Richard A. Hirth

Alternative Management Strategies for Patients with Suspected Peptic Ulcer Disease

The association between Helicobacter pylori and peptic ulcer disease necessitates rethinking of the clinical management of this common, chronic disease [1-4]. Observational studies and prospective trials support the use of antibiotic and antisecretory therapy for patients with H. pylori infection and active ulcer disease unrelated to the use of nonsteroidal anti-inflammatory drugs (NSAIDs) [5-15]. Although elimination of the organism slightly improves ulcer healing rates [16], the principal benefit is the dramatic reduction in ulcer recurrence rates in patients in whom the infection has been successfully eradicated [9, 17-19]. Thus, a recent National Institutes of Health (NIH) Consensus Panel on H. pylori and peptic ulcer disease [20] concluded that antibiotics to eradicate H. pylori were indicated when both an ulcer and H. pylori infection were present. Without invasive diagnostic testing, patients with ulcer disease who would benefit from H. pylori eradication are difficult to distinguish clinically from persons with upper abdominal symptoms not caused by ulcer [21-29]. Moreover, it remains controversial whether antibiotic therapy and eradication of H. pylori provides clinical benefit in persons without active ulcer disease. Therefore, to minimize inappropriate use of antibiotic therapy, guidelines such as those of the NIH Consensus Panel recommend objective documentation of an active ulcer and H. pylori infection before prescription of antibiotic treatment. Such a recommendation makes two assumptions: 1) that diagnostic confirmation of both ulcer disease and H. pylori infection is the optimal strategy after the benefits, risks, and costs of available alternatives are carefully considered and 2) that community physicians, who are accustomed to using initial empiric therapy in patients with ulcer-like symptoms, will find this guideline instructive in their clinical practice, given that several alternative options do not rely on initial invasive diagnostic testing. Accordingly, we used decision analysis to estimate the clinical and economic effects of two immediate endoscopy and three initially noninvasive diagnostic and treatment strategies for patients with symptoms suggestive of peptic ulcer disease: 1) immediate endoscopy for peptic ulcer and biopsy for H. pylori; 2) immediate endoscopy without biopsy; 3) serologic testing for H. pylori infection; 4) empiric treatment with antisecretory therapy; and 5) empiric treatment with antisecretory and antibiotic therapy. Methods Decision Analytic Model Using a decision analysis software program, Decision Maker 7.0 (Pratt Medical Group, Boston, Massachusetts), we constructed a computer simulation to predict the natural history of peptic ulcer disease, its interaction with H. pylori infection, and the effects of various diagnostic and therapeutic medical interventions. The analysis started with a cohort of 1000 hypothetical patients presenting to a physician with symptoms suggestive of peptic ulcer disease who were not concurrently taking NSAIDs. On entry into the simulation, all patients had symptoms severe enough to justify an empiric course of antisecretory agents and had no previously documented peptic ulcer disease. Patients whose symptoms had causes other than peptic ulcer disease were captured in the simulation up to and including the point at which they were objectively identified as not having an ulcer on endoscopic evaluation. Until a diagnosis was made endoscopically, resources were accrued for all patients, including the consumption of pharmaceutical agents, physician visits, and diagnostic tests (including endoscopy and biopsy). Exclusion of treatment costs after the demonstration of a nonulcer cause was consistent with our objective to measure the clinical and economic effect of alternative management strategies for suspected peptic ulcer disease. This exclusion was also in concordance with the assumption that no clinical benefit resulted from the eradication of H. pylori in patients without ulcer disease. Initial Diagnostic and Therapeutic Interventions Immediate Endoscopy Strategies In the first invasive diagnostic strategy, strategy 1, all patients had immediate endoscopy and biopsy to determine the presence of H. pylori. Patients with an active ulcer on endoscopy were prescribed antisecretory therapy. Antibiotic therapy was limited to persons with both an ulcer and evidence of H. pylori infection found on biopsy. With strategy 2, patients had immediate endoscopy but did not have a biopsy to determine the presence of H. pylori. Persons with active ulcer disease confirmed by endoscopy were presumed to be infected with H. pylori and were prescribed both antisecretory and antibiotic therapy. Noninvasive Strategies The noninvasive treatment strategies did not require diagnostic confirmation of an ulcer before the initiation of either antisecretory or antibiotic therapy. Every patient having each of the noninvasive strategies was prescribed an empiric course of antisecretory agents at the initial medical encounter. With strategy 3, all patients also had a qualitative serologic test for H. pylori. Only patients with evidence of previous or current H. pylori infection, as shown by a positive serologic test result, received antibiotic therapy in addition to the antisecretory agent. Persons with a negative serologic test result received only antisecretory therapy. The remaining two noninvasive strategies were purely empiric, with no associated diagnostic testing before therapy was started. With strategy 4, all patients were prescribed antisecretory therapy alone; with strategy 5, all patients received both antisecretory and antibiotic therapy. The model captured resource use, such as physician visits, pharmaceutical use, procedures, and hospitalizations. Direct medical expenditures were calculated from these data. After the initial management encounter, patients moved among different states of health determined by the likelihood of particular clinical events and the effect of certain medical interventions on the natural history of peptic ulcer disease. Each patient was evaluated in the model at 6-week intervals for 1 year for the presence or absence of three clinical conditions, on which all further interactions with the medical care system were based: recurrent symptoms, H. pylori infection, and active ulcer disease. Clinical Conditions and Subsequent Intervention Recurrent Symptoms It was assumed that after the initial intervention, each patient with persistent or recurrent ulcer-like symptoms would return for medical evaluation regardless of physician or patient knowledge of an underlying diagnosis. Patients with recurrent symptoms who were initially managed noninvasively (strategies 3, 4, and 5) had endoscopy with biopsy on the first return visit to determine the presence of active ulcer disease and H. pylori infection. All subsequent treatments were based on the endoscopy results and biopsy findings. Thus, if a single 6-week course of empiric therapy did not completely relieve symptoms for the entire study period, ensuing treatment was always directed by objective diagnostic data. Patients in whom an ulcer was diagnosed by endoscopy at any time were treated with high-dose antisecretory agents. Antibiotic therapy was prescribed when objective evidence suggested H. pylori infection, except for patients having only immediate endoscopy. In this group, patients with ulcers automatically received H. pylori eradication therapy (strategy 2). Patients with ulcers who remained symptomatic after three complete courses of antisecretory therapy had a second endoscopic evaluation to assess ulcer healing and H. pylori status. It was assumed that patients who became asymptomatic at any time after the initial encounter did not visit a physician, regardless of their underlying diagnosis, unless symptoms were to recur. Helicobacter pylori Infection Helicobacter pylori status affected the likelihood of ulcer recurrence but not the development or resolution of symptoms. Pathologic evaluation of the biopsy specimen was assumed to be a perfect test for H. pylori infection. With strategy 3, the qualitative serologic test was presumed to have 95% sensitivity and 95% specificity [30, 31] for identifying previous or current H. pylori infection. If endoscopy and biopsy were not to be done for a particular symptomatic encounter in patients who had previously received antibiotic therapy, a urea breath test was administered to evaluate how effectively the organism was being eliminated [32-37]. Persons who did not clear the infection after three courses of antibiotics, as shown by infection on repeat biopsy specimens or a positive urea breath test result, were assumed to be infected for the rest of the study period. It was assumed that once H. pylori had cleared, infection did not recur [10, 38, 39]. Successful eradication of H. pylori in patients with ulcers associated with NSAIDs or with diagnoses other than active ulcer disease (for example, gastritis) was assumed to offer no benefit in terms of reducing symptom severity or preventing future ulcer development [40]. Active Ulcer Disease Ulcer status determined the likelihood that therapy would relieve symptoms and thus determined the need for future physician visits and related medical interventions. Endoscopy was assumed to be a perfect test for diagnosing ulcer disease and was presumed to have no associated adverse events. Ulcer recurrence not associated with NSAID use was related to H. pylori status and concurrent use of antisecretory therapy [8, 17, 18, 41-49]. Spontaneous ulcer development was assumed not to occur in patients whose initial symptoms were secondary to nonulcer causes [50]. Ulcers that did not completely heal after three courses of antisecretory therapy required maintenance antisecretory therapy for the duration of the study period. Resource use related to persistent ulcer symptoms was calculated for the remaining

Consumer information and competition between nonprofit and for-profit nursing homes

This paper develops implications of Arrows hypothesis that nonprofit organizations are prevalent in health care because of quality uncertainty. The model analyzes the ability of nonprofits to mitigate market failures created by asymmetric information in an environment characterized by potential competition from both explicitly for-profit firms and for-profits in disguise (profit-motivated firms who obtain nonprofit status in order to exploit the perceived trustworthiness of the nonprofit sector). Under certain conditions, it is shown that nonprofit status can serve as a credible signal of quality and that nonprofits can decrease the underprovision of quality both by providing high quality services and indirectly via a spillover effect on quality in the for-profit sector. Applicability to long-term care and implications for empirical research and policy towards nonprofits in health care are discussed.

Competitive spillovers across non-profit and for-profit nursing homes

The importance of non-profit institutions in the health care sector has generated a vast empirical literature examining quality differences between non-profit and for-profit nursing homes. Recent theoretical work has emphasized that much of this empirical literature is flawed in that previous studies rely solely on dummy variables to capture the effects of ownership rather than accounting for the share of non-profit nursing homes in the market. This analysis considers whether competitive spillovers from non-profits lead to higher quality in for-profit nursing homes. Using instrumental variables to account for the potential endogeneity of non-profit market share, this study finds that an increase in non-profit market share improves for-profit and overall nursing home quality. These findings are consistent with the hypothesis that non-profits serve as a quality signal for uninformed nursing home consumers.

Guaranteed Renewability in Insurance

We propose a guaranteed renewability (GR) insurance in which a sequence of premiums would enable insurers to break even and would be chosen by both low- and high-risk buyers, whether or not they had suffered a loss. The premium schedule would continually decline over time, as the insurer collects more information to determine who the low-risk buyers are. The highest premiums are charged initially to protect the insurer if low-risk individuals leave for the spot market. The concluding portion of the article discusses the limitations of a GR policy in the health and environmental liability area, the most serious being instability in estimates of underlying loss trends.

Managed care, medical technology, and health care cost growth : A review of the evidence

Although managed care plans reduce health care expenditures at any point in time, less is known about whether such plans control health care cost growth. Because use of new medical technology is an important determinant of cost growth, the impact of managed care on utilization of medical technology will largely determine whether managed care can reduce expenditure growth to sustainable levels. This article reviews the literature relating medical technology to cost growth and the literature examining the impact of managed care on either cost growth or on the diffusion of medical technology. Studies that examine plan-level data often reach different conclusions than studies that examine market-level data. The evidence suggests that managed care, as currently practiced, may reduce the rate of cost growth. However, managed care is unlikely to prevent the share of gross domestic product spent on health care from rising unless the cost-increasing nature of new technology changes.

Consumers, health insurance and dominated choices

We analyze employee health plan choices when the choice set offered by their employer includes a dominated plan. During our study period, one-third of workers were enrolled in the dominated plan. Some may have selected the plan before it was dominated and then failed to switch out of it. However, a substantial number actively chose the dominated plan when they had an unambiguously better choice. These results suggest limitations in the ability of health reform based solely on consumer choice to achieve efficient outcomes and that implementation of health reform should anticipate, monitor and account for this consumer behavior.

The organization and financing of kidney dialysis and transplant care in the United States of America

In the United States, end-stage renal disease (ESRD) patients are primarily insured by the publicly funded Medicare program. Compared to other countries in the International Study of Health Care Organization and Financing (ISHCOF), the United States has the highest health care expenditures for the general population and among ESRD patients. However, because the Medicare program is more influential in the market for ESRD-related services than for other medical services, ESRD price controls have been relatively stringent. Nonetheless, ESRD costs have grown substantially through increases in prevalence and use of ancillary services. Treatment costs are also controlled by the relatively high rate of transplantation. Proposed reforms include bundling more services into a prospective payment system, developing case-mix adjustments, and financially rewarding providers for quality.

Cost-effectiveness of hospital pay-for-performance incentives.

One increasingly popular mechanism for stimulating quality improvements is pay-for-performance, or incentive, programs. This article examines the cost-effectiveness of a hospital incentive system for heart-related care, using a principal-agent model, where the insurer is the principal and hospitals are the agents. Four-year incentive system costs for the payer were

Out-Of-Pocket Spending And Medication Adherence Among Dialysis Patients In Twelve Countries

22,059,383, composed primarily of payments to the participating hospitals, with approximately 5 percent in administrative costs. Effectiveness is measured in stages, beginning with improvements in the processes of heart care. Care process improvements are converted into quality-adjusted life years (QALYs) gained, with reference to literatures on clinical effectiveness and survival. An estimated 24,418 patients received improved care, resulting in a range of QALYs from 733 to 1,701, depending on assumptions about clinical effectiveness. Cost per QALY was found to be between

Chronic Illness, Treatment Choice and Workforce Participation

12,967 and