Abstract

Background. The impact of choice on consumer decision making is controversial in US health policy. Objective. The authors’ objective was to determine how choice set size influences decision making among Medicare beneficiaries choosing prescription drug plans. Methods. The authors randomly assigned members of an Internet-enabled panel age 65 and older to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. The authors used ordered probit models to estimate the effect of choice set size on the study outcomes. Results. Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan. Conclusions. Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries.

ABSTRACT

Health-care reform could generate major new opportunities to strengthen the central role of neonatology in improving child health in the United States. However, without considerable caution, such reform also could destabilize many of the policies that have facilitated neonatology's most important contributions. This article anticipates the policy issues of greatest consequence for neonatology, including the public's misperception of neonatology's costs and impact on outcomes, the danger of adult-focused cost-containment policies, the potential to improve health services for women, and the generational politics of health-care reform. Neonatologists could provide essential technical guidance and a coherent political voice in shaping the nature and scope of health-care reform.

Abstract

OBJECTIVE:

To assess the evidence for interventions designed to prevent or reduce overweight and obesity in children younger than 2 years.

DATA SOURCES:

MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and references from relevant articles.

STUDY SELECTION:

Included were published studies that evaluated an intervention designed to prevent or reduce overweight or obesity in children younger than 2 years.

DATA EXTRACTION:

Extracted from eligible studies were measured outcomes, including changes in child weight status, dietary intake, and physical activity and parental attitudes and knowledge about nutrition. Studies were assessed for scientific quality using standard criteria, with an assigned quality score ranging from 0.00 to 2.00 (0.00-0.99 is poor, 1.00-1.49 is fair, and 1.50-2.00 is good).

DATA SYNTHESIS:

We retrieved 1557 citations; 38 articles were reviewed, and 12 articles representing 10 studies met study inclusion criteria. Eight studies used educational interventions to promote dietary behaviors, and 2 studies used a combination of nutrition education and physical activity. Study settings included home (n = 2), clinic (n = 3), classroom (n = 4), or a combination (n = 1). Intervention durations were generally less than 6 months and had modest success in affecting measures, such as dietary intake and parental attitudes and knowledge about nutrition. No intervention improved child weight status. Studies were of poor or fair quality (median quality score, 0.86; range, 0.28-1.43).

CONCLUSIONS:

Few published studies attempted to intervene among children younger than 2 years to prevent or reduce obesity. Limited evidence suggests that interventions may improve dietary intake and parental attitudes and knowledge about nutrition for children in this age group. For clinically important and sustainable effect, future research should focus on designing rigorous interventions that target young children and their families.

We explore whether HIV stigma is associated with seeking to conceal testing interest. We examine 86,899 outpatient visits in a 1993-1997 national survey and compare HIV testing to four non-stigmatized tests: spirometry, allergy testing, mammography, and colonoscopy. We explore whether people testing for HIV, compared to people receiving control services, listed reasons for visit (RFV) less related to the test performed, listed their interest in testing more frequently as a non-primary RFV, and received more services unrelated to testing. A total of 48.7% of people tested for HIV listed a reason unrelated to testing as their primary RFV (spirometry: 8.9%; allergy testing: 29.3%), and 69.9% of people asking to test requested HIV testing as a secondary RFV (spirometry: 52%; allergy testing: 0%). People who tested for HIV received more services (M=1.83 additional services) than non-testers (M=0.95) on an index of seven services. We did not find this association for spirometry, allergy testing, colonoscopy, or mammography. We interpret these results to indicate that stigma may have behavioral correlates and that people may attempt to avoid HIV stigma by seeking a psychological cover for HIV testing. To our knowledge, this is the first study to attempt to use observational data on health service usage for assessing stigma and people's attempts to deal with HIV testing stigma.

Abstract

CONTEXT:

Most smokers with mental illness do not receive tobacco cessation treatment.

OBJECTIVE:

To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates.

DESIGN, SETTING, AND PATIENTS:

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.

INTERVENTION:

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.

MAIN OUTCOME MEASURES:

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.

RESULTS:

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.

CONCLUSION:

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.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00118534.

Comparative effectiveness research (CER) has the potential to slow health care spending growth by focusing resources on health interventions that provide the most value. In this article, we discuss issues surrounding CER and its implementation and apply these methods to a salient clinical example: treatment of prostate cancer. Physicians have several options for treating patients recently diagnosed with localized disease, including removal of the prostate (radical prostatectomy), treatment with radioactive seeds (brachytherapy), radiation therapy (IMRT), or-if none of these are pursued- active surveillance. Using a commercial health insurance claims database and after adjustment for comorbid conditions, we estimate that the additional cost of treatment with radical prostatectomy is $7,300, while other alternatives are more expensive-$19,000 for brachytherapy and $46,900 for IMRT. However, a review of the clinical literature uncovers no evidence that justifi es the use of these more expensive approaches. These results imply that if patient management strategies were shifted to those supported by CER-based criteria, an estimated $1.7 to $3.0 billion (2009 present value) could be saved each year.

Recent studies demonstrate procyclical mortality in wealthy countries, but there are reasons to expect a countercyclical relationship in developing nations. We investigate how child survival in Colombia responds to fluctuations in world arabica coffee prices and document starkly procyclical child deaths. In studying this result's behavioral underpinnings, we highlight that (1) the leading determinants of child health are inexpensive but require considerable time, and (2) as the value of time declines with falling coffee prices, so does the relative price of health. We find a variety of direct evidence consistent with the primacy of time in child health production.

Liver disease and liver cancer associated with childhood-acquired chronic hepatitis B are
leading causes of death among adults in China. Despite expanded newborn hepatitis B
vaccination programs, approximately 20% of children under age 5 years and 40% of children aged 5 to 19 years remain unprotected from hepatitis B. Although immunizing them will be beneficial, no studies have examined the cost-effectiveness of hepatitis B catch-up vaccination in an endemic country like China. We examined the cost-effectiveness of a hypothetical nationwide free hepatitis B catch-up vaccination program in China for unvaccinated children and adolescents aged 1 to 19 years. We used a Markov model for disease progression and infections. Cost variables were based on data published by the Chinese Ministry of Health, peer-reviewed Chinese and English publications, and the GAVI Alliance.

We measured costs (2008 U.S. dollars and Chinese renminbi), quality-adjusted life years,and incremental cost-effectiveness from a societal perspective. Our results show that hepatitis B catch-up vaccination for children and adolescents in China is cost-saving across a range of parameters, even for adolescents aged 15 to 19 years old. We estimate that if all 150 million susceptible children under 19 were vaccinated, more than 8 million infections and 65,000 deaths due to hepatitis B would be prevented. Conclusion: The adoption of a nationwide free catch-up hepatitis B vaccination program for unvaccinated children and adolescents in China, in addition to ongoing efforts to improve birth dose and newborn vaccination coverage, will be cost-saving and can generate significant population-wide health benefits. The success of such a program in China could serve as a model for other endemic countries.