Objective: To test the feasibility, acceptability, and potential efficacy of after-school dance classes and a family-based intervention to reduce television viewing, thereby reducing weight gain, among African-American girls.

Design: Twelve-week, 2-arm parallel group, randomized controlled trial.

Setting: Low-income neighborhoods.

Participants: Sixty-one 8-10-year-old African-American girls and their parents/guardians.

Interventions: The treatment intervention consisted of after-school dance classes at 3 community centers, and a 5-lesson intervention, delivered in participants' homes, and designed to reduce television, videotape, and video game use. The active control intervention consisted of disseminating newsletters and delivering health education lectures.

Main Outcome Measures: Implementation and process measures, body mass index, waist circumference, physical activity measured by accelerometry, self-reported media use, and meals eaten with TV.

Results: Recruitment and retention goals were exceeded. High rates of participation were achieved for assessments and intervention activities, except where transportation was lacking. All interventions received high satisfaction ratings. At follow up, girls in the treatment group, as compared to the control group, exhibited trends toward lower body mass index (adjusted difference = -.32 kg/m2, 95% confidence interval [CI] -.77, .12; Cohen's d = .38 standard deviation units) and waist circumference (adjusted difference = -.63 cm, 95% CI -1.92, .67; d = .25); increased after-school physical activity (adjusted difference = 55.1 counts/minute, 95% CI -115.6, 225.8; d = .21); and reduced television, videotape, and video game use (adjusted difference = -4.96 hours/week, 95% CI -11.41, 1.49; d = .40). The treatment group reported significantly reduced household television viewing (d = .73, P = .007) and fewer dinners eaten while watching TV (adjusted difference = -1.60 meals/week, 95% CI -2.99, -.21; d = .59; P = .03). Treatment group girls also reported less concern about weight (d = .60; P = .03), and a trend toward improved school grades (d = .51; P = .07).

Conclusions: This study confirmed the feasibility, acceptability, and potential efficacy of using dance classes and a family-based intervention to reduce television viewing, thereby reducing weight gain, in African-American girls.

Contemporary clinical trials commonly measure quality of life and medical costs to establish whether therapies are both effective and cost effective. Cost-effectiveness analysis, however, requires a measure of patient utility or preferences for various health states. Because utilities are not often measured directly, we sought to develop a method of translating standard quality-of-life scales into a patient utility measure.

Methods

Five hundred fifty-three patients enrolled in the Bypass Angioplasty Revascularization Investigation Study of Economics and Quality of Life completed a battery of quality-of-life measures and a time trade-off utility assessment an average of 7.3 years after random assignment.

Results

The mean time trade-off score was 8.54 (SD ? 2.53) out of a maximum of 10; median score was 9.95. The distribution of scores was skewed, with 12% of patients at the highest possible score of 10. Patients with recurrent angina had significantly lower time trade-off scores than patients without angina (mean 7.03 vs 8.70, P .05). Time trade-off scores were moderately correlated with each quality-of-life measure (Spearman coefficients 0.38-0.52). Time trade-off scores could be predicted by combinations of 4 (r² ? 0.29), 5 (r² ? 0.31), or 6 (r² ? 0.32) variables.

Conclusions

Time trade-off utility scores can be inferred from commonly used quality-of-life measures. Angina significantly reduces patient utility scores.

Objectives

To evaluate recent trends, we examined longitudinal national data on the outpatient use of warfarin in atrial fibrillation (AF), beta-blockers and aspirin in coronary artery disease (CAD), and angiotensin-converting enzyme inhibitors (ACEIs) in congestive heart failure (CHF).

Background

Previous studies indicate that specific cardiac medications are underutilized.

Methods

We used the National Disease and Therapeutic Index (NDTI) (produced by IMS HEALTH, Plymouth Meeting, Pennsylvania) for 1990 to 2002, and the National Ambulatory Medical Care Surveys (NAMCS) for 1990 to 2000 to follow nationally representative samples of outpatient visits. For visits by patients with AF (total N = 14,634 visits), CAD (n = 35,295), and CHF (n = 33,008), we examined trends in the proportion of visits with the selected medications reported.

Results

Warfarin use in AF increased from 12% in 1990, to 41% in 1995, to 58% in 2001 in NDTI; a similar moderation of recent increase was seen in NAMCS. For CAD in NDTI, beta-blocker use increased slowly from 19% in 1990, to 20% in 1995, then to 40% in 2001; NAMCS showed this same pattern. Aspirin use in CAD in NDTI increased from 18% in 1990, to 19% in 1995, to 38% in 2001; NAMCS, however, showed lower use rates. For NDTI, ACEI use in CHF increased from 24% in 1990 to 36% in 1996, but increased to only 39% by 2001, a general pattern also seen in NAMCS.

Conclusions

Both national datasets demonstrate continuing underutilization of these cardiac medications of proven benefit. Although use is increasing, it remains lower than expected, and some increases noted in earlier years have slowed. Substantial public health benefits would result from further adoption of these effective therapies.

The second half of the 20th century witnessed spectacular advances in health care. Innovations such as magnetic resonance imaging, genetically engineered growth factors, and highly effective drugs for the treatment of depression, gastroesophageal reflux, high blood cholesterol, and HIV disease greatly improved the detection and treatment of both rare and common diseases. The advances greatly improved the outcomes of complex procedures such as organ transplantation, coronary artery bypass surgery, and high-dose chemotherapy (bone marrow transplantation) for acute myeloid leukemia and multiple myeloma. As the 21st century opens, technological progress in medicine is continuing and may be accelerating. It is a source of hope for the prevention, effective treatment, and cure of disease.

Technological innovation is also the major source of increases in real per capita medical spending in the United States. If medical advances continue to be adopted as rapidly as they have been, they will pose knotty economic, political, and ethical challenges for health care policy at a time when spending on health care in the United States has once again begun to surge after a mid-1990s pause and the number of Americans without health insurance has once again begun growing.

Background: Data are lacking on primary care interventions to reduce children's television viewing. Low-income African-American children watch greater amounts of television than their peers.

Design/Methods:A randomized controlled pilot and feasibility trial was conducted. Twenty-eight families with 7- to 12-year-old African-American children receiving primary care at an urban community clinic serving a low-income population were randomized to receive counseling alone or counseling plus a behavioral intervention that included an electronic television time manager. The main outcome was hours of children's television, videotape, and video game use. Parents/guardians and children completed baseline and 4-week follow-up self-report surveys. Additional outcomes included overall household television use, time spent in organized physical activity and playing outside, and meals eaten by the child while watching television.

Results: Both intervention groups reported similar decreases in children's television, videotape, and video game use (mean changes of -13.7, SD=26.1 and -14.1, SD=16.8 hours per week). The behavioral intervention group reported significantly greater increases in organized physical activity (changes of +2.5, SD=5.9 and -3.6, SD=4.7 hours per week; p =0.004) and nearly significant greater increases in playing outside (changes of 1.0, SD=5.9 and -4.7, SD=9.4 hours per week; p 0.06). Changes in overall household television use and meals eaten while watching television also appeared to favor the behavioral intervention, with small to medium effect sizes, but differences were not statistically significant.

Conclusions: This small pilot and feasibility study evaluated two promising primary care-based interventions to reduce television, videotape, and video game use among low-income African-American children. The effects on physical activity suggest that the behavioral intervention may be more effective.

Background: Policy and clinical decisions regarding children's nutrition are often based on dietary intake estimates from self-reports. The accuracy of these estimates depends on memory of both the type of food eaten and the amount consumed. Although children's self-reports of food intake are widely used, there is little research on their ability to estimate food portions.

Objective: To assess the validity of children's estimates of the food portions they consume by means of 2 types of measurement aids: standard 2-dimensional food portion visuals and manipulative props.

Design: Randomized controlled trial.

Participants: Fifty-four African American girls aged 8 to 12 years.

Main Outcome Measures: Girls were served a standard meal and actual intake was assessed by weighing food portions before and after the meal. On completion of the meal, dietitians collected food recalls and portion size estimates from the girls by means of both manipulative props and 2-dimensional food portion visuals, administered in a randomized order.

Results: Absolute value percentage differences between actual and estimated grams of food consumed averaged 58.0% (SD, 102.7%) for manipulative props and 32.8% (SD, 72.8%) for 2-dimensional food portion visuals. Spearman correlations between actual and estimated intakes with both portion size measurement aids were high (range, r = 0.56 to 0.79; all P.001), with the exception of bread intake (r = 0.16, P =.43). Correlations with actual intakes did not differ significantly between the 2 methods.

Conclusions: Children's self-reported portion size estimates are appropriate for ranking children's relative intakes, but they result in sizable errors in quantitative estimates of food and energy intakes. Caution should be used in interpreting quantitative dietary intake estimates derived from children's self-reports.

Background: Because no validated "gold standard" for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.

Objective: To assess the relationships between multiple measures of asthma disease status over time.

Design/Methods: We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics' validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.

Results: Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21-0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22-0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24-0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.

Conclusions: These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.

The world of Eli Ginzberg can readily be thought of as a triptych-a career in three parts. In his early years, Ginzberg's work was dedicated to understanding the history of economics, from Adam Smith to C. Wesley Mitchell, and placing that understanding in what might well be considered economic ethnography. His studies took him on travels from Wales in the United Kingdom to California in the United States. For example, the poignant account of Welsh miners in an era of economic depression and technological change remains a landmark work. His report of a cross country trip taken in the first year of the New Deal provides insight and evaluation that can scarcely be captured in present-day writings.

The second period of his career corresponds to Ginzberg's increasing involvement in the practice of economics. He deals with issues related to manpower allocation, employment shifts, and gender and racial changes in the workforce. His writing reflects a growing concern for child welfare and education. In this period, his work increasingly focuses on federal, state and city governments, and how the public sector impacts all basic social issues. His work was sufficiently transcendent of political ideology that seven presidents sought and received his advice and participation.

After receiving all due encomiums and congratulations for intellectual work and policy research well done, Ginzberg then went on to spend the next thirty years of his life carving out a place as a preeminent economist of health, welfare services, and hospital administration. It is this portion of his life that is the subject of Eli Ginzberg: The Economist as a Public Intellectual. What is apparent in Ginzberg's work of this period is his sense of the growing interaction of all the social sciences-pure and applied-to develop a sense of the whole. The contributors to this festschrift, join together to provide a portrait of a figure whose life and work have spanned the twentieth century, and yet pointed the way to changes in the twenty-first century. Eli Ginzberg from the start possessed a strong sense of social justice and economic equality grounded in a Judaic-Christian tradition. All of these aspects come together in the writings of a person who transcends all parochialism and gives substantive content to the often-cloudy phrase, public intellectual.