Abstract

Objectives. We assessed the potential health and economic benefits of reducing common risk factors in older Americans.
Methods. A dynamic simulation model tracked a national cohort of persons 51 and 52 years of age to project their health and medical spending in prevention scenarios for diabetes, hypertension, obesity, and smoking.
Results. The gain in life span from successful treatment of a person aged 51 or 52 years for obesity would be 0.85 years; for hypertension, 2.05 years; and for diabetes, 3.17 years. A 51- or 52-year-old person who quit smoking would gain 3.44 years. Despite living longer, those successfully treated for obesity, hypertension, or diabetes would have lower lifetime medical spending, exclusive of prevention costs. Smoking cessation would lead to increased lifetime spending. We used traditional valuations for a life-year to calculate that successful treatments would be worth, per capita, $198018 (diabetes), $137964 (hypertension), $118946 (smoking), and $51750 (obesity).
Conclusions. Effective prevention could substantially improve the health of older Americans, and—despite increases in longevity—such benefits could be achieved with little or no additional lifetime medical spending.

The utility of the life-course framework to address disparities in child health is based on its ability to integrate the science of child development with the requirements of effective and just public policy. I argue that the life-course framework is best assessed in a historical context and through 4 essential observations. First, early genetic and environmental interactions are complex and influence outcomes in different settings in very different ways. Second, these early-life interactions are themselves subject to considerable later influences and, therefore, may not be highly predictive of later outcomes. Third, the etiologic nature or timing of early-life interactions does not, per se, determine if their life-course effects are amenable to later interventions. Fourth, a highly deterministic view of early-life interactions is not supported by the science and can generate counterproductive approaches to research and policy development. Finally, an alternative approach is proposed on the basis of a "human-capacity" model of the life course that connects the search for underlying basic mechanisms with a policy-based examination of the comparative effectiveness of influences at different developmental stages. This approach suggests an expanded research and policy agenda that might be more capable of generating urgently needed strategies for reducing disparities in child health. Such an approach could ultimately define more comprehensively the power and limits of life-course effects in shaping the social distribution of health outcomes in the real world.

BACKGROUND AND AIMS:: The cost-effectiveness of alternative approaches to the diagnosis of small-bowel Crohn's disease is unknown. This study evaluates whether CT-Enterography (CTE) is a cost-effective alternative to small bowel follow-through (SBFT) and whether capsule endoscopy is a cost-effective third test in patients in whom a high suspicion of disease remains after two previous negative tests.

METHODS:: A decision-analytic model was developed to compare the lifetime costs and benefits of each diagnostic strategy. Patients were considered with low (20%) and high (75%) pretest probability of small-bowel Crohn's disease. Effectiveness was measured in quality-adjusted life-years (QALYs) gained. Parameter assumptions were tested with sensitivity analyses. RESULTS:: With a moderate to high pretest probability of small-bowel Crohn's disease, and higher likelihood of isolated jejunal disease, follow-up with CTE has an incremental cost-effectiveness ratio of less than $54,000/QALY-gained compared to SBFT. The addition of capsule endoscopy after ileocolonoscopy and negative CTE or SBFT costs greater than $500,000 per QALY-gained in all scenarios. Results were not sensitive to costs of tests or complications and were sensitive to test accuracies.

CONCLUSIONS:: The cost-effectiveness of strategies depends critically on the pretest probability of Crohn's disease and if the terminal ileum is examined at ileocolonoscopy. CTE is a cost-effective alternative to SBFT in patients with moderate to high suspicion of small-bowel Crohn's disease. The addition of capsule endoscopy as a third test is not a cost-effective third test even in patients with high pretest probability of disease.

BACKGROUND: The burden of hypertension and related health care needs among Mexican Americans will likely increase substantially in the near future.

OBJECTIVES: In a nationally representative sample of U.S. Mexican American adults we examined: 1) the full range of blood pressure categories, from normal to severe; 2) predictors of hypertension awareness, treatment and control and; 3) prevalence of comorbidities among those with hypertension.

DESIGN: Cross-sectional analysis of pooled data from the National Health and Nutrition Examination Surveys (NHANES), 1999-2004. PARTICIPANTS: The group of participants encompassed 1,359 Mexican American women and 1,421 Mexican American men, aged 25-84 years, who underwent a standardized physical examination.

MEASUREMENTS: Physiologic measures of blood pressure, body mass index, and diabetes. Questionnaire assessment of blood pressure awareness and treatment.

RESULTS: Prevalence of Stage 1 hypertension was low and similar between women and men ( approximately 10%). Among hypertensives, awareness and treatment were suboptimal, particularly among younger adults (65% unaware, 71% untreated) and those without health insurance (51% unaware, 62% untreated). Among treated hypertensives, control was suboptimal for 56%; of these, 23% had stage >/=2 hypertension. Clustering of CVD risk factors was common; among hypertensive adults, 51% of women and 55% of men were also overweight or obese; 24% of women and 23% of men had all three chronic conditions-hypertension, overweight/obesity and diabetes.

CONCLUSION: Management of hypertension in Mexican American adults fails at multiple critical points along an optimal treatment pathway. Tailored strategies to improve hypertension awareness, treatment and control rates must be a public health priority.

BACKGROUND: It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD). METHODS: Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty). RESULTS: The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis. CONCLUSIONS: Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status. 2009 Massachusetts Medical Society

Background: Neuraminidase inhibitors (NAIs) are stockpiled internationally for extended use in an influenza pandemic.

Purpose: To evaluate the safety and efficacy of extended-duration (>4 weeks) NAI chemoprophylaxis against influenza.

Data Sources: Studies published in any language through 11 June 2009 identified by searching 10 electronic databases and 3 trial registries.

Study Selection: Randomized, placebo-controlled, double-blinded human trials of extended-duration NAI chemoprophylaxis that reported outcomes of laboratory-confirmed influenza or adverse events.

Data Extraction: 2 reviewers independently assessed study quality and abstracted information from eligible studies.

Data Synthesis: Of 1876 potentially relevant citations, 7 trials involving 7021 unique participants met inclusion criteria. Data were pooled by using random-effects models. NAI chemoprophylaxis decreased the frequency of symptomatic influenza (relative risk [RR], 0.26 [95% CI, 0.18 to 0.37]; risk difference [RD], –3.9 percentage points [CI, –5.8 to –1.9 percentage points]) but not asymptomatic influenza (RR, 1.03 [CI, 0.81 to 1.30]; RD, –0.4 percentage point [CI, –1.6 to 0.9 percentage point). Adverse effects were not increased overall among NAI recipients (RR, 1.01 [CI, 0.94 to 1.08]; RD, 0.1 percentage point [CI, –0.2 to 0.4 percentage point), but nausea and vomiting were more common among those who took oseltamivir (RR, 1.48 [CI, 1.86 to 2.33]; RD, 1.7 percentage points [CI, 0.6 to 2.9 percentage points]). Prevention of influenza did not statistically significantly differ between zanamivir and oseltamivir.

Limitations: All trials were industry-sponsored. No study was powered to detect rare adverse events, and none included diverse racial groups, children, immunocompromised patients, or individuals who received live attenuated influenza virus vaccine.

Conclusion: Extended-duration zanamivir and oseltamivir chemoprophylaxis appears to be highly efficacious for preventing symptomatic influenza among immunocompetent white and Japanese adults. Extended-duration oseltamivir is associated with increased nausea and vomiting. Safety and efficacy in several subpopulations that might receive extended-duration influenza chemoprophylaxis are unknown.

Aims The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.

Methods We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.

Results Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.

Conclusions With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.

BACKGROUND: Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate.

PURPOSE: This study explored how aspects of general organizational culture relate to hospital patient safety climate.

METHODOLOGY: In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures.

FINDINGS: Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate.

PRACTICE IMPLICATIONS: Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies.