Although the global declines in structure have been documented in the aging human brain, little is known about the functional integrity of the striatum and prefrontal cortex in older adults during incentive processing. We used event-related functional magnetic resonance imaging to determine whether younger and older adults differed in both self-reported and neural responsiveness to anticipated monetary gains and losses. The present study provides evidence for intact striatal and insular activation during gain anticipation with age, but shows a relative reduction in activation during loss anticipation. These findings suggest that there is an asymmetry in the procession of gains and losses in older adults that may have implications for decision-making.

Background

Human growth hormone (GH) is widely used as an antiaging therapy, although its use for this purpose has not been approved by the U.S. Food and Drug Administration and its distribution as an antiaging agent is illegal in the United States.

Purpose

To evaluate the safety and efficacy of GH therapy in the healthy elderly.

Data Sources

The authors searched MEDLINE and EMBASE databases for English-language studies published through 21 November 2005 by using such terms as growth hormone and aging.

Study Selection

The authors included randomized, controlled trials that compared GH therapy with no GH therapy or GH and lifestyle interventions (exercise with or without diet) with lifestyle interventions alone. Included trials provided GH for 2 weeks or more to community-dwelling participants with a mean age of 50 years or more and a body mass index of 35 kg/m2 or less. The authors excluded studies that evaluated GH as treatment for a specific illness.

Data Extraction

Two authors independently reviewed articles and abstracted data.

Data Synthesis

31 articles describing 18 unique study populations met the inclusion criteria. A total of 220 participants who received GH (107 person-years) completed their respective studies. Study participants were elderly (mean age, 69 years [SD, 6]) and overweight (mean body mass index, 28 kg/m^2 [SD, 2]). Initial daily GH dose (mean, 14 µg per kg of body weight [SD, 7]) and treatment duration (mean, 27 weeks [SD, 16]) varied. In participants treated with GH compared with those not treated with GH, overall fat mass decreased (change in fat mass, -2.1g [95% CI, -2.8 to -1.35] and overall lean body mass increased (change in lean body mass, 2.1 kg [CI, 1.3 to 2.9]) (P 0.001), and their weight did not change significantly (change in weight, 0.1 kg [CI, -0.7 to 0.8]; P = 0.87). Total cholesterol levels decreased (change in cholesterol, -0.29 mmol/L [-11.21 mg/dL]; P = 0.006), although not significantly after adjustment for body composition changes. Other outcomes, including bone density and other serum lipid levels, did not change. Persons treated with GH were significantly more likely to experience soft tissue edema, arthralgias, carpal tunnel syndrome, and gynecomastia and were somewhat more likely to experience the onset of diabetes mellitus and impaired fasting glucose.

Limitations

Some important outcomes were infrequently or heterogeneously measured and could not be synthesized. Most included studies had small sample sizes.

Conclusions

The literature published on randomized, controlled trials evaluating GH therapy in the healthy elderly is limited but suggests that it is associated with small changes in body composition and increased rates of adverse events. On the basis of this evidence, GH cannot be recommended as an antiaging therapy.

State public employee health plans (PEHPs) provide health benefits for millions of state and local workers, retirees, and their dependents nationwide. This paper explores major issues and challenges that PEHP leaders and state policymakers are addressing. These include the perennial challenge of funding benefits for a diverse and aging workforce; new accounting standards affecting public employers; and the changing relationship between states, retired public employees, and the Medicare program. Interviews with PEHP executives explored whether these are incremental challenges to which states can effectively adapt, or whether these challenges will catalyze broader and lasting change in the public employee and retiree health benefits arena.

This issue of CHP/PCOR's quarterly newsletter, which covers news from the spring 2006 quarter, includes articles about:

• a study led by CHP/PCOR trainee Hau Liu which found that teriparatide (Forteo) -- the first in a new class of osteoporosis drugs -- is not cost-effective compared with the most commonly prescribed osteoporosis drug, alendronate (Fosamax), due largely to teriparatide's much higher price;
• an update on projects and priorities at CADMA (the Center on Advancing Decision Making in Aging) and CDEHA (the Center on the Demography and Economics of Health and Aging), two multidisciplinary research centers based at CHP/PCOR that support promising early-stage projects on health, economics and aging;
• an April working trip by CHP/PCOR research assistants Meghan Fay and Raina Mahajan, in which they traveled to San Lucas Toliman, Guatemala, with faculty member Paul Wise, assisting him with various medical treatment and health promotion activities in the region; and
• a meta-analysis led by CHP/PCOR trainee Smita Nayak which evaluated the accuracy of an emerging screening test for osteoporosis -- heel ultrasound -- compared with the standard test, known as DXA. The study found that there is not enough evidence to recommend heel ultrasound over DXA as an osteoporosis screening tool.

Background: Teriparatide is a promising new agent for the treatment of osteoporosis.

Methods: The objective of this study was to evaluate the cost-effectiveness of teriparatide-based strategies compared with alendronate sodium for the first-line treatment of high-risk osteoporotic women. We developed a microsimulation with a societal perspective. Key data sources include the Study of Osteoporotic Fractures, the Fracture Intervention Trial, and the Fracture Prevention Trial. We evaluated postmenopausal white women with low bone density and prevalent vertebral fracture. The interventions were usual care (UC) (calcium or vitamin D supplementation) compared with 3 strategies: 5 years of alendronate therapy, 2 years of teriparatide therapy, and 2 years of teriparatide therapy followed by 5 years of alendronate therapy (sequential teriparatide/alendronate). The main outcome measure was cost per quality-adjusted life-year (QALY).

Results: For the base-case analysis, the cost of alendronate treatment was $11 600 per QALY compared with UC. The cost of sequential teriparatide/alendronate therapy was $156 500 per QALY compared with alendronate. Teriparatide treatment alone was more expensive and produced a smaller increase in QALYs than alendronate. For sensitivity analysis, teriparatide alone was less cost-effective than alendronate even if its efficacy lasted 15 years after treatment cessation. Sequential teriparatide/alendronate therapy was less cost-effective than alendronate even if fractures were eliminated during the alendronate phase, although its cost-effectiveness was less than $50 000 per QALY if the price of teriparatide decreased 60%, if used in elderly women with T scores of -4.0 or less, or if 6 months of teriparatide therapy had comparable efficacy to 2 years of treatment.

Conclusions: Alendronate compares favorably to interventions accepted as cost-effective. Therapy with teriparatide alone is more expensive and produces a smaller increase in QALYs than therapy with alendronate. Sequential teriparatide/alendronate therapy appear expensive but could become more cost-effective with reductions in teriparatide price, with restriction to use in exceptionally high-risk women, or if short courses of treatment have comparable efficacy to that observed in clinical trials.

Many developed countries have a market for private health insurance that supplements publicly funded, universal coverage. Government regulation of the supplemental market, including the extent to which insurers are permitted to adjust premiums based on individual characteristics such as age, sex, and health status, varies across countries (OECD, 2004). Proponents of rate regulation argue that the resulting crosssubsidization

from low to high risks is necessary to maintain the affordability of coverage

for high risks. Economic theory, however, raises the concern that the inability to adjust

premiums to reflect individual risk could create adverse selection by driving low risks from the market (Michael Rothschild and Joseph Stiglitz, 1976). Little empirical evidence exists to determine the optimal role of rate regulation in private, supplemental insurance markets. Existing studies of the consequences of rating restrictions focus on markets for primary health insurance and find that these laws have had surprisingly little effect on overall rates of coverage (Simon, 2004).

In this paper, we study the effects of rate regulation in supplemental health insurance

markets by examining the market for individually purchased coverage that supplements

Medicare among the elderly in the United States. While the publicly financed Medicare

program provides nearly universal coverage of a standard set of benefits for those 65 and over, beneficiaries are exposed to significant financial risk due to the cost sharing associated with covered services and a lack of coverage for some important services. The vast majority of Medicare beneficiaries obtain supplemental coverage through a complex system of publicly and privately funded sources. State Medicaid programs provide publicly financed supplemental coverage for low-income and disabled beneficiaries, and employers provide highly subsidized retiree supplemental health insurance for other beneficiaries, but the remainder rely on highly regulated, private insurance markets.

Medicare's Part C managed care plans are a voluntary, private replacement for traditional Medicare, while Medigap coverage is a private policy, bought by about 30 percent of Medicare beneficiaries, that provides only supplemental benefits (Franklin J. Eppig and George S. Chulis, 1997). Our study examines the effects of regulations limiting the information on individual characteristics insurers can use in setting premiums for Medigap coverage.