2011; 12:6. [PMID: 21496244 PMCID: PMC3103481 DOI: 10.1186/1472-6939-12-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 04/15/2011] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND An effectiveness assessment on ASCT in locally advanced and metastatic breast cancer identified serious ethical issues associated with this intervention. Our objective was to systematically review these aspects by means of a literature analysis. METHODS We chose the reflexive Socratic approach as the review method using Hofmann's question list, conducted a comprehensive literature search in biomedical, psychological and ethics bibliographic databases and screened the resulting hits in a 2-step selection process. Relevant arguments were assembled from the included articles, and were assessed and assigned to the question list. Hofmann's questions were addressed by synthesizing these arguments. RESULTS Of the identified 879 documents 102 included arguments related to one or more questions from Hofmann's question list. The most important ethical issues were the implementation of ASCT in clinical practice on the basis of phase-II trials in the 1990s and the publication of falsified data in the first randomized controlled trials (Bezwoda fraud), which caused significant negative effects on recruiting patients for further clinical trials and the doctor-patient relationship. Recent meta-analyses report a marginal effect in prolonging disease-free survival, accompanied by severe harms, including death. ASCT in breast cancer remains a stigmatized technology. Reported health-related-quality-of-life data are often at high risk of bias in favor of the survivors. Furthermore little attention has been paid to those patients who were dying. CONCLUSIONS The questions were addressed in different degrees of completeness. All arguments were assignable to the questions. The central ethical dimensions of ASCT could be discussed by reviewing the published literature.
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Affiliation(s)
- Sigrid Droste
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | | | - Fueloep Scheibler
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Tanja Krones
- Institute of Biomedical Ethics, University Hospital, Zurich, Switzerland
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Sullivan KM, Muraro P, Tyndall A. Hematopoietic cell transplantation for autoimmune disease: updates from Europe and the United States. Biol Blood Marrow Transplant 2009; 16:S48-56. [PMID: 19895895 DOI: 10.1016/j.bbmt.2009.10.034] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Considerable advances have been made in our understanding of the immunobiology of autoimmune disease and its treatment with hematopoietic cell transplantation (HCT). In autoimmune disorders, the reconstituted immune system following lymphoablation and autologous HCT yields qualitative changes in immune defects and modifications in adaptive immune responses. Seminal experiments in animals demonstrated that allogeneic or autologous HCT could prevent progression or reverse organ damage from inherited (genetic) or acquired (antigen induced) autoimmune diseases. Convincing animal and clinical data now show that after HCT, the immune system is normalized and "reset". Following autologous transplantation, this resetting occurs via repertoire replacement. It is currently being studied whether and to what extent suppression of inflammation after HCT is due to reregulation of function or due to the eradication of disease associated T and/or B cell populations. There are now a number of published clinical reports with sufficient follow-up for determinations of safety and efficacy of HCT for autoimmune diseases. On behalf of colleagues in the European League Against Rheumatism (EULAR) and the European Group for Blood and Marrow Transplantation (EBMT), we review the experience with more than 1000 transplants for autoimmune disease in Europe along with the three major multinational randomized trials in for systemic sclerosis (SSc, the ASTIS study), multiple sclerosis (MS, the ASTIMS study), and Crohn's disease (CD, the ASTIC study). Completed phase II studies in the USA of transplantation for severe SSc, SLE and MS yield promising results. For individuals with SSc, there is dramatic improvement/resolution of dermal fibrosis and stabilization/improvement of pulmonary dysfunction reported up to 8 years after lymphoablative conditioning and autologous HCT. Currently, randomized phase III studies are recruiting subjects in the USA with SSc, MS and CD. In addition, 9 other phase I and II trials in the USA are recruiting patients with autoimmune diseases for nonmyeloablative transplants from allogeneic stem cell donors. Research opportunities abound, but recruitment challenges restrict study entry due to organ impairment from advanced autoimmune disease or insurance denial of coverage for HCT. However, within several NIH sponsored trials there are ongoing immunologic, genomic and mechanistic studies to further understand the molecular mechanisms of autoimmunity, immune regulation and response to treatment. These clinical trials will provide basic scientists with insight into immunoregulatory pathways and clinicians with a context to weigh the progress and evidence in this evolving treatment for autoimmune diseases.
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Affiliation(s)
- Keith M Sullivan
- Division of Cellular Therapy, Duke University Medical Center, Durham, North Carolina 27708, USA.
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5
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Mayer M. Listen to all the voices: an advocate's perspective on early access to investigational therapies. Clin Trials 2007; 3:149-53. [PMID: 16773957 DOI: 10.1191/1740774506cn144oa] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this issue of the journal, The Society for Clinical Trials, whose members are clinical investigators and regulators in academia, government and industry, has published the rationale for their opposition to US Senate bill S. 1956, the so-called "ACCESS" act, which would allow the marketing of therapies that have undergone only Phase I studies (dose finding and toxicity testing) in humans, to patients with "serious and life-threatening" disease who have exhausted other treatment options. While this bill reflects the views and efforts of some cancer advocates and their supporters, it does not represent the beliefs of the cancer advocacy community overall. The essay that follows is inspired by the need for other voices from the patient and advocacy communities to be heard in this debate.
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6
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Du W, Reeves JH, Gadgeel S, Abrams J, Peters WP. Cost-effectiveness and lung cancer clinical trials. Cancer 2003; 98:1491-6. [PMID: 14508837 DOI: 10.1002/cncr.11659] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Lung cancer is the leading cause of cancer death in the U.S., with an estimated annual economic burden of $5 billion. Clinical trials offer innovative therapeutic options with potentially better outcomes, but their effects on health care costs are disputed. METHODS The authors analyzed the 1-year facility-based treatment cost and survival of 336 newly diagnosed nonsmall cell lung cancer patients who were deemed eligible for clinical trials between 1994 and 1998 at the Karmanos Cancer Institute. The incremental cost-effectiveness ratio (ICER) of clinical trial treatments with adjustment for confounders was calculated along with its 95% confidence interval (CI) using the bootstrap resampling method. RESULTS Of the 336 patients, 76 (22.6%) were treated on clinical trials. Trial participation was associated significantly with race (P < 0.01), gender (P = 0.01), age (P = 0.02), and insurance type (P = 0.02). The average 1-year cost for trial enrollees was $41,734 with a median survival of 1.3 years, whereas the average 1-year cost for nonenrollees was $34,191 with a median survival period of 0.9 years. Differences in survival and 1-year cost between enrollees and nonenrollees were significant when controlling for age, race, gender, insurance, stage, performance status, and comorbidities. The ICER for trial participation after adjustment for confounders was $9741 per life year saved (95% CI, $3089-$19,149). CONCLUSIONS Enrollment in lung cancer clinical trials was found to be associated with improved survival at a moderate incremental cost. Cancer 2003;98:1491-6.
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Affiliation(s)
- Wei Du
- Center for Cancer Economics, Technology Assessment, Innovation and Development (CETAID), Karmanos Cancer Institute, Detroit, Michigan 48201, USA.
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7
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Morreim EH. A dose of our own medicine: alternative medicine, conventional medicine, and the standards of science. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2003; 31:222-235. [PMID: 12964266 DOI: 10.1111/j.1748-720x.2003.tb00083.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The discussion about complementary and alternative medicine (CAM) is sometimes rather heated. “Quackery!” the cry goes. A large proportion “of unconventional practices entail theories that are patently unscientific.” “It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.” “I submit that if these treatments cannot withstand the test of empirical research, … then we have wasted a lot of time and effort. The time has been wasted on all the people who have spent years learning falsehoods about acupuncture points and the principles of homeopathy. And the patients have wasted their time, money, and efforts receiving treatments that were not what they were represented to be or were harmful.”
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Affiliation(s)
- E Haavi Morreim
- College of Medicine, University of Tennessee Health Science Center, Memphis, USA
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8
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Welch HG, Mogielnicki J. Presumed benefit: lessons from the American experience with marrow transplantation for breast cancer. BMJ 2002; 324:1088-92. [PMID: 11991918 PMCID: PMC1123033 DOI: 10.1136/bmj.324.7345.1088] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- H Gilbert Welch
- VA Outcomes Group (111B), Department of Veterans Affairs, White River Junction, VT 05009 USA.
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Mello MM, Brennan TA. The controversy over high-dose chemotherapy with autologous bone marrow transplant for breast cancer. Health Aff (Millwood) 2001; 20:101-17. [PMID: 11558695 DOI: 10.1377/hlthaff.20.5.101] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the 1990s more than 41,000 patients underwent high-dose chemotherapy plus autologous bone marrow transplant (HDC-ABMT) for breast cancer, despite a paucity of clinical evidence of its efficacy. Most health plans reluctantly agreed to cover the treatment in response to intensive political lobbying and the threat of litigation. The results of five recent major randomized trials showed that HDC-ABMT offers no advantage over standard-dose treatment for breast cancer. Our experience with HDC-ABMT coverage cautions against allowing politics to overwhelm science in the area of evaluating experimental procedures, and against relying on the courts as a means of resolving disagreements about coverage of these interventions.
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Affiliation(s)
- M M Mello
- Harvard School of Public Health in Boston, USA
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10
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De Rosa L, Lalle M, Pandolfi A, Pescador L. Costs of high-dose chemotherapy and peripheral blood progenitor cell autograft for breast cancer. Bone Marrow Transplant 2001; 27:1031-5. [PMID: 11438817 DOI: 10.1038/sj.bmt.1703040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2000] [Accepted: 03/12/2001] [Indexed: 11/09/2022]
Abstract
The aim of the study was to analyze the real cost of single or tandem high-dose chemotherapy (HDC) and peripheral blood progenitor cell autologous transplant (PBPCT) in patients with breast cancer. We analyzed the costs of 40 PBPCT performed in 20 patients. Tandem transplant was planned for each patient. Resources used and direct costs were identified for each patient. The study was carried out using the hospital perspective and monetary values were reported in 1999 Euro. The mean cost of whole procedure for single transplant was 20,816.63 Euro, while the mean cost of tandem transplant was 38,770.83 Euro. The cost distribution in the two groups was similar: the most expensive phase of procedure was the supportive phase post transplant (about 60% of total cost), with the categories of cost most represented being professional fees (about 28%) and pharmacy (about 35%). Awaiting more convincing trials of the clinical advantage of HDC in breast cancer, our analytical evaluation of transplant costs for different therapeutic options, single or tandem, permits identification of the most expensive categories in order to intervene for cost savings.
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Affiliation(s)
- L De Rosa
- Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera S Camillo-Forlanini, Rome, Italy
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11
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Morreim EH. From the clinics to the courts: the role evidence should play in litigating medical care. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2001; 26:409-427. [PMID: 11330087 DOI: 10.1215/03616878-26-2-409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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12
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Ramsey SD, Sullivan SD, Kaplan RM, Wood DE, Chiang YP, Wagner JL. Economic analysis of lung volume reduction surgery as part of the National Emphysema Treatment Trial. NETT Research Group. Ann Thorac Surg 2001; 71:995-1002. [PMID: 11269488 DOI: 10.1016/s0003-4975(00)02283-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND In today's cost-conscious health care environment, obtaining timely and accurate economic information regarding new medical technologies has become extremely important. The National Emphysema Treatment Trial, a multicenter, randomized controlled trial of lung volume reduction surgery (LVRS) plus medical therapy, versus medical therapy for patients with severe emphysema, includes a parallel cost-effectiveness analysis. METHODS The analysis is designed to determine the cost-effectiveness of LVRS versus medical therapy for those who are eligible for the procedure. After describing theoretical foundations of cost-effectiveness analysis as they apply to this study, we describe the economic and quality of life data that are being collected alongside the clinical trial, methods of analysis, and approach to presenting the results. RESULTS The cost-effectiveness of LVRS relative to medical therapy will be presented as costs per quality-adjusted life years gained. CONCLUSIONS This analysis will provide timely economic data that can be considered alongside the clinical results of the National Emphysema Treatment Trial. As one of the largest clinical trials to include a parallel, prospective cost-effectiveness analyses, this study will also provide valuable practical information about conducting an economic analysis alongside a multicenter clinical trial.
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Affiliation(s)
- S D Ramsey
- Department of Medicine, University of Washington, Seattle, USA.
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13
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Abstract
Managed care has affected clinical research at academic medical centers (AMCs) in various ways. It has reduced revenues for both faculty practice plans and major teaching hospitals, thus constraining the internal funds available for the cross-subsidy of research. It has increased the amount of patient care required of academic clinicians to meet target incomes, thus reducing the time for research. Has managed care also reduced the availability of patients for academic clinical research, either indirectly by diverting patients to community hospitals or directly by constraining access to such research, including clinical trials? Consistent with other studies and based on extensive interviews at nine AMCs, this research found little evidence that patients were a scarce resource for academic clinical research.
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14
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Baynes RD, Dansey RD, Klein JL, Karanes C, Cassells L, Abella E, Wei WZ, Galy A, Du W, Wood G, Peters WP. High-dose chemotherapy and autologous stem cell transplantation for breast cancer. Cancer Invest 2000; 18:440-55. [PMID: 10834029 DOI: 10.3109/07357900009032816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- R D Baynes
- Bone Marrow Transplant Program, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
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15
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Astier MP, Mayordomo JI, Abad JM, Gómez LI, Tres A. Cost-analysis of high-dose chemotherapy and peripheral blood stem-cell support in patients with solid tumors. Ann Oncol 2000; 11:603-6. [PMID: 10907956 DOI: 10.1023/a:1008392412590] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of High-dose chemotherapy (HDC) with peripheral blood stem cells (PBSC) rescue in the treatment of solid tumors is controversial, and may be an important determinant of HDC and PBSC use in the future. Until the use of these procedures is proven through disease-free survival and overall survival compared with standard-dose chemotherapy, the associated cost is also under discussion. PATIENTS AND METHODS We evaluate 27 consecutive patients with solid tumors who underwent HDC and PBSC rescue, through an accurate review of medical records and cost estimate for each patient. RESULTS Median age was 45 years. Fifteen had breast cancer, six non-Hodgkin's lymphoma and six other solid tumors. The mean hospital length of stay was 21 days and mean cost was 21,445 US dollars (21,232 euro). Mean cost was clearly lower for the 9 patients treated within phase III trials, 17,571 US dollars (17,747 euro) than for the remaining 18 patients, treated in phase I-II trials, 22,747 US dollars (22,975 euro) (P < 0.001). The distribution of costs shows that wages and pharmacy account for 72% of total cost. The distribution of pharmacy costs per patient shows that chemotherapy (56% of pharmacy costs) and antibiotics (26%) account for most of the cost of medication. CONCLUSIONS Our cost estimates agree with those of most countries with national health insurance programs, and are lower than those from the USA. As wages and pharmacy account for more than 70% of the costs, the great different among the costs estimates compared are due essentialy to doctors fees or salary and drugs utilization. Anyway, taking HDC with PBSC rescue as a model for a therapy that is more aggressive than standard, and that is associated to a possible survival improvement in indications such as relapsed high-grade non-Hodgkin's lymphoma, an adequate cost analysis is crucial both to measure cost-effectiveness and to establish payment to health care providers.
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Affiliation(s)
- M P Astier
- Division of Medical Oncology, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain.
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Bodenheimer T, Casalino L. Executives with white coats--the work and world view of managed-care medical directors. First of two parts. N Engl J Med 1999; 341:1945-8. [PMID: 10601517 DOI: 10.1056/nejm199912163412521] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- T Bodenheimer
- Department of Family and Community Medicine, University of California at San Francisco, USA
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17
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Giacomini MK. The which-hunt: assembling health technologies for assessment and rationing. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 1999; 24:715-758. [PMID: 10503155 DOI: 10.1215/03616878-24-4-715] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
To rationalize and restrict health care spending, policy, makers in many jurisdictions have withdrawn insurance or funding for selected health care technologies. Numerous analytic frameworks and applied exercises have emerged to guide decisions about "which" services to cut. But in their focus on choice-making processes, these efforts have paid little attention to the problem of defining and dividing the set of technologies to choose among. If technology assessment refers to methods for weighing services for their relative value, the term technology assembly might be used to refer to methods for framing the technological trade-offs to enroll in such contests. This article examines technology assemblies found in several types of theoretical and applied rationing exercises (including Oregon's Medicaid rationing process, economic evaluation literature, citizen "values" surveys, and Canadian provincial deinsurance policies). Based on this review, some key conceptual conventions and problems in technology assembly can be identified. The boundaries between health technologies are fuzzy, interlocked, layered, and continuously moving. Consequently, the defining features of technological trade-offs are inevitably socially constructed and negotiated. Trade-offs can be arranged along numerous dimensions, and the divisions typically correspond to broader political, administrative, and ethical dilemmas in health policy. Examples include equity among demographic classes, concepts of need, legitimacy of therapeutic goals, and so forth. Insights into the process of constructing technological trade-offs may help policy makers better question what technologies they are looking at and why, before moving on to the task of determining which ones to cover.
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Khanna V, Silverman H, Schwartz J. Disclosure of Operating Practices By Managed-Care Organizations to Consumers of Healthcare: Obligations of Informed Consent. THE JOURNAL OF CLINICAL ETHICS 1998. [DOI: 10.1086/jce199809308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Lazarus HM. Hematopoietic progenitor cell transplantation in breast cancer: current status and future directions. Cancer Invest 1998; 16:102-26. [PMID: 9512676 DOI: 10.3109/07357909809039764] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Breast cancer remains the second leading cause of cancer death despite numerous advances in medical science. In vitro, preclinical, and clinical trials have shown that chemotherapy dose intensity is an important component of therapy. Many clinical trials addressing the use of high-dose chemotherapy and hematopoietic cellular rescue have been conducted over the past decade. Early trials undertaken in heavily pretreated patients who had metastatic disease were associated with high treatment-related mortality rates; good response rates were noted but overall survivals were short. Subsequent technological advances, including the use of recombinant hematopoietic growth factors and peripheral blood progenitor cells as the source of cellular rescue, have dramatically lowered the morbidity and mortality of the procedure, as well as shortened hospital stay and markedly reduced cost. As a result, the high-dose chemotherapy approach has been used earlier in the disease course, both in patients with metastatic disease who were responding and in the adjuvant setting in patients at high risk for relapse. Results of many of these phase II trials are extremely encouraging, and phase III prospective, randomized trials comparing autotransplant to conventional approaches are currently under way. This review discusses past, current, and future initiatives of this modality. Included is a discussion of new preparative regimens, the addition of agents such as biochemical modifiers to enhance antitumor activity, and issues regarding timing of autotransplant, stem cell technology, use of allogeneic stem cells, and posttransplantation therapies.
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Affiliation(s)
- H M Lazarus
- Department of Medicine, Ireland Cancer Center, University Hospital of Cleveland, Case Western Reserve University, Ohio 44106, USA.
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20
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Gaskin DJ, Kong J, Meropol NJ, Yabroff KR, Weaver C, Schulman KA. Treatment choices by seriously ill patients: the Health Stock Risk Adjustment model. Med Decis Making 1998; 18:84-94. [PMID: 9456213 DOI: 10.1177/0272989x9801800116] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Anecdotal evidence suggests that patients who have life-threatening conditions often choose to undergo high-cost, high-risk treatments for them. This kind of risk-seeking behavior seems irrational because most patients are risk-averse. The Health Stock Risk Adjustment (HSRA) model seeks to explain this phenomenon. The model is based on the concept of relative health stock--the ratio of patients' expected quality-adjusted life years (QALYs) after a diagnosis to their expected QALYs before the diagnosis. The model predicts risk-averse patients will behave in a risk-seeking manner as their relative health stocks deteriorate. The HSRA model can help physicians better understand why some seriously ill patients seek high-risk treatments while others elect to forgo treatment. State legislatures and insurers are attempting to appropriately design insurance benefits for patients with life-threatening conditions. The HSRA model can help predict which patients will most likely take advantage of these benefits.
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Affiliation(s)
- D J Gaskin
- Institute for Health Care Research and Policy, Georgetown University Medical Center, Washington, DC 20007, USA
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21
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Glassman PA, Jacobson PD, Asch S. Medical necessity and defined coverage benefits in the Oregon Health Plan. Am J Public Health 1997; 87:1053-8. [PMID: 9224198 PMCID: PMC1380952 DOI: 10.2105/ajph.87.6.1053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The policy debate in Oregon has primarily focused on the Prioritized List of Services. However, little information is available on how defined coverage benefits and managed care affect the role of medical necessity in determining care for Medicaid patients. This issue is important because medical necessity determinations are currently used by many states to limit extraneous health care costs but require resource-intensive oversight, are open to wide variance, and frequently prompt litigation challenging interpretations of what is necessary and what is not. The qualitative study described here addressed whether medical necessity remains a salient and useful concept in the Oregon Health Plan. Our results indicate that defined coverage benefits, as described by the funded portion of the Prioritized List of Services, supplant medical necessity determinations for coverage, while managed care incentives limit the need for medical necessity determinations at the provider level. Clinical choices are, for the most part, guided by providers' judgment within the financial constraints of capitation and by targeted use management techniques. The combination of capitated care and Oregon's defined coverage benefits package has marginalized the use of medical necessity, albeit with consequences for state oversight of Medicaid services.
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Affiliation(s)
- P A Glassman
- West Los Angeles Veterans Affairs Medical Center, USA
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Steiner CA, Powe NR, Anderson GF, Das A. Technology coverage decisions by health care plans and considerations by medical directors. Med Care 1997; 35:472-89. [PMID: 9140336 DOI: 10.1097/00005650-199705000-00005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Decisions made by private health care plans as to whether to cover new medical technology have a significant impact on access, diffusion, and costs. This study describes the variation in health plan coverage of different laser technologies and the types of considerations used in making coverage decisions for them. METHODS In a cross-sectional national survey of medical directors at private plans, medical directors indicated current coverage of 15 different laser therapies, and then ranked the top five considerations both in favor and against recommending coverage for three of the laser therapies (angioplasty, discectomy, and photodynamic therapy). The influence of explicit clinical information and/or plan characteristics on coverage and the importance of considerations was examined through multivariate analyses (multiple logistic or linear regression analysis). RESULTS Overall, 231 medical directors responded from plans representing 66% and 72% of persons in US health maintenance organization and indemnity plans, respectively. Current coverage for 13 of the 15 laser therapies varied between 20% and 90%. For-profit and indemnity plans covered approximately two more of the different laser technologies than nonprofit plans and health maintenance organizations. Considerations most frequently listed in favor of and against recommending coverage across the three laser technologies were clinical, economic, and regulatory. Legal, competitive, and compassionate concerns were listed less frequently. Considerations were not uniform across laser therapies; they reflected the specifics of the technology under review. Plan characteristics influenced the ranking of considerations as well. For instance, health maintenance organizations were two to three times more likely than indemnity plans to list potential for decreased cost in favor of recommending coverage. CONCLUSIONS These findings demonstrate that there is substantial variation in coverage of new technologies, indicating that a large proportion of the population covered by private health plans are ineligible for treatments that are routinely available to others. A greater range of medical therapy may be available for persons enrolled in indemnity and for-profit plans should their physicians choose to prescribe it. Clinical and economic considerations, including cost-effectiveness, predominate in coverage decisions for new technologies. The importance of considerations appears sensitive not only to specific clinical information, however, but also to characteristics of health plans.
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Affiliation(s)
- C A Steiner
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Cranovsky R, Matillon Y, Banta D. EUR-ASSESS Project Subgroup Report on Coverage. Int J Technol Assess Health Care 1997; 13:287-332. [PMID: 9194354 DOI: 10.1017/s0266462300010382] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The issue of health benefits coverage—and its relation to health technology assessment (HTA)—has gained increasing attention in recent years. Economic constraints on health care, as well as the rapid pace of technological change, have forced European countries to face difficult choices in providing such care. The active use of coverage decision making has been proposed as a tool to help rationalize health care, and HTA has been advocated as a necessary activity to improve coverage decisions.
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Affiliation(s)
- R Cranovsky
- Swiss Medical Association, Aarau, Switzerland
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Holdsworth MT. Ethical issues regarding study designs used in serotonin-antagonist drug development. Ann Pharmacother 1996; 30:1182-4. [PMID: 8893129 DOI: 10.1177/106002809603001019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The time has come to develop new methods for the evaluation of antiemetic compounds. The well-established tenet that combination antiemetic therapy is superior to that achieved with any single agent for severely emetogenic cisplatin-containing chemotherapy does not warrant reevaluation with future cancer patients whenever a new antiemetic enters Phase II and III evaluation. New trials should instead focus on the more important issues of whether the new agent in combination offers comparable or superior efficacy to that achievable with the current standard antiemetic regimen for both acute and delayed nausea and vomiting. While proof of efficacy is crucial in drug trials, adequacy of patient care needs to be the first and foremost priority in any trial.
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Sperduto PW, Hall WA. Radiosurgery, cost-effectiveness, gold standards, the scientific method, cavalier cowboys, and the cost of hope. Int J Radiat Oncol Biol Phys 1996; 36:511-3. [PMID: 8892477 DOI: 10.1016/s0360-3016(96)00347-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Steiner CA, Powe NR, Anderson GF, Das A. The review process used by US health care plans to evaluate new medical technology for coverage. J Gen Intern Med 1996; 11:294-302. [PMID: 8725978 DOI: 10.1007/bf02598272] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To examine the process and information used by medical directors (MDs) of private health plans to make medical coverage determinations for new medical technologies, and to assess the influence of plan characteristics on the process. DESIGN Cross-sectional national survey. PARTICIPANTS Two hundred thirty-one MDs at private health plans representing 66% and 72% of the US population covered by HMOs and indemnity plans, respectively. MEASUREMENTS Actual and optimal review process, final decision authority, sources, and evidence used for technology coverage decisions. RESULTS In 96% of plans, MDs take part in the medical policy review process for new technology. However, MDs have final authority over coverage decisions in only 27% of plans. Indemnity plans are more likely to assert that MDs should be responsible for final decisions, odds ration (OR) = 3.3 (95% confidence interval [95% CI] 1.4, 10). Optimal sources of information of new technology were journals, medical society statements or practice guidelines, and opinions of national experts. Actual sources of information used differed from optimal ones; local experts were used more often than is considered optimal (p < .001). For-profit plans were more likely than nonprofit plans to use national experts, OR 2.5 (95% CI 1.3, 5.0), and practice guidelines, OR 5.0 (95% CI 2.5, 10). Randomized trials (94% of MDs) meta-analyses (61%), and reviews (42%) were considered the best evidence for making coverage decisions. Barriers to making optimal decisions were lack of timely evidence on effectiveness and cost-effectiveness, not legal or regulatory issues; HMO, small, and nonprofit plans were two or three times more likely to list lack of cost-effectiveness data than their counterparts (p < .05). CONCLUSIONS Although MDs are nearly always involved in the technology evaluation process, a minority of MDs retain final authority over coverage decisions. Evidence from strong scientific research designs is the most frequently cited basis for decisions, but there is need for more timely, rigorous scientific evidence on medical interventions. How a health plan evaluates a new medical technology for coverage varies with identifiable plan characteristics.
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Affiliation(s)
- C A Steiner
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md, USA
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Borras JM, Granados A, Escarrabill J, de Lissovoy G. Complex decisions about an uncomplicated therapy: reimbursement for long-term oxygen therapy in Catalonia (Spain). Health Policy 1996; 35:53-9. [PMID: 10157041 DOI: 10.1016/0168-8510(95)00768-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Therapies used in the management of chronic diseases cause specific problems regarding reimbursement policy. Oxygen therapy is an example of such treatments that receive little attention from health care policy makers, due to their low cost to the health care budget and to their little importance from a social point of view. In this paper, we analyze the problems posed by this therapy in the Catalan health care system, as an example of the several aspects implied in the reimbursement of such kind of therapies. A technology assessment of this therapy was carried out showing that a change in the reimbursement of long-term home oxygen therapy (LTOT) was needed. Slow diffusion of new oxygen delivery modalities and over-prescription of LTOT were among the problems observed. The new system proposed is presented, and some preliminary results and consequences of the role of technology assessment in health care policy-making are discussed.
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Affiliation(s)
- J M Borras
- Catalan Agency for Medical Technology Assessment, Catalan Health Service, Barcelona, Spain
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Halpern J. Can the development of practice guidelines safeguard patient values? THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 1995; 23:75-81. [PMID: 7627308 DOI: 10.1111/j.1748-720x.1995.tb01334.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
In response to increasing use of practice guidelines in medicine, physicians have focused their attention on how these guidelines can restrict their medical practices. However, guidelines not only restrict physician discretion, but they also limit the treatment options available to patients. As a result, treatments which patients consider beneficial may not be recommended; for example, some hysterectomies for abnormal uterine bleeding, and cataract surgery in patients with dementia. When guidelines are used to determine which medical treatments a health care organization or insurer will cover, these recommendations become restrictions. Thus far, guidelines have been developed without adequate attention to the impact that their restrictive use has on diverse patient values.Two significant tensions in current medical ethics relate to the inclusion of patient values in practice guidelines. First, a tension exists between the traditional paternalistic model of care, in which the physician judges unilaterally which treatments will benefit the patient, and the more recent autonomy model, in which the physician elicits the individual patient's health values to determine which treatments will be beneficial.
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Abstract
As the number and cost of new technologies grow, it is increasingly important that we develop sound policies for payment for those technologies while their clinical impacts are being defined. Such policies need to balance social interests in promotion of innovation, early access to promising technology, patient safety, control of health care costs, and return on investment. We present a rationale, policy options, and a proposal for insurance coverage of experimental technology.
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Morreim EH. Moral justice and legal justice in managed care: the ascent of contributive justice. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 1995; 23:247-265. [PMID: 8713141 DOI: 10.1111/j.1748-720x.1995.tb01361.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Several prominent cases have recently highlighted tension between the interests of individuals and those of the broader population in gaining access to health care resources. The care of Helga Wanglie, an elderly woman whose family insisted on continuing life support long after she had lapsed into a persistent vegetative state (PVS), cost approximately $750,000, the majority of which was paid by a Medi-gap policy purchased from a health maintenance organization (HMO). Similarly, Baby K was an anencephalic infant whose mother, believing that all life is precious regardless of its quality, insisted that the hospital where her daughter was born provide mechanical ventilation, including intensive care, whenever respiratory distress threatened her life. Over the hospital's objections, courts ruled that aggressive care must be provided. Much of Baby K's care was covered by her mother's HMO policy. In the 1993 case ofFox v. HealthNet, a jury awarded $89 million to the family of a woman whose HMO had refused, as experimental, coverage for autologous bone marrow transplant in treating her advanced breast cancer.
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Hsia DC. Benefits determination under health care reform. Who should decide coverage policy? THE JOURNAL OF LEGAL MEDICINE 1994; 15:533-556. [PMID: 7852830 DOI: 10.1080/01947649409510959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- D C Hsia
- Agency for Health Care Policy & Research, U.S. Department of Health & Human Services, Rockville, MD 20852-3148-46
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Cutler CM, Udvarhelyi IS, Winkenwerder W. Variations in insurance coverage for autologous bone marrow transplantation for breast cancer. N Engl J Med 1994; 331:329-30. [PMID: 8022449 DOI: 10.1056/nejm199408043310514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Breast Cancer Treatment LiteratureWatch. J Womens Health (Larchmt) 1994. [DOI: 10.1089/jwh.1994.3.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Affiliation(s)
- K A Buto
- Health Care Financing Administration HCFA
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