Chronic viral diseases such as human immunodeficiency virus (HIV) and hepatitis B virus (HBV) afflict millions of people worldwide. A key public health challenge in managing such diseases is identifying infected, asymptomatic individuals so that they can receive antiviral treatment. Such treatment can benefit both the treated individual (by improving quality and length of life) and the population as a whole (through reduced transmission). We develop a compartmental model of a chronic, treatable infectious disease and use it to evaluate the cost and effectiveness of different levels of screening and contact tracing.

We show that:

1. the optimal strategy is to get infected individuals into treatment at the maximal rate until the incremental health benefits balance the incremental cost of controlling the disease;
   
2. as one reduces the disease prevalence by moving people into treatment (which decreases the chance that they will infect others), one should increase the level of contact tracing to compensate for the decreased effectiveness of screening;
   
3. as the disease becomes less prevalent, it is optimal to spend more per case identified; and
   
4. the relative mix of screening and contact tracing at any level of disease prevalence is such that the marginal efficiency of contact tracing (cost per infected person found) equals that of screening if possible (e.g., when capacity limitations are not binding).
   

We also show how to determine the costeffective equilibrium level of disease prevalence (among untreated individuals), and we develop an approximation of the path of the optimal prevalence over time. Using this, one can obtain a close approximation of the optimal solution without having to solve an optimal control problem. We apply our methods to an example of hepatitis B virus.

Background. The optimal community-level approach to control pandemic influenza is unknown. Methods. We estimated the health outcomes and costs of combinations of 4 social distancing strategies and 2 antiviral medication strategies to mitigate an influenza pandemic for a demographically typical US community. We used a social network, agent-based model to estimate strategy effectiveness and an economic model to estimate health resource use and costs. We used data from the literature to estimate clinical outcomes and health care utilization. Results. At 1% influenza mortality, moderate infectivity (R(o) of 2.1 or greater), and 60% population compliance, the preferred strategy is adult and child social distancing, school closure, and antiviral treatment and prophylaxis. This strategy reduces the prevalence of cases in the population from 35% to 10%, averts 2480 cases per 10,000 population, costs $2700 per case averted, and costs $31,300 per quality-adjusted life-year gained, compared with the same strategy without school closure. The addition of school closure to adult and child social distancing and antiviral treatment and prophylaxis, if available, is not cost-effective for viral strains with low infectivity (R(o) of 1.6 and below) and low case fatality rates (below 1%). High population compliance lowers costs to society substantially when the pandemic strain is severe (R(o) of 2.1 or greater). Conclusions. Multilayered mitigation strategies that include adult and child social distancing, use of antivirals, and school closure are cost-effective for a moderate to severe pandemic. Choice of strategy should be driven by the severity of the pandemic, as defined by the case fatality rate and infectivity.

Background— Family members of patients with established long-QT syndrome (LQTS) often lack definitive clinical findings, yet may have inherited an LQTS mutation and be at risk of sudden death. Genetic testing can identify mutations in 75% of patients with LQTS, but genetic testing of family members remains controversial.

Methods and Results— We used a Markov model to assess the cost-effectiveness of 3 strategies for treating an asymptomatic 10-year-old, first-degree relative of a patient with clinically evident LQTS. In the genetic testing strategy, relatives undergo genetic testing only for the mutation identified in the index patient, and relatives who test positive for the mutation are treated with β-blockers. This strategy was compared with (1) empirical treatment of relatives with β-blockers and (2) watchful waiting, with treatment only after development of symptoms. The genetic testing strategy resulted in better survival and quality-adjusted life years at higher cost, with a cost-effectiveness ratio of $67 400 per quality-adjusted life year gained compared with watchful waiting. The cost-effectiveness of the genetic testing strategy improved to less than $50 000 per quality-adjusted life year gained when applied selectively either to (1) relatives with higher clinical suspicion of LQTS (pretest probability 65% to 81%), or to (2) families with a higher than average risk of sudden death, or to (3) larger families (2 or more first-degree relatives tested).

Conclusions— Genetic testing of young first-degree relatives of patients with definite LQTS is moderately expensive, but can reach acceptable thresholds of cost-effectiveness when applied to selected patients.

The Affordable Care Act promises to add 32 million Americans to the rolls of the insured at a time when there is a shortage of primary care providers. There is broad consensus that the next phase of reform must slow the growth of health care costs and improve value through payment reforms, including bundling of payments and payments for episodes of care. Some savings will derive from implementation of innovative models of care, such as accountable care organizations, medical homes, transitional care, and community-based care. We believe that if we are to bridge the gap in primary care and establish new approaches to care delivery, all health care providers must be permitted to practice to the fullest extent of their knowledge and competence. This will require establishing a standardized and broadened scope of practice for advanced-practice registered nurses — in particular, nurse practitioners — for all states.

The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for “regionalized, coordinated, and accountable emergency care systems throughout the country.” There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled “Beyond Regionalization: Integrated Networks of Emergency Care.” This article is a product of the conference breakout session on “Defining and Measuring Successful Networks”; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non–time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM’s vision of regionalized, coordinated, and accountable emergency care systems.

Objective To determine the association of reductions in price of antiretroviral drugs and foreign assistance for HIV with coverage of antiretroviral treatment.

Design Retrospective study.

Setting Africa.

Participants 13 African countries, 2003-8.

Main outcome measures A price index of first line antiretroviral therapy with data on foreign assistance for HIV was used to estimate the associations of prices and foreign assistance with antiretroviral coverage (percentage of people with advanced HIV infection receiving antiretroviral therapy), controlling for national public health spending, HIV prevalence, governance, and fixed effects for countries and years.

Results Between 2003 and 2008 the annual price of first line antiretroviral therapy decreased from $1177 (£733; €844) to $96 and foreign assistance for HIV per capita increased from $0.4 to $13.8. At an annual price of $100, a $10 decrease was associated with a 0.16% adjusted increase in coverage (95% confidence interval 0.11% to 0.20%; 0.19% unadjusted, 0.14% to 0.24%). Each additional $1 per capita in foreign assistance for HIV was associated with a 1.0% adjusted increase in coverage (0.7% to 1.2%; 1.4% unadjusted, 1.1% to 1.6%). If the annual price of antiretroviral therapy stayed at $100, foreign assistance would need to quadruple to $64 per capita to be associated with universal coverage. Government effectiveness and national public health expenditures were also positively associated with increasing coverage.

Conclusions Reductions in price of antiretroviral drugs were important in broadening coverage of HIV treatment in Africa from 2003 to 2008, but their future role may be limited. Foreign assistance and national public health expenditures for HIV seem more important in expanding future coverage.