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The recent discovery of the cystic fibrosis gene has offered the possibility of population-based cystic fibrosis carrier screening. Although > 100 distinct mutations have been identified, five of these in aggregate represent about 85% of the alleles in Britain and the United States. Screening programs that test for these five mutations can be designed to offer several alternative ways to communicate the risk to a pregnancy and several alternative ways to manage a pregnancy. At this time we favor a strategy of screening partners in a couple in sequence, screening the second partner only if the first is positive; nevertheless, different strategies will appeal to different couples.

In evaluating diagnostic tests, traditional methods in decision analysis often emphasize how the results of the test will or will not affect patient management. Clinicians are advised to avoid testing if the results will not alter treatment strategy or other management plans. But patients may be interested in the prognostic information that testing provides even if it is not used to guide treatment. The authors present a model that defines this prognostic information as the expected deviation from the prior probability of disease. The model generates utility functions that are curvilinear over prior probabilities. Whereas the traditional threshold ap proach to medical decision making produces at most three zones of management strategy (withhold, test, and treat), the incorporation of prognostic information into threshold analysis produces two additional zones (test but withhold anyway, and test but treat anyway). Con ditions under which one or both of these additional zones will appear are described. The model justifies the practice of performing tests that cannot alter management plans; it explains the unwillingness of some patients to undergo diagnostic testing when they fear unwanted results; and it provides a method for quantifying the sensitive nature of confidential tests. The model is illustrated using the antibody test for the Smith antigen. This test has a high specificity but a low sensitivity for lupus erythematosus. Clinicians may use the test because a positive result will support their prior suspicion of disease even though they may not change their management strategy if the test result is negative. The advantage of testing in this setting lies in the test's potential for establishing with virtual certainty that the disease is present. Thus, the test is valued for the prognostic information it provides apart from its effect on patient management. Key words: confidentiality; decision making; diagnostic tests; in formation theory; privacy; probability; prognosis; utility analysis. (Med Decis Making 1990;10:47-57)

OBJECTIVES: This paper explores several critical assumptions and methodological issues arising in cost-effectiveness analyses of genetic screening strategies in the reproductive setting. METHODS: Seven issues that arose in the development of a decision analysis of alternative strategies for cystic fibrosis carrier screening are discussed. Each of these issues required a choice in technique. RESULTS: The presentations of these analyses frequently mask underlying assumptions and methodological choices. Often there is no best choice. In the case of genetic screening in the reproductive setting, these underlying issues often touch on deeply felt human values. CONCLUSIONS: Space limitations for published papers often preclude explaining such choices in detail; yet these decisions determine the way the results should be interpreted. Those who develop these analyses need to make sure that the implications of important assumptions are understood by the clinicians who will use them. At the same time, clinicians need to enhance their understanding of what these models truly mean and how they address underlying clinical, ethical, and economic issues.

Health care workers with needlestick exposures to patients' blood often request a test of the patient for evidence of infection with human immunodeficiency virus. If the patient refuses the test, a conflict develops between the interests of the health care worker and those of the patient. Traditional approaches to this dilemma attempt to balance the rights or utilities of abstract patients and health care workers. While these approaches have the advantage of offering clear guidelines in advance of conflict, the interests of the actual participants may differ from those used to create the guidelines. In nonmedical settings, conflicts are often resolved efficiently through negotiation and monetary exchanges. Although negotiated monetary settlements between health care workers and patients may be an impractical way to resolve medical conflicts, models developed from these perspectives provide insights into the individual interests of physicians and patients. Changing existing rules about medical record documentation, or increasing the penalties for the misuse of medical information, may satisfy the interests on both sides of the conflict and so represent integrative bargaining solutions. Even so, as the relationship between health care workers and their patients evolves, more explicit strategies for negotiation may become a reasonable solution to the problem of conflict.

Despite a burgeoning interest in and acceptance of corporate health promotion, the overall economic effects of these programs are not clear. Although ultimate resolution of this question awaits detailed empiric research, a theoretical approach can be useful in structuring the problem and understanding the critical issues. The financial model presented views the firm as a value-maximizing enterprise and evaluates health promotion as a use of corporate assets. The model projects the benefits and costs to the firm of a 7-year health promotion program under a variety of assumptions regarding the employee mix and the effects of the health promotion program on health and productivity. The analysis reveals that the base case assumptions result in a program that creates value for the firm when the cost is less than $193 per participating employee per year. Firms with a highly productive, difficult to replace, and older employee group are most likely to find health promotion to be a good investment. Productivity gains produce the majority of the economic benefits of the program. Effects on health care expense alone are projected to be relatively small. Gains from reduction in employee mortality or retiree health expense are found to be insignificant in this model.

Urinary tract infection results in significant morbidity and mortality while consuming large amounts of national resources. The prevention, diagnosis, and treatment of urinary tract infection produce both costs and benefits, and economic analysis provides a rational framework for looking at these effects. The goals and methods of economic analysis in medicine are summarized, and strategies to address uncomplicated cystitis, nosocomial urinary tract infection, and pyelonephritis are reviewed, with an emphasis on the economic trade-offs faced by decision makers.

Source Citation Schulman KA, Glick HA, Rubin H, Eisenberg JM. Cost-effectiveness of HA-1A monoclonal antibody for gram-negative sepsis. Economic assessment of a new therapeutic agent. JAMA. 1991 De...

Excerpt To the editor: In their article on sex bias and coronary bypass surgery, Tobin and associates (1) found that men with abnormal nuclear scans were ten times as likely to undergo catheterizat...

Objectives. To evaluate the costs and clinical effects of 16 alternative strategies for cystic fibrosis (CF) carrier screening in the reproductive setting; and to test the sensitivity of the results to assumptions about cost and detection rate, stakeholder perspective, DNA test specificity, chance of nonpaternity, and couples' reproductive plans. Method. Cost-effectiveness analysis. Results. A sequential screening strategy had the lowest cost per CF birth avoided. In this strategy, the first partner was screened with a standard test that identifies 85% of carriers. The second partner was screened with an expanded test if the first partner's screen was positive. This strategy identified 75% of anticipated CF births at a cost of $367,000 each. This figure does not include the lifetime medical costs of caring for a patient with CF, and it assumes that couples who identify a pregnancy at risk will choose to have prenatal diagnosis and termination of affected pregnancies. The cost per CF birth identified is approximately half this figure when couples plan two children. Conclusions. The cost-effectiveness of CF carrier screening depends greatly on couples' reproductive plans. CF carrier screening is most cost-effective when it is performed sequentially, when the information is used for more than one pregnancy, and when the intention of the couple is to identify and terminate affected pregnancies. These conclusions are important for policy considerations regarding population-based screening for CF, and may also have important implications for screening for less common diseases.