Abstract

The Medicare Part D Prescription Drug Program places an unprecedented degree of choice in the hands of older adults despite concerns over their ability to make effective decisions and desire to have extensive choice in this context. While previous research has compared older adults to younger adults along these dimensions, our study, in contrast, examines how likelihood to delay decision making and preferences for choice differ by age among older age cohorts. Our analysis is based on responses of older adults to a simulation of enrollment in Medicare Part D. We examine how age, numeracy, cognitive reflection, and the interaction between age and performance on these instruments are related to the decision to enroll in a Medicare prescription drug plan and preference for choice in this context. We find that numeracy and cognitive reflection are positively associated with enrollment likelihood and that they are more important determinants of enrollment than age. We also find that greater numeracy is associated with a lower willingness to pay for choice. Hence, our findings raise concern that older adults, and, in particular, those with poorer numerical processing skills, may need extra support in enrolling in the program: they are less likely to enroll than those with stronger numerical processing skills, even though they show greater willingness to pay for choice.

Abstract

BACKGROUND:

Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in the effects of patient safety practice (PSP) implementations. However, knowledge of which contextual features are important determinants of PSP effectiveness is limited and consensus is lacking on a taxonomy of which contexts matter.

METHODS:

Iterative, formal discussions were held with a 22-member technical expert panel composed of experts or leaders in patient safety, healthcare systems, and methods. First, potentially important contextual features were identified, focusing on five PSPs. Then, two surveys were conducted to determine the context likely to influence PSP implementations.

RESULTS:

The panel reached a consensus on a taxonomy of four broad domains of contextual features important for PSP implementations: safety culture, teamwork and leadership involvement; structural organisational characteristics (eg, size, organisational complexity or financial status); external factors (eg, financial or performance incentives or PSP regulations); and availability of implementation and management tools (eg, training organisational incentives). Panelists also tended to rate specific patient safety culture, teamwork and leadership contexts as high priority for assessing their effects on PSP implementations, but tended to rate specific organisational characteristic contexts as high priority only for use in PSP evaluations. Panelists appeared split on whether specific external factors and implementation/management tools were important for assessment or only description.

CONCLUSION:

This work can guide research commissioners and evaluators on the contextual features of PSP implementations that are important to report or evaluate. It represents a first step towards developing guidelines on contexts in PSP implementation evaluations. However, the science of context measurement needs maturing.

Abstract

In an era of limited healthcare budgets, mathematical models can be useful tools to identify cost-effective programs and to support policymakers in informed decision making. This paper reports results of our work carried out over several years with the Asian Liver Center at Stanford University, a nonprofit outreach and advocacy organization that is an international leader in the fight against hepatitis B and liver cancer. Hepatitis B is a vaccine-preventable viral disease that, if untreated, can lead to death from cirrhosis and liver cancer. Infection with hepatitis B is a major public health problem, particularly in Asian populations. We used new combinations of decision analysis and Markov models to analyze the cost-effectiveness of several interventions to combat hepatitis B in the United States and China. The results of our OR-based analyses have helped change United States public health policy on hepatitis B screening for millions of people and have helped encourage policymakers in China to enact legislation to provide free catch-up vaccination for hundreds of millions of children. These policies are an important step in eliminating health disparities, reducing discrimination, and ensuring that millions of people who need it can now receive hepatitis B vaccination or lifesaving treatment.

Abstract

BACKGROUND- The majority of current implantable cardioverter-defibrillator (ICD) recipients are significantly older than those in the ICD trials. Data on periprocedural complications among the elderly are insufficient. We evaluated the influence of age on perioperative complications among primary prevention ICD recipients in the United States. METHODS AND RESULTS- Using the National Cardiovascular Data's ICD Registry, we identified 150 264 primary prevention patients who received ICDs from January 2006 to December 2008. The primary end point was any adverse event or in-hospital mortality. Secondary end points included major adverse events, minor adverse events, and length of stay. Of 150 264 patients, 61% (n=91 863) were 65 years and older. A higher proportion of patients ≥65 years had diabetes, congestive heart failure, atrial fibrillation, renal disease, and coronary artery disease. Approximately 3.4% of the entire cohort had any complication, including death, after ICD implant. Any adverse event or death occurred in 2.8% of patients under 65 years old; 3.1% of 65- to 69-year-olds; 3.5% of 70- to 74-year-olds; 3.9% of 75- to 79-year-olds, 4.5% of 80- to 84-year-olds; and 4.5% of patients 85 years and older. After adjustment for clinical covariates, multivariate analysis found an increased odds of any adverse event or death among 75- to 79-year-olds (1.14 [95% confidence interval, 1.03 to 1.25], 80-to 84-year-olds (1.22 [95% confidence interval, 1.10 to 1.36], and patients 85 years and older (1.15 [95% confidence interval, 1.01 to 1.32], compared with patients under 65 years old. CONCLUSIONS- Older patients had a modestly increased-but acceptably safe-risk of periprocedural complications and in-hospital mortality, driven mostly by increased comorbidity.

Abstract

OBJECTIVES:

To estimate the potentially inappropriate use of implantable cardioverter-defibrillator ICDs in older U.S. adults.

DESIGN:

Retrospective study.

SETTING:

The National Cardiovascular Data ICD Registry.

PARTICIPANTS:

Forty-four thousand eight hundred five individuals in the National Cardiovascular Data's ICD Registry(™) who had received ICDs for primary prevention from January 2006 to December 2008. Individuals with a prior myocardial infarction and ejection fraction less than 30% were included.

MEASUREMENTS:

Mortality risk was categorized using the Multicenter Automatic Defibrillator Implantation (MADIT) II risk-stratification system. Low-risk and very-high-risk individuals were considered potentially inappropriate recipients.

RESULTS:

Of 44,805 individuals, 67% (n=29,893) were aged 65 and older, of whom 51% were aged 75 and older. A significant proportion of ICD recipients had a low risk of death (16%, n=6,969) or very high risk of nonarrhythmic death (8%, n=3,693). Potentially inappropriate ICD use was 10% in those aged 75 and older, much less than in younger groups (40%,

CONCLUSION:

Potentially inappropriate ICD use appears significantly less-and at modest rates-in older Americans than in younger age groups. Overall, almost one-quarter of individuals may have received ICDs inappropriately based on their risk of death. Physicians appear to be conservatively referring older adults and wisely deferring those with high comorbid burden.

Abstract

The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.

Abstract

OBJECTIVE:

The diagnosis of bipolar spectrum disorders (BPSDs [bipolar I and II disorders, cyclothymic disorder, and bipolar disorder not otherwise specified]) in youth remains controversial. The present study evaluated the possibility that the presence of persistent manic symptoms over a relatively short interval may increase the probability of a BPSD DSM diagnosis.

METHOD:

Data were obtained from the screening and baseline assessments collected from 2005 through 2008 of an ongoing prospective, longitudinal study (Longitudinal Assessment of Manic Symptoms) examining the diagnosis and phenomenology of youth (N = 692) presenting to outpatient centers at ages 6-12 years. Youth were assessed for elevated symptoms of mania (ESM) with the Parent General Behavior Inventory-10-Item Mania Scale (PGBI-10M), the primary outcome measure. Screening and baseline scores separated individuals into those with ESM (ESM+; PGBI-10M score ≥ 12) and a control group of youth without ESM (ESM-; PGBI-10M score < 12). Youth were classified into 4 groups: persistent ESM+, remitted ESM+, persistent ESM-, and progressed to ESM+.

RESULTS:

Individuals with persistent ESM+ were more likely to have a BPSD (relative risk = 3.04; 95% CI, 2.15-4.30). Using 2 administrations of the PGBI-10M spaced over a relatively brief interval (median = 4.0, mean = 6.1, SD = 5.9 weeks) improved the prediction of BPSD over using only the first administration (ΔR(2) = 0.10, Δχ(2)(1) = 50.06, P < .001). Likelihood ratios indicated that persistent ESM- substantially decreased the probability of BPSD. While high levels of persistent ESM+ increased the probability of a BPSD diagnosis, the final positive predictive value was only sufficient to signify the need for more thorough clinical evaluation.

CONCLUSIONS:

In many cases, obtaining repeated parent report of mania symptoms substantially altered the probability of a BPSD diagnosis and may be a useful adjunct to a careful clinical evaluation. Future waves of data collection from this longitudinal study will be crucial for devising clinically useful methods for identifying or ruling out pediatric BPSD.

OBJECTIVES:

The objective of this study was to determine whether a 5-module self-paced computerized educational program improves residents' skills in assessing and managing youth presenting to the emergency department in acute psychiatric distress.

METHODS:

The evaluation used a quasi-experimental posttest-only design assessing both knowledge of the educational context of the program and self-rated pretest knowledge of program content with 32 residents recruited from 1 medical center in Cleveland, Ohio.

RESULTS:

About half of the respondents were female (48%); almost two thirds were white (65%), and few were trained in psychiatric assessment of children/adolescents. On average, residents had significantly higher scores on the posttest compared with the self-rated pretest (6.4 ± 1.1 vs 3.8 ± 2.3; P < 0.001), an effect size of 1.32. Residents responded positively to the modules and rated them highly on educational content (4.2 ± 0.5 on a 5-point scale) and satisfaction with clinical applicability (8.2 ± 1.2 on a 10-point scale) and found the program easy to navigate (8.5 ± 1.9 on a 10-point scale).

CONCLUSIONS:

A brief, self-administered, Web-based training program shows promise for improving residents' knowledge about suicidal behaviors in youth.

This study explored the demographic and diagnostic features of children who were currently receiving antipsychotics compared to children who were receiving other psychotropics in a cohort of children with and without elevated symptoms of mania (ESM). Participants were recruited from 10 child outpatient mental health clinics associated with four universities. Guardians with children between 6-12 years who presented for new clinical evaluations completed the Parent General Behavior Inventory-10 Item Mania Scale (PGBI-10M). All children who scored ≥12 on the PGBI-10M and a select demographically matched comparison group of patients who scored ≤11 were invited to participate. Children were divided into two groups: those receiving at least one antipsychotic medication and those receiving other psychotropic medications. The groups were compared on demographics, diagnoses, psychiatric symptoms, functioning, and past hospitalizations. Of the 707 children enrolled in the Longitudinal Assessment of Manic Symptoms (LAMS) study, 443 (63%) were prescribed psychotropic medication at baseline: 157 (35%) were receiving an antipsychotic and 286 (65%) were prescribed other agents. Multivariate results indicated that being prescribed antipsychotics was related to being white, previous hospitalization, having a psychotic or bipolar 1 disorder and the site where the child was receiving services (p<0.001). In this sample, it is relatively common for a child to be prescribed an antipsychotic medication. However, the only diagnoses associated with a greater likelihood of being treated with an antipsychotic were psychotic disorders or unmodified DSM-IV bipolar 1 disorder.

OBJECTIVES:

With over 1 million children served by the US Child Welfare system at a cost of $20 billion annually, this study examines the economic evaluation literature on interventions to improve outcomes for children at risk for and currently involved with the system, identifies areas where additional research is needed, and discusses the use of decision-analytic modeling to advance Child Welfare policy and practice.

METHODS:

The review included 19 repositories of peer-reviewed and non-peer-reviewed "gray" literatures, including items in English published before November, 2009. Original researcharticles were included if they evaluated interventions based on costs and outcomes. Review articles were included to assess the relevance of these techniques over time and to highlight the increasing discussion of methods needed to undertake such research. Items were categorized by their focus on: interventions for the US Child Welfare system; primary prevention of entry into the system; and use of models to make long-term projections of costs and outcomes.

RESULTS:

Searches identified 2,640 articles, with 49 ultimately included (19 reviews and 30 original research articles). Between 1988 and 2009, reviews consistently advocated economicevaluation and increasingly provided methodological guidance. 21 of the original research articles focused on Child Welfare, while 9 focused on child mental health. Of the 21 Child Welfarearticles, 81% (17) focused on the US system. 47% (8/17) focused exclusively on primary prevention, though 83% of the US system, peer-reviewed articles focused exclusively on prevention (5/6). 9 of the 17 articles included empirical follow-up (mean sample size: 264 individuals; mean follow-up: 3.8 years). 10 of the 17 articles used modeling to project longer-term outcomes, but 80% of the articles using modeling were not peer-reviewed. Although 60% of modeling studies included interventions for children in the system, all peer-reviewed modeling articles focused on prevention.

CONCLUSIONS:

Methodological guidance for economic evaluations in Child Welfare is increasingly available. Such analyses are feasible given the availability of nationally representative data on children involved with Child Welfare and evidence-based interventions.

PRACTICE IMPLICATIONS:

Policy analyses considering the long-term costs and effects of interventions to improve Child Welfare outcomes are scarce, feasible, and urgently needed.