799 research outputs found
Vertical Integration and Optimal Reimbursement Policy
Health care providers may vertically integrate not only to facilitate coordination of care, but also for strategic reasons that may not be in patients' best interests. Optimal Medicare reimbursement policy depends upon the extent to which each of these explanations is correct. To investigate, we compare the consequences of the 1997 adoption of prospective payment for skilled nursing facilities (SNF PPS) in geographic areas with high versus low levels of hospital/SNF integration. We find that SNF PPS decreased spending more in high integration areas, with no measurable consequences for patient health outcomes. Our findings suggest that subjecting integrated providers to higher-powered reimbursement incentives, i.e., less cost-sharing, may enhance medical productivity. More generally, we conclude that it may be efficient for purchasers of health services (and other services subject to agency problems) to consider the organizational form of their suppliers when choosing a reimbursement mechanism.
Averting HIV Infections in New York City: A Modeling Approach Estimating the Future Impact of Additional Behavioral and Biomedical HIV Prevention Strategies
Background:New York City (NYC) remains an epicenter of the HIV epidemic in the United States. Given the variety of evidence-based HIV prevention strategies available and the significant resources required to implement each of them, comparative studies are needed to identify how to maximize the number of HIV cases prevented most economically.Methods:A new model of HIV disease transmission was developed integrating information from a previously validated micro-simulation HIV disease progression model. Specification and parameterization of the model and its inputs, including the intervention portfolio, intervention effects and costs were conducted through a collaborative process between the academic modeling team and the NYC Department of Health and Mental Hygiene. The model projects the impact of different prevention strategies, or portfolios of prevention strategies, on the HIV epidemic in NYC.Results:Ten unique interventions were able to provide a prevention benefit at an annual program cost of less than 106,378; the total cost was in excess of 100 million per year, on average). The cost-savings of prevented infections was estimated at more than 250 million per year, on average).Conclusions:Optimal implementation of a portfolio of evidence-based interventions can have a substantial, favorable impact on the ongoing HIV epidemic in NYC and provide future cost-saving despite significant initial costs. © 2013 Kessler et al
Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial
Background:
Cognitive behavioural therapy (CBT) is an effective treatment for people whose depression has not responded to antidepressants. However, the long-term outcome is unknown. In a long-term follow-up of the CoBalT trial, we examined the clinical and cost-effectiveness of cognitive behavioural therapy as an adjunct to usual care that included medication over 3–5 years in primary care patients with treatment-resistant depression.
Methods:
CoBalT was a randomised controlled trial done across 73 general practices in three UK centres. CoBalT recruited patients aged 18–75 years who had adhered to antidepressants for at least 6 weeks and had substantial depressive symptoms (Beck Depression Inventory [BDI-II] score ≥14 and met ICD-10 depression criteria). Participants were randomly assigned using a computer generated code, to receive either usual care or CBT in addition to usual care. Patients eligible for the long-term follow-up were those who had not withdrawn by the 12 month follow-up and had given their consent to being re-contacted. Those willing to participate were asked to return the postal questionnaire to the research team. One postal reminder was sent and non-responders were contacted by telephone to complete a brief questionnaire. Data were also collected from general practitioner notes. Follow-up took place at a variable interval after randomisation (3–5 years). The primary outcome was self-report of depressive symptoms assessed by BDI-II score (range 0–63), analysed by intention to treat. Cost-utility analysis compared health and social care costs with quality-adjusted life-years (QALYs). This study is registered with isrctn.com, number ISRCTN38231611.
Findings:
Between Nov 4, 2008, and Sept 30, 2010, 469 eligible participants were randomised into the CoBalT study. Of these, 248 individuals completed a long-term follow-up questionnaire and provided data for the primary outcome (136 in the intervention group vs 112 in the usual care group). At follow-up (median 45·5 months [IQR 42·5–51·1]), the intervention group had a mean BDI-II score of 19·2 (SD 13·8) compared with a mean BDI-II score of 23·4 (SD 13·2) for the usual care group (repeated measures analysis over the 46 months: difference in means −4·7 [95% CI −6·4 to −3·0, p<0·001]). Follow-up was, on average, 40 months after therapy ended. The average annual cost of trial CBT per participant was £343 (SD 129). The incremental cost-effectiveness ratio was £5374 per QALY gain. This represented a 92% probability of being cost effective at the National Institute for Health and Care Excellence QALY threshold of £20 000.
Interpretation:
CBT as an adjunct to usual care that includes antidepressants is clinically effective and cost effective over the long-term for individuals whose depression has not responded to pharmacotherapy. In view of this robust evidence of long-term effectiveness and the fact that the intervention represented good value-for-money, clinicians should discuss referral for CBT with all those for whom antidepressants are not effective
Rationale and design for the development of a novel nitroxyl donor in patients with acute heart failure
Hospitalisation for acute heart failure remains a major public health problem with high prevalence, morbidity, mortality, and cost. Prior attempts to develop new therapies for this condition have not been successful. Nitroxyl (HNO) plays a unique role in cardiovascular physiology by direct post‐translational modification of thiol residues on target proteins, specifically SERCA2a, phospholamban, the ryanodine receptor and myofilament proteins in cardiomyocytes. In animal models, these biological effects lead to vasodilatation, increased inotropy and lusitropy, but without tachyphylaxis, pro‐arrhythmia or evidence of increased myocardial oxygen demand. BMS‐986231 is an HNO donor being developed as a therapy for heart failure, and initial studies in patients with heart failure support the potential clinical value of these physiological effects. In this manuscript, we describe the ongoing phase II development programme for BMS‐986231, which consists of three related randomised placebo‐controlled clinical trials, StandUP‐AHF, StandUP‐Imaging and StandUP‐Kidney, which are designed to provide evidence of tolerability and efficacy as well as confirm the anticipated physiological effects in patients with heart failure with reduced ejection fraction. These studies will set the stage for the further study of BMS‐986231 in future phase III clinical trials
Statistical coverage for supersymmetric parameter estimation: a case study with direct detection of dark matter
Models of weak-scale supersymmetry offer viable dark matter (DM) candidates.
Their parameter spaces are however rather large and complex, such that pinning
down the actual parameter values from experimental data can depend strongly on
the employed statistical framework and scanning algorithm. In frequentist
parameter estimation, a central requirement for properly constructed confidence
intervals is that they cover true parameter values, preferably at exactly the
stated confidence level when experiments are repeated infinitely many times.
Since most widely-used scanning techniques are optimised for Bayesian
statistics, one needs to assess their abilities in providing correct confidence
intervals in terms of the statistical coverage. Here we investigate this for
the Constrained Minimal Supersymmetric Standard Model (CMSSM) when only
constrained by data from direct searches for dark matter. We construct
confidence intervals from one-dimensional profile likelihoods and study the
coverage by generating several pseudo-experiments for a few benchmark sets of
pseudo-true parameters. We use nested sampling to scan the parameter space and
evaluate the coverage for the benchmarks when either flat or logarithmic priors
are imposed on gaugino and scalar mass parameters. The sampling algorithm has
been used in the configuration usually adopted for exploration of the Bayesian
posterior. We observe both under- and over-coverage, which in some cases vary
quite dramatically when benchmarks or priors are modified. We show how most of
the variation can be explained as the impact of explicit priors as well as
sampling effects, where the latter are indirectly imposed by physicality
conditions. For comparison, we also evaluate the coverage for Bayesian credible
intervals, and observe significant under-coverage in those cases.Comment: 30 pages, 5 figures; v2 includes major updates in response to
referee's comments; extra scans and tables added, discussion expanded, typos
corrected; matches published versio
A Bubbling Nearby Molecular Cloud: COMPLETE Shells in Perseus
We present a study on the shells (and bubbles) in the Perseus molecular cloud
using the COMPLETE survey large-scale 12CO(1-0) and 13CO(1-0) maps. The twelve
shells reported here are spread throughout most of the Perseus cloud and have
circular or arc-like morphologies with a range in radius of about 0.1 to 3 pc.
Most of them have not been detected before most likely as maps of the region
lacked the coverage and resolution needed to distinguish them. The majority of
the shells are coincident with infrared nebulosity of similar shape and have a
candidate powering source near the center. We suggest they are formed by the
interaction of spherical or very wide-angle winds powered by young stars inside
or near the Perseus molecular cloud -a cloud that is commonly considered to be
mostly forming low-mass stars. Two of the twelve shells are powered by
high-mass stars close to the cloud, while the others appear to be powered by
low or intermediate mass stars in the cloud. We argue that winds with a mass
loss rate of about 10^-8 to 10^-6 M_sun/yr are required to produce the observed
shells. Our estimates indicate that the energy input rate from these stellar
winds is similar to the turbulence dissipation rate. We conclude that in
Perseus the total energy input from both collimated protostellar outflows and
powerful spherical winds from young stars is sufficient to maintain the
turbulence in the molecular cloud. Large scale molecular line and IR continuum
maps of a sample of clouds will help determine the frequency of this phenomenon
in other star forming regions.Comment: 48 pages in total: 16 pages of text and references; 2 pages of
tables; 30 figures (one page per figure). Accepted for publication in the
Astrophysical Journa
Sex and depression in the National Comorbidity Survey I: Lifetime prevalence, chronicity and recurrence
Basic epidemiologic prevalence data are presented on sex differences in DSM-III-R major depressive episodes (MDE). The data come from the National Comorbidity Survey (NCS), the first survey in the U.S. to administer a structured psychiatric interview to a nationally representative sample of the general population. Consistent with previous research, women are approximately 1.7 times as likely as men to report a lifetime history of MDE. Age of onset analysis shows that this sex difference begins in early adolescence and persists through the mid-50s. Women also have a much higher rate of 12-month depression than men. However, women with a history of depression do not differ from men with a history of depression in either the probability of being chronically depressed in the past year or in the probability of having an acute recurrence in the past year. This means that the higher prevalence of 12-month depression among women than men is largely due to women having a higher risk of first onset. The implications of these results for future research are discussed in a closing section of the paper.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/30529/1/0000161.pd
Modified Pediatric ASPECTS Correlates with Infarct Volume in Childhood Arterial Ischemic Stroke
Background and Purpose: Larger infarct volume as a percent of supratentorial brain volume (SBV) predicts poor outcome and hemorrhagic transformation in childhood arterial ischemic stroke (AIS). In perinatal AIS, higher scores on a modified pediatric version of the Alberta Stroke Program Early CT Score using acute MRI (modASPECTS) predict later seizure occurrence. The objectives were to establish the relationship of modASPECTS to infarct volume in perinatal and childhood AIS and to establish the interrater reliability of the score. Methods: We performed a cross sectional study of 31 neonates and 40 children identified from a tertiary care center stroke registry with supratentorial AIS and acute MRI with diffusion weighted imaging (DWI) and T2 axial sequences. Infarct volume was expressed as a percent of SBV using computer-assisted manual segmentation tracings. ModASPECTS was performed on DWI by three independent raters. The modASPECTS were compared among raters and to infarct volume as a percent of SBV. Results: ModASPECTS correlated well with infarct volume. Spearman rank correlation coefficients (ρ) for the perinatal and childhood groups were 0.76, p < 0.001 and 0.69, p < 0.001, respectively. Excluding one perinatal and two childhood subjects with multifocal punctate ischemia without large or medium sized vessel stroke, ρ for the perinatal and childhood groups were 0.87, p < 0.001 and 0.80, p < 0.001, respectively. The intraclass correlation coefficients for the three raters for the neonates and children were 0.93 [95% confidence interval (CI) 0.89–0.97, p < 0.001] and 0.94 (95% CI 0.91–0.97, p < 0.001), respectively. Conclusion: The modified pediatric ASPECTS on acute MRI can be used to estimate infarct volume as a percent of SBV with a high degree of validity and interrater reliability
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