Is higher nursing home quality more costly?

Widespread issues regarding quality in nursing homes call for an improved understanding of the relationship with costs. This relationship may differ in European countries, where care is mainly delivered by nonprofit providers. In accordance with the economic theory of production, we estimate a total cost function for nursing home services using data from 45 nursing homes in Switzerland between 2006 and 2010. Quality is measured by means of clinical indicators regarding process and outcome derived from the minimum data set. We consider both composite and single quality indicators. Contrary to most previous studies, we use panel data and control for omitted variables bias. This allows us to capture features specific to nursing homes that may explain differences in structural quality or cost levels. Additional analysis is provided to address simultaneity bias using an instrumental variable approach. We find evidence that poor levels of quality regarding outcome, as measured by the prevalence of severe pain and weight loss, lead to higher costs. This may have important implications for the design of payment schemes for nursing homes.     

Is patriarchy the source of men's higher mortality?

OBJECTIVE: To examine the relation between levels of patriarchy and male health by comparing female homicide rates with male mortality within countries. HYPOTHESIS: High levels of patriarchy in a society are associated with increased mortality among men. DESIGN: Cross sectional ecological study design. SETTING: 51 countries from four continents were represented in the data-America, Europe, Australasia, and Asia. No data were available for Africa. RESULTS: A multivariate stepwise linear regression model was used. Main outcome measure was age standardised male mortality rates for 51 countries for the year 1995. Age standardised female homicide rates and GDP per capita ranking were the explanatory variables in the model. Results were also adjusted for the effects of general rates of homicide. Age standardised female homicide rates and ranking of GDP were strongly correlated with age standardised male mortality rates (Pearson's r=0.699 and Spearman's 0.744 respectively) and both correlations achieved significance (p<0.005). Both factors were subsequently included in the stepwise regression model. Female homicide rates explained 48.8% of the variance in male mortality, and GDP a further 13.6% showing that the higher the rate of female homicide, and hence the greater the indicator of patriarchy, the higher is the rate of mortality among men. CONCLUSION: These data suggest that oppression and exploitation harm the oppressors as well as those they oppress, and that men's higher mortality is a preventable social condition, which could be tackled through global social policy measures.     

A higher rate of eating is associated with higher circulating interluekin-1β concentrations in Japanese men not being treated for metabolic diseases

ObjectiveIn this study, we examined the relations between the rate of eating and circulating interleukin (IL)-1β and IL-6 levels in Japanese men not being treated for metabolic diseases.MethodsWe conducted a cross-sectional study of 170 men 40 to 59 y old (mean ± standard deviation, 51.4 ± 5.7 y old) who participated in health checkups in Japan and were not being treated for metabolic diseases. We measured clinical serum parameters and plasma IL-1β and IL-6 concentrations and assessed by questionnaire lifestyle factors such as the dietary intake of food/nutrition and the rate of eating. Using multivariate linear regression analysis, we analyzed the relations between the rate of eating and IL-1β and IL-6 concentrations, clinical parameters, and lifestyle factors.ResultsSignificant Spearman correlation coefficients with the rate of eating were observed for IL-1β and IL-6 (0.250 and 0.195, respectively). The rate of eating was positively associated with IL-1β independently of IL-6, body mass index, homeostasis model assessment for insulin resistance, alcohol intake, energy intake, smoking status, and physical activity.ConclusionsThese results indicate that a higher rate of eating is positively and independently associated with circulating IL-1β concentrations in Japanese men not being treated for metabolic diseases.     

Which general practices have higher list inflation? An exploratory study

BACKGROUND: There is a 7% discrepancy between English population estimates based on census figures and those based on the registered lists of GPs. GP income under the 2004 new contract will be based on registered patient populations but a national 'de-ghosting' exercise will ensue, aiming to eliminate list inflation. OBJECTIVE: To derive an estimate of the variation in list inflation between individual general practices. METHODS: Letters were sent to all men aged 20-29 years and registered at practices based in three inner city Primary Care Trusts (n = 42 712). Non respondents received one further reminder. Cards were issued to each GP listing non responders. Patients were deducted from the GP list after six months if the GP did not verify the address. RESULTS: 42 712 letters were sent. 33.5% of registered patients were eventually deducted from the GP list (deduction figures only available for 20-24 year old group). Practice level deduction rates ranged from 7-76%. Practices with higher deduction rates achieved lower vaccination rates for 2 year olds (Pearson's r = 20.25; P = 0.005) and cervical smear rates (Pearson's r = 20.18; P = 0.04); they also had cheaper prescribing costs per ASTRO-PU (Pearson's r = 20.20; P = 0.03). CONCLUSIONS: If these findings apply to the whole registered population, the national de-ghosting exercise is likely to result in large changes to the list size of some practices. Without correcting for list inflation, primary care research based on patient list size as the denominator may underestimate various measures of GP activity, particularly in deprived inner city areas. Resource allocation is also likely to be distorted by differences in list inflation.     

Do Medicare Advantage plans select enrollees in higher margin clinical categories?

The CMS-HCC risk adjustment system for Medicare Advantage (MA) plans calculates weights, which are effectively relative prices, for beneficiaries with different observable characteristics. To do so it uses the relative amounts spent per beneficiary with those characteristics in Traditional Medicare (TM). For multiple reasons one might expect relative amounts in MA to differ from TM, thereby making some beneficiaries more profitable to treat than others. Much of the difference comes from differences in how TM and MA treat different diseases or diagnoses. Using data on actual medical spending from two MA-HMO plans, we show that the weights calculated from MA costs do indeed differ from those calculated using TM spending. One of the two plans (Plan 1) is more typical of MA-HMO plans in that it contracts with independent community providers, while the other (Plan 2) is vertically integrated with care delivery. We calculate margins, or average revenue/average cost, for Medicare beneficiaries in the two plans who have one of 48 different combinations of medical conditions. The two plans’ margins for these 48 conditions are correlated (r = 0.39, p < 0.01). Both plans have margins that are more positive for persons with conditions that are managed by primary care physicians and where medical management can be effective. Conversely they have lower margins for persons with conditions that tend to be treated by specialists with greater market power than primary care physicians and for acute conditions where little medical management is possible. The two plan's margins among beneficiaries with different observable characteristics vary over a range of 160 and 98 percentage points, respectively, and thus would appear to offer substantial incentive for selection by HCC. Nonetheless, we find no evidence of overrepresentation of beneficiaries in high margin HCC's in either plan. Nor, using the margins from Plan 1, the more typical plan, do we find evidence of overrepresentation of high margin HCC's in Medicare more generally. These results do not permit a conclusion on overall social efficiency, but we note that selection according to margin could be socially efficient. In addition, our findings suggest there are omitted interaction terms in the risk adjustment model that Medicare currently uses.     

Are children with birth defects at higher risk of childhood cancers?

Birth defects may influence the risk of childhood cancer development through a variety of mechanisms. The rarity of both birth defects and childhood cancers makes it challenging to study these associations, particularly for the very rare instances of each. To address this limitation, the authors conducted a record linkage-based cohort study among Texas children born between 1996 and 2005. Birth defects in the cohort were identified through the Texas Birth Defects Registry, and children who developed cancer were identified by using record linkage with Texas Cancer Registry data. Over 3 million birth records were included; 115,686 subjects had birth defects, and there were 2,351 cancer cases. Overall, children with a birth defect had a 3-fold increased risk of developing cancer (incidence rate ratio (IRR) = 3.05, 95% confidence interval (CI): 2.65, 3.50), with germ cell tumors (IRR = 5.19, 95% CI: 2.67, 9.41), retinoblastomas (IRR = 2.34, 95% CI: 1.21, 4.16), soft-tissue sarcomas (IRR = 2.12, 95% CI: 1.09, 3.79), and leukemias (IRR = 1.39, 95% CI: 1.09, 1.75) having statistically significant elevated point estimates. All birth defect groups except for musculoskeletal had increased cancer incidence. Untangling the strong relation between birth defects and childhood cancers could lead to a better understanding of the genetic and environmental factors that affect both conditions.     

Are cancer patients at higher suicide risk than the general population?

OBJECTIVES: The aims were to test whether suicide is more prevalent among cancer patients than among the general population, whether the association changes over time, and whether the risk depends on the severity of the cancer disease. DESIGN: A register study was carried out, where standardized suicide rates for different cancer sites were analysed by sex, time periods (1965-74, 1975-84, and 1985-94), and five-year survival rates. Setting: The setting was the Swedish population from 1965 to 1999. SUBJECTS: The cohort studied was 1,031,919 cancer cases and 2,587,152 person-years. MAIN OUTCOME MEASURES: The main outcome measure was the standardized mortality ratio (SMR) with the world population as standard population. RESULTS: Cancer patients run a higher risk of suicide than the general population. The suicide rate ratio between male cancer patients and the general population was about 2.5 in 1965-74, which thereafter reduced to about 1.5 in 1985-94. The suicide rate among female cancer patients was in excess of 2.9 in 1965-74 and 2.3 in 1985-94. In fact, a slightly higher rate for women was observed for 1985-94 than for 1975-84. There is also a strong negative association between survival rates and suicide rates, i.e. suicide rates are higher for severe cancer sites with low survival rates. CONCLUSIONS: Our findings support the hypothesis that cancer patients run greater risks of committing suicide than the general population does. The severity of the cancer increases the suicide risk. More attention to cancer patients' psychological and care situation is called for.     

Do sunscreens increase risk of melanoma in populations residing at higher latitudes?

BACKGROUND: Sunscreens may allow overexposure to ultraviolet A (UVA) in fair-skinned persons and prevent symptoms of sunburn, but their benefits for the prevention of melanoma are uncertain. METHODS: A PubMed search was performed that identified all known studies of the association of sunscreen use with melanoma risk during 1966-2007. A total of 18 studies were identified, of which 17 met criteria for inclusion in the analysis. Of these, 10 were conducted at latitudes >40 degrees from the equator and 7 at 40 degrees from the equator, the odds ratio was 1.6 (95% C.I. 1.3-1.9; p for heterogeneity = 0.006), whereas it was 0.7 at 40 degrees.     

Do implementation intentions help to turn good intentions into higher fruit intakes?

OBJECTIVE: The present study examined (1) whether respondents who were encouraged to make implementation intentions to eat more fruit increased their fruit intakes, as measured by three measures of fruit intake; (2) whether the effects of implementation intentions on fruit intake were dependent on positive goal intentions at baseline; and (3) the respondents' commitment to perform their implementation intentions. DESIGN: Dutch adults (n = 535) were randomly assigned to either receive implementation intention instructions or not. Two questionnaires were completed with a 1.5-week time interval. Respondents in the implementation intention condition were asked to form implementation intentions to eat an extra serving of fruit per day during one week. RESULTS: Respondents in the implementation intention group reported a high frequency of eating an extra serving of fruit per day. The implementation intention effect on frequency of extra fruit did not depend on goal intention at baseline. The more committed respondents were to carrying out their implementation intention, the more likely they were to increase their fruit intake. CONCLUSION: These results provide some indications that implementation intentions could be a useful strategy to induce a short-term increase in fruit intake.     

Is time-to-treatment associated with higher mortality in Korean elderly lung cancer patients?

Lung cancer is a leading cause of cancer-related deaths in many countries, including South Korea. As treatment delays after diagnosis may correlate with survival, this study aimed to investigate the association between time-to-treatment and one-and five-year overall mortality in patients aged 60 years or above. Survival analysis using the Cox proportional hazard model were conducted after controlling for all independent variables. Of a total of 1,535 individuals who received surgical treatment due to lung cancer, 837 patients received treatment within 30 days and 698 after 30 days of initial diagnosis. Individuals who received surgical treatment after 30 days of diagnosis were more likely to die within 1-year (Hazard Ratio, HR: 1.15, 95% Confidence Interval, CI: 1.01-1.32) and 5-year (HR: 1.16, 95% CI: 1.02-1.33) compared to those who received treatment within 30 days. The increase in mortality risk with time delay persisted when applying other cut-off times, including standards at 2, 3, and 6 months. We also found that the mortality rate of lung cancer patients differs depending on age (74 years or younger), household income (<80 percentile), patient severity, and the residing region. Our findings show that time delay is an important factor that can influence the outcome of lung cancer patients, highlighting the importance of monitoring and providing appropriate and timely treatment.     

Hospital pricing and the uninsured: do the uninsured pay higher prices?

Although the health care pricing literature has grown substantially in recent years, there has been little empirical analysis of how hospital pricing behavior affects the uninsured. We use unique data from California to compare actual prices paid by uninsured patients with prices paid by commercial and Medicare patients. We find that uninsured patients pay prices similar to those of Medicare patients. Further, we find that despite increased media attention, hospital prices to the uninsured have risen in recent years.     

Does a higher educational level protect against anxiety and depression? The HUNT study

The relationship of education to the experience of anxiety and depression throughout adult life is unclear. Our knowledge of this relationship is limited and inconclusive. The aim of this study was to examine (1) whether higher educational level protects against anxiety and/or depression, (2) whether this protection accumulates or attenuates with age or time, and (3) whether such a relationship appears to be mediated by other variables. In a sample from the Nord-Trøndelag Health Study 1995–1997 (HUNT 2) (N = 50,918) of adults, the cross-sectional associations between educational level and symptom levels of anxiety and depression were examined, stratified by age. The long-term effects of educational level on anxiety/depression were studied in a cohort followed up from HUNT 1 (1984–1986) to HUNT 2 (N = 33,774). Low educational levels were significantly associated with both anxiety and depression. The coefficients decreased with increasing age, except for the age group 65–74 years. In the longitudinal analysis, however, the protective effect of education accumulated somewhat with time. The discrepancy between these two analyses may be due to a cohort effect in the cross-sectional analysis. Among the mediators, somatic health exerted the strongest influence, followed by health behaviors and socio-demographic factors. Higher educational level seems to have a protective effect against anxiety and depression, which accumulates throughout life.     

Why is the Doppler pressure gradient higher than the one measured by catheter?]

Hemodynamic assessment of aorto-iliac occlusive disease is necessary for successful arterial reconstruction of the legs. Various methods have been proposed and the "pull-through" intra-arterial pressure measurement method is accepted as the best standard. The pressure readings, however, seemed to depend on the intraluminal position of the catheter. To explain these observations and make a comparison between the Doppler method and the "pull-through" method, we have studied center-line velocity changes at the stenosis throat by Doppler ultrasound, and axial and lateral pressure gradients using pressure transducers, mounted 10 mm and 40 mm downstream of short (4 mm) and long (40 mm) axisymmetric sharp-edged model stenoses having cross sectional reduced areas of 64%, 84%, 91%, and 96%. Axial manometric pressures measured 10 mm after the throat of 84% stenosis were more than twice as high as the lateral pressures. There was no significant difference between axial and lateral pressures measured 40 mm downstream from throat. This pressure distribution has important clinical relevance. Mean and peak pressure gradients for both the Doppler method and manometric measurements were compared. Measurements with Doppler method and manometric measurements, indicated that mean pressure gradients (r = 0.98; SEE = +/- -2.4 mmHg) correlate better than peak pressure gradients (r = 0.90; SEE = +/- 16.5 mmHg). Doppler gradients were higher than manometer gradients. Overestimation was 13% for mean pressure gradients, and ranging from 10% to 150% for peak pressure gradients. Explanation for the difference between mean Doppler and catheter gradient may be the pressure recovery occurring in the relaminarized poststenotic regions.     

Which ‘imperfect vaccines’ encourage the evolution of higher virulence?

Background and objectivesTheory suggests that some types of vaccines against infectious pathogens may lead to the evolution of variants that cause increased harm, particularly when they infect unvaccinated individuals. This theory was supported by the observation that the use of an imperfect vaccine to control Marek’s disease virus in chickens resulted in the virus evolving to be more lethal to unvaccinated birds. This raises the concern that the use of some other vaccines may lead to similar pernicious outcomes. We examine that theory with a focus on considering the regimes in which such outcomes are expected.MethodologyWe evaluate the plausibility of assumptions in the original theory. The previous theory rested heavily on a particular form of transmission–mortality–recovery trade-off and invoked other assumptions about the pathways of evolution. We review alternatives to mortality in limiting transmission and consider evolutionary pathways that were omitted in the original theory.ResultsThe regime where the pernicious evolutionary outcome occurs is narrowed by our analysis but remains possible in various scenarios. We propose a more nuanced consideration of alternative models for the within-host dynamics of infections and for factors that limit virulence. Our analysis suggests imperfect vaccines against many pathogens will not lead to the evolution of pathogens with increased virulence in unvaccinated individuals.Conclusions and implicationsEvolution of greater pathogen mortality driven by vaccination remains difficult to predict, but the scope for such outcomes appears limited. Incorporation of mechanistic details into the framework, especially regarding immunity, may be requisite for prediction accuracy.Lay SummaryA virus of chickens appears to have evolved high mortality in response to a vaccine that merely prevented disease symptoms. Theory has predicted this type of evolution in response to a variety of vaccines and other interventions such as drug treatment. Under what circumstances is this pernicious result likely to occur? Analysis of the theory in light of recent changes in our understanding of viral biology raises doubts that medicine-driven, pernicious evolution is likely to be common. But we are far from a mechanistic understanding of the interaction between pathogen and host that can predict when vaccines and other medical interventions will lead to the unwanted evolution of more virulent pathogens. So, while the regime where a pernicious result obtains may be limited, caution remains warranted in designing many types of interventions.