Medicaid coverage for the working uninsured: the role of state policy

Low-income workers face the highest gap in health coverage; 37.3 percent were uninsured in 1999. Although employer-sponsored insurance covered many more low-income workers, state programs are very important to those without private insurance. We examined the wide variations across thirteen representative states in public insurance coverage of low-income workers to develop insights into the reasons for the variations and to suggest strategies for encouraging states to expand public insurance coverage. The analysis suggests that expanded and better-targeted federal assistance coupled with greater state flexibility would be needed to achieve this goal.     

Theorizing about causes at the individual level while estimating effects at the population level: implications for prevention

The dominant philosophy of modern epidemiology is individualism, despite the limitations of epidemiologic tools and methods when considering the individual level. We pursue information on increasingly reductionist causes in our search for knowledge of causes of specific cases. Philosophical reasoning and empiric evidence suggest that this search may not be as fruitful as proponents claim. I argue that using individualism to guide our search for causes of disease hinders our effectiveness in contributing to disease prevention, because the positive predictive values of most established genetic and environmental risk factors for noninfectious diseases are too low to be quantitatively convincing to an individual.     

Trends in news coverage about skin cancer prevention, 1993-2006: increasingly mixed messages for the public

Objective: To provide a comprehensive overview of trends in news coverage about sun protection issues in an Australian setting over a 14‐year period. Methods: A content analysis was performed on all relevant articles (N=547) published in two major daily newspapers, The Age and the Herald Sun, from 1993 to 2006. Articles were coded for article type, prominence, theme, spokesperson, topic slant and opinion slant. Results: The most frequent themes were the health effects of ultraviolet (UV) radiation exposure (24% of articles), education/prevention (14%) and product issues (12%). Themes that became more dominant over time were vitamin D issues, solaria issues and fake tans. Sixty per cent of articles included a pro‐sun protection spokesperson and 12% an anti‐sun protection spokesperson, with the profile of anti‐sun protection spokespeople increasing over time. Half the articles reported on topics positive for sun protection, whereas 18% reported on negative topics; however, this difference narrowed considerably from 2001 onwards. In opinionated articles, the opinions expressed by authors were mainly positive (57%) rather than negative (7%) for sun protection. Conclusions and implications: The findings suggest that the mix of sun protection issues covered and views of sun protection have changed over time, resulting in greater coverage of controversies and issues not necessarily positive for sun protection objectives. These findings imply that evaluation of paid skin cancer prevention public education campaigns may need to take account of the changing news media environment in which they take place.     

Trends in the United States cesarean section rate and reasons for the 1980-85 rise.

The rate of cesarean section delivery in the United States rose from 4.5 per 100 deliveries in 1965 to 22.7 in 1985, and in 1985 an estimated 851,000 live births were cesarean deliveries, according to data from the National Hospital Discharge Survey. This increase has been observed for all ages, and within all regions of the country. The rate for teenagers and mothers aged 20 to 29 was five to six times as high in 1985 as in 1965, and four times as high for mothers aged 30 years and older. Repeat cesareans account for an increasing share of all cesarean deliveries; in 1985 one in three cesareans were repeats. The increase in the cesarean rate of 6.2 percentage points between 1980 and 1985 (from 16.5 to 22.7) was partitioned according to five complications of delivery recorded on hospital discharge records: previous cesarean delivery, breech presentation, dystocia, fetal distress, and all other complications. Nearly half (48 per cent) of the increase was associated with previous cesarean delivery, 29 per cent with dystocia, 16 per cent with fetal distress, 5 per cent with breech presentation, and 2 per cent with all other complications.     

Health care coverage and access for children in an urban state: The New York perspective

Conclusion New York and the nation stand at the brink of an unprecedented opportunity to improve health care coverage and access for children. New York can continue to be a national leader in ensuring access to coverage and care for low-income children by combining eligibility expansions with effective outreach and enrollment efforts. Between half and three-quarters of a million children could benefit if these activities are successful. As monumental an accomplishment as that would be, however, three-quarters of the state's total uninsured population would remain without coverage. Successful advocacy for low-income children should serve as models for additional efforts to provide health care coverage to their parents and to other uninsured adults in the state. During a strong state economy and renewed interest in health care issues, the time is now to seize this momentum and fulfill New York's historic commitment to health care for all its citizens.     

Health state values for the HUI 2 descriptive system: results from a UK survey

This paper reports the results of a study to estimate a statistical health state valuation model for a revised version of the Health Utilities Index Mark 2, using Standard Gamble health state preference data. A sample of 51 health states were valued by a sample of the 198 members of the UK general population. Models are estimated for predicting health state valuations for all 8000 states defined by the revised HUI2. The recommended model produces logical and significant coefficients for all levels of all dimensions in the HUI2. These coefficients appear to be robust across model specifications. This model performs well in predicting the observed health state values within the valuation sample and for a separate validation sample of health states. However, there are concerns over large prediction errors for two health states in the valuation sample. These problems must be balanced against concerns over the validity of using the VAS based health state valuation data of the original HUI2 valuation model.     

中国糖尿病患者健康效用值系统综述与Meta分析

目的 系统评价中国大陆糖尿病患者的健康效用值,为药物经济学评价与卫生技术评估提供基础数据。方法 计算机检索PubMed、Web of Science、Cochrane Library、Embase、CNKI、WanFang Data、VIP 和 CBM数据库,搜索各数据库建库至2020年04月10日。采用Stata 15.0软件对健康效用值进行meta分析。结果 最终纳入31篇文献,中国大陆糖尿病患者的健康效用值及95%CI为0.860（0.837～0.884）,1型和2型糖尿病患者健康效用值及95%CI分别为0.790（0.779～0.801）和0.868（0.842～0.895）。在糖尿病并发症中,糖尿病外周神经病变、糖尿病眼部疾病、糖尿病肾脏疾病、糖尿病足的健康效用值均值及95%CI分别为0.779（0.753～0.806）、0.830（0.796～0.863）、0.751（0.725～0.776）、0.698（0.660～0.736）,糖尿病合并脑血管疾病、中风、高血脂、心血管病、高血压、外周血管疾病的健康效用值均值及95%CI分别为0.741（0.731～0.752）、0.726（0.697～0.756）、0.847（0.831～0.862）、0.771（0.749～0.793）、0.797（0.766～0.829）、0.632（0.578～0.686）。结论 不同研究测量的糖尿病患者健康效用值异质性较大,糖尿病合并症与并发症给患者生命质量带来的影响较大。     

A comparison of individual and social time trade-off values for health states in the general population

This study aimed to compare directly elicited individual time trade-off (TTO) values in a general population sample with the social values derived using the UK EQ-5D index tariff. In the Stockholm County 1998 postal Public Health Survey (n=4950, 20-88 years), the EQ-5D self-classifier, a TTO and a rating scale (RS) question were included (n=2549 for all three questions). The mean TTO (EQ-5D) value was 0.943 (0.890) in the youngest age-group and 0.699 (0.733) in the oldest age-group. The difference between TTO and EQ-5D values was greater in more severe health status groups was. The same equation as for the UK EQ-5D index tariff was estimated for TTO and RS and resulted in significant and consistent coefficients for nearly all dimensions. The coefficients for moderate problems were closer to the EQ-5D index tariff than the coefficients for severe problems. Age was also significant after controlling for the EQ-5D dimensions (p<0.05). The results suggest that individual and social TTO values differ systematically and that the difference is greater the more severe the health status is. The social EQ-5D index tariff may also underestimate the severity in health status at older ages; age appears to correlate with additional health problems not captured by the EQ-5D classification.     

Childhood immunization coverage in US states: the impact of state policy interventions and programmatic support

Although research suggests numerous interventions that can improve immunization coverage (Taskforce on Community Preventive Services, 2000), there is often a gap between policies supported by and public entities. The question for this study is whether the variation in childhood (19 to 35 months) immunization coverage rates across states is related to significant variations in state regulatory regimes that may optimize the benefits of state registries and systems that are designed to improve assessment of immunization practices. Utilizing 2002 data from the CDC and survey data collected from state immunization program officials, we find that financial support for state immunization programs, opt-out state registries, and state-mandated participation in provider quality improvement and assessment programs have positive associations with statewide coverage rates. We also suggest that more active state governmental support for interventions supported by rigorous scientific evaluation will not only improve early childhood immunization coverage, but may also support other public health objectives such as life-time full immunization and improve bioterrorism response planning.     

Enhancing the private provision of care through premiums for ability: the case of tuberculosis care in the Philippines

This paper examines how premiums for ability are set and how these can enhance the quality of care provided in private markets. The specific context for this study is the market for tuberculosis (TB) care in the Philippines. While the most cost- and clinically-effective treatment method known as TB Directly Observed Treatment Short Course (TB DOTS) is increasingly being provided by the public sector, few private doctors have adopted this protocol. As findings of multivariate regression analyses of private physicians' fees suggest, this low adoption rate can be partly explained by the modest premiums private doctors receive for using TB DOTS. While the public provision of TB DOTS should be pursued in earnest, this paper argues that the complementarity between public and private provision of TB DOTS should be strengthened, especially since Filipino TB patients seem to prefer private doctors. This goal can be achieved through user fees that (i) include a sufficiently large premium for physician ability and (ii) are paid through the social insurance system.     

Recruiting for values in healthcare: a preliminary review of the evidence

Displaying compassion, benevolence and respect, and preserving the dignity of patients are important for any healthcare professional to ensure the provision of high quality care and patient outcomes. This paper presents a structured search and thematic review of the research evidence relating to values-based recruitment within healthcare. Several different databases, journals and government reports were searched to retrieve studies relating to values-based recruitment published between 1998 and 2013, both in healthcare settings and other occupational contexts. There is limited published research related to values-based recruitment directly, so the available theoretical context of values is explored alongside an analysis of the impact of value congruence. The implications for the design of selection methods to measure values is explored beyond the scope of the initial literature search. Research suggests some selection methods may be appropriate for values-based recruitment, such as situational judgment tests (SJTs), structured interviews and multiple-mini interviews (MMIs). Personality tests were also identified as having the potential to compliment other methods (e.g. structured interviews), as part of a values-based recruitment agenda. Methods including personal statements, references and unstructured/‘traditional’ interviews were identified as inappropriate for values-based recruitment. Practical implications are discussed in the context of values-based recruitment in the healthcare context. Theoretical implications of our findings imply that prosocial implicit trait policies, which could be measured by selection tools such as SJTs and MMIs, may be linked to individuals’ values via the behaviours individuals consider to be effective in given situations. Further research is required to state this conclusively however, and methods for values-based recruitment represent an exciting and relatively unchartered territory for further research.     

Screening for colorectal cancer using the fecal occult blood test: an actuarial assessment of the impact of a population-based screening program in Canada

OBJECTIVES: A series of randomized controlled trials have demonstrated that screening for colorectal cancer (CRC) using the fecal occult blood (FOB) test can decrease mortality from this disease. These findings were used to develop an actuarial model to estimate the impact that a FOB screening program for colorectal cancer would have on the Canadian population. METHODS: The mortality experience of the year 2000 cohort of Canadians fifty to seventy-four years of age, with follow-up extending to 2010, was modelled according to three scenarios: no screening, annual screening, biennial screening. The primary screening tool was the FOB test using unrehydrated samples, with follow-up of positive test results using colonoscopy. The framework of the model was developed based on published findings from the relevant randomized controlled trials, available data, and a literature review that yielded parameter values for some model items. RESULTS: During the 10-year follow-up of the cohort, we estimated that 4,444 and 2,827 deaths would be averted with annual and biennial FOB screening, respectively. We estimated that for an annual FOB screening program, approximately 3,400 FOB tests would be required to prevent one death, whereas 2,700 tests would be required within a biennial program. CONCLUSIONS: Our analysis documents the population health impact of using the FOB test to screen for CRC. Additional information on the natural history of the disease, and Canadian pilot data are needed to better model the effectiveness of population-based FOB screening programs.     

Group care for children in California: Trends in the '90s

Based upon a cross-sectional mailed survey of all group home providers in the state of California, this study provides current information on the size of group home settings, the cost of care, and the staffing in various group home arrangements. Issues such as staff turnover are discussed in addition to the need for a commitment to ethnic and cultural diversity among staff. Agency administrators' views of the future trends in group home care are provided along with recommendations for change.Funding for this study was provided by the U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau and the California State Department of Social Services, Office of Child Abuse Prevention.     

Extended coverage for preventive services for the elderly: response and results in a demonstration population.

OBJECTIVES. This study was undertaken to test the acceptability of preventive services under Medicare waivers to a community-dwelling population aged 65 and over and to examine the effect of such services on health. METHODS. Medicare beneficiaries and designated primary care providers were sampled, and beneficiaries were screened and surveyed. A total of 4195 individuals were then randomized into intervention or control groups. Those in the intervention group were offered free preventive visits (under waivers) to their physicians. A follow-up survey of the entire group was administered after completion of the intervention. RESULTS. Sixty-three percent of the intervention group made a preventive clinical visit, and about half of them a counseling visit. For men, being married and having a solo practitioner were positively associated with accepting the intervention services, while for women, having had a mammogram, having a confidant, having a high school education, and having a female practitioner were so associated. The intervention group showed a greater health benefit than did the control group and had a significantly lower death rate: 8.3% vs 11.1%. CONCLUSIONS: Older individuals will respond to preventive programs, and such services will result in modest health gains.     

Health state utility values of high prevalence mental disorders in Australia: results from the National Survey of Mental Health and Wellbeing

Purpose

High prevalence mental disorders including depression, anxiety and substance use disorders are associated with high economic and disease burden. However, there is little information regarding the health state utility values of such disorders according to their clinical severity using comparable instruments across all disorders. This study reports utility values for high prevalence mental disorders using data from the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB).

Methods

Utility values were derived from the AQoL-4D and analysed by disorder classification (affective only (AD), anxiety-related only (ANX), substance use only (SUB) plus four comorbidity groups), severity level (mild, moderate, severe), symptom recency (reported in the past 30 days), and comorbidity (combination of disorders). The adjusted Wald test was applied to detect statistically significant differences of weighted means and the magnitude of difference between groups was presented as a modified Cohen’s d.

Results

In total, 1526 individuals met criteria for a 12-month mental disorder. The mean utility value was 0.67 (SD?=?0.27), with lower utility values associated with higher severity levels and some comorbidities. Utility values for AD, ANX and SUB were 0.64 (SD?=?0.25), 0.71 (SD?=?0.25) and 0.81 (SD?=?0.19), respectively. No differences in utility values were observed between disorders within disorder groups. Utility values were significantly lower among people with recent symptoms (within past 30 days) than those without; when examined by diagnostic group, this pattern held for people with SUB, but not for people with ANX or AD.

Conclusions

Health state utility values of people with high prevalence mental disorders differ significantly by severity level, number of mental health comorbidities and the recency of symptoms, which provide new insights on the burden associated with high prevalence mental disorders in Australia. The derived utility values can be used to populate future economic models.