Different Outcomes According to Needling Point Location Used in Sham Acupuncture for Cancer-Related Pain: A Systematic Review and Network Meta-Analysis.

Numerous acupuncture studies have been conducted on cancer-related pain; however, its efficacy compared to sham acupuncture remains controversial. We confirmed whether the outcome of acupuncture differs according to the needling points of sham acupuncture for cancer-related pain. We searched 10 databases on 23 May 2023 to screen acupuncture trials using sham acupuncture or waiting list as controls for cancer-related pain. Sham acupuncture was classified into two types, depending on whether the needling was applied at the same locations as verum acupuncture (SATV) or not (SATS). A network meta-analysis (NMA) was performed on the basis of a frequentist approach to assess pain severity. Eight studies (n = 574 participants) were included in the review, seven of which (n = 527 participants) were included in the NMA. The pain severity was not significantly different between SATV and verum acupuncture, but verum acupuncture significantly improved pain severity compared to SATS. The risk of bias affecting the comparisons between the verum and sham acupuncture was generally low. Previous acupuncture trials for cancer-related pain showed differing outcomes of sham and verum acupuncture, depending on the needling points of sham acupuncture. The application of SATV cannot be considered a true placebo, which leads to an underestimation of the efficacy of verum acupuncture.

Needling Point Location Used in Sham Acupuncture for Chronic Nonspecific Low Back Pain: A Systematic Review and Network Meta-Analysis.

Importance: When sham acupuncture is set as a control in evaluating acupuncture, the sham needling technique is usually different from acupuncture. However, the sham procedure is conducted either at the same points that are used for the acupuncture group or at nonindicated points. Objective: To assess whether the outcome of sham acupuncture varies according to the needling points in sham-controlled trials of acupuncture for chronic nonspecific low back pain (CLBP) as an example. Data sources: Searches of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and the Allied and Complementary Medicine Database were conducted on February 12, 2023. Study selection: Randomized clinical trials (RCTs) assessing the outcomes of acupuncture in sham acupuncture-controlled or waiting list-controlled trials on CLBP were included. Data extraction and synthesis: Two researchers independently extracted data on study characteristics and outcomes and assessed quality. Sham acupuncture was classified according to whether it was conducted at the same acupuncture points used in the acupuncture group, referred to as sham acupuncture therapy (verum) (SATV) or at different points, referred to as sham acupuncture therapy (sham) (SATS). Clinical similarity, transitivity, and consistency tests were conducted, followed by a random-effects frequentist network meta-analysis (NMA). Main outcomes and measures: The primary outcome was pain, and the secondary outcome was back-specific function. The first assessment after the end of treatment was chosen for analysis. Effect sizes are reported as standardized mean differences (SMD) with 95% CIs. The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence for findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results: Ten RCTs involving 4379 participants were included. In comparison with SATS, acupuncture was significantly associated with improvements in both pain (SMD, -0.33; 95% CI, -0.52 to -0.15) and function outcomes (SMD, -0.13; 95% CI, -0.25 to -0.02); however, there were no differences between acupuncture and SATV. In comparison with SATS, SATV was significantly associated with better pain (SMD, -0.45; 95% CI, -0.88 to -0.03) and function outcomes (SMD, -0.30; 95% CI, -0.56 to -0.05). The risk of bias that could affect the interpretation of the results was usually low, and the certainty of evidence was moderate to low. Conclusions and relevance: In this NMA, sham acupuncture needling at the same points as those in acupuncture was not a true placebo control for assessing the efficacy of acupuncture for CLBP and might underestimate the outcome of acupuncture in clinical settings.

Using Acupuncture for Adjunct Treatment for Cancer-Related Fatigue in Breast Cancer Patients Is Practicable. Reply to Hu et al. Is Acupuncture an Ideal Adjunctive Treatment for Cancer-Related Fatigue? Comment on "Choi et al. Acupuncture for Managing Cancer-Related Fatigue in Breast Cancer Patients: A Systematic Review and Meta-Analysis. Cancers 2022, 14, 4419".

We are grateful for the relevant comments by Hu et al. [...].

General population preferences for cancer care in health systems of China: A discrete choice experiment.

BACKGROUND: The increasing incidence of cancer in China has posed considerable challenges for cancer care delivery systems. This study aimed to determine the general population's preferences for cancer care, to provide evidence for building a people-centered integrated cancer care system. METHODS: We conducted a discrete choice experiment that involved 1,200 participants in Shandong Province. Individuals were asked to choose between cancer care scenarios based on the type and level of hospitals, with various out-of-pocket costs, waiting time, and contact working in the hospitals. Individual preferences, willingness to pay, and uptake rate were estimated using a mixed-logit model. RESULTS: This study included 848 respondents (70.67%). Respondents preferred county hospitals with shorter hospitalization waiting times and contact working in hospitals. Compared to the reference levels, the three highest willingness to pay values were related to waiting time for hospitalization (¥97,857.69-¥145411.70-¥212,992.10/$14512.70-$21565.16-$31587.61), followed by the county-level hospital (¥32,545.13/$4826.58). The preferences of the different groups of respondents were diverse. Based on a county-level general hospital with contact in the hospital, 50% out-of-pocket costs and a waiting time of 15 days, the probability of seeking baseline care was 0.37. Reducing the waiting time from 15 to 7, 3, and 0 days, increases the probability of choosing a county-level hospital from 0.37 to 0.58, 0.64, and 0.70, respectively. CONCLUSIONS: This study suggests that there is a substantial interest in attending county-level hospitals and that reducing hospitalization waiting time is the most effective measure to increase the probability of seeking cancer care in county-level hospitals.

Acupuncture for Managing Cancer-Related Fatigue in Breast Cancer Patients: A Systematic Review and Meta-Analysis.

Breast cancer (BC) is the most common cancer in women and is a serious threat to women's health. Cancer-related fatigue (CRF) is a distressing symptom in BC patients during and after chemotherapy or radiation therapy that severely affects quality of life (QoL). AT is widely used for fatigue management. However, the effect of AT on CRF is still uncertain. This study aimed to evaluate the efficacy and safety of AT in the management of CRF in patients with BC. Eleven databases were searched through June 2022. Two researchers independently performed the database search, study selection, data extraction, and risk of bias assessment. Study selection was performed based on predefined Participants, Intervention, Comparators, Outcomes, Study design (PICOS) criteria, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed when reporting the results. A meta-analysis was performed according to the Cochrane systematic review method using RevMan 5.3. A total of 12 studies including a total of 1084 participants were included. The results showed that AT had a beneficial effect compared with sham AT (n = 256, SMD = -0.26, 95% CI [-0.51, -0.01], p = 0.04, I2 = 0%) and a long-term effect on fatigue score (n = 209, MD = -0.32, 95% CI [-0.59, -0.04], p = 0.02, I2 = 0%). Meta-analysis showed that AT had a beneficial effect compared with usual care (UC) on fatigue scores (n = 238, SMD = -0.39, 95% CI [-0.66 to -0.12], p = 0.005, I2 = 0%). Of the 12 articles, 3 articles were judged as having a low risk of bias in all domains and hence were of high quality. No serious adverse effects were identified. AT is an effective and safe treatment for CRF, and AT is more effective than sham AT or UC or wait-list control (WLC). Nevertheless, the methodological quality of most of these studies was low, and the included studies/sample sizes were small, so the ability to derive decisive implications was limited. Further research is needed to confirm these findings.

An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation.

OBJECTIVE: Oral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage. METHOD: A health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination. RESULTS: The proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings. CONCLUSIONS: Implementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.

Provision of home medicines reviews in Australia: linking population need with service provision and available pharmacist workforce.

Objective Identifying and quantifying the health needs of a population are the basis of evidence-based health policy and workforce planning. The motivation for undertaking the present study was to evaluate whether the current level of medication review services corresponds to population need, as proxied by the rate of polypharmacy, and to undertake a preliminary analysis of the sufficiency of the current workforce. This paper: (1) estimates the age- and sex-standardised rates of polypharmacy as a proxy for population need for home medicines review; (2) compares the rate of polypharmacy with current service provision of home medicines reviews; and (3) links the estimated need for services with the current number and location of pharmacist providers. Methods Age- and sex-adjusted polypharmacy rates, by state, were estimated from the National Health Survey of Australia (2017-18), service levels were estimated from national-level administrative claims data (2017-18) and the current workforce was estimated from the Australian Association of Consultant Pharmacists (2018). The current level of service provision was compared to the estimated population need for services, alongside the size of the pharmacy workforce required if need was met. Results The adjusted rate of polypharmacy in Australia, using the strictest definition of ≥10 medications and ≥3 current chronic illnesses, was 1389 per 100000 population. The illustrative needs-based analysis suggests that there may be a disconnect between the current level of service provision and population health needs. Conclusion Given that polypharmacy is a risk factor for medication-related problems, and that medication review is one of the few targeted strategies currently available to address medication-related problems in the population, service provision may be inadequate. Policy options to improve service provision could include interventions to increase workforce productivity and relaxing the current eligibility criteria for review, especially in rural and remote areas. What is known about the topic? Polypharmacy is a risk factor for medication-related problems, which can cause increased morbidity and mortality in the population. What does this paper add? This paper provides representative, population-based rates of polypharmacy in Australia and uses these rates in a needs-based analysis of service provision and workforce adequacy to provide home medicines review services. What are the implications for practitioners? Several policy options are available for consideration, including interventions to increase workforce productivity and relaxation of the current eligibility criteria for medicines review, especially in rural and remote areas.

Acupuncture as a Treatment Within Integrative Health for Palliative Care: A Brief Narrative Review of Evidence and Recommendations.

Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care. Methods: Electronic searches were performed in PubMed using the terms "acupuncture" + "palliative" and adding the term "safety" to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author. Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care. Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.

Evidence, safety and recommendations for when to use acupuncture for treating cancer related symptoms: a narrative review.

BACKGROUND: Recently research on acupuncture for cancer related symptoms has significantly increased. To what extent have medical professionals recommended to use acupuncture in light of that evidence? METHODS: Evidence of effectiveness and safety was found by searching Pubmed for reviews to identify for what conditions and general results. Publications that recommend acupuncture in oncology were searched in the database of an ongoing general search for publications that recommend acupuncture. This database was developed by searching google for publications that recommend the use of acupuncture with the terms 'name of symptom' and 'clinical practice guideline' or 'treatment guideline'. RESULTS: Acupuncture is moderately or weakly effective for 19 symptoms in patients with cancer and cancer survivors. Acupuncture is a safe therapy in cancer care if administered by trained acupuncturists. Acupuncture is targeted to improve symptoms associated with the cancer and different cancer treatments, not to treat the cancer itself. More than 350 publications by clinical practice guideline groups and expert groups, including public health statements made by national and government agencies recommended the use of acupuncture for 61 cancer related symptoms many with positive evidence of effectiveness. CONCLUSION: The strength of evidence is weak for many indications, however the evidence for many standard therapies is either not very strong or if stronger, the incidence of adverse events is more, which makes acupuncture a treatment option despite the weak evidence. We have found evidence that many oncologists around the world have started to incorporate acupuncture into the treatment of various cancer related symptoms.

Low prioritization of latent tuberculosis infection-A systemic barrier to tuberculosis control: A qualitative study in Ontario, Canada.

BACKGROUND: Eliminating tuberculosis (TB) in low-incidence countries is an important global health priority, and Canada has committed to achieve this goal. The elimination of TB in low-incidence countries requires effective management and treatment of latent tuberculosis infection (LTBI). This study aimed to understand and describe the system-level barriers to LTBI treatment for immigrant populations in the Greater Toronto and Hamilton Area, Ontario, Canada. METHODS: A qualitative study that used purposive sampling to recruit and interview health system advisors and planners (n = 10), providers (n = 13), and clients of LTBI health services (n = 9). Data were recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: Low prioritization of LTBI was an overarching theme that impacted four dimensions of LTBI care: management, service delivery, health literacy, and health care access. These factors explained, in part, inequities in the system that were linked to variations in health care quality and health care access. While some planners and providers at the local level were attempting to prioritize LTBI care, there was no clear pathway for information sharing. CONCLUSIONS: This multiperspective study identified barriers beyond the typical socioeconomic determinants and highlighted important upstream factors that hinder treatment initiation and adherence. Addressing these factors is critical if Canada is to meet the WHO's global call to eradicate TB in all low incidence settings.

Willingness to Pay for Colorectal Cancer Screening and Effect of Copayment in Southern Thailand

Background: The incidence rate of colorectal cancer in Thailand is increasing. Hence, the nationwide screening programme with copayment is being considered. There are two proposed screening alternatives: annual fecal immunochemical test (FIT) and once-in-10-year colonoscopy. A copayment for FIT is 60 Thai baht (THB) per test (≈ 1.7 USD); a copayment for colonoscopy is 2,300 THB per test (≈ 65.5 USD). Methods: The willingness to pay (WTP) technique, which is theoretically founded on a cost-benefit analysis, was used to assess an effect of copayment on the uptake. Subjects were patients aged 50-69 years without cancer or screening experience. WTP for the proposed tests was elicited. Results: Nearly two thirds of subjects were willing to pay for FIT. Less than half of subjects were willing to pay for colonoscopy. Among them, median WTP for both tests was greater than the proposed copayments. In a probit model, knowing CRC patient and presence of companion were associated with non-zero WTP for FIT. Presence of companion, female, and family history of cancer were associated with non-zero WTP for colonoscopy. After adjustment for starting price in the linear model, marital status, drinking behavior, and risk attitude were associated with WTP. None of factors was significant for colonoscopy. Uptake decreased as levels of copayment increased. At proposed copayments, the uptake rates of 59.8% and 21.6% were estimated for colonoscopy and FIT respectively. The demand for FIT was price inelastic; the demand for colonoscopy was price elastic. Estimates of optimal copayment were 62.1 THB for FIT and 460.2 THB for colonoscopy. At the optimal copayment, uptake rates would be 59.8% for FIT and 42.3% for colonoscopy.Conclusion(s): More subjects were willing to pay for FIT than for colonoscopy (59.0% versus 46.5%). The estimated uptake rates were 59.8% and 21.6% for colonoscopy and FIT at the proposed copayments.

New Evidence on End-of-Life Hospital Utilization for Enhanced Health Policy and Services Planning.

BACKGROUND: Long-standing concern exists over hospital use by people near or at the end of life (EOL) related to the appropriateness, quality, and cost of care in hospital. It is widely believed that most people die in hospital after an escalation in hospital use over the last year of life. As most deaths in high-income countries are not sudden or unexpected, opportunities exist for planning compassionate, effective, and evidence-based EOL care. OBJECTIVE: Gain current population-based evidence for EOL health policy and services planning. DESIGN: Retrospective study of population-based hospital utilization data. SETTING/SUBJECTS: All hospital patients in every Canadian province and territory except Quebec. All decedents with hospital separations in 2014-2015. MEASURES: Descriptive-comparative and logical regression analysis tests. RESULTS: In 2014-2015, 3.5% of hospital episodes ended in death and 43.7% of all deaths in Canada (excluding Quebec) took place in hospital. 95.2% of those dying in hospital were only admitted once or twice during their last 365 days of life. 3.6% of those dying in hospital had been living in the community and receiving publicly funded home care before the hospital admission that ended in death, while 67.0% had been living at home without home care. 79.0% of hospital deaths followed an unplanned admission through the emergency room, with 70.5% arriving by ambulance. The hospital care provided in the last stay was largely noninterventionist. CONCLUSIONS: These findings reveal the need for a major reconceptualization of death, dying, and EOL care to ensure sufficient capacity of palliative home care and other services to support dying people and prevent the health and family caregiver crises that lead to hospital-based EOL care and death.

Preferences and acceptance of colorectal cancer screening in Thailand.

Colorectal cancer (CRC) is now common in Thailand with an increase in incidence over time. Health authorities are planning to implement a nationwide CRC screening program using fecal immunochemical test (FIT) as a primary screening tool. This study aimed to estimate preferences and acceptance of FIT and colonoscopy, explore factors influencing the acceptance, and investigate reasons behind choosing and rejecting to screen before the program was implemented. Patients aged 50-69, visiting the primary care unit during the study period, were invited to join this study. Patients with a history of cancer or past CRC screening were excluded. Face-to-face interviews were conducted. Subjects were informed about CRC and the screening tests: FIT and colonoscopy. Then, they were asked for their opinions regarding the screening. The total number of subjects was 437 (86.7% response rate). Fifty-eight percent were females. The median age was 58 years. FIT was accepted by 74.1% of subjects compared to 55.6% for colonoscopy. The acceptance of colonoscopy was associated with perceived susceptibility to CRC and family history of cancer. No symptoms, unwilling to screen, healthy, too busy and anxious about diagnosis were reasons for refusing to screen. FIT was preferred for its simplicity and non-invasiveness compared with colonoscopy. Those rejecting FIT expressed a strong preference for colonoscopy. Subjects chose colonoscopy because of its accuracy; it was refused for the process and complications. If the screening program is implemented for the entire target population in Thailand, we estimate that 106,546 will have a positive FIT, between 8,618 and 12,749 identified with advanced adenoma and between 2,645 and 3,912 identified with CRC in the first round of the program.

Tax-deductible provisions for gluten-free diet in Canada compared with systems for gluten-free diet coverage available in various countries.

Celiac disease affects 1% of the North American population, with an estimated 350,000 Canadians diagnosed with this condition. The disease is triggered by the ingestion of gluten, and a lifelong, strict gluten-free diet (GFD) is the only currently available treatment. Compliance with a strict GFD is essential not only for intestinal mucosal recovery and alleviation of symptoms, but also for the prevention of complications such as anemia, osteoporotic fractures and small bowel lymphoma. However, a GFD is difficult to follow, socially inconvenient and expensive. Different approaches, such as tax reduction, cash transfer, food provision, prescription and subsidy, have been used to reduce the additional costs of the GFD to patients with celiac disease. The current review showed that the systems in place exhibit particular advantages and disadvantages in relation to promoting uptake and compliance with GFD. The tax offset system used in Canada for GFD coverage takes the form of a reimbursement of a cost previously incurred. Hence, the program does not help celiac patients meet the incremental cost of the GFD - it simply provides some future refund of that cost. An ideal balanced approach would involve subsidizing gluten-free products through controlled vouchers or direct food provision to those who most need it, independently of 'ability or willingness to pay'. Moreover, if the cost of such a program is inhibitive, the value of the benefits could be made taxable to ensure that any patient contribution, in terms of additional taxation, is directly related to ability to pay. The limited coverage of GFD in Canada is concerning. There is an unmet need for GFD among celiac patients in Canada. More efforts are required by the Canadian medical community and the Canadian Celiac Association to act as agents in identifying ways of improving resource allocation in celiac disease.

In place of fear: aligning health care planning with system objectives to achieve financial sustainability.

The financial sustainability of publicly funded health care systems is a challenge to policymakers in many countries as health care absorbs an ever increasing share of both national wealth and government spending. New technology, aging populations and increasing public expectations of the health care system are often cited as reasons why health care systems need ever increasing funding as well as reasons why universal and comprehensive public systems are unsustainable. However, increases in health care spending are not usually linked to corresponding increases in need for care within populations. Attempts to promote financial sustainability of systems such as limiting the range of services is covered or the groups of population covered may compromise their political sustainability as some groups are left to seek private cover for some or all services. In this paper, an alternative view of financial sustainability is presented which identifies the failure of planning and management of health care to reflect needs for care in populations and to integrate planning and management functions for health care expenditure, health care services and the health care workforce. We present a Health Care Sustainability Framework based on disaggregating the health care expenditure into separate planning components. Unlike other approaches to planning health care expenditure, this framework explicitly incorporates population health needs as a determinant of health care requirements, and provides a diagnostic tool for understanding the sources of expenditure increase.

Using small-area variations to inform health care service planning: what do we 'need' to know?

RATIONALE, AIMS AND OBJECTIVES: Allocating resources on the basis of population need is a health care policy goal in many countries. Thus, resources must be allocated in accordance with need if stakeholders are to achieve policy goals. Small area methods have been presented as a means for revealing important information that can assist stakeholders in meeting policy goals. The purpose of this review is to examine the extent to which small area methods provide information relevant to meeting the goals of a needs-based health care policy. METHODS: We present a conceptual framework explaining the terms 'demand', 'need', 'use' and 'supply', as commonly used in the literature. We critically review the literature on small area methods through the lens of this framework. RESULTS: 'Use' cannot be used as a proxy or surrogate of 'need'. Thus, if the goal of health care policy is to provide equal access for equal need, then traditional small area methods are inadequate because they measure small area variations in use of services in different populations, independent of the levels of need in those populations. CONCLUSIONS: Small area methods can be modified by incorporating direct measures of relative population need from population health surveys or by adjusting population size for levels of health risks in populations such as the prevalence of smoking and low birth weight. This might improve what can be learned from studies employing small area methods if they are to inform needs-based health care policies.

Technology resource planning in radiation oncology: application of a needs-based analytic framework to radiosurgery planning in Ontario.

PURPOSE: With the emergence of radiosurgery as a new radiotherapeutic technique, health care decision makers are required to allocate capital radiotherapy resources to meet both current and future radiosurgery requirements. The goal of this article is to demonstrate the feasibility of applying an explicit, needs-based model to resource planning in radiation oncology. METHODS: Using an analytic model that relates radiosurgery need to population size, epidemiology, level of service planned, and productivity, the current radiosurgical need for single brain metastases in Ontario was estimated. The model was populated using Ontario-specific data where possible and supplemented with information from the published literature. Multiway sensitivity analyses were performed to calculate the minimum and maximum technology requirements. RESULTS: The calculated number of full-time radiosurgical units required to treat patients with single brain metastases in Ontario was 5.9. Sensitivity analyses performed varying both level of service planned and productivity yielded a range of requirements from 2.5 to 12.2 full-time radiosurgery units. CONCLUSION: We have shown through the example of single brain metastases in Ontario that it is feasible to perform explicit, needs-based resource planning in radiation oncology. As the availability of new specialized technology increases, health care decision makers may use this approach to ensure the needs of their population are met while maximizing productivity and minimizing opportunity cost.

Surveillance after treatment for cervical intraepithelial neoplasia: outcomes, costs, and cost-effectiveness.

OBJECTIVE: To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN). METHODS: A hypothetical cohort of women was evaluated after treatment for CIN 2 or 3 using a Markov model incorporating data from a large study of women treated for CIN, systematic reviews of test accuracy, and individual preferences. Surveillance strategies included initial conventional or liquid-based cytology, human papillomavirus testing, or colposcopy 6 months after treatment, followed by annual or triennial cytology. Estimated outcomes included CIN, cervical cancer, cervical cancer deaths, life expectancy, costs, cost per life-year, and cost per quality-adjusted life-year. RESULTS: Conventional cytology at 6 and 12 months, followed by triennial cytology, was least costly. Compared with triennial cytology, annual cytology follow-up reduced expected cervical cancer deaths by 73% to 77% and had an average incremental cost per life-year gained of $69,000 to $81,000. For colposcopy followed by annual cytology, the incremental cost per life-year gained ranged from $70,000 to more than $1 million, depending on risk. Between-strategy differences in mean additional life expectancy per woman were less than 4 days; differences in mean incremental costs per woman were as high as $822. In the cost-utility analysis, colposcopy at 6 months followed by annual cytology had an incremental cost per quality-adjusted life-year of less than $5,500. Human papillomavirus testing or liquid-based cytology added little to no improvement to life-expectancy with higher costs. CONCLUSION: Annual conventional cytology surveillance reduced cervical cancers and cancer deaths compared with triennial cytology. For high risk of recurrence, a strategy of colposcopy at 6 months increased life expectancy and quality-adjusted life expectancy. Human papillomavirus testing and liquid-based cytology increased costs, but not effectiveness, compared with traditional approaches.