Cost-effectiveness of intensive glycemic control,intensified hypertension control,and serum cholesterol level reduction for type 2 diabetes

Context  Several treatment interventions can reduce complications of type 2 diabetes, but their relative cost-effectiveness is not known. Objective  To estimate the incremental cost-effectiveness of intensive glycemic control (relative to conventional control), intensified hypertension control, and reduction in serum cholesterol level for patients with type 2 diabetes. Design, Setting, and Patients  Cost-effectiveness analysis of a hypothetical cohort of individuals living in the United States, aged 25 years or older, who were newly diagnosed as having type 2 diabetes. The results of the United Kingdom Prospective Diabetes Study (UKPDS) and other studies were used to create a model of disease progression and treatment patterns. Costs were based on those used in community practices in the United States. Interventions  Insulin or sulfonylurea therapy for intensive glycemic control; angiotensin-converting enzyme inhibitor or -blocker for intensified hypertension control; and pravastatin for reduction of serum cholesterol level. Main Outcome Measures  Cost per quality-adjusted life-year (QALY) gained. Costs (in 1997 US dollars) and QALYs were discounted at a 3% annual rate. Results  The incremental cost-effectiveness ratio for intensive glycemic control is $41 384 per QALY; this ratio increased with age at diagnosis from $9614 per QALY for patients aged 25 to 34 years to $2.1 million for patients aged 85 to 94 years. For intensified hypertension control the cost-effectiveness ratio is -$1959 per QALY. The cost-effectiveness ratio for reduction in serum cholesterol level is $51 889 per QALY; this ratio varied by age at diagnosis and is lowest for patients diagnosed between the ages of 45 and 84 years. Conclusions  Intensified hypertension control reduces costs and improves health outcomes relative to moderate hypertension control. Intensive glycemic control and reduction in serum cholesterol level increase costs and improve health outcomes. The cost-effectiveness ratios for these 2 interventions are comparable with those of several other frequently adopted health care interventions.      

The Cost-effectiveness of Screening for Type 2 Diabetes

Context.— Type 2 diabetes mellitus is a common and serious disease in the United States, but one third of those affected are unaware they have it. Objective.— To estimate the cost-effectiveness of early detection and treatment of type 2 diabetes. Design.— A Monte Carlo computer simulation model was developed to estimate the lifetime costs and benefits of 1-time opportunistic screening (ie, performed during routine contact with the medical care system) for type 2 diabetes and to compare them with current clinical practice. Cost-effectiveness was estimated for all persons aged 25 years or older, for age-specific subgroups, and for African Americans. Data were obtained from clinical trials, epidemiologic studies, and population surveys, and a single-payer perspective was assumed. Costs and benefits are discounted at 3% and costs are expressed in 1995 US dollars. Setting.— Single-payer health care system. Participants.— Hypothetical cohort of 10,000 persons with newly diagnosed diabetes from the general US population. Main Outcome Measures.— Cost per additional life-year gained and cost per quality-adjusted life-year (QALY) gained. Results.— The incremental cost of opportunistic screening among all persons aged 25 years or older is estimated at $236,449 per life-year gained and $56,649 per QALY gained. Screening is more cost-effective among younger people and among African Americans. The benefits of early detection and treatment accrue more from postponement of complications and the resulting improvement in quality of life than from additional life-years. Conclusions.— Early diagnosis and treatment through opportunistic screening of type 2 diabetes may reduce the lifetime incidence of major microvascular complications and result in gains in both life-years and QALYs. Incremental increases in costs attributable to screening and earlier treatment are incurred but may well be in the range of acceptable cost-effectiveness for US health care systems, especially for younger adults and for some subpopulations (eg, minorities) who are at relatively high risk of developing the major complications of type 2 diabetes. Although current recommendations are that screening begin at age 45 years, these results suggest that screening is more cost-effective at younger ages. The selection of appropriate target populations for screening should consider factors in addition to the prevalence of diabetes.      

Lung cancer screening with helical computed tomography in older adult smokers: a decision and cost-effectiveness analysis

Context  Encouraged by direct-to-consumer marketing, smokers and their physicians are contemplating lung cancer screening with a promising but unproven imaging procedure, helical computed tomography (CT). Objective  To estimate the potential benefits, harms, and cost-effectiveness of lung cancer screening with helical CT in various efficacy scenarios. Design, Setting, and Population  Using a computer-simulated model, we compared annual helical CT screening to no screening for hypothetical cohorts of 100 000 current, quitting, and former heavy smokers, aged 60 years, of whom 55% were men. We simulated efficacy by changing the clinical stage distribution of lung cancers so that the screened group would have fewer advanced-stage cancers and more localized-stage cancers than the nonscreened group (ie, a stage shift). Our model incorporated known biases in screening programs such as lead time, length, and overdiagnosis bias. Main Outcome Measures  We measured the benefits of screening by comparing the absolute and relative difference in lung cancer–specific deaths. We measured harms by the number of false-positive invasive tests or surgeries per 100 000 and incremental cost-effectiveness in US dollars per quality-adjusted life-year (QALY) gained. Results  Over a 20-year period, assuming a 50% stage shift, the current heavy smoker cohort had 553 fewer lung cancer deaths (13% lung cancer–specific mortality reduction) and 1186 false-positive invasive procedures per 100 000 persons. The incremental cost-effectiveness for current smokers was $116 300 per QALY gained. For quitting and former smokers, the incremental cost-effectiveness was $558 600 and $2 322 700 per QALY gained, respectively. Other than the degree of stage shift, the most influential parameters were adherence to screening, degree of length or overdiagnosis bias in the first year of screening, quality of life of persons with screen-detected localized lung cancers, cost of helical CT, and anxiety about indeterminate nodule diagnoses. In 1-way sensitivity analyses, none of these parameters was sufficient to make screening highly cost-effective for any of the cohorts. In multiway sensitivity analyses, a program screening current smokers was $42 500 per QALY gained if extremely favorable estimates were used for all of the influential parameters simultaneously. Conclusion  Even if efficacy is eventually proven, screening must overcome multiple additional barriers to be highly cost-effective. Given the current uncertainty of benefits, the harms from invasive testing, and the high costs associated with screening, direct-to-consumer marketing of helical CT is not advisable.      

Cost-effectiveness of treatment for chronic hepatitis C infection in an evolving patient population

Context  Approximately 2.7 million US individuals are chronically infected with the hepatitis C virus (HCV). As public health campaigns are pursued, a growing number of treatment candidates are likely to have minimal evidence of liver damage. Objective  To examine the clinical benefits and cost-effectiveness of newer treatments for chronic hepatitis C infection in a population of asymptomatic, HCV sero-positive but otherwise healthy individuals. Design and Setting  Cost-effectiveness analysis using a Markov model of the natural history of HCV infection and impact of treatment. We used an epidemiologic model to derive a range of natural history parameters that were empirically calibrated to provide a good fit to observed data on both prevalence of HCV seropositivity and time trends in outcomes related to HCV infection. Patients  Cohorts of 40-year-old men and women with elevated levels of alanine aminotransferase, positive results on quantitative HCV RNA assays and serologic tests for antibody to HCV, and no histological evidence of fibrosis on liver biopsy. Interventions  Monotherapy with standard or pegylated interferon alfa-2b; combination therapy with standard or pegylated interferon plus ribavirin. Main Outcome Measures  Lifetime costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results  The probability of patients with chronic HCV developing cirrhosis over a 30-year period ranged from 13% to 46% for men and from 1% to 29% for women. The incremental cost-effectiveness of combination therapy with pegylated interferon for men ranged from $26 000 to $64 000 per QALY for genotype 1 and from $10 000 to $28 000 per QALY for other genotypes; and for women ranged from $32 000 to $90 000 for genotype 1 and from $12 000 to $42 000 for other genotypes. Because the benefits of treatment were realized largely in the form of improvements in health-related quality of life, rather than prolonged survivorship, cost-effectiveness ratios expressed as dollars per year of life were substantially higher. Results were most sensitive to assumptions about the gains and decrements in health-related quality of life associated with treatment. Conclusions  While newer treatment options for hepatitis C appear to be reasonably cost-effective on average, these results vary widely across different patient subgroups and depend critically on quality-of-life assumptions. As the pool of persons eligible for treatment for HCV infection expands to the more general population, it will be imperative for patients and their physicians to consider these assumptions in making individual-level treatment decisions.      

Costs and effectiveness of ximelagatran for stroke prophylaxis in chronic atrial fibrillation

Context  Recent trials have found that ximelagatran and warfarin are equally effective in stroke prevention for patients with atrial fibrillation. Because ximelagatran can be taken in a fixed, oral dose without international normalized ratio monitoring and may have a lower risk of hemorrhage, it might improve quality-adjusted survival compared with dose-adjusted warfarin. Objective  To compare quality-adjusted survival and cost among 3 alternative therapies for patients with chronic atrial fibrillation: ximelagatran, warfarin, and aspirin. Design  Semi-Markov decision model. Patients  Hypothetical cohort of 70-year-old patients with chronic atrial fibrillation, varying risk of stroke, and no contraindications to anticoagulation therapy. Main Outcome Measures  Quality-adjusted life-years (QALYs) and costs in US dollars. Results  For patients with atrial fibrillation but no additional risk factors for stroke, both ximelagatran and warfarin cost more than $50 000 per QALY compared with aspirin. For patients with additional stroke risk factors and low hemorrhage risk, ximelagatran modestly increased quality-adjusted survival (0.12 QALY) at a substantial cost ($116 000 per QALY) compared with warfarin. For ximelagatran to cost less than $50 000 per QALY it would have to cost less than $1100 per year or be prescribed to patients who have an elevated risk of intracranial hemorrhage (>1.0% per year of warfarin) or a low quality of life with warfarin therapy. Conclusion  Assuming equal effectiveness in stroke prevention and decreased hemorrhage risk, ximelagatran is not likely to be cost-effective in patients with atrial fibrillation unless they have a high risk of intracranial hemorrhage or a low quality of life with warfarin.      

Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men

Context  Osteoporotic fractures are common among elderly men. Objective  To evaluate among older men the cost-effectiveness of bone densitometry followed by 5 years of oral bisphosphonate therapy to prevent fractures for those found to have osteoporosis (femoral neck T score –2.5), compared with no intervention. Design, Setting, and Population  Computer Markov microsimulation model using a societal perspective and a lifetime horizon. Simulations were performed for hypothetical cohorts of white men aged 65, 70, 75, 80, or 85 years, with or without prior clinical fracture. Data sources for model parameters included the Rochester Epidemiology Project for fracture costs and population-based age-specific fracture rates; the Osteoporotic Fractures in Men (MrOS) study and published meta-analyses for the associations among prior fractures, bone density, and incident fractures; and published studies of fracture disutility. Main Outcome Measures  Costs per quality-adjusted life-year (QALY) gained for the densitometry and follow-up treatment strategy compared with no intervention, calculated from lifetime costs and accumulated QALYs for each strategy. Results  Lifetime costs per QALY gained for the densitometry and follow-up treatment strategy were less than $50 000 for men aged 65 years or older with a prior clinical fracture and for men aged 80 years or older without a prior fracture. These results were most sensitive to oral bisphosphonate cost and fracture reduction efficacy, the strength of association between bone mineral density and fractures, fracture rates and disutility, and medication adherence. Conclusions  Bone densitometry followed by bisphosphonate therapy for those with osteoporosis may be cost-effective for men aged 65 years or older with a self-reported prior clinical fracture and for men aged 80 to 85 years with no prior fracture. This strategy may also be cost-effective for men as young as 70 years without a prior clinical fracture if oral bisphosphonate costs are less than $500 per year or if the societal willingness to pay per QALY gained is $100 000.      

Cardiovascular mortality risk in chronic kidney disease: comparison of traditional and novel risk factors

Context  Elderly persons with chronic kidney disease have substantial risk for cardiovascular mortality, but the relative importance of traditional and novel risk factors is unknown. Objective  To compare traditional and novel risk factors as predictors of cardiovascular mortality. Design, Setting, and Patients  A total of 5808 community-dwelling persons aged 65 years or older living in 4 communities in the United States participated in the Cardiovascular Health Study cohort. Participants were initially recruited from 1989 to June 1990; an additional 687 black participants were recruited in 1992-1993. The average length of follow-up in this longitudinal study was 8.6 years. Main Outcome Measures  Cardiovascular mortality among those with and without chronic kidney disease. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m². Results  Among the participants, 1249 (22%) had chronic kidney disease at baseline. The cardiovascular mortality risk rate was 32 deaths/1000 person-years among those with chronic kidney disease vs 16/1000 person-years among those without it. In multivariate analyses, diabetes, systolic hypertension, smoking, low physical activity, nonuse of alcohol, and left ventricular hypertrophy were predictors of cardiovascular mortality in persons with chronic kidney disease (all P values <.05). Among the novel risk factors, only log C-reactive protein (P = .05) and log interleukin 6 (P<.001) were associated with the outcome as linear predictors. Traditional risk factors were associated with the largest absolute increases in risks for cardiovascular deaths among persons with chronic kidney disease: for left ventricular hypertrophy, there were 25 deaths per 1000 person-years; current smoking, 20 per 1000 person-years; physical inactivity, 15 per 1000 person-years; systolic hypertension, 14 per 1000 person-years; diabetes, 14 per 1000 person-years; and nonuse of alcohol, 11 per 1000 person-years vs 5 deaths per 1000 person-years for those with increased C-reactive protein and 5 per 1000 person-years for those with increased interleukin 6 levels. A receiver operating characteristic analysis found that traditional risk factors had an area under the curve of 0.73 (95% confidence interval, 0.70-0.77) among those with chronic kidney disease. Adding novel risk factors only increased the area under the curve to 0.74 (95% confidence interval, 0.71-0.78; P for difference = .15). Conclusions  Traditional cardiovascular risk factors had larger associations with cardiovascular mortality than novel risk factors in elderly persons with chronic kidney disease. Future research should investigate whether aggressive lifestyle intervention in patients with chronic kidney disease can reduce their substantial cardiovascular risk.      

Potential health and economic impact of adding a human papillomavirus vaccine to screening programs

Context  Recently published results suggest that effective vaccines against cervical cancer—associated human papillomavirus (HPV) may become available within the next decade. Objective  To examine the potential health and economic effects of an HPV vaccine in a setting of existing screening. Design, Setting, and Population  A Markov model was used to estimate the lifetime (age 12-85 years) costs and life expectancy of a hypothetical cohort of women screened for cervical cancer in the United States. Three strategies were compared: (1) vaccination only; (2) conventional cytological screening only; and (3) vaccination followed by screening. Two of the strategies incorporated a vaccine targeted against a defined proportion of high-risk (oncogenic) HPV types. Screening intervals of 1, 2, 3, and 5 years and starting ages for screening of 18, 22, 24, 26, and 30 years were chosen for 2 of the strategies (conventional cytological screening only and vaccination followed by screening). Main Outcome Measures  Incremental cost per life-year gained. Results  Vaccination only or adding vaccination to screening conducted every 3 and 5 years was not cost-effective. However, at more frequent screening intervals, strategies combining vaccination and screening were preferred. Vaccination plus biennial screening delayed until age 24 years had the most attractive cost-effectiveness ratio ($44 889) compared with screening only beginning at age 18 years and conducted every 3 years. However, the strategy of vaccination with annual screening beginning at age 18 years had the largest overall reduction in cancer incidence and mortality at a cost of $236 250 per life-year gained compared with vaccination and annual screening beginning at age 22 years. The cost-effectiveness of vaccination plus delayed screening was highly sensitive to age of vaccination, duration of vaccine efficacy, and cost of vaccination. Conclusions  Vaccination for HPV in combination with screening can be a cost-effective health intervention, but it depends on maintaining effectiveness during the ages of peak oncogenic HPV incidence. Identifying the optimal age for vaccination should be a top research priority.      

Cost-effectiveness of screening BRCA1/2 mutation carriers with breast magnetic resonance imaging

Context  Women with inherited BRCA1/2 mutations are at high risk for breast cancer, which mammography often misses. Screening with contrast-enhanced breast magnetic resonance imaging (MRI) detects cancer earlier but increases costs and results in more false-positive scans. Objective  To evaluate the cost-effectiveness of screening BRCA1/2 mutation carriers with mammography plus breast MRI compared with mammography alone. Design, Setting, and Patients  A computer model that simulates the life histories of individual BRCA1/2 mutation carriers, incorporating the effects of mammographic and MRI screening was used. The accuracy of mammography and breast MRI was estimated from published data in high-risk women. Breast cancer survival in the absence of screening was based on the Surveillance, Epidemiology and End Results database of breast cancer patients diagnosed in the prescreening period (1975-1981), adjusted for the current use of adjuvant therapy. Utilization rates and costs of diagnostic and treatment interventions were based on a combination of published literature and Medicare payments for 2005. Main Outcome Measures  The survival benefit, incremental costs, and cost-effectiveness of MRI screening strategies, which varied by ages of starting and stopping MRI screening, were computed separately for BRCA1 and BRCA2 mutation carriers. Results  Screening strategies that incorporate annual MRI as well as annual mammography have a cost per quality-adjusted life-year (QALY) gained ranging from less than $45 000 to more than $700 000, depending on the ages selected for MRI screening and the specific BRCA mutation. Relative to screening with mammography alone, the cost per QALY gained by adding MRI from ages 35 to 54 years is $55 420 for BRCA1 mutation carriers, $130 695 for BRCA2 mutation carriers, and $98 454 for BRCA2 mutation carriers who have mammographically dense breasts. Conclusions  Breast MRI screening is more cost-effective for BRCA1 than BRCA2 mutation carriers. The cost-effectiveness of adding MRI to mammography varies greatly by age.      

Hypertension prevalence and blood pressure levels in 6 European countries,Canada, and the United States

Context  Geographic variations in cardiovascular disease (CVD) and associated risk factors have been recognized worldwide. However, little attention has been directed to potential differences in hypertension between Europe and North America. Objective  To determine whether higher blood pressure (BP) levels and hypertension are more prevalent in Europe than in the United States and Canada. Design, Setting, and Participants  Sample surveys that were national in scope and conducted in the 1990s were identified in Germany, Finland, Sweden, England, Spain, Italy, Canada, and the United States. Collaborating investigators provided tabular data in a consistent format by age and sex for persons at least 35 years of age. Population registries were the main basis for sampling. Survey sizes ranged from 1800 to 23 100, with response rates of 61% to 87.5%. The data were analyzed to provide age-specific and age-adjusted estimates of BP and hypertension prevalence by country and region (eg, European vs North American). Main Outcome Measures  Blood pressure levels and prevalence of hypertension in Europe, the United States, and Canada. Results  Average BP was 136/83 mm Hg in the European countries and 127/77 mm Hg in Canada and the United States among men and women combined who were 35 to 74 years of age. This difference already existed among younger persons (35-39 years) in whom treatment was uncommon (ie, 124/78 mm Hg and 115/75 mm Hg, respectively), and the slope with age was steeper in the European countries. For all age groups, BP measurements were lowest in the United States and highest in Germany. The age- and sex-adjusted prevalence of hypertension was 28% in the North American countries and 44% in the European countries at the 140/90 mm Hg threshold. The findings for men and women by region were similar. Hypertension prevalence was strongly correlated with stroke mortality (r = 0.78) and more modestly with total CVD (r = 0.44). Conclusions  Despite extensive research on geographic patterns of CVD, the 60% higher prevalence of hypertension in Europe compared with the United States and Canada has not been generally appreciated. The implication of this finding for national prevention strategies should be vigorously explored.      

Mental health problems among adults in tsunami-affected areas in southern Thailand

Context  On December 26, 2004, an undersea earthquake occurred off the northwestern coast of Sumatra, Indonesia. The tsunami that followed severely affected all 6 southwestern provinces of Thailand, where 5395 individuals died, 2991 were unaccounted for, and 8457 were injured. Objective  To assess the prevalence of symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression among individuals residing in areas affected by the tsunami in southern Thailand as part of a public health emergency response and rapid assessment. Design, Setting, and Participants  A multistage, cluster, population-based mental health survey was conducted from February 15 to 22, 2005, of random samples of displaced (n = 371) and nondisplaced persons in Phang Nga province (n = 322) and nondisplaced persons in the provinces of Krabi and Phuket (n = 368). Data were collected using an interviewer-administered questionnaire on handheld computers. A surveillance follow-up survey of the displaced persons (n = 371) and nondisplaced persons (n = 322) in Phang Na was conducted in September 2005. Main Outcomes Measures  Medical Outcomes Study-36 Short-Form Health Survey SF-36 to assess self-perceived general health, bodily pain, and social and emotional functioning; the Harvard Trauma Questionnaire to assess tsunami-specific traumatic events; and the Hopkins Checklist-25 to detect symptoms of anxiety and depression. Results  Participation rates for displaced and nondisplaced persons in the rapid assessment survey were 69% and 58%, respectively. Symptoms of PTSD were reported by 12% of displaced and 7% of nondisplaced persons in Phang Nga and 3% of nondisplaced persons in Krabi and Phuket. Anxiety symptoms were reported by 37% of displaced and 30% of nondisplaced persons in Phang Nga and 22% of nondisplaced persons in Krabi and Phuket. Symptoms of depression were reported by 30% of displaced and 21% of nondisplaced persons in Phang Nga and 10% of nondisplaced persons in Krabi and Phuket. In multivariate analysis, loss of livelihood was independently and significantly associated with symptoms of all 3 mental health outcomes (PTSD, anxiety, and depression). In the 9-month follow-up surveillance survey of 270 (73%) displaced and 250 (80%) nondisplaced participants in Phang Nga, prevalence rates of symptoms of PTSD, anxiety, and depression among displaced persons decreased to 7%, 24.8%, and 16.7%, respectively, and among nondisplaced persons, prevalence rates decreased to 2.3%, 25.9%, and 14.3%, respectively. Conclusions  Among survivors of the tsunami in southern Thailand, elevated rates of symptoms of PTSD, anxiety, and depression were reported 8 weeks after the disaster, with higher rates for anxiety and depression than PTSD symptoms. Nine months after the disaster, the rates of those reporting these symptoms decreased but were still elevated. This information is important for directing, strengthening, and evaluating posttsunami mental health needs and interventions.      

Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder

Context  A shortage of data exists on medical care use by persons with attention-deficit/hyperactivity disorder (ADHD). Objective  To compare medical care use and costs among persons with and without ADHD. Design and Setting  Population-based cohort study conducted in Rochester, Minn. Subjects  All children born in 1976-1982 were followed up through 1995, using school and medical records to identify those with ADHD. The 4880 birth cohort members (mean age, 7.3 years) still residing in Rochester in 1987 were followed up in medical facility–linked billing databases until death, emigration, or December 31, 1995. Main Outcome Measures  Clinical diagnoses, likelihood and frequency of inpatient and outpatient hospitalizations, emergency department (ED) visits, and total medical costs (including ambulatory care), compared among individuals with and without ADHD. Results  Among the 4119 birth cohort members who remained in the area through 1995 (mean age, 15.3 years), 7.5% (n = 309) had met criteria for ADHD. Compared with persons without ADHD, those with ADHD were more likely to have diagnoses in multiple categories, including major injuries (59% vs 49%; P<.001) and asthma (22% vs 13%; P<.001). The proportion with any hospital inpatient, hospital outpatient, or ED admission was higher for persons with ADHD vs those without ADHD (26% vs 18% [P<.001], 41% vs 33% [P = .006], and 81% vs 74% [P = .005], respectively). The 9-year median costs for persons with ADHD compared with those without ADHD were more than double ($4306 vs $1944; P<.001), even for the subset with no hospital or ED admissions (eg, median 1987 costs, $128 vs $65; P<.001). The differences between individuals with and without ADHD were similar for males and females and across all age groups. Conclusion  In our cohort, compared with persons without ADHD, those with ADHD exhibited substantially greater use of medical care in multiple care delivery settings.      

Cost-effectiveness of 3 Methods to Enhance the Sensitivity of Papanicolaou Testing

Context  ThinPrep, AutoPap, and Papnet are 3 new technologies that increase the sensitivity and cost of cervical cancer screening. Objective  To estimate the cost-effectiveness of these technological enhancements to Papanicolaou (Pap) tests. Design  We estimated the increase in sensitivity from using these technologies by combining results of 8 studies meeting defined criteria. We used published literature and additional sources for cost estimates. To estimate overall cost-effectiveness, we applied a 9-state time-varying transition state model to these data and information about specific populations. Setting  A hypothetical program serving a cohort of 20- to 65-year-old women who begin screening at the same age and are representative of the US population. Results  The new technologies increased life expectancy by 5 hours to 1.6 days, varying with the technology and the frequency of screening. All 3 technologies also increased the cost per woman screened by $30 to $257 (1996 US dollars). AutoPap dominated ThinPrep in the base case. At each screening interval, AutoPap increased survival at the lowest cost. The cost per year of life saved rose from $7777 with quadrennial screening to $166,000 with annual screening. Papnet produced more life-years at a higher cost per year of life saved. However, when used with triennial screening, each of them produced more life-years at lower cost than conventional Pap testing every 2 years. The cost-effectiveness ratio of each technology improved with increases in the prevalence of disease, decreases in the sensitivity of conventional Pap testing, and increases in the improvement in sensitivity produced by the technology. Conclusions  Technologies to increase the sensitivity of Pap testing are more cost-effective when incorporated into infrequent screening. Increases in sensitivity and decreases in cost may eventually make each technology more cost-effective.      

Hypertension in adults across the age spectrum: current outcomes and control in the community

Context  Data are sparse regarding current rates of hypertension treatment and control, and risks associated with hypertension, among persons older than 80 years. Objective  To determine the prevalence of blood pressure stages, hypertension treatment and control, and cardiovascular risk among older patients with hypertension. Design, Setting, and Participants  A community-based cohort study in which data were collected during all Framingham Heart Study examinations attended in the 1990s. Participants were pooled according to age: younger than 60 years, 60 to 79 years, or 80 years or older. There were 5296 participants who contributed 14 458 person-examinations of observation, including 7135 hypertensive person-examinations (4919 treated). Main Outcome Measures  Prevalence of hypertension, its treatment, and its control were compared across age groups. Risks for incident cardiovascular disease during follow-up of up to 6 years were estimated as multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression. Results  Prevalence of hypertension and drug treatment increased with advancing age, whereas control rates were markedly lower in older women (systolic <140 and diastolic <90 mm Hg). For ages younger than 60 years, 60 to 79, and 80 years and older, respectively, control rates were 38%, 36%, and 38% in men (P = .30) and 38%, 28%, and 23% in women (P<.001). Relative risks for cardiovascular disease associated with increasing blood pressure stage did not decline with advancing age, and absolute risks increased markedly. Among participants 80 years of age or older, major cardiovascular events occurred in 9.5% of the normal blood pressure (referent) group, 19.8% of the prehypertension group (HR, 1.9; 95% CI, 0.9-3.9), 20.3% of the stage 1 hypertension group (HR, 1.8; 95% CI, 0.8-3.7), and 24.7% of the stage 2 or treated hypertension group (HR, 2.4; 95% CI, 1.2-4.6). Conclusions  Relative to current national guidelines, rates of blood pressure control in the community are low, especially among older women with hypertension. Short-term risks for cardiovascular disease are substantial, indicating the need for greater efforts at safe, effective risk reduction among the oldest patients with hypertension.      

Reproductive health indicators and outcomes among refugee and internally displaced persons in postemergency phase camps

Context  Despite increasing awareness of the importance of reproductive health programs and services for refugee and internally displaced populations, there is a paucity of basic epidemiological data on reproductive health outcomes. Objectives  To collect data on reproductive health outcomes among refugees and internally displaced persons in postemergency phase camps and compare these outcomes with those of host country and country-of-origin populations. To determine programmatic factors that may affect reproductive health outcomes. Design, Setting, and Participants  Retrospective study of data collected from August 1998 through March 2000 of 688 766 persons living in 52 postemergency phase camps in 7 countries. Reproductive health outcomes of refugee and internally displaced populations were compared with available data of reference populations within their respective host country and country of origin. Main Outcome Measures  Crude birth rate (CBR), neonatal mortality rate (NNMR), maternal mortality ratio (MMR), percentage of newborns with low birth weight (LBW), and incidence of complications of unsafe or spontaneous abortions. Results  Six of 11 groups had lower CBRs than their country of origin and 5 of 9 groups had lower CBRs than their host country. Four of 5 had lower NNMRs than their country of origin and 6 of 9 had lower NNMRs than the host country. Four of 6 had lower MMRs than their country of origin, and 5 of 6 had lower MMRs than their host country. Seven of 9 had lower percentages of LBWs than in the country of origin and 5 of 9 had lower percentages of LBWs than the host country. Higher CBRs were associated with more recently established camps and higher numbers of local health staff per 1000 persons; and higher percentages of LBW newborns were associated with rainy season, more recently established camps, lower numbers of community health workers per 1000 persons, and camps without supplementary feeding programs. Conclusions  Refugees and internally displaced persons in most postemergency phase camps had better reproductive health outcomes than their respective host country and country-of-origin populations.      

Trends in heart failure incidence and survival in a community-based population

Context  The epidemic of heart failure has yet to be fully investigated, and data on incidence, survival, and sex-specific temporal trends in community-based populations are limited. Objective  To test the hypothesis that the incidence of heart failure has declined and survival after heart failure diagnosis has improved over time but that secular trends have diverged by sex. Design, Setting, and Participants  Population-based cohort study using the resources of the Rochester Epidemiology Project conducted in Olmsted County, Minnesota. Patients were 4537 Olmsted County residents (57% women; mean [SD] age, 74 [14] years) with a diagnosis of heart failure between 1979 and 2000. Framingham criteria and clinical criteria were used to validate the diagnosis Main Outcome Measures  Incidence of heart failure and survival after heart failure diagnosis. Results  The incidence of heart failure was higher among men (378/100 000 persons; 95% confidence interval [CI], 361-395 for men; 289/100 000 persons; 95% CI, 277-300 for women) and did not change over time among men or women. After a mean follow-up of 4.2 years (range, 0-23.8 years), 3347 deaths occurred, including 1930 among women and 1417 among men. Survival after heart failure diagnosis was worse among men than women (relative risk, 1.33; 95% CI, 1.24-1.43) but overall improved over time (5-year age-adjusted survival, 43% in 1979-1984 vs 52% in 1996-2000, P<.001). However, men and younger persons experienced larger survival gains, contrasting with less or no improvement for women and elderly persons. Conclusion  In this community-based cohort, the incidence of heart failure has not declined during 2 decades, but survival after onset of heart failure has increased overall, with less improvement among women and elderly persons.      

Health of previously uninsured adults after acquiring Medicare coverage

J. Michael McWilliams, MD; Ellen Meara, PhD; Alan M. Zaslavsky, PhD; John Z. Ayanian, MD, MPP

JAMA. 2007;298(24):2886-2894.

Context  Uninsured near-elderly adults, particularly those with cardiovascular disease or diabetes, experience worse health outcomes than insured adults. However, the health benefits of providing insurance coverage for uninsured adults have not been clearly demonstrated.

Objective  To assess the effect of acquiring Medicare coverage on the health of previously uninsured adults.

Design and Setting  We conducted quasi-experimental analyses of longitudinal survey data from 1992 through 2004 from the nationally representative Health and Retirement Study. We compared changes in health trends reported by previously uninsured and insured adults after they acquired Medicare coverage at age 65 years.

Participants  Five thousand six adults who were continuously insured and 2227 adults who were persistently or intermittently uninsured from ages 55 to 64 years.

Main Outcome Measures  Differential changes in self-reported trends after age 65 years in general health, change in general health, mobility, agility, pain, depressive symptoms, and a summary measure of these 6 domains; and adverse cardiovascular outcomes (all trend changes reported in health scores per year).

Results  Compared with previously insured adults, previously uninsured adults reported significantly improved health trends after age 65 years for the summary measure (differential change in annual trend, +0.20; P = .002) and several component measures. Relative to previously insured adults with cardiovascular disease or diabetes, previously uninsured adults with these conditions reported significantly improved trends in summary health (differential change in annual trend, +0.26; P = .006), change in general health (+0.02; P = .03), mobility (+0.04; P = .05), agility (+0.08; P = .003), and adverse cardiovascular outcomes (–0.015; P = .02) but not in depressive symptoms (+0.04; P = .32). Previously uninsured adults without these conditions reported differential improvement in depressive symptoms (+0.08; P = .002) but not in summary health (+0.10; P = .17) or any other measure. By age 70 years, the expected difference in summary health between previously uninsured and insured adults with cardiovascular disease or diabetes was reduced by 50%.

Conclusion  In this study, acquisition of Medicare coverage was associated with improved trends in self-reported health for previously uninsured adults, particularly those with cardiovascular disease or diabetes.

     

Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy

Context  Current guidelines do not include an upper age cutoff for colorectal cancer screening with colonoscopy. Although the prevalence of colonic neoplasia increases with age, life expectancy decreases. Thus, the benefit of screening colonoscopy in very elderly patients may be limited. Objective  To compare estimated life-years saved with screening colonoscopy in very elderly vs younger persons. Design, Setting, and Participants  Cross-sectional study conducted among 1244 asymptomatic individuals in 3 age groups (50-54 years [n = 1034], 75-79 years [n = 147], and 80 years [n = 63]) who underwent screening colonoscopy at a US teaching hospital and clinic. Main Outcome Measures  Prevalence of various types of colon neoplasia; estimated gain in life expectancy, calculated as life expectancy – (life expectancy during polyp lag time + life expectancy after colorectal cancer diagnosis); and comparison of mean gain in life expectancy across the 3 groups. Life expectancy and mortality data were derived from life tables, previous studies, and national databases. Results  The prevalence of neoplasia was 13.8% in the 50- to 54-year-old group, 26.5% in the 75- to 79-year-old group, and 28.6% in the group aged 80 years or older. Despite higher prevalence of neoplasia in elderly patients, mean extension in life expectancy was much lower in the group aged 80 years or older than in the 50- to 54-year-old group (0.13 vs 0.85 years). In sensitivity analysis, with longer polyp lag times the mean extension in life expectancy decreased more in the elderly than in the younger patients; alternatively, if it was assumed that a smaller proportion of adenomas progress to colorectal cancer, the mean extension in life expectancy decreased less in the elderly than in the younger patients. Conclusions  Even though prevalence of neoplasia increases with age, screening colonoscopy in very elderly persons (aged 80 years) results in only 15% of the expected gain in life expectancy in younger patients. Screening colonoscopy in very elderly patients should be performed only after careful consideration of potential benefits, risks, and patient preferences.      

Annual revaccination against influenza and mortality risk in community-dwelling elderly persons

Context  Although large-scale observational studies have demonstrated the effectiveness of influenza vaccination, no large studies have systematically addressed the clinical benefit of annual revaccinations. Objective  To investigate the effect of annual influenza revaccination on mortality in community-dwelling elderly persons. Design, Setting, and Participants  A population-based cohort study using the computerized Integrated Primary Care Information (IPCI) database in the Netherlands including community-dwelling individuals aged 65 years or older from 1996 through 2002. For each year, we computed the individual cumulative exposure to influenza vaccination since study start. Main Outcome Measure  Association between the number of consecutive influenza vaccinations and all-cause mortality vs no vaccination after adjusting for age, sex, chronic respiratory and cardiovascular disease, hypertension, diabetes mellitus, renal failure, and cancer. Results  The study population included 26 071 individuals, of whom 3485 died during follow-up. Overall, a first vaccination was associated with a nonsignificant annual reduction of mortality risk of 10% (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.78-1.03) while revaccination was associated with a reduced mortality risk of 24% (HR, 0.76; 95% CI, 0.70-0.83). Compared with a first vaccination, revaccination was associated with a reduced annual mortality risk of 15% (HR, 0.85; 95% CI, 0.75-0.96). During the epidemic periods this reduction was 28% (HR, 0.72; 95% CI, 0.53-0.96). Similar estimates were obtained for persons with and without chronic comorbidity and those aged 70 years or older at baseline. Overall, influenza vaccination is estimated to prevent 1 death for every 302 vaccinees at a vaccination coverage that varied between 64% and 74%. Conclusion  Annual influenza vaccination is associated with a reduction in all-cause mortality risk in a population of community-dwelling elderly persons, particularly in older individuals.      

Cost and cost-effectiveness of an early invasive vs conservative strategy for the treatment of unstable angina and non-ST-segment elevation myocardial infarction

Context  In the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)–Thrombolysis in Myocardial Infarction (TIMI) 18 trial, patients with either unstable angina or non–ST-segment elevation myocardial infarction (UA/NSTEMI) treated with the platelet glycoprotein (Gp IIb/IIIa) inhibitor tirofiban had a significantly reduced rate of major cardiac events at 6 months with an early invasive vs a conservative strategy. Objective  To examine total 6-month costs and long-term cost-effectiveness of an invasive vs a conservative strategy. Design  Randomized controlled trial including a priori economic end points. Setting  Hospitalization for UA/NSTEMI with 6-month follow-up period. Patients  A total of 2220 patients with UA/NSTEMI; economic data from 1722 patients at US–non-VA hospitals. Intervention  Early invasive strategy with routine catheterization and revascularization as appropriate vs a conservative strategy with catheterization performed only for recurrent ischemia or a positive stress test. Main Outcome Measure  Total 6-month costs and incremental cost-effectiveness ratio. Results  The average initial hospitalization costs among those in the invasive strategy group were $15714 vs $14047 among those in the conservative stategy group, a difference of $1667 (95% confidence interval [CI], $387-3091). The in-hospital costs were offset significantly at the 6-month follow-up, with an average cost in the invasive group of $6098 vs $7180 in the conservative group, a difference of $1082 (95% CI, -$2051 to $76). The average total costs at 6 months, including productivity costs, for the invasive group was $21 813 vs $21 227 for the conservative group, a $586 difference (95% CI, -$1087 to $2486). The average 6-month costs excluding productivity costs in the invasive group was $19 780 vs $19 111 in the conservative group, a difference of $670, 95% CI; (-$1035 to $2321). Estimated cost per year of life gained for the invasive strategy, based on projected life expectancy, was $12739 for the base case, and ranged from $8371 to $25769, based on model assumptions. Conclusions  In patients with UA/NSTEMI treated with the Gp IIb/IIIa inhibitor tirofiban, the clinical benefit of an early invasive strategy was achieved with a small increase in cost, yielding favorable projected estimates of cost per year of life gained. These results support the broader use of an early invasive strategy in these patients.