Stanford Health Policy is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford School of Medicine
Context: Studies of prostitution have focused largely on individuals involved in the commercial sex trade, with an emphasis on understanding the public health effect of this behavior. However, a broader understanding of how prostitution affects mental and physical health is needed. In particular, the study of prostitution among individuals in substance use treatment would improve efforts to provide comprehensive treatment. Objectives: To document the prevalence of prostitution among women and men entering substance use treatment, and to test the association between prostitution, physical and mental health, and health care utilization while adjusting for reported history of childhood sexual abuse, a known correlate of prostitution and poor health outcomes.
Design, Setting, and Participants: Cross-sectional, secondary data analysis of 1606 women and 3001 men entering substance use treatment in the United States who completed a semistructured intake interview as part of a larger study. Main Outcome
Measures: Self-reported physical health (respiratory, circulatory, neurological, and internal organ conditions, bloodborne infections) and mental health (depression, anxiety, psychotic symptoms, and suicidal behavior), and use of emergency department, clinic, hospital, or inpatient mental health services within the past year.
Results: Many participants reported prostitution in their lifetime (50.8% of women and 18.5% of men) and in the past year (41.4% of women and 11.2% of men). Prostitution was associated with increased risk for bloodborne viral infections, sexually transmitted diseases, and mental health symptoms. Prostitution was associated with use of emergency care in women and use of inpatient mental health services for men.
Conclusions: Prostitution was common among a sample of individuals entering substance use treatment in the United States and was associated with higher risk of physical and mental health problems. Increased efforts toward understanding prostitution among patients in substance use treatment are warranted. Screening for prostitution in substance use treatment could allow for more comprehensive care to this population.
Via Columbia 2
00133 Rome Italy
Vincenzo Atella is Associate Professor of Economics at the University of Rome "Tor Vergata" where he teaches Macroeconomics and courses in Applied Health Economics at graduate and post graduate level. He is also adjunct associate of the Center for Health Policy at Stanford where he has been visiting professor in different occasions.
Currently, he is CEIS Tor Vergata Director and Scientific Director of the Farmafactoring Foundation, member of SIVEAS (Health Care Services National Evaluation System) of the Ministry of Health, chief economist of the Italian Association of General Practitionners (Società Italiana di Medicina Generale – SIMG) and member and co-founder of the Italian Public Affair Association.
In the recent past he has been member of the International Committee of Experts advising IQWiG (the German Agency for Health Care) for setting national guidelines for Economic Evaluation and member of the Italian Committee for Drug Price appointed by the Ministry of Treasury. He also served as member of the “Strategic Evaluation Committee” of the Italian Drug Agency (AIFA), and has been consultant for the Italian Regional Agency for Health Care Services (http://www.assr.it/), the National Institute of Health (http://www.iss.it/), the WHO and the World Bank. Prof. Atella has been coordinator of a large European Research Network called TECH Europe (http://healthpolicy.fsi.stanford.edu/tech/) which has received financial support by the European Science Foundation. His most recent research activity has focused on poverty, income distribution and health economics. In this last field his research deals with the introduction of new technologies in the health sector, the impact of different co-payment systems on pharmaceutical decision making by physicians and on drug consumption by patients, forecasting health expenditure and with health related income inequalities. The results of this research activity have been published on several international refereed journals as well books.
Background: Health-related quality of life is decreased in patients with GERD and Barrett's esophagus (BE).
Objective: To determine whether time-tradeoff (TTO) values would differ in patients with BE when patients were asked to trade away the potential risk of esophageal adenocarcinoma rather than chronic heartburn symptoms.
Design: A prospective clinical trial.
Patients: Subjects with biopsy-proven BE.
Interventions: Custom-designed computer program to elicit health-state utility values, quality of life in reflux and dyspepsia (QOLRAD), and Medical Outcomes Survey short form-36 surveys.
Main Outcome Measurements: TTO utility values for the annual cancer-risk–associated current health state and for hypothetical scenarios of dysplasia and esophageal cancer.
Results: We studied 60 patients in the cancer-risk cohort (57 men, 92% veteran; mean age [standard deviation; SD], 65 years [11 years], mean GERD duration 17 years [12 years]). The heartburn cohort included 40 patients with GERD and BE with TTO values derived for GERD symptoms. The mean (SD) utility for nondysplastic BE was 0.91 (0.13) compared with 0.90 (0.12) for the heartburn cohort (P = .7). The mean utility values were significantly lower for scenarios of low-grade dysplasia (0.85 [0.12], P = .02) and high-grade dysplasia (0.77 [0.14], P < .005). The mean TTO was 0.67 (0.19) for the scenario of esophageal cancer. There was no correlation between the utility scores and the disease-specific survey scores.
Utilities are measures of quality of life that reflect the strength of individuals' preferences or values for a particular health outcome. As such, utilities represent a measure of disease burden. The aim of this article is to introduce the concept of utilities to the dermatology community and to present a catalog of dermatology utilities obtained from direct patient interviews. Our data are based on 236 total subjects from Grady Hospital (Atlanta, GA), Stanford Medical Center (Palo Alto, CA), and Parkland Hospital (Dallas, TX). The mean time trade-off utilities ranged from 0.640 for blistering disorders to 1.000 for alopecia, cosmetic, and urticaria. The mean utility across all diagnoses was 0.943. We present utilities for 17 diagnostic categories and discuss the underlying reasons for the significant disease burden that these utilities represent. We also present these dermatology categories relative to noncutaneous diseases to place the cutaneous utilities in perspective and to compare the burden of disease. We have demonstrated that skin diseases have considerable burden of disease and provided a preliminary repository of utility data for future researchers and policy makers.
Contemporary clinical trials commonly measure quality of life and medical costs to establish whether therapies are both effective and cost effective. Cost-effectiveness analysis, however, requires a measure of patient utility or preferences for various health states. Because utilities are not often measured directly, we sought to develop a method of translating standard quality-of-life scales into a patient utility measure.
Methods
Five hundred fifty-three patients enrolled in the Bypass Angioplasty Revascularization Investigation Study of Economics and Quality of Life completed a battery of quality-of-life measures and a time trade-off utility assessment an average of 7.3 years after random assignment.
Results
The mean time trade-off score was 8.54 (SD ? 2.53) out of a maximum of 10; median score was 9.95. The distribution of scores was skewed, with 12% of patients at the highest possible score of 10. Patients with recurrent angina had significantly lower time trade-off scores than patients without angina (mean 7.03 vs 8.70, P .05). Time trade-off scores were moderately correlated with each quality-of-life measure (Spearman coefficients 0.38-0.52). Time trade-off scores could be predicted by combinations of 4 (r2 ? 0.29), 5 (r2 ? 0.31), or 6 (r2 ? 0.32) variables.
Conclusions
Time trade-off utility scores can be inferred from commonly used quality-of-life measures. Angina significantly reduces patient utility scores.
To understand "managed care," one needs to understand the traditional model of health care organization and finance that managed care was intended to replace. That model was aptly characterized "Guild Free Choice" by Charles Weller to indicate that "free choice" was being used as a restraint of trade to block the emergence of any form of economic competition among doctors. Its principles were: "Free choice of doctor at all times;" "free choice of treatment, i.e. nobody 'interferes with the doctor's decisions and recommendations;'" "fee for service payment;" "direct doctor-patient negotiation of fees;" and "solo (or small single-specialty group) practice." The model was widely accepted because of the pre-Wennberg view of most people that "the medical care they receive [is] a necessity provided by doctors who adhere to scientific norms based on previously tested and proven treatments." In combination with well-insured patients, there was no way that employers or insurers could control health spending in this model. Organized medicine is still fighting to hold on to parts of it. Some people say that managed care is "anything other than Guild Free Choice."
