Using the net benefit regression framework to construct cost-effectiveness acceptability curves: an example using data from a trial of external loop recorders versus Holter monitoring for ambulatory monitoring of "community acquired" syncope.

BACKGROUND: Cost-effectiveness acceptability curves (CEACs) describe the probability that a new treatment or intervention is cost-effective. The net benefit regression framework (NBRF) allows cost-effectiveness analysis to be done in a simple regression framework. The objective of the paper is to illustrate how net benefit regression can be used to construct a CEAC. METHODS: One hundred patients referred for ambulatory monitoring with syncope or presyncope were randomized to a one-month external loop recorder (n = 49) or 48-hour Holter monitor (n = 51). The primary endpoint was symptom-rhythm correlation during monitoring. Direct costs were calculated based on the 2003 Ontario Health Insurance Plan (OHIP) fee schedule combined with hospital case costing of labour, materials, service and overhead costs for diagnostic testing and related equipment. RESULTS: In the loop recorder group, 63.27% of patients (31/49) had symptom recurrence and successful activation, compared to 23.53% in the Holter group (12/51). The cost in US dollars for loop recording was 648.50 dollars and 212.92 dollars for Holter monitoring. The incremental cost-effectiveness ratio (ICER) of the loop recorder was 1,096 dollars per extra successful diagnosis. The probability that the loop recorder was cost-effective compared to the Holter monitor was estimated using net benefit regression and plotted on a CEAC. In a sensitivity analysis, bootstrapping was used to examine the effect of distributional assumptions. CONCLUSION: The NBRF is straightforward to use and interpret. The resulting uncertainty surrounding the regression coefficient relates to the CEAC. When the link from the regression's p-value to the probability of cost-effectiveness is tentative, bootstrapping may be used.

Use of audiotapes for patient education, medical record documentation, and informed consent in lower extremity reconstruction.

Since 1992, the authors have audiotaped each new patient visit and provided a copy of that tape to the patient. In addition, an office copy of the entire patient interaction is maintained in an office file. One hundred twelve patients seen over a 6-month period participated in a survey measuring their satisfaction with this procedure, and six attorneys were surveyed after listening to a representative tape. Ninety percent of patients had positive comments about receiving the tape. Seventy percent played the tape for others, most commonly their spouses. The attorneys concluded the patient was well served by this process, and there were no increased malpractice issues or exposure. The cost of providing patients with the tapes is minimal, and the high level of patient satisfaction and increased understanding offer a considerable benefit to patients and office staff.

The cost of medical dictation transcription at an academic family practice center.

BACKGROUND: Very little is known about the volume or cost of medical transcription in primary care. A study of the number of lines and cost of transcription at an academic family practice center was performed to establish the average number of lines and costs of transcription by level of service and type of provider (faculty physician, physician assistant, resident physician, and others). METHODS: Parallel 4-month sets of computerized billing records and computerized transcription summary logs (listing the patient name and identification, the dictator, the number of lines of dictation, and the date for each dictation) were merged and analyzed to compare the cost and volume of dictation by types of service and types of provider. RESULTS: During the study period there were 11,085 patient encounters, 9013 with transcription. The average cost of transcription per encounter using transcription was $3.96 and the median was $3.64. The cost per encounter ranged from $0.39 (3 lines of dictation) to $24.83 (191 lines of dictation). Faculty physicians and physician assistants had the lowest cost, resident physicians were intermediate in cost, and others (such as medical students) had the highest costs for medical transcription. Transcription costs rose with increasing level of service but became a smaller proportion of the collected fee, averaging only 5% for a level 5 encounter. CONCLUSIONS: The cost of transcription as a part of overhead was higher than anticipated. Specific education regarding dictation form and content and ways to decrease these costs is appropriate.

A randomized trial of the impact of telephone and recorded delivery reminders on the response rate to research questionnaires.

BACKGROUND: A range of factors have been shown to affect the response rate to mailed questionnaires, but particular strategies to improve patients' response in trials conducted in general practice require further study. METHODS: Non-responders in a larger trial were randomized to receive a telephone or recorded delivery reminder on the third contact. The cost of administration of each method was estimated. RESULTS: Significantly more patients returned completed questionnaires when sent questionnaires by recorded delivery, although the cost per patient contacted was nearly three times more than for contact by telephone. CONCLUSION: Our study indicates that sending reminders by recorded delivery, although more expensive, is more effective than telephone reminders for recruiting patients to a study in general practice using research questionnaires.

Patient interest in receiving audiotapes of information presented by their physicians. A survey of patients awaiting treatment in university and private practice settings.

OBJECTIVE: To investigate patient interest in, and willingness to pay for, tape recordings of physicians' explanations and recommendations. DESIGN: Survey. SETTINGS: An outpatient university-based practice and an outpatient private group practice of family physicians. SUBJECTS: A convenience sample of 425 patients. Of the 409 who agreed to complete the survey, 257 (63%) were awaiting treatment in a university practice and 152 (37%) were awaiting treatment in a private practice. RESULTS: Fifty-four percent of respondents believed that a tape would be helpful, 59.1% thought their family would ask to listen to it, and 77.5% said they would play it for family members. If asked to bring a blank tape, 84.5% indicated that they would do so. If recordings were available for purchase, respondents indicated they would be willing to pay a mean of $1.46 for them. CONCLUSIONS: If physicians offer recordings of their explanations and recommendations, patients are likely to want them. Investigations of actual compliance and health outcomes associated with the use of these recordings appear warranted.

Cost-effectiveness of home relaxation training for tension headaches.

Taped home relaxation training was evaluated in a single-case replication design across three patients suffering from tension headaches. Data from daily headache diaries indicated that headache frequency decreased substantially for two of the patients. For the third patient who reported almost continual headache pain, intensity was reduced by over 50%. When compared with results of our previous research taped home relaxation training appeared as effective as (and therefore, more cost-effective than) live clinic relaxation training.