Cost–Effectiveness of Osteoporosis Screening Followed by Treatment: The Impact of Medication Adherence

ObjectiveTo estimate the impact of medication adherence on the cost–effectiveness of mass-screening by bone densitometry followed by alendronate therapy for women diagnosed with osteoporosis.MethodsA validated Markov microsimulation model with a Belgian health-care payer perspective and a lifetime horizon was used to assess the cost per quality-adjusted life year (QALY) gained of the screening/treatment strategy compared with no intervention. Real-world adherence to alendronate therapy and full adherence over 5 years were both investigated. The real-world adherence scenario employed adherence data from published observational studies, and medication adherence was divided into persistence, compliance, and primary adherence. Uncertainty was investigated using one-way and probabilistic sensitivity analyses.ResultsAt 65 years of age, the costs per QALY gained because of the screening/treatment strategy versus no intervention are €32,008 and €16,918 in the real-world adherence and full adherence scenarios, respectively. The equivalent values are €80,836 and €40,462 at the age of 55 years, and they decrease to €10,600 and €1229 at the age of 75 years. Sensitivity analyses show that the presence of the upfront cost of case finding has a substantial role in the impact of medication adherence on cost–effectiveness.ConclusionThis study indicates that nonadherence with osteoporosis medications substantially increases the incremental cost–effectiveness ratio of osteoporosis screening strategies. All aspects of medication adherence (i.e., compliance, persistence, and primary adherence) should therefore be reported and included in pharmacoeconomic analyses, and especially in the presence of the upfront cost of case finding (such as screening cost).     

On the Hospital Volume and Outcome Relationship: Does Specialization Matter More Than Volume?

Objective

To evaluate the relationship between hospital volume and outcome by focusing on alternative measures of volume that capture specialization and overall throughput of hospitals.

Data Sources/Study Setting

Hospital administrative data from the state of Victoria, Australia; data contain 1,798,474 admitted episodes reported by 135 public and private acute‐care hospitals.

Study Design

This study contrasts the volume–outcome relationship using regression models with different measures of volume; two‐step and single‐step risk‐adjustment methods are used.

Data Collection/Extraction Methods

The sample is restricted to ischemic heart disease (IHD) patients (ICD‐10 codes: I20–I25) admitted during 2001/02 to 2004/05.

Principal Findings

Overall hospital throughput and degree of specialization display more substantive implications for the volume–outcome relationship than conventional caseload volume measure. Two‐step estimation when corrected for heteroscedasticity produces comparable results to single‐step methods.

Conclusions

Different measures of volume could lead to vastly different conclusions about the volume–outcome relationship. Hospital specialization and throughput should both be included as measures of volume to capture the notion of size, focus, and possible congestion effects.     

The Cost‐Effectiveness of Independent Housing for the Chronically Mentally Ill: Do Housing and Neighborhood Features Matter?

OBJECTIVE: To determine the effects of housing and neighborhood features on residential instability and the costs of mental health services for individuals with chronic mental illness (CMI). DATA SOURCES: Medicaid and service provider data on the mental health service utilization of 670 individuals with CMI between 1988 and 1993 were combined with primary data on housing attributes and costs, as well as census data on neighborhood characteristics. Study participants were living in independent housing units developed under the Robert Wood Johnson Foundation Program on Chronic Mental Illness in four of nine demonstration cities between 1988 and 1993. STUDY DESIGN: Participants were assigned on a first-come, first-served basis to housing units as they became available for occupancy after renovation by the housing providers. Multivariate statistical models are used to examine the relationship between features of the residential environment and three outcomes that were measured during the participant's occupancy in a study property: residential instability, community-based service costs, and hospital-based service costs. To assess cost-effectiveness, the mental health care cost savings associated with some residential features are compared with the cost of providing housing with these features. DATA COLLECTION/EXTRACTION METHODS: Health service utilization data were obtained from Medicaid and from state and local departments of mental health. Non-mental-health services, substance abuse services, and pharmaceuticals were screened out. PRINCIPAL FINDINGS: Study participants living in newer and properly maintained buildings had lower mental health care costs and residential instability. Buildings with a richer set of amenity features, neighborhoods with no outward signs of physical deterioration, and neighborhoods with newer housing stock were also associated with reduced mental health care costs. Study participants were more residentially stable in buildings with fewer units and where a greater proportion of tenants were other individuals with CMI. Mental health care costs and residential instability tend to be reduced in neighborhoods with many nonresidential land uses and a higher proportion of renters. Mixed-race neighborhoods are associated with reduced probability of mental health hospitalization, but they also are associated with much higher hospitalization costs if hospitalized. The degree of income mixing in the neighborhood has no effect. CONCLUSIONS: Several of the key findings are consistent with theoretical expectations that higher-quality housing and neighborhoods lead to better mental health outcomes among individuals with CMI. The mental health care cost savings associated with these favorable features far outweigh the costs of developing and operating properties with them. Support for the hypothesis that "diverse-disorganized" neighborhoods are more accepting of individuals with CMI and, hence, associated with better mental health outcomes, is mixed.     

Suburban Migration and the Birth Outcome of Chicago-Born White and African–American Women: The Merit of the Healthy Migrant Theory?

The healthy migrant theory posits that women who migrate before pregnancy are intrinsically healthier and therefore have better birth outcomes than those who don’t move. Objective. To determine whether migration to the suburbs is associated with lower rates of preterm (<37 weeks) birth among Chicago-born White and African–American mothers. We performed stratified and multilevel logistic regression analyses on an Illinois transgenerational dataset of non-Latino White and African–American infants (1989–1991) and their mothers (1956–1976) with appended US census income information. Forty percent of Chicago-born White mothers (N = 45,135) migrated to Suburban Cook County and 30 % migrated to the more geographically distant collar counties. In contrast, 10 % of Chicago-born African–American mothers (N = 41,221) migrated to Suburban Cook and only two percent migrated to the collar counties. Chicago-born White and African–American migrant mothers to Suburban Cook County had lower preterm birth rates than their non-migrant counterparts; RR = 0.8 (0.8–0.9) and 0.8 (0.7–0.8), respectively. When neighborhood income was singularly taken into account, the protective association of suburban migration and preterm birth disappeared among Chicago-born Whites. In race-specific multilevel multivariate regression models which included neighborhood income, the adjusted odds ratio of preterm birth, low birth weight, and small for gestational-age for Chicago-born White and African–American migrant (compared to non-migrant) mothers approximated unity. Neighborhood income underlies the protective association of suburban migration and birth outcome among Chicago-born White and African–American mothers. These findings do not support the healthy migrant hypothesis of reproductive outcome.     

The Impact of Differences in EQ-5D and SF-6D Utility Scores on the Acceptability of Cost–Utility Ratios: Results across Five Trial-Based Cost–Utility Studies

ObjectiveThis article investigates whether differences in utility scores based on the EQ-5D and the SF-6D have impact on the incremental cost–utility ratios in five distinct patient groups.MethodsWe used five empirical data sets of trial-based cost–utility studies that included patients with different disease conditions and severity (musculoskeletal disease, cardiovascular pulmonary disease, and psychological disorders) to calculate differences in quality-adjusted life-years (QALYs) based on EQ-5D and SF-6D utility scores. We compared incremental QALYs, incremental cost–utility ratios, and the probability that the incremental cost–utility ratio was acceptable within and across the data sets.ResultsWe observed small differences in incremental QALYs, but large differences in the incremental cost–utility ratios and in the probability that these ratios were acceptable at a given threshold, in the majority of the presented cost–utility analyses. More specifically, in the patient groups with relatively mild health conditions the probability of acceptance of the incremental cost–utility ratio was considerably larger when using the EQ-5D to estimate utility. While in the patient groups with worse health conditions the probability of acceptance of the incremental cost–utility ratio was considerably larger when using the SF-6D to estimate utility.ConclusionsMuch of the appeal in using QALYs as measure of effectiveness in economic evaluations is in the comparability across conditions and interventions. The incomparability of the results of cost–utility analyses using different instruments to estimate a single index value for health severely undermines this aspect and reduces the credibility of the use of incremental cost–utility ratios for decision-making.     

Effectiveness of the seven-valent and thirteen-valent pneumococcal conjugate vaccines in England: The indirect cohort design, 2006–2018

BackgroundThe 7-valent pneumococcal conjugate vaccine (PCV7) was introduced into the UK childhood immunisation programme in 2006 and replaced with a 13-valent vaccine (PCV13) in 2010. Both vaccines led to rapid declines in vaccine-serotype invasive pneumococcal disease (IPD). Here, we assessed the long-term vaccine-effectiveness (VE) of both vaccines in England.MethodsPublic Health England conducts enhanced national surveillance of IPD in England. VE against IPD was estimated using vaccine-serotype IPD cases and non-vaccine serotype IPD controls among vaccine-eligible children from September 2006 to June 2018 (the Broome method).ResultsVaccine history was available for 3421 IPD cases, including 1299 due to the additional PCV13 serotypes and the PCV13-related serotype 6C, 274 PCV7 serotypes and 1848 non-PCV13 serotypes. For the complete 2 + 1 schedule, both PCV7 and PCV13 showed high effectiveness against PCV7 serotypes with a combined VE of 92.0% (95%CI, 81.7–96.7). For the 2 + 1 schedule, PCV13 VE against the additional PCV13 serotypes plus 6C was 73.7% (31.1–89.9) compared to 90.0% (75.3 – 96.0) for PCV7 against PCV7 serotypes, although PCV13 VE increased to 84.8% (58.7–94.4) if serotype 3 was excluded; all 36 eligible serotype 3 IPD cases were fully-vaccinated with PCV13. Case numbers were low in older ages but there was evidence of waning, which was significant for serotype 19A for which there were sufficient numbers of cases for analysis.ConclusionsPCVs are highly effective in preventing vaccine-serotype IPD except for serotype 3 which has been increasing in incidence. Serotype 19A IPD has also persisted, likely due to a slightly lower VE and/or more rapid waning of protection.     

Incremental Costs and Cost Effectiveness of Intensive Treatment in Individuals with Type 2 Diabetes Detected by Screening in the ADDITION-UK Trial: An Update with Empirical Trial–Based Cost Data

Background

There is uncertainty about the cost effectiveness of early intensive treatment versus routine care in individuals with type 2 diabetes detected by screening.

Sorption of Polycyclic Musks on Soil Components of Different Aggregate Sizes: The Effect of Organic Matter–Mineral Interactions

Bulletin of Environmental Contamination and Toxicology - Polycyclic musks (PCMs) in soils have been of increasing concern because of their potential characteristics of persistence, bioaccumulation,...     

Effects of Message Framing in Anti–Binge Drinking PSAs: The Moderating Role of Counterfactual Thinking

This experiment examined the interaction effects of message framing and counterfactual thinking on attitudes toward binge drinking and behavioral intentions. Data from a 2 (message framing: gain vs. loss) × 2 (counterfactual thinking priming: additive vs. subtractive) between-subjects factorial design showed that a gain-framed message resulted in lower binge drinking intentions than did a loss-framed message after subjects engaged in additive counterfactual thinking. The effects of a loss-framed message on binge drinking intentions occurred when subtractive counterfactual thinking was induced. Theoretical and practical implications for anti–binge drinking public service announcements are discussed.     

The Self-Assessment of Role-Performance and Activities of Daily Living Abilities (SARA™): Development and Clinical Utility of a Client-Centered Screening Tool and Outcome Measure

This article describes the development and use of the Self-Assessment of Role-performance and activities of daily living Abilities (SARA?), a standardized client-centered index of functional abilities. Developed in four phases, this article describes the initial development, pilot testing and revision, examination of psychometric properties, and finalization. Pilot studies found the SARA? to be reliable, valid, and responsive to change. The use of the SARA? in clinical practice and for outcome monitoring promotes client-centered goal setting and client-valued rehabilitation. It is a viable alternative to deficit-focused measures. The SARA? is a promising new tool that warrants increased utilization and further research.     

Enhancing Health Communication Outcomes Among Ethnic Minority Patients: The Effects of the Match Between Participation Preferences and Perceptions and Doctor–Patient Concordance

Ethnic minority patients are less participative in medical consultations compared to ethnic majority patients. It is thus important to find effective strategies to enhance ethnic minority patients’ participation and improve subsequent health outcomes. This study therefore aimed to investigate the relation between the match between patients’ preferred and perceived participation and doctor–patient concordance in preferred doctor–patient relationship on patient satisfaction, fulfillment of information needs, and understanding of information among Turkish-Dutch and Dutch patients. Pre- and postconsultation questionnaires were filled out by 136 Dutch and 100 Turkish-Dutch patients in the waiting rooms of 32 general practitioners (GPs). GPs completed a questionnaire too. Results showed that a match between patients’ preferred and perceived participation was related to higher patient satisfaction, more fulfillment of information needs, and more understanding of information than a mismatch for both patient groups. For doctor–patient concordance a conditional main effect on all outcome measures emerged only among Turkish-Dutch patients. That is, for patients who were discordant with their GP, higher perceived participation was related to lower satisfaction, worse fulfillment of information needs, and worse understanding of the information. In order to improve medical communication GPs should thus primarily be trained to tailor their communication styles to match patients’ preferences for participation.     

Examining the Effects of MTV’s 16 and Pregnant on Adolescent Girls’ Sexual Health: The Implications of Character Affinity,Pregnancy Risk Factors,and Health Literacy on Message Effectiveness

Health communication strategies to decrease teen pregnancies include the employment of entertainment-education (E-E), which involves embedding health messages in an entertainment media vehicle that is relatable and attractive to the intended audience. MTV’s 16 and Pregnant is an example of such an effort as an E-E documentary-style reality show that aimed to reduce the U.S. teen pregnancy rate. A pretest–posttest experiment was conducted with 147 adolescent girls (ages 14–18) to investigate the effectiveness of 16 and Pregnant on beliefs, attitudes, and intentions to avoid teen pregnancy. Among participants who reported the lowest levels of identification, parasocial relationship, and homophily, viewing 16 and Pregnant resulted in more negative attitudes toward teen pregnancy. Among participants who reported the highest level of homophily, viewing 16 and Pregnant resulted in more positive attitudes toward teen pregnancy. Levels of pregnancy risk and health literacy were examined but were not significant moderators. Results are discussed in light of E-E theory and research.