Context:

Women with inherited BRCA1/2 mutations are at high risk for breast cancer, which mammography often misses. Screening with contrast-enhanced breast magnetic resonance imaging (MRI) detects cancer earlier but increases costs and results in more false-positive scans.

Objective:

To evaluate the cost-effectiveness of screening BRCA1/2 mutation carriers with mammography plus breast MRI compared with mammography alone.

Design, Setting, and Patients:

A computer model that simulates the life histories of individual BRCA1/2 mutation carriers, incorporating the effects of mammographic and MRI screening was used. The accuracy of mammography and breast MRI was estimated from published data in high-risk women. Breast cancer survival in the absence of screening was based on the Surveillance, Epidemiology and End Results database of breast cancer patients diagnosed in the prescreening period (1975-1981), adjusted for the current use of adjuvant therapy. Utilization rates and costs of diagnostic and treatment interventions were based on a combination of published literature and Medicare payments for 2005.

Main Outcome Measures:

The survival benefit, incremental costs, and cost-effectiveness of MRI screening strategies, which varied by ages of starting and stopping MRI screening, were computed separately for BRCA1 and BRCA2 mutation carriers.

Results:

Screening strategies that incorporate annual MRI as well as annual mammography have a cost per quality-adjusted life-year (QALY) gained ranging from less than $45 000 to more than $700 000, depending on the ages selected for MRI screening and the specific BRCA mutation. Relative to screening with mammography alone, the cost per QALY gained by adding MRI from ages 35 to 54 years is $55 420 for BRCA1 mutation carriers, $130 695 for BRCA2 mutation carriers, and $98 454 for BRCA2 mutation carriers who have mammographically dense breasts.

Conclusions:

Breast MRI screening is more cost-effective for BRCA1 than BRCA2 mutation carriers. The cost-effectiveness of adding MRI to mammography varies greatly by age.

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.

Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.

Although the quality of health care would logically seem to be a universal concept, this study hypothesized that physicians and their patients could differ in their perceptions of high-quality care and that those beliefs might vary by country. Such a mismatch in beliefs may be especially important as clinical practice guidelines developed in the United States are globalized.

A survey of 20 statements describing various components of health care delivery and quality was sent to pediatric cardiologists in 33 countries, who ranked the statements in order of priority for ideal health care. Each participating physician administered the questionnaire to the parents of children with congenital heart disease; 554 questionnaires were received and analyzed. A subanalysis of 9 countries with the largest number of responses was done (Canada, the Czech Republic, France, Germany, Italy, The Netherlands, Sweden, the United Kingdom, and the United States). Doctors and parents rated the same 4 statements among the top 5: the doctor is skillful and knowledgeable; the doctor explains health problems, tests, and treatments in a way the patient can understand; a basic level of healthcare is available to all citizens regardless of their ability to pay; and treatment causes the patient to feel physically well.

Overall, parents' responses differed more among countries than those of physicians; the magnitude of the difference between parents and physicians varied by country. This discrepancy highlights a potential mismatch between patients' and physicians' views about the desired components of health care delivery, in particular the application of American quality standards for health care to systems in other countries.

As Vietnam opens its economy to privatization, its system of healthcare will face a series of crucial tests. Vietnam's system of private healthcare -- once comprised only of individual physicians holding clinic hours in their homes -- has come to also include larger customer-oriented clinics based on an American business model. As the two models compete in the expanding private market, it becomes increasingly important to understand patients' perceptions of the alternative models of care.

This study reports on interviews with 194 patients in two different types of private-sector clinics in Vietnam: a western-style clinic and a traditional style, after-hours clinic. In bivariate and multivariate analyses, we found that patients at the western style clinic reported both higher expectations of the facility and higher satisfaction with many

aspects of care than patients at the after-hours clinic. These different perceptions appear to be based on the interpersonal manner of the physician seen and the clinic's delivery methods rather than perceptions of the physician's technical skill and method of treatment. These fndings were unaffected by the ethnicity of physician seen.

These fndings suggest that patients in Vietnam recognize and prefer more customer-oriented care and amenities, regardless of physician ethnicity and perceive no signiccant differences in technical skill between the private delivery models.

Most panels that develop clinical practice guidelines are poorly equipped to address resource allocation or cost issues associated with management options. This risks neglect, arbitrariness, lack of transparency, and methodological flaws in consideration of resource allocation. We provide recommendations for guideline panels to promote greater transparency and rigor. We suggest focusing on resource allocation issues for only a limited number of recommendations and provide criteria for selecting those in which economic considerations are likely to influence the direction or strength of the recommendation. Panels should involve a health economist to assist with the systematic review and critical interpretation of relevant economic analyses. They should carefully define the intended audience and may consider issuing alternative recommendations when available resources vary widely across target clinical settings. Targeting a limited number of recommendations for the consideration of resource allocation issues, and ensuring methodologically high-quality review, will best serve guideline panels, and the health-care providers and patients they hope to assist.

PURPOSE: Poor blood pressure control remains a common problem that contributes to significant cardiovascular morbidity and mortality, particularly among African Americans. We explored antihypertensive medication adherence and other factors that may explain racial differences in blood pressure control.

METHODS: Baseline data were obtained from the Veteran's Study to Improve The Control of Hypertension, a randomized controlled trial designed to improve blood pressure control. Clinical, demographic, and psychosocial factors relating to blood pressure control were examined.

RESULTS: A total of 569 patients who were African American (41%) or white (59%) were enrolled in the study. African Americans were more likely to have inadequate baseline blood pressure control than whites (63% vs 50%; odds ratio = 1.70; 95% confidence interval [CI] 1.20-2.41). Among 20 factors related to blood pressure control, African Americans also had a higher odds ratio of being nonadherent to their medication, being more functionally illiterate, and having a family member with hypertension compared with whites. Compared with whites, African Americans also were more likely to perceive high blood pressure as serious and to experience the side effect of increased urination compared with whites. Adjusting for these differences reduced the odds ratio of African Americans having adequate blood pressure control to 1.59 (95% confidence interval 1.09-2.29).

CONCLUSIONS: In this sample of hypertensive patients who have good access to health care and medication benefits, African Americans continued to have lower levels of blood pressure control despite considering more than 20 factors related to blood pressure control. Interventions designed to improve medication adherence need to take race into account. Patients' self-reports of failure to take medications provide an opportunity for clinicians to explore reasons for medication nonadherence, thereby improving adherence and potentially blood pressure control.

There has been concern about the dramatic growth in obesity seen in developed countries. This paper advances the view that a neoclassical interpretation of weight growth that relies on changing incentives does surprisingly well in explaining the observed trends, without resorting to psychological, genetic, or addictive models.

OBJECTIVE: Hypertension affects more than 50 million people in the United States alone. Despite clear evidence regarding the beneficial effects of quality treatment for high blood pressure, many millions of diagnosed and undiagnosed hypertensives are not receiving the optimal standard of care. The difference in patient outcomes achieved with present hypertension treatment methods and those thought to be possible using best practice treatment methods is known as a quality gap, and such gaps are at least partly responsible for the loss of thousands of lives each year. This review was organized to bring a systematic assessment of different quality improvement (QI) strategies and their effects to the process of identifying and managing hypertension. SEARCH STRATEGY AND
INCLUSION CRITERIA: Investigators searched the MEDLINE® database, the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) registry, article bibliographies, and relevant journals for experimental evaluations of QI interventions aimed at improving hypertension screening and management of non-pregnant adults with primary hypertension. The reviewers included randomized or quasi-randomized controlled trials, controlled before-after studies, and interrupted time series in which at least one reported outcome measure included changes in blood pressure, or provider or patient adherence to a recommended process of care.
DATA COLLECTION AND ANALYSIS: Relevant data were abstracted independently by two reviewers. Each QI intervention was classified into one or more of the following components: provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self-management, patient reminders, audit and feedback, organizational change, or financial incentives. Certain categories were further subdivided into major subtypes (e.g., professional meetings for provider education and disease management for organizational change). The researchers also evaluated the impact of clinical information systems as a mediator for interventions of all types. They compared the different QI strategies in terms of the median effects achieved for blood pressure control and for a generalized measure of provider or patient adherence.
MAIN RESULTS: Sixty-three articles reporting a total of 82 comparisons met the inclusion criteria. Studies of hypertension identification were found to be too heterogeneous for quantitative analysis. The majority of screening studies were clinic-based (with a few offered at work sites), and the most common strategies involved patient and/or provider reminders. These generally showed positive results; several studies found that patients were more likely to know their blood pressure or attend clinic visits after receiving reminders. Across all studies with a variety of strategies, the median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 4.5 mmHg (interquartile range: 1.5, 11.0) and 2.1 mmHg (interquartile range: -0.2, 5.0), respectively. The median increase in the proportion of patients in the target SBP range and target DBP range was 16.2 percent (interquartile range: 10.3, 32.2), and 6.0 percent (interquartile range: 1.5, 17.5), respectively. Studies that focused on improving provider adherence showed a range of median reduction of 1.3 percent to a median improvement of 3.3 percent across all QI strategies. Overall, patient adherence showed a median improvement of 2.8 percent (interquartile range: 1.9, 3.0).
CONCLUSION: The findings of this review suggest that QI strategies appear, in general, to be associated with the improved identification and control of hypertension. It is not possible to discern with complete confidence which specific QI strategies have the greatest effects, since most of the studies included more than one QI strategy. All of the assessed strategies may be beneficial under some circumstances, and in varying combinations. There may be other useful strategies that have not been studied in trials meeting the inclusion criteria for evidence-based review; it is not possible to draw conclusions about these strategies.