To address growing concerns over childhood obesity, the United States Preventive Services Task Force (USPSTF) recently recommended that children undergo obesity screening beginning at age 6. An Expert Committee recommends starting at age 2. Analysis is needed to assess these recommendations and investigate whether there are better alternatives. We model the age- and sex-specific population-wide distribution of BMI through age 18 using National Longitudinal Survey of Youth (NLSY) data. The impact of treatment on BMI is estimated using the targeted systematic review performed to aid the USPSTF. The prevalence of hypertension and diabetes at age 40 are estimated from the Panel Study of Income Dynamics (PSID). We fix the screening interval at 2 years, and derive the age- and sex-dependent BMI thresholds that minimize adult disease prevalence, subject to referring a specified percentage of children for treatment yearly. We compare this optimal biennial policy to biennial versions of the USPSTF and Expert Committee recommendations. Compared to the USPSTF recommendation, the optimal policy reduces adult disease prevalence by 3% in relative terms (the absolute reductions are <1%) at the same treatment referral rate, or achieves the same disease prevalence at a 28% reduction in treatment referral rate. If compared to the Expert Committee recommendation, the reductions change to 6 and 40%, respectively. The optimal policy treats mostly 16-year olds and few children under age 14. Our results suggest that adult disease is minimized by focusing childhood obesity screening and treatment on older adolescents.

Inflammatory bowel diseases (IBDs) are costly chronic gastrointestinal diseases, with pediatric IBD representing increased costs per patient compared to adult disease. Health care expenditures for ulcerative colitis (UC) are >$2 billion annually. It is not clear whether the addition of VSL#3 to standard medical therapy in UC induction and maintenance of remission is a cost-effective strategy.

The United States spends more for healthcare than any other country in the world. With the rising prevalence of both Crohn's disease and ulcerative colitis, inflammatory bowel disease (IBD) represents the leading chronic gastrointestinal disease with increasing healthcare expenditures in the US. IBD costs have shifted from inpatient to outpatient care since the introduction of biologic therapies as the standard of care. Gastroenterologists need to be aware of the national cost burden of IBD and clinical practices that optimize cost-efficiency. This investigation offers a systematic review of the economics of IBD and evidence-based strategies for cost-effective management.

Abstract

Context: Coronary computed tomography angiography (CCTA) is a new noninvasive diagnostic test for coronary artery disease (CAD), but its association with subsequent clinical management has not been established. Objective: To compare utilization and spending associated with functional (stress testing) and anatomical (CCTA) noninvasive cardiac testing in a Medicare population. Design, Setting, and Patients: Retrospective, observational cohort study using claims data from a 20% random sample of 2005-2008 Medicare fee-for-service beneficiaries 66 years or older with no claims for CAD in the preceding year, who received nonemergent, noninvasive testing for CAD (n=282 830). Main Outcome Measures: Cardiac catheterization, coronary revascularization, acute myocardial infarction, all-cause mortality, and total and CAD-related Medicare spending over 180 days of follow-up. Results: Compared with stress myocardial perfusion scintigraphy (MPS), CCTA was associated with an increased likelihood of subsequent cardiac catheterization (22.9% vs 12.1%; adjusted odds ratio [AOR], 2.19 [95% CI, 2.08 to 2.32]; P<.001), percutaneous coronary intervention (7.8% vs 3.4%; AOR, 2.49 [2.28 to 2.72]; P<.001), and coronary artery bypass graft surgery (3.7% vs 1.3%; AOR, 3.00 [2.63 to 3.41]; P<.001). CCTA was also associated with higher total health care spending ($4200 [$3193 to $5267]; P<.001), which was almost entirely attributable to payments for any claims for CAD ($4007 [$3256 to $4835]; P<.001). Compared with MPS, there was lower associated spending with stress echocardiography (-$4981 [-$4991 to -$4969]; P<.001) and exercise electrocardiography (-$7449 [-$7452 to -$7444]; P<.001). At 180 days, CCTA was associated with a similar likelihood of all-cause mortality (1.05% vs 1.28%; AOR, 1.11 [0.88 to 1.38]; P=.32) and a slightly lower likelihood of hospitalization for acute myocardial infarction (0.19% vs 0.43%; AOR, 0.60 [0.37 to 0.98]; P=.04). Conclusion: Medicare beneficiaries who underwent CCTA in a nonacute setting were more likely to undergo subsequent invasive cardiac procedures and have higher CAD related spending than patients who underwent stress testing. ©2011 American Medical Association. All rights reserved.

Abstract

OBJECTIVE: Sickle cell disease (SCD) affects 70 000 to 100 000 people in the United States, and 2000 infants are born with the disease each year. The purpose of this study was to review the quality of the literature for preventive interventions and treatment of complications for children with SCD to facilitate the use of evidence-based medicine in clinical practice and identify areas in need of additional research. METHODS: We searched the Ovid Medline database and the Cochrane Library for articles published between January 1995 and April 2010 for English-language abstracts on 28 topics thought to be important for the care of children with SCD. We also added pertinent references cited by studies identified in our search. Each abstract was reviewed independently by 2 authors. Data from articles retrieved for full review were abstracted by using a common form. RESULTS: There were 3188 abstracts screened, and 321 articles underwent full review. Twenty-six articles (<1% of abstracts initially screened), which consisted of 25 randomized controlled trials and 1 meta-analysis, were rated as having level I evidence. Eighteen of the 28 topics selected for this review did not have level I evidence studies published. The management and prevention of pain episodes accounted for more than one-third of the level I studies. CONCLUSIONS: Although significant strides have been made in the care of children with SCD in the past 2 decades, more research needs to be performed, especially for acute events associated with SCD, to ensure that the health and well-being of children with SCD continues to improve. Copyright © 2011 by the American Academy of Pediatrics.

Abstract

BACKGROUND:

The Agency for Healthcare Research and Quality's prevention quality indicators (PQIs) are used as a metric of area-level access to quality care. Recently, interest has expanded to using the measures at the level of payer or large physician groups, including public reporting or pay-for-performance programs. However, the validity of these expanded applications is unknown.

RESEARCH DESIGN:

We conducted a novel panel process to establish face validity of the 12 PQIs at 3 denominator levels: geographic area, payer, and large physician groups; and 3 uses: quality improvement, comparative reporting, and pay for performance. Sixty-four clinician panelists were split into Delphi and Nominal Groups. We aimed to capitalize on the reliability of the Delphi method and information sharing in the Nominal group method by applying these techniques simultaneously. We examined panelists' perceived usefulness of the indicators for specific uses using median scores and agreement within and between groups.

RESULTS:

Panelists showed stronger support of the usefulness of chronic disease indicators at the payer and large physician group levels than for acute disease indicators. Panelists fully supported the usefulness of 2 indicators for comparative reporting (asthma, congestive heart failure) and no indicators for pay-for-performance applications. Panelists expressed serious concerns about the usefulness of all new applications of 3 indicators (angina, perforated appendix, dehydration). Panelists rated age, current comorbidities, earlier hospitalization, and socioeconomic status as the most important risk-adjustment factors.

CONCLUSIONS:

Clinicians supported some expanded uses of the PQIs, but generally expressed reservations. Attention to denominator definitions and risk adjustment are essential for expanded use.