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Using MR imaging–based detection of carotid plaque intraplaque hemorrhage as a risk stratification strategy is cost-effective in most patients and may be a useful means to inform personalized medical decision making for stroke prevention in asymptomatic carotid artery stenosis.

Led by the Affordable Care Act, the U.S. health care system is undergoing a transformative shift toward greater accountability for quality and efficiency. Academic health centers (AHCs), whose triple mission of clinical care, research, and education serves a critical role in the country’s health care system, must adapt to this evolving environment. Doing so successfully, however, requires a broader understanding of the wide-ranging roles of the AHC. This article proposes a conceptual framework through which the triple mission is expanded along four new dimensions: health, innovation, community, and policy. Examples within the conceptual framework categories, such as the AHCs’ safety net function, their contributions to local economies, and their role in right-sizing the health care workforce, illustrate how each of these dimensions provides a more robust picture of the modern AHC and demonstrates the value added by AHCs. This conceptual framework also offers a basis for developing new performance metrics by which AHCs, both individually and as a group, can be held accountable, and that can inform policy decisions affecting them. This closer examination of the myriad activities of modern AHCs clarifies their essential role in our health care system and will enable these institutions to evolve, improve, be held accountable for, and more fully serve the health of the nation.

Ultrasonographic plaque echolucency has been studied as a stroke risk marker in carotid atherosclerotic disease. We performed a systematic review and meta-analysis to summarize the association between ultrasound-determined carotid plaque echolucency and future ipsilateral stroke risk.

Wide variations exist in healthcare expenditures, though most prior studies have assessed aggregate utilization. We sought to examine healthcare utilization variation in New York State by assessing hospitals in peer groups of similar capabilities.

The United States Food and Drug Administration (FDA) has proposed creating a unique device identification (UDI) system for medical devices to facilitate postmarket surveillance, quality improvement, and other applications. Although a small number of health care institutions have implemented initiatives comparable with the proposed UDI system by capturing data in electronic health record (EHR) systems, it is unknown whether institutions with fewer resources will be able to similarly implement UDI.

Aims:To provide evidence on the comparative effectiveness of oral diabetes drug combinations. Methods:We performed a retrospective, observational cohort study of glycosylated hemoglobin change in outpatients newly exposed to dual- or triple-drug oral diabetes treatment. Results:Adjusted response to a second drug added to metformin ranged from 0.85 to 1.21% glycosylated hemoglobin decline. Response to a third drug was smaller (0.53–0.91%). Higher baseline glycosylated hemoglobin was associated with larger response; sulfonylurea effectiveness declined over time; and thiazolidinediones were more effective in obese patients and women. Conclusion:Observational data provide results qualitatively consistent with the limited available randomized data on diabetes drug effectiveness, and extend these findings into common clinical scenarios where randomized data are unavailable. Sex and BMI influence the comparative effectiveness of diabetes drug combinations.

MRI characterization of carotid plaque has been studied recently as a potential tool to predict stroke caused by carotid atherosclerosis. We performed a systematic review and meta-analysis to summarize the association of MRI-determined intraplaque hemorrhage, lipid-rich necrotic core, and thinningrupture of the fibrous cap with subsequent ischemic events.

The regional variability of percutaneous coronary intervention (PCI) rates may be explained by variations in the medical treatment of stable coronary artery disease. We sought to determine whether greater regional use of antianginal medications in PCI patients is associated with lower regional rates of PCI.

Racial disparities in medical care in the United States are pervasive and persistent. Minorities, African American patients in particular, have lower utilization rates for coronary artery bypass graft surgery (CABG) and, compared with white patients, they receive care from surgeons with worse records of performance.

Quality report cards have become common in many health care markets. This study evaluates their effectiveness by examining the impact of the New York State (NYS) Cardiac Surgery Reports on selection of cardiac surgeons. The analyses compares selection of surgeons in 1991 (pre-report publication) and 1992 (post-report publication). We find that the information about a surgeon's quality published in the reports influences selection directly and diminishes the importance of surgeon experience and price as signals for quality. Furthermore, selection of surgeons for black patients is as sensitive to the published information as is the selection for white patients.

Background Post-exposure prophylaxis is a critical component of the public health response to bioterrorism. Computer simulation modeling may assist in designing antibiotic distribution centers for this task.Methods The authors used discrete event simulation modeling to determine staffing levels for entry screening, triage, medical evaluation, and drug dispensing stations in a hypothetical antibiotic distribution center operating in low, medium, and high disease prevalence bioterrorism response scenarios. Patient arrival rates and processing times were based on prior mass prophylaxis campaigns. Multiple sensitivity analyses examined the relationship between average staff utilization rate (UR) (i.e., percentage of time occupied in patient contact) and capacity of the model to handle surge arrivals.Results Distribution center operation required from 93 staff for the low-prevalence scenario to 111 staff for the high-prevalence scenario to process approximately 1000 people per hour within the baseline model assumptions. Excess capacity to process surge arrivals approximated (1-UR) for triage staffing.Conclusions Discrete event simulation modeling is a useful tool in developing the public health infrastructure for bioterrorism response. Live exercises to validate the assumptions and outcomes presented here may improve preparedness to respond to bioterrorism.

The American Academy of Pediatrics (AAP) recommends oral rehydration therapy (ORT) for management of uncomplicated childhood gastroenteritis with mild-moderate dehydration. However, ORT is widely underused relative to their recommendations. We compared ORT use by directors of Pediatric Emergency Medicine (PEM) fellowship training programs with AAP recommendations, and sought to identify their barriers to ORT.

Combining medical decision theory and epidemiologic information, the authors have devel oped a strategy to assess diagnostic technologies. For any patient, patient utilities with new diagnostic information are compared with the preferred fallback action absent that diagnostic information. After determination of whether the expected value of diagnostic information (EVDI) justifies its cost, the method adds across the eligible population to determine whether the global EVDI justifies the technology's deployment, employing a screen (Hurdle 1) that assumes that the diagnostic device has perfect accuracy. This preliminary evaluation relies on published data on treatment efficacy, population probabilities of illness, etc., but not on new clinical trials. If the technology is not sufficiently cost-effective, even with this optimistic assumption, the strategy recommends against its use. Otherwise, the next step is Hurdle II, in which the critical clinical studies, identified by the decision-theory model, are undertaken. These commonly include measuring the actual diagnostic accuracy of a device, with which the cost-effectiveness is recalculated. These studies in general do not require randomized controlled trials. Key words:technology assessment; decision theory; diagnostic information. (Med Decis Making 8:279-289, 1988)

OBJECTIVE: Magnetic resonance imaging, computed tomography, cerebrospinal fluid analysis, and evoked potential testing are used to assist in the diagnosis of patients suspected to have multiple sclerosis (MS). The impact of these tests on a clinician's diagnosis of patients suspected to have MS has not been studied systematically. DESIGN: Clinicians made a diagnosis of each patient following clinical evaluation, again after reviewing the results of magnetic resonance imaging, and finally after reviewing information from other laboratory testing. These diagnoses were compared with the criterion standard of a masked "gold standard" panel reviewing all information after a mean follow-up of 0.9 year. SETTING: The General Neurology Clinic and Multiple Sclerosis Clinic of the University of Rochester (NY). PATIENTS: A consecutive sample of 62 patients diagnosed as having either possible or probable MS following clinical evaluation. MAIN OUTCOME MEASURE: Changes in diagnostic certainty of clinicians following incremental presentation of new laboratory data and the accuracy of such diagnoses. RESULTS: Clinicians used magnetic resonance imaging findings to diagnose definite MS or to eliminate MS from diagnostic consideration in 44% of cases. In these cases, further laboratory testing did not alter clinicians' decisions. In the remaining 56% of cases, in which magnetic resonance imaging did not lead to a diagnosis of definite MS or eliminate MS from diagnostic consideration, further laboratory testing led to such diagnoses in an additional 13% of cases. Gold standard diagnoses were in agreement with the clinician's assessments. CONCLUSIONS: Magnetic resonance imaging aids in the evaluation of patients suspected to have MS; other subsequent studies (computed tomography, cerebrospinal fluid analysis, and evoked potential testing) have less impact. After all studies are performed, about half of such patients still have a tentative diagnosis.

OBJECTIVE: To determine the value of diagnostic information to patients with suspected multiple sclerosis (MS). Because treatment choices would be only minimally affected by earlier diagnosis for most patients with this clinical problem, this study assessed the "nondecisional" value of diagnosis. DESIGN: Prospective survey of patients before and after diagnostic workup, including imaging with magnetic resonance scanning. We assessed the effect of diagnostic information on patients' sense of well-being, as well as direct measures of the utility of information (using time trade-off and willingness-to-pay techniques). SETTING: Patients referred from primary care practices for diagnostic workup for suspected MS to neurology clinics and practices. PATIENTS: Sixty-eight individuals, mean age 37.5 years, 53 female and 15 male. Thirty-one patients were classified as having "probable MS,"and 37 were classifed as having "possible MS" by the examining neurologist before workup. MEASUREMENTS: Present and future health perception, uncertainty about diagnosis-prognosis, and level of anxiety. Willingness to pay for diagnostic information, quality of life as measured by the time trade-off technique, and psychological state of the patient before and after diagnosis. RESULTS: Diagnostic uncertainty fell significantly as a result of the diagnostic workup. Most patients (59/62) said that they were better off having received diagnostic information. Although anxiety seemed to be reduced by testing, overall anxiety levels did not decrease as much as anticipated. Patients also became less optimistic about their future health after testing. On average, patients were willing to forgo 4.5 quality-adjusted life days to receive an earlier diagnosis and their quality of life after diagnosis improved slightly. Subgroups of patients differed in their response to diagnostic information. Those in whom no definitive diagnosis emerged tend to be more anxious rather than being reassured by the "negative" workup. Individuals with "positive" workups became less anxious and expressed favorable feelings about the diagnostic workup even though they often faced a chronic disease. CONCLUSIONS: Overall, the diagnostic workup seemed to benefit patients and improve their sense of well-being. However, whether the effects were beneficial or not depended on the results of the diagnostic workup itself. In clinical practice the decision to undergo testing in situations in which definitive treatment is unavailable should be individualized. The potential for negative as well as positive consequences should be recognized.

To determine the clinical usefulness of the activated partial thromboplastin time in screening patients before surgery, we related preoperative test results to the occurrence of hemorrhagic complications, studying all adult inpatients undergoing invasive diagnostic or therapeutic procedures at a large university hospital during a one-year period. Using clinical characteristics to divide the population into two groups according to a priori risk of hemorrhagic complications, we found that the activated partial thromboplastin time had no ability to predict the occurrence or absence of hemorrhage in the low-risk group, but that it was a predictor of modest strength in the high-risk group. Our data justify limiting preoperative coagulation screening to patients with active bleeding, known or clinically suspected bleeding disorders (including use of anticoagulants), liver disease, malabsorption, malnutrition, or other conditions associated with acquired coagulopathies and patients whose procedures may interfere with normal coagulation.(JAMA 1986;256:750-753)

We describe an outcome-based approach to quality assurance in primary care and present data from an initial study made to explore its usefulness. A questionnaire, which asked patients to report on the status of their problem in terms of the amount of symptoms, activity limitation, and anxiety it caused, was mailed to adults who had been seen a month previously for upper respiratory tract infection, sore throat, or urinary tract infection. Outcome standards developed for these conditions indicated that patients should report no symptoms, activity limitation, or anxiety. Of the 127 patients who responded, 17% failed to meet these standards. A review of their medical records was conducted to test the value of using substandard problem-status outcome as an indicator of important deficiencies in care. Definite deficiencies in care were found for 57% of those with substandard outcomes and for 2% of those with acceptable outcomes. Corrective action was judged likely to benefit 95% of the cases with substandard outcome and 7% of those with acceptable outcomes. Data from the medical records were insufficient to explain the reasons for substandard outcome in all cases, thus emphasizing the need to examine also patient- and system-related variables not evident in the medical record.

Decision-analytic methods can be valuable for targeting research in technology assessment. They can indicate whether further evaluation of a technology is warranted, and if so, which variables are key determinants of its clinical utility and cost-effectiveness. This approach was tested on a salient issue—whether magnetic resonance imaging (MR) should be used in evaluating patients with mild neurologic symptoms who might have multiple sclerosis (MS). The authors developed a decision-analytic model to assess the expected utility and costs associated with immediately using MR in this situation, compared with waiting for further symptoms to emerge before testing. Sensitivity analyses demonstrated that priorities for technology assessment research include estimating the value of information to patients in resolving uncertainty, evaluating the impact on patients of being labeled with a diagnosis of MS, and measuring the test characteristics of MR. Key words: cost-benefit analysis; multiple sclerosis; magnetic resonance imaging; decision analysis; Markov models. (Med Decis Making 1990;10:77-94)

The degree of consensus and the accuracy of subjective prior probability estimates made by 104 clinicians were examined. The clinicians' estimates were compared with objective prior probabilities obtained from published sources and actual patient outcomes. Each cli nician made seven estimates based upon written case summaries abstracted from patient records. Consensus was measured by calculating estimate ranges and standard deviations. The clinicians' estimates varied widely: the smallest range was 80 (2%-82%); four of the seven probability ranges were greater than 90. The average standard deviation was 19.5. Using these prior probabilities and Bayes' theorem, widely varying posttest probabilities would result after many common diagnostic tests. Accuracy was measured using the Brier score, which ranges from 0 to 1; a score of 0 indicates perfect accuracy. The clinicians' Brier scores ranged from 0.05 to 0.57. The objectively determined probabilities achieved a Brier score of 0.11, better than that of 96% of the clinicians. Clinical experience did not consistently affect estimate accuracy or consensus. The clinicians' subjective estimates were inaccurate measures of the prior probability of disease. There was little consensus regarding disease likelihood among the clinicians. Objective prior probabilities were more accurate and less variable. Key words: diagnosis; decision making; probability. (Med Decis Making 6:216- 223, 1986)

The purpose of this study was to determine the cost-effectiveness of prostate biopsy at different excess prostate-specific antigen (PSA) levels as a function of age.

• We examined the clinical utility of routine admission laboratory testing for medical disorders in 250 psychiatric inpatients by using clinical criteria to classify laboratory abnormalities as true- or false-positive results. The mean number of tests per patient was 27.7. The mean percentage of true-positive results was 1.8%; the mean predictive value was 12%. When three clinically defined subgroups were examined, both measures of test performance varied in direct proportion to the pretest probability of medical disease. Eleven patients (4%) had important medical problems discovered through routine laboratory testing. A testing battery consisting of nine tests in women and 13 in men would have identified all of these patients. Our results suggest that extensive, routine testing for medical disorders in this setting is unnecessary and that more efficient and accurate testing strategies, based on clinical information, can and should be developed.(Arch Intern Med 1985;145:2085-2088)

The ambulatory component of residency training jointly produces two products, namely, training and patient services. In costing educational programs of this type, two approaches are frequently taken. The first considers the total costs of the educational program, including training and patient services. These costs are usually constructed from historical accounting records. The second approach attempts to cost the joint products separately, based upon estimates of future changes in program costs, if the product in question is added to or removed from the program. The second approach relates to typical decisions facing the managers of medical centers and practices used for teaching purposes. This article reports such a study of costs in a primary-care residency training program in a hospital outpatient setting. The costs of the product, i.e., on-the-job training, are evaluated using a replacement-cost concept under different levels of patient services. The results show that the cost of the product, training, is small at full clinical utilization and is sensitive to changes in the volume of services provided.

The costs of postgraduate medical education remain a relevant topic for educators and managers as well as for the payors of medical care. Historically, the pervasive problem has been that of identifying education costs in a program that jointly produces patient services and research as well as training. This problem is often approached by an accounting “allocation” of program costs to education. The previous literature on calculating the costs of medical education is reviewed in this paper and the theory related to joint product costing presented as an alternative to the accounting approach. A discussion of the issue centered around an example selected from a teaching hospital outpatient practice is presented.

To determine whether a community-wide experiment in hospital prospective payment adversely affected quality of care, availability and outcomes of care were studied in Rochester, NY from 1980 to 1984. During this 5-year period, prospective payment contained hospital expenditures in a community that was already below the national average in health-care costs. Access to necessary care was maintained, and there were increased admissions for management of maternal illness and acute myocardial infarction. Rates of inpatient elective surgery declined. Outcomes of care remained stable, including neonatal deaths, ischemic heart disease deaths, deaths from five selected surgical conditions, and rates of adverse outcomes from sentinel medical and surgical conditions. These results indicated that prospective payment programs in which incentives to decrease marginal or unneeded care are linked with a community-wide effort to plan for the delivery of services can be financially and clinically successful.

• We performed a double-blind, controlled clinical trial comparing phentermine resin (30 mg in the morning), fenfluramine hydrochloride (20 mg three times a day), and a combination of phentermine resin (15 mg in the morning) and fenfluramine hydrochloride (30 mg before the evening meal), and placebo. We combined low doses of the two drugs to maintain efficacy while diminishing adverse effects. Eighty-one people with simple obesity (130% to 180% of ideal body weight) participated. Individualized diets were prescribed and discussed again during the 24-week study period. Weight loss in those receiving the combination (8.4±1.1 kg; mean±SEM) was significantly greater than in those receiving placebo (4.4±0.9 kg; Scheffé's test) and equivalent to that of those receiving fenfluramine (7.5±1.2 kg) or phentermine (10.0±1.2 kg) alone. Adverse effects were less frequent with the combination regimen than with other active treatments. Thirty-seven participants dropped out of the study, 18 for reasons related to drug treatment. Combining fenfluramine and phentermine capitalized on their pharmacodynamic differences, resulting in equivalent weight loss, fewer adverse effects, and better appetite control.(Arch Intern Med 1984;144:1143-1148)

To evaluate the cost-effectiveness of routine antenatal varicella serologic screening of pregnant women with negative or indeterminate varicella histories.

Practice patterns and patient-reported outcomes of care are compared in detail for ten physicians and 12 new health practitioners delivering ambulatory care in two departments of a prepaid group practice, the Columbia Medical Plan (CMP). All providers completed questionnaires for a 50 per cent random sample of patients seen during a two-week period. Patients completed questionnaires prior to receiving care and were interviewed one week and one month after their clinic visits.

Quality report cards are becoming increasingly more common and receive much publicity. They can have significant impact on competition among providers, costs, and quality of health care. The authors test the hypotheses that hospitals and surgeons with better outcomes reported in the NYS Cardiac Surgery Reports experience a relative increase in their market share and prices.

Early identification of patients at low risk for poor outcome after acute upper gastrointestinal hemorrhage would allow reduction of diagnostic and therapeutic interventions. We identified six early predictors of good outcome: age less than 75 years, no unstable comorbid illness, no ascites found on physical examination, normal prothrombin time, and, within an hour after presentation, systolic blood pressure of 100 mm Hg or greater and nasogastric aspirate free of fresh blood. Presence of all six predictors defined the low-risk population. Among 162 patients in the development and retrospective validation phases of our study, all 74 low-risk patients had good outcomes. A prospective validation study of 111 patients further established the accuracy of our predictive method; only two of 52 low-risk patients had poor outcomes. Application of our method should allow more selective management of patients with acute upper gastrointestinal hemorrhage.(JAMA 1985;253:3282-3285)