Joseph S. Pliskin

Health economic evaluations: the special case of end-stage renal disease treatment.

This article synthesizes the evidence on the cost-effectiveness of renal replacement therapy and discusses the findings in light of the frequent practice of using the cost-effectiveness of hemodialysis as a benchmark of societal willingness to pay. The authors conducted a meta-analytic review of the medical and economic literature for economic evaluations of hemodialysis, peritoneal dialysis, and kidney transplantation. Cost-effectiveness ratios were translated into 2000 U.S. dollars per life-year (LY) saved. Thirteen studies published between 1968 and 1998 provided such information. The cost-effectiveness of center hemodialysis remained within a narrow range of

The Economic Value of Changing Mortality Probabilities: A Decision-Theoretic Approach

55,000 to

Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis: A Propensity Score Approach

80,000/LY in most studies despite considerable variation in methodology and imputed costs. The cost-effectiveness of home hemodialysis was found to be between

A longitudinal analysis from bite-wing radiographs of the rate of progression of approximal carious lesions through human dental enamel

33,000 and

A note on QALYs, time tradeoff, and discounting.

50,000/LY. Kidney transplantation, however, has become more cost-effective over time, approaching

A benchmark solution for the risk-averse newsvendor problem

10,000/LY. Estimates of the cost per life-year gained from hemodialysis have been remarkably stable over the past 3 decades, after adjusting for price levels. Uses of the cost-effectiveness ratio of

Are Healthy-years Equivalents an Improvement over Quality-adjusted Life Years?

55,000/LY for center hemodialysis as a lower boundary of society’s willingness to pay for an additional life-year can be supported under certain assumptions.

Late nephrologist referral and access to renal transplantation.

Properties of individual willingness to pay for changes in mortality probabilities are examined using a decision-theoretic model. There is no unique value per life saved. The willingness to pay for a mortality reduction depends not only on the amount of reduction but also on the initial probability level and on whether the valuation is ex ante (e.g., decisions regarding health insurance, preventive medicine, or environmental health) or ex post (e.g., acute medical care). Several inequalities relating the imputed willingness to pay in various paradigm decision contexts are derived from the model with the addition of few additional behavioral assumptions.

Growth Hormone Therapy and Quality of Life in Adults and Children

The objective of this study was to evaluate differences in mortality over the first year of renal replacement therapy (RRT) between elderly patients starting treatment on hemodialysis (HD) versus peritoneal dialysis (PD). For the period of 1991 to mid-1996, this study defined an inception cohort of all patients aged >65 yr with new-onset chronic RRT who were New Jersey Medicare and/or Medicaid beneficiaries in the year before RRT and who had been diagnosed with renal disease more than 1 yr before RRT. Propensity scores were calculated for first treatment assignment from a large number of baseline covariates. Mortality was then compared among patients initially assigned to HD versus PD using multivariate 90-d interval Cox models controlled for propensity scores and center stratification. Peritoneal dialysis starters had a 16% higher rate of death during the first 90 d of RRT compared with HD patients (hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.96 to 1.42)]. Mortality did not differ between day 91 and 180 (HR, 1.03; 95% CI, 0.71 to 1.51). Thereafter, PD starters again died at a higher rate (HR, 1.45; 95% CI, 1.07 to 1.98). These findings were more pronounced among patients with diabetes. Sensitivity analyses using more stringent criteria to ensure that first treatment choice reflected long-term treatment choice confirmed the presence of an association between PD and mortality. In conclusion, compared with HD, peritoneal dialysis appears to be associated with higher mortality among older patients, particularly among those with diabetes, even after controlling for a large number of risk factors for mortality, propensity scores to control for nonrandom treatment assignment, and center stratification.

Decisions to adopt new technologies at the hospital level: insights from Israeli medical centers.

Four to ten years of serial bite-wing radiographs from over 700 children from five groups, three in Sweden and two in the U.S., were interpreted. By analysing changes in the depth of unfilled lesions over time, the mean time and probability distribution for the time a lesion remains in both the outer half and inner half of the enamel were estimated. The procedure incorporated information on filled lesions and non-progressing lesions and thus minimized bias that results in overestimation of the progression rate. In primary teeth, in both the U.S. and Swedish groups, it took on average 12 months for a lesion to progress through the outer half of the enamel and on average 10-12 months for a lesion to progress through the inner half. In newly-erupted first permanent molars, it took 21-23 months for a lesion to progress through the outer half of the enamel and between 19 (U.S. data) and 28 months (Swedish data) for progression through the inner half. In older adolescents in the two Swedish groups, progression was slower: 38-41 months through the outer-half and 47-56 months through the inner-half. In older U.S. adolescents, progression appeared to be more rapid: 16 months through the outer half of the enamel and 27 months through the inner half. The duration of time a lesion remains in different halves of the enamel could be approximated by a piecewise exponential or exponential probability distribution, which exhibits extreme variability. Assuming duration in each half of the enamel follows an exponential distribution with a mean of 2 yr, about 10 per cent of new lesions will progress through the enamel in one year and 25 per cent in two years. However, over 40 per cent of the lesions will not have progressed in 4 yr. There were no consistent differences in the rate of progression by sex, between upper and lower dentitions, for premolars versus molars, or between high and low-risk individuals.