This issue of CHP/PCOR's quarterly newsletter, which covers news from the summer 2005 quarter, includes articles about:

• our new core faculty member Grant Miller, a Harvard-trained health economist with an interest in improving health in developing countries;
• a discussion with center director Alan Garber on key issues and challenges facing the Medicare program;
• the fourth meeting of the Patient Safety Consortium, a group of more than 100 U.S. hospitals taking part in CHP/PCOR research on patient safety culture;
• core faculty member Jay Bhattacharya's research on HIV patients' perceptions of their lifespan as examined through viatical settlement transactions; and
• a research project on technology coverage decisions in the U.S. vs. the U.K., undertaken by Stirling Bryan, a U.K.-based Harkness Fellow in Health Care Policy who is spending the next academic year at CHP/PCOR.

Investors systematically deviate from rationality when making financial decisions, yet the mechanisms responsible for these deviations have not been identified. Using event-related fMRI, we examined whether anticipatory neural activity would predict optimal and suboptimal choices in a financial decision-making task. We characterized two types of deviations from the optimal investment strategy of a rational risk-neutral agent as risk-seeking mistakes and risk-aversion mistakes. Nucleus accumbens activation preceded risky choices as well as risk-seeking mistakes, while anterior insula activation preceded riskless choices as well as risk-aversion mistakes. These findings suggest that distinct neural circuits linked to anticipatory affect promote different types of financial choices and indicate that excessive activation of these circuits may lead to investing mistakes. Thus, consideration of anticipatory neural mechanisms may add predictive power to the rational actor model of economic decision making.

This issue of CHP/PCOR's quarterly newsletter covers developments from the spring 2005 quarter. It includes articles about:

• research on HIV/AIDS in Russia -- presented in May at an international conference -- which shows that in order to contain the country's rapidly expanding HIV/AIDS epidemic, Russia must aggressively treat HIV-positive injection drug users;
• a CHP/PCOR-hosted discussion session with Edward Sondik, director of the National Center for Health Statistics;
• an ongoing CHP/PCOR study that examines older adults' preferences about health states in which they would need help with basic tasks like bathing or eating;
• a panel discussion on "International Responses to Infectious Diseases," led by CHP/PCOR at the Stanford Institute for International Studies' first annual conference, featuring the World Health Organization's chief of infectious diseases;
• a widely publicized study by CHP/PCOR researchers which found that obese workers are paid less than non-obese workers in similar jobs, but only when they have employer-sponsored health insurance -- a finding suggesting that the wage gap is due to obese workers' higher medical costs, rather than outright prejudice; and
• an update on the Center on Advancing Decision Making for Aging, including two new seed projects and a lecture given by economics and psychology professor George Loewenstein.

Purpose:

To examine U.S. adolescents' (age 13-18) utilization of ambulatory care and the likelihood of receiving preventive counseling from 1993 through 2000.

Methods:

The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey provided visit-based data on counseling services that occurred in private physician offices and hospital outpatient departments. Main outcome measures included adolescents' use of outpatient care and their likelihood of being counseled on 3 health promotion topics (i.e., diet, exercise, and growth/development) and 5 risk reduction topics (i.e., tobacco use/exposure, skin cancer prevention, injury prevention, family planning/contraception, and HIV/STD transmission).

Results:

Adolescents had the lowest rates of outpatient visits among all age groups, with particularly low rates among boys and ethnic minorities. Most frequently, adolescent visits were for upper respiratory tract conditions, acne, routine medical or physical examinations, and, for girls, prenatal care. In 1997-2000, counseling services were documented for 39% (99% CI: 32-46%) of all adolescent general medical/physical examination (GME) visits. Diet [26% of GME visits (20-32%)] and exercise [22% (17-28%)] were the most frequent counseling topics. The counseling rates of the other six topics ranged from as low as 3 to 20%, with skin cancer prevention, HIV/STD transmission, and family planning/contraception ranking the lowest. These rates represented minimal improvements from 1993-1996 both in absolute term and in relation to the gaps between practices and recommendations.

Conclusions:

Adolescents underutilize primary care, and even those who do receive care are underserved for their health counseling needs. The noted lack of change over time suggests that satisfactory improvement is unlikely unless substantial interventions are undertaken.

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the winter 2004 quarter. It features articles about:

• a widely publicized study by CHP/PCOR researchers which found that routine HIV screening is cost-effective and would extend the lives of HIV-positive patients;
• publication of the first three volumes of "Closing the Quality Gap," a report prepared by researchers at CHP/PCOR and UCSF that evaluates quality improvement strategies for specific medical conditions;
• a health vouchers plan co-authored by Victor Fuchs, which would provide comprehensive health coverage for all Americans, while maintaining individual choice and free-market competition;
• a research collaboration led by CHP/PCOR that has been awarded a grant to develop a comprehensive Medicare reform plan; and
• the work of former CHP/PCOR trainee Jessica Haberer, who is doing HIV/AIDS research in China for the William J. Clinton foundation, and recently met the former president in this capacity.

Background: Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy.

Methods: We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness.

Results: In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was $36,000 per quality-adjusted life-year gained. Testing every five years cost $50,000 per quality-adjusted life-year gained, and testing every three years cost $63,000 per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was $38,000 per quality-adjusted life-year gained, whereas testing every five years cost $71,000 per quality-adjusted life-year gained, and testing every three years cost $85,000 per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost $113,000 per quality-adjusted life-year gained.

Conclusions: In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.

Background:

The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined.

Methods:

We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling.

Results:

Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of $194 per screened patient, for a cost-effectiveness ratio of $15,078 per quality-adjusted life-year. Screening cost less than $50,000 per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was $41,736 per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost $57,138 per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection.

Conclusions:

The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.