Why prioritize when there isn't enough money?

In an informal address to the 4th International Conference on Priorities in Health (Oslo, 23 September 2002), Professor Jeffrey Sachs – Chairperson of the WHO Commission on Macroeconomics and Health – maintained that the real causes of the inability of the world's poorest people to receive help for the lethal diseases that burden them did not include the "usual suspects" (corruption, mismanagement, and wrong priorities). Rather, the root cause was argued to be an inherent lack of money, indicating that the burden of disease would be lifted only if rich countries gave more money to poor ones.     

Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system

Background

Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization.

Methods

We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents ≥70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity.

Results

Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001).

Conclusions

We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.     

Disenrollment information and Medicare plan choice: is more information better?

To help Medicare beneficiaries and their intermediaries select the best health plan, CMS publicly reports comparative plan information. Using a laboratory version of Medicare Health Plan Compare that involved a simulated plan choice by 359 Medicare intermediaries, we experimentally investigated plan recommendations with and without disenrollment information and time constraints for viewing materials. Results indicated that the presence of disenrollment information reduced time spent on other measures of plan performance. It also reduced decision quality for less educated intermediaries. Designers and sponsors of consumer-oriented materials should recognize that more information is not always better.     

The role of research--how much is enough?

A great deal of research is involved in bringing PARNUTs to the marketplace. Research often begins with identifying an unfilled nutritional need, determining if that need is great enough to warrant development of a new product, and then evaluating the efficacy and safety of the potential product in animal models and clinical trials. This approach tends to emphasize short-term outcomes, however, while neglecting the issues of whether a product offers long term benefit or holds long term risks. This article presents discussion centered around the need for selecting appropriate outcomes for nutritional intervention trials, designing trials with a follow-up time sufficient to allow for outcome measurement, and enrolling a patient population large enough to accurately gauge efficacy and tolerability.     

Is one theory better than another in nutrition education? A viewpoint: more is better

Health behavior theories describe the relations among variables influencing a behavior and specify targets for facilitating behavior change. Nutrition education does not have a dominant theory specific to the discipline. Instead, constructs from multiple theories have been borrowed, primarily from the social sciences, and have been applied to describe or predict nutrition-related behaviors. However, current theories do not fully predict behavior or behavior change. A more effective approach may be to integrate distinct constructs from competing theories into one or more polytheoretical models that can be empirically tested and refined into a more comprehensive, tailored theory or set of theories specific to food and nutrition behavior changes. In our view, more than one will be needed to address the complex array of people, issues, and contexts that we routinely address in nutrition education and behavioral interventions.     

The complex enterprise of modelling prenatal exposure to cigarettes: what is ‘enough’?

While there is a burgeoning body of research linking smoking during pregnancy to problem behaviour in offspring, a major criticism of this work has been the crude measurement of exposure in these studies (e.g. retrospective, self-reported only) that could lead to biased estimates. To address this issue, we used a pregnancy cohort with repeated prospective measures of exposure as well as biological assays to generate estimates of exposure patterns using a range of modelling techniques. In this paper we report on the analytical approaches we have developed, including patterns of exposure over time and best-estimate approaches that combine self-report and cotinine measures, and compare their predictive value in relation to different dimensions of fetal growth as a first step towards examining the utility of greater precision of exposure measurement.
Surprisingly, in this sample the more complex assessments of exposure, including biological measures, generally did not perform better than simple indicators of exposure based on repeated self-report measures, with one exception: a combined self-report cotinine 'best estimate' of third trimester exposure was uniquely associated with lower brain : body ratio. Further study is needed using more sophisticated cotinine assays and testing prediction of a range of outcomes to ascertain whether these findings represent true differences or are specific to the sample, methods and outcomes used. Such research will inform the development of guidelines for adequate exposure characterisation in developmental studies.     

The evolution of physical activity recommendations: how much is enough?

Physical inactivity is a major public health problem, and compelling evidence suggests that it is a contributing factor in several chronic diseases and conditions. Recognition of the health and functional hazards of a sedentary way of life has led numerous groups to promulgate public health recommendations for physical activity. In this report, we review the evolution of physical activity recommendations, discuss reasons for differences in the recommendations, and provide a summary recommendation in an attempt to harmonize existing differences. Current public health recommendations for physical activity are for 30 min of moderate-intensity activity each day, which provides substantial benefits across a broad range of health outcomes for sedentary adults. This dose of exercise may be insufficient to prevent unhealthful weight gain for some persons who may need additional exercise or caloric restriction to minimize the likelihood of further weight gain. Persons who get 30 min of moderate-intensity exercise per day are likely to achieve additional health benefits if they exercise more. In addition to aerobic exercise, people should engage in resistance training and flexibility exercises at least twice a week, which will promote the maintenance of lean body mass, improvements in muscular strength and endurance, and preservation of function, all of which enable long-term participation in regular physical activity and promote quality of life.     

The sector-wide approach in health: what is it? Where is it leading?

This paper describes early experience with the Sector-Wide Approach (SWAp), an emerging trend in development practice in low-income countries. The paper describes what a SWAp is, and why it is now being pursued. The SWAp is characterized as a sustained government-led partnership with donor agencies and other groups. By applying sector-wide policies to an expenditure framework and national implementation systems, explicit health sector reforms are undertaken to meet sectoral and national development objectives. The approach has changed the dynamic between governments and donor agencies, requiring systemic changes in policy-making and management in both governments and donor agencies. With the SWAp, ongoing joint assessment and negotiations around sectoral plans and review of performance replaces the old way of preparing and supervising projects. Early experiences in countries undergoing SWAps are discussed, including the problem of reconciling priority programs and old practices with broader health sector reforms and new ways of managing development assistance. The paper concludes by identifying some of the key challenges for the future of SWAps.