Glass Slippers and Glass Cliffs: Fitting In and Falling Off.

BACKGROUND: A glass ceiling effect exists for women in male-dominated professions. Recent studies also show a glass-cliff effect where senior women can more easily fall from positions of leadership. Transplantation remains a male-dominated specialty. This study investigated gender and the perception of adverse clinical incidents in transplantation. METHODS: Prospective randomised web-based survey involving five clinical scenarios presenting two versions of episodes with errors or mistakes, with either a male or female as a randomly named protagonist (Set1 and Set2). To address unconscious bias, the study was described as examining actions following clinical adverse incidents in transplantation. Each scenario was followed by 2 closed questions: (1) clinical performance rating and (2) selection of action required. Reasoning was invited (open-text comments). Responses were analyzed using quantitative and qualitative methods. RESULTS: One hundred ninety-one invitees responded; 134 completed questionnaires. There were no statistically significant differences (P > 0.05) in responses between sets for performance ratings or recommended actions. However, for "first solo laparoscopic surgery" scenario, there was some indication that "No Action" was more likely if surgeon was male (P = 0.056). Male responses rated female performance as significantly worse (P = 0.035) for the laboratory-based scenario. One hundred two participants provided open-text comments. Thematic analysis identified 7 themes. Acceptable levels of risk theme demonstrated engendered leadership beliefs, that is, when clinical judgment proved incorrect, males described as forceful but females as needing support. In cases where things went wrong, respondents were more likely to comment females should not have decided to proceed. CONCLUSIONS: While gender may no longer be an overt issue in perceived performance of senior staff in transplantation, respondents' use of language and their choice of words display elements of unconscious (covert) engendered views.

Measuring trade-offs in nephrology: a systematic review of discrete choice experiments and conjoint analysis studies.

Background: Discrete choice experiment (DCE), conjoint analysis or adaptive conjoint analysis methods are increasingly applied to obtain patient, clinician or community preferences in nephrology. This study systematically reviews the above-mentioned published choice studies providing an overview of the issues addressed, methods and findings. Methods: Choice studies relating to nephrology were identified using electronic databases, including Medline, Embase, PsychINFO and Econlit from 1990 to 2015. For inclusion in the review, studies had to primarily relate to kidney disease and include results from statistical (econometric) analyses of respondents' choice or preference. Studies meeting the inclusion criteria were assessed against a range of systematic review criteria, and methods and results summarized. Results: We identified 14 eligible studies from Europe, Australasia, North America and Asia, reporting preferences for treatment or screening, patient experiences, quality of life (QOL), health outcomes and priority-setting frameworks. Specific contexts included medical interventions in kidney transplantation and renal cell carcinoma, health policies for organ donation and allocation, dialysis modalities and end-of-life care, using a variety of statistical models. The characteristics of 'time' (i.e. transplant waiting time, dialysis hours, transport time) and QOL (pre- and post-transplant, or pre- and post-dialysis) consistently influenced patient and clinician preferences across the choice studies. Conclusions: DCE are increasingly used to obtain information about key preferences in kidney transplantation and dialysis. These study methods provide quantitative information about respondents' trade-offs between conflicting clinical and policy objectives, and can establish how preferences vary among stakeholder groups.

South Asian ethnicity, socioeconomic status, and psychological mediators of faecal occult blood colorectal screening participation: A prospective test of a process model.

OBJECTIVE: Although ethnicity and socioeconomic status (SES) correlate with health inequality, efforts to explain variance in health behavior attributable to these factors are limited by difficulties in population sampling. We used ethnicity identification software to test effects of psychological beliefs about screening as mediators of ethnicity and SES on faecal occult blood colorectal screening behavior in a no-cost health care context. METHOD: Adults aged 50-67 years (N = 1,678), of whom 28% were from minority South Asian religiolinguistic ethnic groups (Hindu-Gujarati/Hindi, Muslim-Urdu and Sikh-Punjabi), participated in a prospective survey study. Subsequent screening participation was determined from medical records. RESULTS: Screening nonparticipation in the most deprived SES quintile was 1.6 times that of the least deprived quintile. Nonparticipation was 1.6 times higher in South Asians compared with non-Asians. A process model in which psychological variables mediated effects of ethnicity and SES on uptake was tested using structural equation modeling. Self-efficacy and perceived psychological costs of screening were, respectively, positive and negative direct predictors of uptake. Paths from Hindu, Muslim, and Sikh ethnicity, and SES on uptake were fully mediated by lower self-efficacy and higher perceived psychological costs. Paths from South Asian ethnicity to participation via self-efficacy and psychological costs were direct, and indirect via SES. CONCLUSION: SES is implicated, but does not fully account for low colorectal screening uptake among South Asians. Targeting increased self-efficacy and reduced perceived psychological costs may minimize health inequality effects. Future research should test independent effects of SES and ethnicity on lower self-efficacy and higher psychological costs. (PsycINFO Database Record

Effect of Using the Same vs Different Order for Second Readings of Screening Mammograms on Rates of Breast Cancer Detection: A Randomized Clinical Trial.

IMPORTANCE: Interpreting screening mammograms is a difficult repetitive task that can result in missed cancers and false-positive recalls. In the United Kingdom, 2 film readers independently evaluate each mammogram to search for signs of cancer and examine digital mammograms in batches. However, a vigilance decrement (reduced detection rate with time on task) has been observed in similar settings. OBJECTIVE: To determine the effect of changing the order for the second film reader of batches of screening mammograms on rates of breast cancer detection. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, double-blind, cluster randomized clinical trial conducted at 46 specialized breast screening centers from the National Health Service Breast Screening Program in England for 1 year (all between December 20, 2012, and November 3, 2014). Three hundred sixty readers participated (mean, 7.8 readers per center)-186 radiologists, 143 radiography advanced practitioners, and 31 breast clinicians, all fully qualified to report mammograms in the NHS breast screening program. INTERVENTIONS: The 2 readers examined each batch of digital mammograms in the same order in the control group and in the opposite order to one another in the intervention group. MAIN OUTCOMES AND MEASURES: The primary outcome was cancer detection rate; secondary outcomes were rates of recall and disagreements between readers. RESULTS: Among 1,194,147 women (mean age, 59.3; SD, 7.49) who had screening mammograms (596,642 in the intervention group; 597,505 in the control group), the images were interpreted in 37,688 batches (median batch size, 35; interquartile range [IQR]; 16-46), with each reader interpreting a median of 176 batches (IQR, 96-278). After completion of all subsequent diagnostic tests, a total of 10,484 cases (0.88%) of breast cancer were detected. There was no significant difference in cancer detection rate with 5272 cancers (0.88%) detected in the intervention group vs 5212 cancers (0.87%) detected in the control group (difference, 0.01% points; 95% CI, -0.02% to 0.04% points; recall rate, 24,681 [4.14%] vs 24,894 [4.17%]; difference, -0.03% points; 95% CI, -0.10% to 0.04% points; or rate of reader disagreements, 20,471 [3.43%] vs 20,793 [3.48%]; difference, -0.05% points; 95% CI, -0.11% to 0.02% points). CONCLUSIONS AND RELEVANCE: Interpretation of batches of mammograms by qualified screening mammography readers using a different order vs the same order for the second reading resulted in no significant difference in rates of detection of breast cancer. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN46603370.

Changing case Order to Optimise patterns of Performance in mammography Screening (CO-OPS): study protocol for a randomized controlled trial.

BACKGROUND: X-ray mammography remains the predominant test for screening for breast cancer, with the aim of reducing breast cancer mortality. In the English NHS Breast Screening Programme each woman's mammograms are examined separately by two expert readers. The two readers read each batch in the same order and each indicates if there should be recall for further tests. This is a highly skilled, pressurised, repetitive and frequently intellectually unchallenging activity where readers examine one or more batches of 30-50 women's mammograms in each session. A vigilance decrement or performance decrease over time has been observed in similar repetitive visual tasks such as radar operation. METHODS/DESIGN: The CO-OPS study is a pragmatic, multi-centre, two-arm, double blind cluster randomised controlled trial of a computer software intervention designed to reduce the effects of a vigilance decrement in breast cancer screening. The unit of randomisation is the batch. Intervention batches will be examined in the opposite order by the two readers (one forwards, one backwards). Control batches will be read in the same order as one another, as is current standard practice. The hypothesis is that cancer detection rates will be higher in the intervention group because each readers' peak performance will occur when examining different women's mammograms. The trial will take place in 44 English breast screening centres for 1 year and 4 months. The primary outcome is cancer detection rate, which will be extracted from computer records after 1 year of the trial. The secondary outcomes include rate of disagreement between readers (a more statistically powerful surrogate for cancer detection rate), recall rate, positive predictive value, and interval cancer rate (cancers found between screening rounds which will be measured three years after the end of the trial). DISCUSSION: This is the first trial of an intervention to ameliorate a vigilance decrement in breast cancer screening. TRIAL REGISTRATION: ISRCTN46603370 (submitted: 24 October 2012, date of registration: 26 March 2013).

A cluster randomized controlled trial of the effectiveness and cost-effectiveness of intermediate care clinics for diabetes (ICCD): study protocol for a randomized controlled trial.

BACKGROUND: World-wide healthcare systems are faced with an epidemic of type 2 diabetes. In the United Kingdom, clinical care is primarily provided by general practitioners (GPs) rather than hospital specialists. Intermediate care clinics for diabetes (ICCD) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors. This study aims to (1) compare patients with type 2 diabetes registered with practices that have access to an ICCD service with those that have access only to usual hospital care; (2) assess the cost-effectiveness of the intervention; and (3) explore the views and experiences of patients, health professionals and other stakeholders. METHODS/DESIGN: This two-arm cluster randomized controlled trial (with integral economic evaluation and qualitative study) is set in general practices in three UK Primary Care Trusts. Practices are randomized to one of two groups with patients referred to either an ICCD (intervention) or to hospital care (control). Intervention group: GP practices in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist. Patients are reviewed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice. or CONTROL GROUP: Standard GP care, with referral to secondary care as required, but no access to ICCD. Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control. The primary outcome is the proportion of participants reaching three risk factor targets: HbA1c (≤7.0%); blood pressure (<140/80); and cholesterol (<4 mmol/l), at the end of the 18-month intervention period. The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD) and stroke assessed by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine. Other secondary outcomes include body mass index and waist circumference, use of medication, reported smoking, emotional adjustment, patient satisfaction and views on continuity, costs and health related quality of life. We aimed to randomize 50 practices and recruit 2,555 patients. DISCUSSION: Forty-nine practices have been randomized, 1,997 patients have been recruited to the trial, and 20 patients have been recruited to the qualitative study. Results will be available late 2012. TRIAL REGISTRATION: [ClinicalTrials.gov: Identifier NCT00945204].

UK ethnicity data collection for healthcare statistics: the South Asian perspective.

BACKGROUND: Ethnicity data collection has been proven to be important in health care but despite government initiatives remains incomplete and mostly un-validated in the UK. Accurate self-reported ethnicity data would enable experts to assess inequalities in health and access to services and help to ensure resources are targeted appropriately. The aim of this paper is to explore the reasons for the observed gap in ethnicity data by examining the perceptions and experiences of healthy South Asian volunteers. South Asians are the largest ethnic minority group accounting for 50% of all ethnic minorities in the UK 2001 census. METHODS: Five focus groups, conducted by trained facilitators in the native language of each group, recruited 36 South Asian volunteers from local community centres and places of worship. The topic guide focused on five key areas:1) general opinions on the collection of ethnicity, 2) experiences of providing ethnicity information, 3) categories used in practice, 4) opinions of other indicators of ethnicity e.g. language, religion and culture and 5) views on how should this information be collected. The translated transcripts were analysed using a qualitative thematic approach. RESULTS: The findings of this Cancer Research UK commissioned study revealed that participants felt that accurate recording of ethnicity data was important in healthcare with several stating the increased prevalence of certain diseases in minority ethnic groups as an appropriate justification to improve this data. The overwhelming majority raised no objections to providing this data when the purpose of data collection is fully explained. CONCLUSIONS: This study confirmed that the collection of patients' ethnicity data is deemed important by potential patients but there remains uncertainty and unease as to how the data may be used. A common theme running through the focus groups was the willingness to provide these data, strongly accompanied by a desire to have more information with regard to its use.

A new fetal RHD genotyping test: costs and benefits of mass testing to target antenatal anti-D prophylaxis in England and Wales.

BACKGROUND: Postnatal and antenatal anti-D prophylaxis have dramatically reduced maternal sensitisations and cases of rhesus disease in babies born to women with RhD negative blood group. Recent scientific advances mean that non-invasive prenatal diagnosis (NIPD), based on the presence of cell-free fetal DNA in maternal plasma, could be used to target prophylaxis on "at risk" pregnancies where the fetus is RhD positive. This paper provides the first assessment of cost-effectiveness of NIPD-targeted prophylaxis compared to current policies. METHODS: We conducted an economic analysis of NIPD implementation in England and Wales. Two scenarios were considered. Scenario 1 assumed that NIPD will be only used to target antenatal prophylaxis with serology tests continuing to direct post-delivery prophylaxis. In Scenario 2, NIPD would also displace postnatal serology testing if an RhD negative fetus was identified. Costs were estimated from the provider's perspective for both scenarios together with a threshold royalty fee per test. Incremental costs were compared with clinical implications. RESULTS: The basic cost of an NIPD in-house test is £16.25 per sample (excluding royalty fee). The two-dose antenatal prophylaxis policy recommended by NICE is estimated to cost the NHS £3.37 million each year. The estimated threshold royalty fee is £2.18 and £8.83 for Scenarios 1 and 2 respectively. At a £2.00 royalty fee, mass NIPD testing would produce no saving for Scenario 1 and £507,154 per annum for Scenario 2. Incremental cost-effectiveness analysis indicates that, at a test sensitivity of 99.7% and this royalty fee, NIPD testing in Scenario 2 will generate one additional sensitisation for every £9,190 saved. If a single-dose prophylaxis policy were implemented nationally, as recently recommended by NICE, Scenario 2 savings would fall. CONCLUSIONS: Currently, NIPD testing to target anti-D prophylaxis is unlikely to be sufficiently cost-effective to warrant its large scale introduction in England and Wales. Only minor savings are calculated and, balanced against this, the predicted increase in maternal sensitisations may be unacceptably high. Reliability of NIPD assays still needs to be demonstrated rigorously in different ethnic minority populations. First trimester testing is unlikely to alter this picture significantly although other emerging technologies may.

Comparison of breast and bowel cancer screening uptake patterns in a common cohort of South Asian women in England.

BACKGROUND: Inequalities in uptake of cancer screening by ethnic minority populations are well documented in a number of international studies. However, most studies to date have explored screening uptake for a single cancer only. This paper compares breast and bowel cancer screening uptake for a cohort of South Asian women invited to undertake both, and similarly investigates these women's breast cancer screening behaviour over a period of fifteen years. METHODS: Screening data for rounds 1, 2 and 5 (1989-2004) of the NHS breast cancer screening programme and for round 1 of the NHS bowel screening pilot (2000-2002) were obtained for women aged 50-69 resident in the English bowel screening pilot site, Coventry and Warwickshire, who had been invited to undertake breast and bowel cancer screening in the period 2000-2002. Breast and bowel cancer screening uptake levels were calculated and compared using the chi-squared test. RESULTS: 72,566 women were invited to breast and bowel cancer screening after exclusions. Of these, 3,539 were South Asian and 69,027 non-Asian; 18,730 had been invited to mammography over the previous fifteen years (rounds 1 to 5). South Asian women were significantly less likely to undertake both breast and bowel cancer screening; 29.9% (n = 1,057) compared to 59.4% (n = 40,969) for non-Asians (p < 0.001). Women in both groups who consistently chose to undertake breast cancer screening in rounds 1, 2 and 5 were more likely to complete round 1 bowel cancer screening. However, the likelihood of completion of bowel cancer screening was still significantly lower for South Asians; 49.5% vs. 82.3% for non-Asians, p < 0.001. South Asian women who undertook breast cancer screening in only one round were no more likely to complete bowel cancer screening than those who decided against breast cancer screening in all three rounds. In contrast, similar women in the non-Asian population had an increased likelihood of completing the new bowel cancer screening test. The likelihood of continued uptake of mammography after undertaking screening in round 1 differed between South Asian religio-linguistic groups. Noticeably, women in the Muslim population were less likely to continue to participate in mammography than those in other South Asian groups. CONCLUSIONS: Culturally appropriate targeted interventions are required to reduce observed disparities in cancer screening uptakes.

Limited role of multi-attribute utility scale and SF-36 in predicting management outcome of heavy menstrual bleeding.

OBJECTIVE: To compare the value of SF36v2 versus multi-attribute utility score (MAS) for predicting treatment outcome in heavy menstrual bleeding (HMB). STUDY DESIGN: Longitudinal observational study, in an outpatient service of a large UK teaching hospital. 193 women took part. Women were asked to complete SF36v2 and a multi-attribute utility score (MAS) for menorrhagia before the first consultation. Patient management was determined through an evidence based guideline and blind to their response to the questionnaire. Treatment outcome at 8 months was examined in relation to the physical (PCS) and mental (MCS) health summary scales of SF36v2 and to MAS. RESULTS: At study entry equal numbers of patients, 179 (93%), returned usable responses for SF36v2 and the multi-attribute scale; 178 (92%) returned both. Baseline SF36v2 scores for role physical, bodily pain, social functioning and mental health were significantly lower (p<0.05) for the group of women who finally required surgery, but the difference in PCS or MCS was not statistically significant. The mean MAS score for those who did not need surgery was 50.7, and for those who needed surgery following failed medical treatment was 35.06. The difference was statistically significant (p<0.001, 95% CI 7.47-23.82). Using logistic regression analysis there was a statistically significant association between baseline MAS but not MCS or PCS and the need for surgery. However, there was considerable overlap between treatment groups. CONCLUSIONS: MAS may be a better predictor of management outcome compared to SF36v2 for HMB; but its utility for the individual patient is limited.

Reduction in the rate of methicillin-resistant Staphylococcus aureus acquisition in surgical wards by rapid screening for colonization: a prospective, cross-over study.

Identification of patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) and subsequent isolation and decolonization is pivotal to the control of cross infection in hospitals. The aim of this study was to establish if early identification of colonized patients using rapid methods alone reduces transmission. A prospective, cluster, two-period cross-over design was used. Seven surgical wards at a large hospital were allocated to two groups, and for the first 8 months four wards used rapid MRSA screening and three wards used a standard culture method. The groups were reversed for the second 8 months. Regardless of the method of detection, all patients were screened for nasal carriage on admission and then every 4 days. MRSA control measures remained constant. Results were analysed using a log linear Poisson regression model. A total of 12 682/13 952 patient ward episodes (PWE) were included in the study. Admission screening identified 453 (3.6%) MRSA-positive patient ward episodes, with a further 268 (2.2%) acquiring MRSA. After adjusting for other variables, rapid screening was shown to statistically reduce MRSA acquisition, with patients being 1.49 times (p 0.007) more likely to acquire MRSA in wards where they were screened using the culture method. Screening of surgical patients using rapid testing resulted in a statistically significant reduction in MRSA acquisition. This result was achieved in a routine surgical service with high bed occupancy and low availability of isolation rooms, making it applicable to the majority of health-care systems worldwide.

Breast and bowel cancer screening uptake patterns over 15 years for UK south Asian ethnic minority populations, corrected for differences in socio-demographic characteristics.

BACKGROUND: A number of studies have reported low uptake of cancer screening programmes by South Asian populations in the UK. However, studies to date have not adjusted findings for differences in demographics and socio-economic status of these populations. SUBJECTS: All residents in Coventry and Warwickshire, UK, eligible for screening. Uptakes compared for round 1 (2000-02) and round 2 (2003-05) of a national bowel cancer screening pilot, and for rounds 1, 2 and 5 of the established NHS breast cancer screening programme (commenced 1989). DATA: Bowel screening data were analysed for 123,367 invitees in round 1 and 116,773 in round 2 (total 240,140 cases). Breast screening data were analysed for 61,934, 62,829 and 86,749 invitees in rounds 1, 2 and 5 respectively (total 211,512 cases). ANALYSIS: Screening uptake was compared for two broad meta-categories (South Asian and non-Asian) and for five Asian subgroups (Hindu-Gujarati; Hindu-Other; Muslim; Sikh; South Asian Other). Univariate and multivariate analyses examined screening uptake and various demographic attributes of invitees, including age, gender, deprivation and ethnic group. RESULTS: South Asians demonstrated significantly lower (p < 0.001) unadjusted bowel screening uptake; 32.8% vs. 61.3% for non-Asians (round 1). Rates were particularly low for the Muslim subgroup: 26.1% (round 1), 21.5% (round 2). For breast screening, a smaller difference was observed between South Asians and non-Asians; initially 60.8% vs. 75.4% (round 1) and later 66.8% vs. 77.7% (round 5). Thus, the disparity reduced gradually over time, alongside an overall trend of increased uptake. However, figures remained consistently low for Muslims (51% in rounds 1 and 5). After adjusting for age, deprivation (and gender), bowel screening uptake remained significantly lower for all South Asian subgroups. After similar adjustments, breast screening uptake remained lower for all subgroups except Hindu-Gujaratis. For Muslims registered with an Asian (vs. non-Asian) GP, bowel screening uptake was significantly lower (p < 0.001). However, breast screening uptake for Muslims with an Asian (vs. non-Asian) GP showed no difference (p = 0.12) in the same period. Colonoscopy and breast assessment uptakes were similar for both meta-categories, but Asian response time appeared slower for colonoscopy. The percentage of abnormal FOBT results was significantly higher for South Asian invitees. A slight increase in abnormal mammograms was observed for Muslims over time (2.7% to 4.2% in rounds 1 and 5 respectively). CONCLUSION: The lower cancer screening uptakes observed for the South Asian population cannot be attributed to socio-economic, age or gender population differences. Although breast screening disparities have reduced over time, significant differences remain. We conclude that both programmes need to implement and assess interventions to reduce such differences.

A study of the efficacy and cost-effectiveness of MRSA screening and monitoring on surgical wards using a new, rapid molecular test (EMMS).

BACKGROUND: MRSA is a significant contributor to prolonged hospital stay, poor clinical outcome and increased healthcare costs amongst surgical patients. A PCR test has been developed for rapid detection of MRSA in nasal swabs. The aims of this study are (1) to estimate the effectiveness of screening using this rapid PCR tests vs culture in reducing MRSA cross-infection rates; (2) to compare the cost of each testing strategy, including subsequent health care costs; and (3) to model different policies for the early identification and control of MRSA infection in surgical patients. METHODS/DESIGN: The study is a prospective two-period cross-over study set in 7 surgical wards covering different surgical specialities. A total of 10,000 patients > 18 years will be tested over 16 months. The only difference between the two study periods is the method used for the detection of MRSA in each ward (rapid v conventional culture), with all other infection control practices remaining consistent between the arms. The study has been designed to complement routine practice in the NHS. Outcomes are MRSA cross-infection rates (primary outcome) and need for antibiotic therapy and MRSA-related morbidity. Parallel economic and modelling studies are being conducted to aid in the interpretation of the results and to evaluate the cost-effectiveness of the rapid PCR screening strategy. DISCUSSION: This paper highlights the design, methods and operational aspects of a study evaluating rapid MRSA screening in the surgical ward setting.

Healthcare outcomes: gemcitabine cost-effectiveness in the treatment of non-small cell lung cancer.

The introduction of any new chemotherapy agent for non-small cell lung cancer (NSCLC) ought to be considered carefully in light of both costs and measurable benefits. Decision making is straightforward if a new treatment is relatively cheaper and more effective (i.e. introduce new therapy) or more expensive and less effective (i.e. reject new treatment) than standard therapies. However, if a treatment is more expensive and also more effective, or less expensive but also less effective, decision making becomes more complicated. An economic evaluation of the cost-effectiveness of gemcitabine in advanced NSCLC was performed as a case study. A comprehensive literature search for published economic evaluations of gemcitabine was carried out. Economic studies examining treatment for advanced NSCLC were limited to cost-minimization analyses and cost-effectiveness analyses. The analyses included primary economic studies, e.g. trials that included an integral economic evaluation, and secondary research, e.g. analyses based on published trial data and modeling. Overall, gemcitabine regimens proved cost-effective against standard therapies in this analysis. Prospective economic and quality-of-life analyses should be incorporated into study designs to help identify treatments that will maximize societal health benefits.