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)
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References
1.
Phelps CE, Mushlin AIFocusing technology assessment using medical decision theory. Med Decis Making.1988;8:279-89.
2.
Baker HL, Berquist TH, Kispert DB, et al.Magnetic resonance imaging in a routine clinical setting. Mayo Clin Proc.1985;60:75-90.
3.
Bradley WG, Waluch V., Yadley RA, Wycoff RRComparison of CT and MR in 400 patients with suspected disease of the brain and cervical spinal cord. Radiology. 1984;152:695-702.
4.
Milliren JWHealth policy analysis and magnetic resonance imaging: the case of the New York State Demonstration Project. Clin Imag.1989;13:16-28.
5.
Doubilet P., Weinstein MC, McNeil BJUse and misuse of the term "cost effective" in medicine. N Engl J Med.1986;314:253-5.
6.
Pauker SG, Kassirer JPThe threshold approach to clinical decision making. N Engl J Med.1980;302:1109-17.
7.
Weinstein MC , Fineberg HVClinical decision analysis. Philadelphia : W.B. Saunders, 1980 .
8.
Phelps CE, Mushlin AIThe (near) equivalence of cost-effectiveness and cost-benefit analysis [abstr] . Med Decis Making.1987;7:286.
9.
Hollenberg JPSMLTREE, Version 2.9. New York, 1986.
10.
Patrick DL, Bush JW, Chen MMToward an operational definition of health. J Health Soc Behav.1973;14:6-22.
11.
Health Insurance Association of America. Source book of health insurance data: Update 1988. Washington, DC: Health Insurance Association of America, 1988 ;23.
12.
Barro RTMacroeconomics. New York: Wiley , 1984.
13.
Kent DL, Larson EBMagnetic resonance imaging of the brain and spine. Ann Intern Med.1988;108:402-24.
14.
Haughton VM , Rimm AA, Sobocinski KA, et al. A blinded clinical comparison of MR imaging and CT in neuroradiology. Radiology.1986;160:751-5.
15.
National Center for Health Statistics.Patients' reasons for visiting physicians. National Ambulatory Medical Care Survey United States, 1977-1978 (data from the National Health Survey, Series 13, No. 56). DHHS Publication No. (PHS) 82-1717. Hyattsville, MD: National Center for Health Statistics , 1981.
16.
Baum HM, Rothschild BBThe incidence and prevalence of reported multiple sclerosis. Ann Neurol.1981;10:420-8.
17.
Poser CM, ed. The diagnosis of multiple sclerosis. New York: Thieme-Stratton, 1984.
18.
Matsumoto N. , Whisnant JP, Kurland LT, Okazaki H.Natural history of stroke in Rochester, Minnesota, 1955 through 1969: an extension of a previous study, 1945 through 1954. Stroke. 1973;4:20-9.
19.
Wolf PA, Dawber TR, Thomas HE, Kannel WBEpidemiologic assessment of chronic atrial fibrillation and risk of stroke . Neurology.1978;28:973-7.
20.
Horm JW, Asire AJ, Young JL, et al, eds. SEER program: cancer incidence and mortality in the United States 1973-1981. DHHS Publication No. (NIH) 85-1837. Bethesda : National Cancer Institute, November 1984.
21.
Lausberg G. , Farhoumand E., Collmann H., et al. Misdiagnosis— cerebral form of multiple sclerosis. Adv Neurosurg.1975 ;2:169-82.
22.
Murray TJ, Murray SJCharacteristics of patients found not to have multiple sclerosis. Can Med Assoc J.1984;131:336-7.
23.
Kurtzke JFMultiple sclerosis: what's in a name? Neurology.1988;38:309-14.
24.
Paty DW, Asbury AK, Herndon RM, et al. Use of magnetic resonance imaging in the diagnosis of multiple sclerosis: policy statement. Neurology.1986 ;36:1575.
25.
Paty DW, Oger Jjf, Kastrukoff LF, et al. MRI in the diagnosis of MS: a prospective study with comparison of clinical evaluation, evoked potentials, oligoclonal banding, and CT. Neurology.1988;38:180-4.
26.
Beck JR, Pauker SGThe Markov process in medical prognosis. Med Decis Making.1983;3:419-58.
27.
McDonald WI, Halliday AMDiagnosis and classification of multiple sclerosis. Br Med Bull.1977;33:4-8.
28.
Poser CM, Paty DW, Scheinberg L., et al. New diagnostic criteria for multiple sclerosis: guidelines for research protocols. Ann Neurol.1983;13:227-31.
29.
Grindal AB, Cohen RJ, Saul RF, Taylor JRCerebral infarction in young adults. Stroke.1978;9:39-42.
30.
Hart RG, Miller VTCerebral infarction in young adults: a practical approach. Stroke.1983;14:110-114.
31.
Snyder BD, Ramirez-Lassepas M.Cerebral infarction in young adults. Stroke.1980;11:149-53.
32.
National Center for Health Statistics.Current estimates from the National Health Interview Survey United States, 1985 (data from the National Health Survey, Series 10, No. 160). DHHS Publication No. (PHS) 86-1588. Hyattsville, MD: National Center for Health Statistics, 1986 .
33.
Earnest F., Forbes G., Sandok BA, et al. Complications of cerebral angiography: prospective assessment of risk. AJNR.1983;4:1191-7.
34.
Drummond MF, Stoddart GL, Torrance GWMethods for the economic evaluation of health care programmes. New York: Oxford University Press, 1987;120-4.
35.
Sacco RL, Wolf PA, kannel WB, McNamara PMSurvival and recurrence following stroke: the Framingham study. Stroke.1982;13:290-5.
36.
Beck JR, Pauker SG, Gottlieb JE, Klein K., Kassirer JPA convenient approximation of life expectancy (the "DEALE"I. II. Use in medical decision making. Am J Med.1982 ;73:889-97.
Torrance GW , Boyle MH, Horwood SPApplication of multi-attribute utility theory to measure social preferences for health states. Oper Res.1982;30:1043-71.
39.
Hauser SL, Dawson DM, Lehrich JR, et al. Intensive immunosuppression in progressive multiple sclerosis . N Engl J Med.1983;308:173-214.
40.
Myers LWThe use of cyclophosphamide to treat multiple sclerosis. Clin Neuropharmacol.1987;10:155-61.
41.
Scheinberg LC, Van den Noort S.Editorial on multiple sclerosis treatments . Neurology.1986;36:703-4.
42.
Clark VA, Detels R., Vissher BR, et al. Factors associated with a malignant or benign course of multiple sclerosis. JAMA.1982;248:856-60.
43.
Confavreux C., Aimard G., Devic M.Course and prognosis of multiple sclerosis assessed by the computerized data processing of 349 patients. Brain.1980;103:281-300.
44.
Kraft GH, Freal JE, Coryell JK, et al. Multiple sclerosis: early prognostic guidelines. Arch Phys Med Rehabil.1981;62:54-8.
45.
Malgrem R., Dudley JP, Visscher B., Valdiviezo NL, Clark VA, Detels R.Mortality in persons with multiple sclerosis in the Seattle and Los Angeles areas. JAMA.1981;246:2042-5.
46.
McAlpine D.The benign form of multiple sclerosis: a study based on 241 cases seen within three years of onset and followed up until the tenth year or more of the disease. Brain.1961;84:186-203.
47.
Poser S., Raun NE, Poser W.Age at onset, initial symptomatology and the course of multiple sclerosis . Acta Neurol Scand.1982 ;66:355-62.
48.
Beukelman DR , Kraft GH, Freal J.Expressive communications disorders in persons with multiple sclerosis. Arch Phys Rehabil.1985;66:675-7.
49.
Surridge D.An investigation into some psychiatric aspects of multiple sclerosis. Br J Psychiat.1969 ;115:749-64.
50.
McFarlin DE , McFarland HFMultiple sclerosis (second of two parts). N Engl J Med.1982;307:1246-51.
51.
National Center for Health Statistics.Discharges from nursing homes. 1977 National Nursing Home Survey (Data from the National Health Surrey, Series 13, No. 54.). DHHS Publication No. (PHS) 81-1715. Hvattsville, MD: National Center for Health Statistics , 1981.
52.
Inman RPDisability indices, the economic costs of illness, and social insurance: the case of multiple sclerosis. Acta Neurol Scand Suppl.1984;101:46-55.
53.
Health Care Financing Administration.Medicare Program; Changes to the inpatient hospital prospective payment system: fiscal year 1988. Fed Reg.1987;52:33034.
54.
Elian M., Dean G.To tell or not to tell the diagnosis of multiple sclerosis. Lancet.1985;ii:27-8.
55.
Gorman E., Rudd A., Ebers GCGiving the diagnosis of multiple sclerosis. In: Poser C, ed. The diagnosis of multiple sclerosis . New York: Thieme-Stratton, 1984.
56.
Levine HJWhich atrial fibrillation patients should be on chronic anticoagulation ? J Cardiovasc Med.1981;6:483-7.
57.
Axtell LM, Asire AJ, Myers MHCancer patient survival report number 5: a report from the Cancer Surveillance, Epidemiology and End Results (SEER) Program. DHEW Publication No. (NIH) 77-992 . Bethesda: National Cancer Institute , 1976.
58.
Simon DG, Lubin MFCost-effectiveness of computerized tomography and magnetic resonance imaging in dementia. Med Decis Making.1985 ;5:335-54.
59.
State of New York Department of Health.An analysis and evaluation of the New York State Hospice Demonstration Program . Albany, NY: New York Department of Health, December 1982.
60.
Phelps CERisk aversion in medical decisions: variance matters! [abstr]. Med Decis Making.1988;8:349.
61.
Pratt JWRisk aversion in the small and in the large. Econometrica.1964;3211-2):122-36.
62.
Phelps CEIllness prevention and medical insurance. J Hum Resources.1978;13( suppl):183-207.
63.
Keeler EB, Buchanan JL, Roth JE, et al. Demand for episodes of medical treatment in the health insurance experiment. Report R-3454-HHS. Santa Monica, CA: RAND Corporation, 1988.
64.
Bryant GD, Norman GRExpressions of probability: words and numbers (letter). N Engl J Med.1980;302:411.
65.
Kong A., Barnett GO, Mosteller F., et al. How medical professionals evaluate expressions of probability . N Engl J Med.1986;315:740-4.
Evens RG, Jost RG, Evens RG Jr. Economic and utilization analysis of magnetic resonance imaging units in the United States in 1985. AJR. 1985 ;145:393-8.
68.
Mitchell J.Physician DRGs. N Engl J Med.1985;313:670-5.
69.
Health Care Financing Administration.Medicare directory of prevailing charges 1983. HCFA-10015 11/83. Baltimore: Health Care Financing Administration , 1983.
70.
Hartunian NSThe incidence and economic costs of major health impairments. Lexington, MA: Lexington Books, 1981.
71.
Weinfeld FD, ed. The national survey of stroke. Bethesda, MD: National Institute of Neurological and Communicative Disorders, NIH, 1981.
