How does MyPyramid compare to other population-based recommendations for controlling chronic disease?

The Department of Agriculture's MyPyramid is presented as food guidance for the US general public and not "a therapeutic diet for any specific health condition," although many adults in this country are overweight or obese and many experience diet-related disorders. This paper shows the recommendations in MyPyramid are remarkably consistent with the various recommendations to control obesity and diabetes, heart disease and stroke, hypertension, cancer, and osteoporosis. Specifically, the food intake recommendations are similar to those recommended by the Dietary Approaches to Stop Hypertension Eating Plan, the American Heart Association, and the American Cancer Society; plus, the calculated nutrient intakes associated with following the guide are generally within the ranges of nutrient recommendations from the Clinical Guidelines on Overweight and Obesity, the American Diabetes Association, the National Cholesterol Education Program, the American Heart Association, the National Committee on High Blood Pressure, and the American Institute for Cancer Research. However, for actual nutrient levels to conform to dietary guidance, key assumptions regarding how closely individuals will follow the MyPyramid patterns must be made: an appropriate energy level must be selected and adhered to, and an appropriate profile of foods must be selected. These issues must be understood by food and nutrition professionals and disseminated to the public for MyPyramid to reach its potential.     

How does the quality of care compare in five countries?

International data on quality of medical care allow countries to compare their performance to that of other countries. The Commonwealth Fund International Working Group on Quality Indicators collected data on twenty-one indicators that reflect medical care in Australia, Canada, New Zealand, England, and the United States. The indicators include five-year cancer relative survival rates, thirty-day case-fatality rates after acute myocardial infarction and stroke, breast cancer screening rates, and asthma mortality rates. No country scores consistently the best or worst overall. Each country has at least one area of care where it could learn from international experiences and one area where its experiences could teach others.     

Clinical inquiries. How does tissue adhesive compare with suturing for superficial lacerations?

Tissue adhesives are effective and yield results comparable to those with conventional suturing of superficial, linear, and low-tension lacerations. The cosmetic outcome is similar; wound complications, such as infection and dehiscence, may be lower with tissue adhesives. Wound closure of superficial lacerations by tissue adhesives is quicker and less painful compared with conventional suturing (strength of recommendation: A, systematic reviews of randomized trials).     

How does satisfaction with the health-care system relate to patient experience?

Objective

To explore what determines people’s satisfaction with the health-care system above and beyond their experience as patients.

Methods

Data on health system responsiveness, which refers to the manner and environment in which people are treated when they seek health care, provide a unique opportunity to better understand the determinants of people’s satisfaction with the health-care system and how strongly this is influenced by an individual’s experience as a patient. The data were obtained from 21 European Union countries in the World Health Survey for 2003. Additive ordinary least-squares regression models were used to assess the extent to which variables commonly associated with satisfaction with the health-care system, as recorded in the literature, explain the variation around the concept of satisfaction. A residual analysis was used to identify other predictors of satisfaction with the health-care system.

Findings

Patient experience was significantly associated with satisfaction with the health-care system and explained 10.4% of the variation around the concept of satisfaction. Other factors such as patient expectations, health status, type of care, and immunization coverage were also significant predictors of health system satisfaction; although together they explained only 17.5% of the observed variation, while broader societal factors may largely account for the unexplained portion of satisfaction with the health-care system.

Conclusion

Contrary to published reports, people’s satisfaction with the health-care system depends more on factors external to the health system than on the experience of care as a patient. Thus, measuring the latter may be of limited use as a basis for quality improvement and health system reform.     

How good is the Prevent model for estimating the health benefits of prevention?

STUDY OBJECTIVE: Prevent is a public health model for estimating the effect on mortality of changes in exposure to risk factors. When the model is tested by simulating a development that has already taken place, the results may differ considerably from the actual situation. The purpose of this study is to test the Prevent model by applying it to a synthetic cohort in which the development is unaffected by concealed factors. DESIGN: A micro-simulation model was developed to create basic data for Prevent and give "exact" results as to changes in risk factor prevalences and mortality. The estimates of Prevent simulations were compared with the "exact" results. MAIN RESULTS: Modelling one risk factor related to a cause specific mortality gave fairly similar results by the two methods. Including two risk factors Prevent tends slightly to overestimate the health benefits of prevention. CONCLUSIONS: The differences between the "exact" mortality and the Prevent estimates will be small for realistic scenarios and Prevent provide reasonable estimates of the health benefits of prevention.     

How far from non-differential does exposure or disease misclassification have to be to bias measures of association away from the null?

A well-known heuristic in epidemiology is that non-differential exposure or disease misclassification biases the expected values of an estimator toward the null value. This heuristic works correctly only when additional conditions are met, such as independence of classification errors. We present examples to show that, even when the additional conditions are met, if the misclassification is only approximately non-differential, then bias is not guaranteed to be toward the null. In light of such examples, we advise that evaluation of misclassification should not be based on the assumption of exact non-differentiality unless the latter can be deduced logically from the facts of the situation.     

How does crop type influence risk from pesticides to the aquatic environment?

National-level risk mapping was undertaken to identify specific situations within England with the greatest potential for impacts on aquatic biodiversity from normal agricultural use of pesticides. Calculations of exposure via spray drift and drainflow were differentiated by landscape type, region, and crop and then compared with toxicity to the indicator organisms Daphnia magna and algae. The approach incorporated regional-level information regarding pesticide usage derived from farm visits. Risk was calculated for individual water bodies and then aggregated and mapped for each of 5,760 individual catchments ranging in area up to 248 km2. Type of crop adjacent to water was the major driver for risk, and orchards were identified as the crop associated with the greatest potential risk to the aquatic environment. Crops such as cereals, oilseeds, and potatoes are more widely grown in England but have potential risk an order of magnitude smaller than that for orchards. Several of the pesticides that contribute most to risk have been withdrawn from use since collection of the most recent usage data. Driven by crop distribution, surface waters adjacent to orchards in the midwest and southeast of England are predicted to be most at risk of ecological impacts from agricultural pesticide use. This information can be used in targeting monitoring campaigns designed to protect the aquatic environment.     

Health care delivery systems for older adults: How do the Netherlands and Lebanon compare?

Older individuals are given low priority compared to other age groups in many societies and geriatric care is not well-developed in many countries. With the global trend in population aging, the increasing number of older adults can be expected to challenge already-fragile health care facilities. Health care systems vary greatly from one country to another. Based on common research interests and through an educational exchange program between the University of Groningen (the Netherlands) and the American University of Beirut (Lebanon), a project was started to compare the Dutch and Lebanese health care delivery systems for older individuals, demonstrate their strengths and pitfalls, and draw from their resemblance and differences pivotal conclusions leading to positive change. In particular we examined the nursing homes, geriatric medicine and insurance coverage, and pension plans of both countries.     

Human health risks from arsenic in soils: does one model fit all?

In the absence of a "soil model" on arsenic bioavailability, many investigators conducting baseline risk assessments of arsenic-enriched sites have assumed that all arsenic present in the soil is bioavailable. This assumption overestimates actual human health risk because various geochemical forms of arsenic are stable, or insoluble, in human digestive juices. The authors conducted a laboratory incubation study to analyze the in vitro bioavailability of arsenic in soils as a function of soil properties. Four different soil types were selected on the basis of their potential differences with respect to arsenic reactivity. Each soil was amended with sodium arsenite at a rate representative of a routine 1-yr application of arsenical pesticide in an agricultural system. The soils were incubated for 1 yr, after which the authors measured soil-specific total and bioavailable arsenic concentrations. Results demonstrated that soil physicochemical properties significantly affect arsenic bioavailability, and hence estimates of cancer risk, which in turn affect site cleanup cost projections.     

How much does it cost to achieve coverage targets for primary healthcare services? A costing model from Aceh,Indonesia

Despite significant investment in improving service infrastructure and training of staff, public primary healthcare services in low‐income and middle‐income countries tend to perform poorly in reaching coverage targets. One of the factors identified in Aceh, Indonesia was the lack of operational funds for service provision. The objective of this study was to develop a simple and transparent costing tool that enables health planners to calculate the unit costs of providing basic health services to estimate additional budgets required to deliver services in accordance with national targets. The tool was developed using a standard economic approach that linked the input activities to achieving six national priority programs at primary healthcare level: health promotion, sanitation and environment health, maternal and child health and family planning, nutrition, immunization and communicable diseases control, and treatment of common illness. Costing was focused on costs of delivery of the programs that need to be funded by local government budgets. The costing tool consisting of 16 linked Microsoft Excel worksheets was developed and tested in several districts enabled the calculation of the unit costs of delivering of the six national priority programs per coverage target of each program (such as unit costs of delivering of maternal and child health program per pregnant mother). This costing tool can be used by health planners to estimate additional money required to achieve a certain level of coverage of programs, and it can be adjusted for different costs and program delivery parameters in different settings. Copyright © 2012 John Wiley & Sons, Ltd.     

Dealing with competing risks in clinical trials: How to choose the primary efficacy analysis?

We investigate different primary efficacy analysis approaches for a 2‐armed randomized clinical trial when interest is focused on a time to event primary outcome that is subject to a competing risk. We extend the work of Friedlin and Korn (2005) by considering estimation as well as testing and by simulating the primary and competing events' times from both a cause‐specific hazards model as well as a joint subdistribution–cause‐specific hazards model. We show that the cumulative incidence function can provide useful prognostic information for a particular patient but is not advisable for the primary efficacy analysis. Instead, it is preferable to fit a Cox model for the primary event which treats the competing event as an independent censoring. This is reasonably robust for controlling type I error and treatment effect bias with respect to the true primary and competing events' cause‐specific hazards model, even when there is a shared, moderately prognostic, unobserved baseline frailty for the primary and competing events in that model. However, when it is plausible that a strongly prognostic frailty exists, combining the primary and competing events into a composite event should be considered. Finally, when there is an a priori interest in having both the primary and competing events in the primary analysis, we compare a bivariate approach for establishing overall treatment efficacy to the composite event approach. The ideas are illustrated by analyzing the Women's Health Initiative clinical trials sponsored by the National Heart, Lung, and Blood Institute.     

How does the employer contribution for the federal employees health benefits program influence plan selection?

Market reform of health insurance is proposed to increase coverage and reduce growth in spending by providing an incentive to choose low-cost plans. However, having a choice of plans could result in risk segmentation. Risk-adjusted payments have been proposed to address risk segmentation but are criticized as ineffective. An alternative to risk adjustment is to subsidize premiums, as in the Federal Employees Health Benefits Program (FEHBP). Subsidizing premiums may also increase total premium spending. We find that there is little risk segmentation in the FEHBP and that reducing the premium subsidy would lower government premium spending and slightly increase risk segmentation.