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World Journal of Otorhinolaryngology - Head and Neck Surgery logoLink to World Journal of Otorhinolaryngology - Head and Neck Surgery
. 2016 Jan 26;2(1):28–37. doi: 10.1016/j.wjorl.2016.01.001

Value within otolaryngology: Assessment of the cost-utility analysis literature

Krupa R Patel a, David J Phillips b, Jason M Leibowitz c, Theresa Scognamiglio d, Victoria E Banuchi b, William I Kuhel b, David I Kutler b, Marc A Cohen b,∗
PMCID: PMC5698524  PMID: 29204546

Abstract

Objective

To assess the characteristics and quality of cost utility analyses (CUA) related to otolaryngology within the CEA registry and to summarize their collective results.

Methods

All cost-utility analyses published between 1976 and 2011 contained in the Cost-Effectiveness Analysis Registry (CEA Registry) were evaluated. Topics that fall within the care of an otolaryngologist were included in the review regardless of the presence of an otolaryngologist author. Potential associations between various study characteristics and CEA registry quality scores were evaluated using the Pearson product moment correlation coefficient.

Results

Sixty-one of 2913 (2.1%) total CUA publications screened were related to otolaryngology. Eighteen of 61 (29.5%) publications included an otolaryngologist as an author. Fourteen studies agreed on the cost effectiveness of at least unilateral cochlear implantation and six of seven (85.7%) studies demonstrated the cost effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA). Forty-six percent (28 of 61) of all manuscripts were published between 2008 and 2011. A more recent publication year was associated with a higher CEA registry quality score while the presence of an otolaryngologist author and journal impact factor had no significant correlation with the quality of the CUA.

Conclusion

Based on current evidence in the CEA registry, unilateral cochlear implantation for hearing loss and CPAP for OSA are both cost-effective therapeutic interventions. Although CUAs in otolaryngology have increased in quantity and improved in quality in more recent years, there is a relative lack of CUAs in otolaryngology in comparison to other subspecialties.

Keyword: Cost-utility analysis

Introduction

The cost of medicine in the United States and abroad is increasing at an exponential and economically unsustainable rate. Technological advances leading to more expensive diagnostic and therapeutic tools have contributed to this increase, which in turn has led to rising pressure to demonstrate the value of such interventions. This has ultimately led to growing governmental, professional, organizational, and academic interests in the value propositions in the healthcare system. Cost-effectiveness analysis (CEA) is the primary modality by which investigators assess the value of an intervention. CEA evaluates the price of an intervention, either to the payer or to society, for an individual measure of effectiveness of that intervention.1 This can include the years of life added and quality of life added, among others.

A subset of cost-effectiveness analysis is cost-utility analysis (CUAs), which expresses the effectiveness of an intervention using a uniform unit of cost per quality adjusted life year (QALY). The QALY describes the time spent in a certain health state, multiplied by the quality of each state (with 1 QALY being perfectly healthy for one year).2 In this way, both a treatment that improves health related quality of life from 0.5 to 1.0 for 5 years and a treatment that leads to 5 additional years of life with a health condition of 0.5 both yield 2.5 QALYs. One general way to look at value is to assess the cost of an intervention and to correlate this with the benefits rendered, either in life gained or in quality of life improved. In cost-utility analysis, interventions are considered of favorable value if their cost is less than $50,000 (USD) per QALY gained. As the cost per QALY decreases, the intervention becomes more cost effective. When comparing two interventions with the same intended goal, the intervention with the lower cost per QALY is the more economic choice.

Within all aspects of medical literature, there are an increasing number of studies evaluating cost utility. However, this is challenging within subspecialties such as otolaryngology due to a limited number of investigators and conditions compared to other specialties. Nevertheless, because otolaryngology utilizes costly diagnostic and therapeutic strategies for managing conditions such as head and neck cancer, hearing loss, and chronic sinusitis, it provides a fertile landscape for the assessment of cost effectiveness. The objectives of this study are to detail specific characteristics of CUAs within otolaryngology, to evaluate the quality of these studies and to summarize the collective results of the most common topics of economic evaluations in otolaryngology.

Methods

We performed a quantitative and qualitative assessment of studies within the spectrum of otolaryngology between 1976 and 2011 using the CEA registry.3 The CEA registry is a database updated three times per year with publically available data on all publications that are published in English, are original cost-effectiveness analyses, and measure health benefits of QALYs. The CEA registry is supported by the Center for the Evaluation of Value and Risk in Health (CEVR) and is part of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center. The total number of studies available in the registry at the time of analysis was 2913. The registry's rigorous methodology for screening cost utility analysis manuscripts is described on the website. In short, a MEDLINE search is performed with the keywords, “QALYs” “quality,” and “cost-utility analysis.” The CEA registry team screens abstracts to assess if there is an original cost-utility estimate. Each article is then abstracted for methodology, cost-effectiveness ratios, and utility weights. Two trained readers audit each article independently and a consensus audit resolves discrepancies.

Author MAC systematically reviewed all of the articles within the CEA registry and screened for publications that fall within the field of otolaryngology, which includes head and neck surgery, endocrine surgery, otology, pediatric otolaryngology, rhinology, allergy and sleep medicine. The presence of an otolaryngologist author, as determined per affiliations listed on the manuscript, was not a factor in inclusion. In the unique case that affiliations were not named, an Internet search was conducted. Study characteristics, including year of publication, journal of publication, author affiliation, country of research, type of funding, analysis perspective, intervention type, and CEA registry quality score (numbered from 1 (low) to 7 (high) by expert readers). The criteria used to determine the CEA registry quality score of each study includes: 1. accurate computation of incremental cost-effectiveness ratios, 2. comprehensive characterization of the uncertainty of results, 3. explicit specification of health economic assumptions used in the study, and 4. appropriate and explicit estimation of utility weights (Table 1). The strength and direction of association between characteristics of each study and CEA registry quality scores were measured using the Pearson product moment correlation coefficient using the Statistical Package for Social Sciences (SPSS Version 22.0, Chicago, IL). The collective results of CUAs of the most commonly evaluated interventions were also assessed in order to identify economically attractive management options within otolaryngology.

Table 1.

CEA registry quality score criteria, adapted from the Tufts CEA Registry.3

CEA registry quality score criteria (in order of importance)
  • 1

    Did the study authors correctly compute the incremental cost-effectiveness ratios?

  • 2

    Did the authors comprehensively characterize the uncertainty of the results?

  • 3

    Were the health economic assumptions used in the study (discount rate, currency, time horizon) explicitly specified?

  • 4

    Was there an appropriate and explicit estimation of utility weights?
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Results

Assessment of 2913 studies revealed 61CUAs that evaluated interventions related to otolaryngology. The earliest study was published in 1991 and assessed the cost-effectiveness of tympanostomy tubes versus antibiotic prophylaxis for acute otitis media (AOM). Eighty-five percent (52 of 61) of studies were published later than 2000, with 28 (45.9%) published between 2008 and 2011 (Fig. 1). The 61 publications addressed topics within the subspecialties of otology (31.1%), endocrine surgery (19.6%), sleep medicine/surgery (18.0%), head and neck surgery (13.0%), pediatric otolaryngology (8.2%), allergy (6.6%), and rhinology (3.3%) (Fig. 2). Of the 61 manuscripts related to otolaryngology, 18 (29.5%) studies had at least one author who was an otolaryngologist. Eight (13.0%) manuscripts had a first author and seven (11.4%) had a final author primarily affiliated with a department of otolaryngology. Seventy-two percent of publications with an otolaryngologist as a first author were related to otology.

Fig. 1.

Fig. 1

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CUA publications per time period.

Fig. 2.

Fig. 2

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Publication subspecialties.

The otolaryngology CUAs were published in 41 journals, with only five journals having three or more manuscripts (Table 2). Thirty-two (52.4%) economic analyses had the United States as the country of interest. Eight studies focused on the United Kingdom and five on Canada. Ninety-eight percent of manuscripts had at least one author with an academic affiliation. Seventy-one percent of analyses had the perspective of healthcare payer. The funding sources of the manuscripts were stated as none or could not be determined in 29 (47.5%), government funding in 17 (27.9%), pharmaceutical or device in 14 (22.9%), foundation in 6 (9.8%) and healthcare organization in 3 (4.9%) (Table 2). Two studies (3.3%) evaluated primary prevention strategies, which are defined as efforts to prevent disease prior to its occurrence. One of these primary prevention strategies analyzed oral cancer screening programs for high-risk males4 and the second evaluated candidate vaccines for prevention of pediatric acute otitis media.5 Thirteen studies assessed secondary prevention interventions (methods that identify and treat asymptomatic individuals with risk factors or preclinical disease) and 46 (75.4%) evaluated tertiary prevention interventions (methods that limit disability after harm has occurred). A majority of the studies evaluated the cost utility of devices (47.5%) or pharmaceuticals (29.5%) (Table 2).

Table 2.

Demographic characteristics of CUAs.

Study characteristic No. Studies (%) Mean CEA registry quality score (range)
Subspecialty
 Otology 19 (31.1) 3.8 (1.5–6.0)
 Endocrine surgery 12 (19.7) 4.2 (3.5–5.5)
 Sleep medicine/surgery 11 (18.0) 4.2 (2.5–6.0)
 Head and neck surgery 8 (13.0) 3.4 (2.5–5.0)
 Pediatric otolaryngology 5 (8.2) 4.3 (3.0–5.5)
 Allergy 4 (6.6) 4.5 (3.5–6.0)
 Rhinology 2 (3.3) 4.5 (4.0–5.0)
Journal (2011 impact factor)
 Laryngoscope (1.752) 6 (9.8) 3.3 (1.5–4.5)
 Arch of Otolaryngology Head Neck Surg (1.63) 4 (6.6) 4.1 (1.5–5.0)
 Ear Hearing (2.578) 3 (4.9) 4.5 (3.0–6.0)
 Sleep (5.051) 3 (4.9) 4.2 (2.5–5.0)
 Value Health (2.191) 3 (4.9) 5.0 (4.0–6.0)
 Others 36 (59) 4.1 (1.5–6.0)
Total No. of Journals 41 4.0 (1.5–6.0)
Year of publication
 1976–1991 1 (1.6) 3.0
 1992–1995 4 (6.6) 2.1 (1.5–3.0)
 1996–1999 4 (6.6) 3.9 (2–5.5)
 2000–2003 10 (16.4) 3.9 (1.5–5.5)
 2004–2007 14 (22.9) 4.0 (3.0–6.0)
 2008–2011 28 (45.9) 4.4 (2.5–6.0)
Country of analysis
 United States 32 (52.4) 3.9 (1.5–6.0)
 United Kingdom 8 (13.1) 4.7 (1.5–6.0)
 Canada 5 (8.2) 4.1 (2.5–5.5)
 Australia 3 (4.9) 3.3 (3.0–4.0)
 Germany 3 (4.9) 4.2 (4.0–4.5)
 France 2 (3.3) 4.5 (3.5–5.5)
 Netherlands 2 (3.3) 3.5 (2.0–5.0)
 New Zealand 1 (1.6) 4.0
 Austria 1 (1.6) 3.5
 China 1 (1.6) 3.0
 Finland 1 (1.6) 3.0
 Belgium 1 (1.6) 5.0
 Taiwan 1 (1.6) 5.0
Funding source
 Government 17 (27.9) 4.1 (1.5–6.0)
 Pharmaceutical or device 14 (22.9) 3.8 (1.5–5.5)
 Could not be determined 29 (47.5) 3.9 (1.5–6.0)
 Foundation 6 (9.8) 4.3 (3.0–5.5)
 Healthcare organization 3 (4.9) 3.5 (1.5–4.5)
Perspective of study
 Healthcare payer 43 (70.5) 3.9 (1.5–6.0)
 Societal 17 (27.9) 4.4 (3.0–5.5)
 Could not be determined 1 (1.6) 1.5
Intervention type
 Primary 2 (3.3) 4.8 (4.0–5.5)
 Secondary 13 (21.3) 3.8 (2.0–6.0)
 Tertiary 46 (75.4) 4.0 (1.5–6.0)
Authors affiliation
 Academic 60 (98.4) 4.0 (1.5–6.0)
 Consultant 7 (11.5) 4.4 (3.5–5.0)
 Government 1 (1.6) 3.0
Intervention assessed
 Device 29 (47.5) 3.8 (1.5–6.0)
 Diagnostic 6 (9.8) 4.0 (3.0–5.0)
 Screening 6 (9.8) 3.4 (2.0–5.0)
 Health education 1 (1.6) 4.0
 Medical procedure 9 (14.7) 4.1 (3.0–5.0)
 Pharmaceutical 18 (29.5) 4.6 (3.5–6.0)
 Surgical 12 (19.7) 3.9 (2.5–5.5)
 Immunization 2 (3.3) 5.0 (4.5–5.5)
 Care delivery 2 (3.3) 3.3 (3.0–3.5)
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The mean CEA registry quality score (on a scale of 1–7) for all 61 studies was 4.00. A more recent publication year was associated with a higher CEA registry quality score (r = 0.412, P < 0.01) (Table 3). The mean quality score for studies with at least one otolaryngology author was 3.77 and 4.09 for those without an otolaryngology author. There was no significant correlation between the number of otolaryngologist authors and the CEA quality score. The impact factor of the journal in which each study was published also had no significant association with the quality of the CUA. The references and topics for all 61 studies that relate to otolaryngology in the CEA database are listed in Table 4. Fourteen studies agreed on the cost-effectiveness of at least unilateral cochlear implantation and 6 of 7 studies demonstrated CPAP to be a cost-effective strategy for treating patients with OSA.

Table 3.

Correlations between CUA characteristics and CEA registry quality score.

Variable Correlation coefficient, r P value
# of Otolaryngology authors −0.043 0.749
Publication year 0.412 0.001a
Journal impact factor 0.184 0.160
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a

Statistically significant.

Table 4.

Summary of evaluated CUAs.

Year Specialty Journal Reference Topic of CUA publication
1991 General Fam Pract Res J Bisonni et al9 Tympanostomy tubes vs antibiotic prophylaxis for AOM
1994 Sleep Sleep Tousignant et al10 Impact of nasal CPAP on quality of life for OSA
1995 Otology Ann Otol Rhinol Laryngol Suppl Evans et al11 Adult unilateral cochlear implant
1995 Otology Med Prog Technol Lea et al12 Cochlear implantation vs vibrotactile devices
1995 Otology Arch Otolaryngol Head Neck Surg Harris et al13 Cochlear implantation for profound deafness
1996 Otology Laryngoscope Wyatt et al14 Multichannel cochlear implants
1996 Pediatrics Clin Ther Oh et al15 Second-line antibiotics for pediatric AOM
1999 Otology Int J Technol Assess Health Care Carter et al16 Pediatric and adult cochlear implantation
1999 Otology Arch Otolaryngol Head Neck Surg Palmer et al17 Adult cochlear implantation
2000 Otology Laryngoscope O'Neill et al18 Pediatric cochlear implantation
2000 Otology JAMA Cheng et al19 Pediatric cochlear implantation
2001 Head and neck Cancer Hollenbeak et al20 FDG-PET for N0 HNSCC
2002 Endocrine Eur J Endocrinol Vidal-Trecan et al21 Management of toxic thyroid adenomas
2002 Otology Otol Neurotol Bichey et al22 Cochlear implantation for large vestibular aqueduct syndrome
2002 Otology Laryngoscope Francis et al23 Cochlear implantation in older adults
2002 Head and neck Community Dent Oral Epidemiol Van der Meij et al24 Cancer screening of patients with oral lichen planus
2002 Otology Arch Otolaryngol Head Neck Surg Summerfield et al25 Unilateral vs bilateral cochlear implantation
2003 Otology Arch Otolaryngol Head Neck Surg Joore et al26 Fitting of hearing aids
2003 Otology Laryngoscope Wilson et al27 Intraoperative facial nerve monitoring for otologic surgery
2004 Otology Ear Hear Group, UKCIS et al28 Unilateral cochlear implantation in postlingually deafened adults
2004 Endocrine Thyroid Vidal-Trecan et al29 Radioiodine vs surgery for toxic thyroid adenoma
2005 Endocrine Eur J Endocrinol Sejean et al30 Surgery vs medical follow-up for primary hyperparathyroidism
2005 Endocrine ANZ J Surg Blamey et al31 Recombinant human TSH for diagnosis of recurrent thyroid cancer
2005 Sleep Stroke Brown et al32 Sleep study screening of stroke victims for OSA
2006 Pediatrics Pediatrics Van Howe et al33 Observation without testing for pediatric pharyngitis
2006 Sleep Arch Int Med Ayas et al34 CPAP for moderate to severe OSA
2006 Otology Ear Hear Barton et al35 Pediatric cochlear implantation
2006 Endocrine Surgery Zanocco et al36 Management of asymptomatic primary hyperparathyroidism
2007 Pediatrics Ann Fam Med Coco et al37 Management of pediatric acute otitis media
2007 Endocrine Am J Kidney Dis Narayan et al38 Parathyroidectomy vs cinacalcet for hyperparathyroidism in ESRD
2007 Allergy Curr Med Res Opin Keiding et al39 Immunotherapy for seasonal allergic rhinoconjunctivitis
2007 Rhinology Am J Rhinol Anzai et al40 Management of acute sinusitis
2007 Otology Genet Med Veenstra et al41 Testing for mitochondrial mutation (A155G) in cystic fibrosis
2008 Sleep J Int Med Res Lojander et al42 Nasal CPAP for OSA
2008 Otology Otol Neurotol Chang et al43 Hearing aid outcome in the elderly
2008 Allergy Ann Allergy Asthma Immunol Bruggenjurgen et al44 Subcutaneous immunotherapy for allergic rhinitis and allergic asthma
2008 Head and neck Value Health Brown et al45 Cetuximab plus radiotherapy for head and neck cancer
2008 Sleep Thorax Guest et al46 CPAP for OSA
2008 Sleep Can Respir J Tan et al47 CPAP for OSA
2008 Endocrine Surgery Zanocco et al48 Parathyroidectomy vs observation for primary hyperparathyroidism
2009 Endocrine Value Health Mernagh et al49 Recombinant human TSH before RAI ablation for thyroid cancer
2009 Head and neck Ann Oncol Sher et al50 CT and PET-CT for determining need for neck dissection in HNSCC
2009 Head and neck Dermatol Surg Seidler et al51 Mohs vs traditional surgery for nonmelanoma skin cancer
2009 Rhinology Appl Health Encon Health Policy Kneis et al52 Sinfrontal, homeopathic medication, for acute maxillary sinusitis
2009 Head and neck Acad Radiol Yen et al53 MRI vs PET vs MRI-PET for diagnosis of recurrent NPC
2009 Sleep Int J Technol Assess Health Care Weatherly et al54 CPAP vs dental devices and lifestyle advice for OSA
2009 Allergy Am J Epidemiol Witt et al55 Acupuncture for allergic rhinitis
2009 Sleep Sleep Breath Sadatsafavi et al56 CPAP vs oral appliances for OSAH
2009 Otology Fam Pract Hernandez et al57 Management of Bell's palsy
2009 Pediatrics Pediatrics O'Brien et al5 Candidate vaccines for prevention of pediatric AOM
2009 Sleep Sleep Snedecor et al58 Eszopiclone for primary chronic insomnia
2009 Endocrine J Am Coll Surg In et al59 Treatment options for Graves disease
2010 Endocrine Ann Surg Oncol Wang et al60 Oral calcium and calcitriol following total thyroidectomy
2010 Otology Ear Hear Summerfield et al61 Bilateral pediatric cochlear implantation
2010 Endocrine JCEM Wang et al60 Recombinant TSH prior to RAI for thyroid cancer
2010 Allergy Value Health Petrou et al62 Topical intranasal steroids for pediatric OME
2011 Sleep Sleep Pietzsch et al63 Diagnostic and therapeutic strategies for OSA
2011 Sleep Cost Eff Resour Alloc Scott et al64 Treatment of insomnia
2011 Endocrine JCEM Li et al65 Novel molecular test for indeterminate thyroid nodules
2011 Head and neck Laryngoscope Higgins et al66 Radiation vs transoral laser surgery for early-stage glottic carcinoma
2011 Head and neck Laryngoscope Dedhia et al4 Oral cancer screening programs for high-risk males
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Abbreviations: AOM, acute otitis media; PAP, continuous positive airway pressure; T, computed tomography; CUA, cost-utility analysis; ESRD, end stage renal disease; FDG-PET, 18-F fluoro-2-deoxyglucose positron emission tomography; HNSCC, head and neck squamous cell carcinoma; MRI, magnetic resonance imaging; NPC, nasopharyngeal carcinoma; OME, otitis media with effusion; OSA, obstructive sleep apnea; OSAH, obstructive sleep apnea-hypopnea; PET-CT, positron emission tomography-computed tomography; TSH, thyroid stimulating hormone; RAI, radioiodine.

Discussion

In an effort to limit healthcare expenditures and to allocate resources efficiently, many groups have focused their work on the economic appraisal of clinical interventions. As healthcare costs rise, it remains unclear how the increasing economic burden will be handled. There is an increasing need for policy makers, administrators, and physicians alike to evaluate the cost-effectiveness of the services provided. Assessment of value has been investigated for decades, with an exponential increase in cost effectiveness analyses published in the past 10 years. Cost effectiveness research in otolaryngology may have an especially profound impact on limiting healthcare expenditures, as otolaryngologists manage many conditions associated with high costs. The cost of allergic rhinitis alone has been estimated to be close to 5.3 billions dollars per year in the United States.6 Interestingly, these costs are far surpassed by that of managing sinusitis, which impacts one in seven adults and has direct costs alone estimated at 5.8 billion dollars per year.7 Within otolaryngology, the management of head and neck cancer and thyroid disease is also especially costly, with only a portion of the costs reflected in direct expenditures of imaging, surgery, and radiation therapy. As healthcare costs continue to rise, it is vital that otolaryngologists take on a more active role in assessing the cost effectiveness of various management options as more expensive innovative technologies continue to be developed.

We have evaluated the CEA registry to assess the characteristics, results and quality of CUAs, which include only those studies measuring health benefits in QALYs, in otolaryngology. Despite the high cost of managing conditions in the practice of otolaryngology, only 2% of the total CUA literature in the CEA registry evaluates intervention sutilized by otolaryngologists and only 0.61% of the cost utility literature in the CEA registry included an otolaryngologist as an author. The relative paucity of otolaryngologists with published studies in the CEA registry may be related to a relative infrequency of conditions with well-established QALYs, fewer clinicians in otolaryngology with training to perform these investigations, or perhaps decreased awareness of these issues among otolaryngologists. Regardless of the reason, it is important that otolaryngologists become more involved in conducting these studies in order to actively participate in discussions regarding the allocation of heath care resources.

In a recent review assessing the quality of 50 economic evaluations published in otolaryngology, Liu and colleagues found that study characteristics such as journal impact factor and presence of an author with a PhD in health economics were associated with higher quality studies.8 Interestingly, in our study, the subjective quality score bestowed by the CEA registry revealed no statistically significant correlation between the quality of the manuscripts and the number of otolaryngologist authors or the impact factor of the journal in which the study was published. Our review did reveal that studies with a more recent publication year are associated with a higher quality score, indicating that despite the relative lack of CUAs related to otolaryngology, the studies have been improving in both quantity and quality in recent years. Assessment of the topics addressed by all of the studies and their collective results revealed that unilateral cochlear implantation is cost effective in all settings evaluated. Furthermore, 86% of studies identified CPAP to be a cost effective strategy for the management of OSA (Table 3).

Although the relatively large number of studies evaluated and the use of the CEA registry make this review unique, there are several limitations. The CEA registry is a limited database with regards to cost effectiveness literature as a whole. It is possible that many other cost-effectiveness analyses related to otolaryngology that do not adhere to the stringent CUA criteria, yet have made important contributions to understanding the cost of interventions in otolaryngology, have not been evaluated in this particular study. We did not perform our own manual search of all English literature to ensure that no publications were missing from the CEA registry, nor did we perform our own assessment of the individual studies included in this study. Despite this, we are the first group to perform a review of the CUA literature in otolaryngology that has fit the inclusion criteria of the CEA registry. Future reviews of CUAs in otolaryngology may wish to combine search results from multiple databases in order to more comprehensively review the literature in this field.

Conclusion

Based on current evidence in the CEA registry, there is consensus that unilateral cochlear implantation for hearing loss and near consensus that CPAP for OSA are both cost effective interventions. Although CUAs in otolaryngology have increased in quantity and quality in more recent years, there is a lack of CUAs evaluating interventions in otolaryngology. A significant need exists for more otolaryngologists to become involved in evaluating the cost effectiveness of the therapeutic interventions they utilize.

Conflicts of interest/disclosures

None to report.

Funding information

No grant support was received in the preparation of this study.

Footnotes

Peer review under responsibility of Chinese Medical Association.

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