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OBJECTIVE:To determine health utility scores for specific debilitated health states and to identify whether race or other demographic differences predict significant variation in these utility scores. DESIGN: Utility analysis.SETTING: A community hospital general internal medicine clinic, a private internal medicine practice, and a private pulmonary medicine practice. PARTICIPANTS:Sixty-four consecutive patients aged 50 to 75 years awaiting appointments. In order to participate, patients at the pulmonary clinic had to meet prespecified criteria of breathing impairment. MEASUREMENTS:

OBJECTIVE: To compare strategies for diagnosing cancer in primary care patients with low back pain. Strategies differed in their use of clinical findings, erythrocyte sedimentation rate (ESR), and plain x-rays prior to imaging and biopsy.DESIGN: Decision analysis and cost effectiveness analysis with sensitivity analyses. Strategies were compared in terms of sensitivity, specificity, and diagnostic cost effectiveness ratios. SETTING: Hypothetical.MEASUREMENTS: Estimates of disease prevalence and test characteristics were taken from the literature. Costs were represented by the Medicare reimbursement for the tests and procedures employed. MAIN RESULTS:In the baseline analysis, using magnetic resonance imaging (MRI) as the imaging procedure prior to a single biopsy, strategies ranged in sensitivity from 0.40 to 0.73, with corresponding diagnostic costs of $14 to $241 per patient and average cost effectiveness ratios of $5,283 to $49,814 per case of cancer found. Incremental cost effectiveness ratios varied from $8,397 to $624,781; five strategies were dominant in the baseline analysis. Use of a higher ESR cutoff point (50 mm/hr) improved specificity and cost effectiveness for certain strategies. Imaging with MRI, or bone scan followed in series by MRI, resulted in fewer unnecessary biopsies than imaging with bone scan alone. Cancer prevalence was an important determinant of cost effectiveness. CONCLUSIONS:We recommend a strateg y of imaging patients who have a clinical finding (history of cancer, age 50 years, weight loss, or failure to improve with conservative therapy) in combination with either an elevated ESR ( 50 mm/hr) or a positive x-ray, or using the same approach but imaging directly those patients with a history of cancer. KEY WORDS: low back pain; decision analysis; costeffectiveness analysis.