Stanford Health Policy is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford School of Medicine
This project studied the patterns of health and health care disparities across elderly and non-elderly in China, including the impact of earlier educational and public health interventions on contemporary elderly.
We calculated the incremental cost per quit of a telephone care intervention versus usual care using the provider's perspective. The study population was 819 smokers at five US Veterans Affairs (VA) primary care clinics. They enrolled in the clinical trial between June 2001 and December 2002. After 12 months the participants were assessed for short- and long-term abstinence over the previous six months. VA records were used to extract the cost of VA services over 12 months, and the cost of care purchased by the VA from others. Intervention costs were derived through micro-costing. On average, the intervention cost $142 per person, excluding medications. The average cost of all VA-funded medical care during the study period was $8959 in the telephone-care arm and $7939 in the usual care arm (P = 0.37). Under a standard intent-to-treat analysis the average cost per quit was $11,408 and thus the intervention was cost-effective by conventional standards.
Most smokers with mental illness do not receive tobacco cessation treatment.
To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates.
A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009.
Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment.
Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status.
Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time.
Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence.
clinicaltrials.gov Identifier: NCT00118534.
The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.
This study examined whether externally rated job demand and control were associated with depression diagnosis claims in a heavy industrial cohort. The retrospective cohort sample consisted of 7,566 hourly workers aged 18-64 years who were actively employed at 11 US plants between January 1, 1996, and December 31, 2003, and free of depression diagnosis claims during an initial 2-year run-in period. Logistic regression analysis was used to model the effect of tertiles of demand and control exposure on depression diagnosis claims. Demand had a significant positive association with depression diagnosis claims in bivariate models and models adjusted for demographic (age, gender, race, education, job grade, tenure) and lifestyle (smoking status, body mass index, cholesterol level) variables (high demand odds ratio = 1.39, 95% confidence interval: 1.04, 1.86). Control was associated with greater risk of depression diagnosis at moderate levels in unadjusted models only (odds ratio = 1.47, 95% confidence interval: 1.12, 1.93), while low control, contrary to expectation, was not associated with depression. The effects of the externally rated demand exposure were lost with adjustment for location. This may reflect differences in measurement or classification of exposure, differences in depression diagnosis by location, or other location-specific factors.
Abstract
Objectives. We assessed the potential health and economic benefits of reducing common risk factors in older Americans.
Methods. A dynamic simulation model tracked a national cohort of persons 51 and 52 years of age to project their health and medical spending in prevention scenarios for diabetes, hypertension, obesity, and smoking.
Results. The gain in life span from successful treatment of a person aged 51 or 52 years for obesity would be 0.85 years; for hypertension, 2.05 years; and for diabetes, 3.17 years. A 51- or 52-year-old person who quit smoking would gain 3.44 years. Despite living longer, those successfully treated for obesity, hypertension, or diabetes would have lower lifetime medical spending, exclusive of prevention costs. Smoking cessation would lead to increased lifetime spending. We used traditional valuations for a life-year to calculate that successful treatments would be worth, per capita, $198018 (diabetes), $137964 (hypertension), $118946 (smoking), and $51750 (obesity).
Conclusions. Effective prevention could substantially improve the health of older Americans, and—despite increases in longevity—such benefits could be achieved with little or no additional lifetime medical spending.
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Jeremy Goldhaber-Fiebert, PhD, is a Professor of Health Policy, a Core Faculty Member at the Center for Health Policy and the Department of Health Policy, and a Faculty Affiliate of the Stanford Center on Longevity and Stanford Center for International Development. His research focuses on complex policy decisions surrounding the prevention and management of increasingly common, chronic diseases and the life course impact of exposure to their risk factors. In the context of both developing and developed countries including the US, India, China, and South Africa, he has examined chronic conditions including type 2 diabetes and cardiovascular diseases, human papillomavirus and cervical cancer, tuberculosis, and hepatitis C and on risk factors including smoking, physical activity, obesity, malnutrition, and other diseases themselves. He combines simulation modeling methods and cost-effectiveness analyses with econometric approaches and behavioral economic studies to address these issues. Dr. Goldhaber-Fiebert graduated magna cum laude from Harvard College in 1997, with an A.B. in the History and Literature of America. After working as a software engineer and consultant, he conducted a year-long public health research program in Costa Rica with his wife in 2001. Winner of the Lee B. Lusted Prize for Outstanding Student Research from the Society for Medical Decision Making in 2006 and in 2008, he completed his PhD in Health Policy concentrating in Decision Science at Harvard University in 2008. He was elected as a Trustee of the Society for Medical Decision Making in 2011.
Past and current research topics:
PRIMARY AIM: Examine the effectiveness of extended cognitive behavior therapy (CBT) in promoting longer-term smoking abstinence.
DESIGN: Open-label treatment phase followed by extended treatment phase. Randomization conducted prior to entry into open-label treatment phase; analysis based on intention-to-treat to avoid threat of selection bias.
SETTING: Community smoking cessation clinic.
PARTICIPANTS: A total of 304 adult smokers (> or = 18 years of age; > or = 10 cigarettes/day). INTERVENTION: Open-label (8 weeks): all participants received bupropion SR, nicotine patch, CBT. Extended treatment (12 weeks): participants received either CBT + voicemail monitoring and telephone counseling or telephone-based general support.
MEASUREMENTS: Seven-day point prevalence abstinence, expired-air carbon monoxide. RESULTS: At week 20 follow-up, CBT produced a higher 7-day point prevalence abstinence rate: 45% versus 29%, P = 0.006; at 52 weeks the difference in abstinence rates (31% versus 27%) was not significant. History of depression was a moderator of treatment. Those with a positive history had a better treatment response at 20 weeks when assigned to the less intensive telephone support therapy (P < 0.05).
CONCLUSION: The superiority of CBT to 20 weeks suggests that continued emphasis on the development of cognitive and behavioral strategies for maintaining non-smoking during an extended treatment phase may help smokers to maintain abstinence in the longer term. At present, the minimum duration of therapy is unknown.
OBJECTIVE: To examine the quantity (density) and location (proximity) of tobacco outlets and retail cigarette advertising in high school neighborhoods and their association with school smoking prevalence.
METHODS: Data from the 135 high schools that participated in the 2005-2006 California Student Tobacco Survey were combined with retailer licensing data about the location of tobacco outlets within walking distance (1/2 mi or 805 m) of the schools and with observations about the quantity of cigarette advertising in a random sample of those stores (n=384). Multiple regressions, adjusting for school and neighborhood demographics, tested the associations of high school smoking prevalence with the density of tobacco outlets and retail cigarette advertising and with the proximity of tobacco outlets to schools.
RESULTS: The prevalence of current smoking was 3.2 percentage points higher at schools in neighborhoods with the highest tobacco outlet density (>5 outlets) than in neighborhoods without any tobacco outlets. The density of retail cigarette advertising in school neighborhoods was similarly associated with high school smoking prevalence. However, neither the presence of a tobacco outlet within 1000 ft of a high school nor the distance to the nearest tobacco outlet from school was associated with smoking prevalence.
CONCLUSIONS: Policy efforts to reduce adolescent smoking should aim to reduce the density of tobacco outlets and retail cigarette advertising in school neighborhoods. This may be achieved through local zoning ordinances, including limiting the proximity of tobacco outlets to schools.