Three Essays in Preventive Health Economics.

This dissertation examines the oftentimes complicated nature of preventive care utilization decisions to help inform preventive health policy. The first paper examines how patient experiences with two seemingly disparate types of preventive care—mammography and medication adherence—can significantly affect each other. Using Marketscan Medicaid and commercial claims data and a difference-in-difference approach, I show that a false-positive mammogram leads to improved cholesterol medication adherence for the Medicaid insured population, with suggestive evidence showing that the improvement may be due to increased interaction with the health care system for a population with access problems. However, I find reduced adherence for the commercially insured, possibly resulting from reduced trust in the health care system following the negative experience of a false-positive. The second paper provides evidence that a false-positive mammogram can lead to significant increases in the probability of initiating depression or anxiety medication utilization compared to women who have a true-negative mammogram for both the Medicaid and commercially insured populations. In terms of magnitude the effect is 4 to 6 times smaller than for women diagnosed with breast cancer (true-positives). I also find several factors that appear to increase the risk of initiating depression or anxiety medication for women experiencing a false-positive mammogram—the first experienced false-positive for women with Medicaid; and invasiveness of the test and greater time to resolution for the commercially insured. The final paper analyzes how anticipated unemployment and uninsurance affect preventive health utilization using MEPS data. To find more exogenous sources of variation in unemployment and uninsurance, my primary analyses restrict analysis to individuals in the 75th percentile or greater of predicted unemployment or uninsurance and separate unemployment into layoffs and non-layoffs. Across both methods, I find evidence of significant stocking up for a variety of preventive care services in anticipation of future unemployment but evidence of significant delaying for individuals who anticipate becoming uninsured. Particularly strong delays for cancer screenings, suggest the delays may result from lower expected net benefits of screening for people who anticipate becoming uninsured and therefore facing high out-of-pocket costs for any treatments.PhDHealth Services Organization and PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/113620/1/jesegel_1.pd

Palifermin for management of treatment-induced oral mucositis in cancer patients

Oral mucositis (OM) remains a major side effect of various cancer therapies, which exacts a significant price in terms of morbidity and cost of care. Efforts aimed at prevention and/or therapy of OM have been largely unsuccessful. Few agents have shown efficacy, and even those were applicable to limited types of patients. The advent of small-molecule targeted agents opened new possibilities for intervention in the mucopathogenic processes induced by cancer therapies. One of these agents, recombinant human keratinocyte growth factor (KGF), has been studied extensively and has shown promising results in reducing chemotherapy induced OM. This drug’s effects on stem cell engraftment, graft-versus-host disease and other treatment-induced morbidities remain undefined. In this article we evaluate the pre-clinical and clinical evidence and discuss the clinical applications of KGF as an adjunct therapeutic agent in oncology

Oral and Pharyngeal Cancer Control and Early Detection

Sixty-four standardized continuing education courses were given for dentists throughout the ten public health districts of the USA to determine if certain behaviors regarding oral and pharyngeal cancer (OPC) control could be modified. Questionnaires were obtained at baseline and at 6 months along with matched control groups. One thousand eight hundred two general dentists participated at baseline and 988 at a 6-month questionnaire follow-up. Analysis of the data indicated that continuing education courses had a positive influence on participants’ oral cancer attitudes, knowledge, and behavior that potentially could make a difference on prevention, early detection, and ultimately OPC control

Toward multimodality oral cancer diagnosis in the XXI century: Blending cutting edge imaging and genomic/proteomic definition of suspicious lesions

If emergent genomic and proteomic approaches to early oral cancer detection are to be successful, a means of reliably and comprehensively identifying high-risk tissue sampling sites constitutes an essential step in the oral cancer screening process. Recent studies have determined that in vivo Optical Coherence Tomography (OCT) is a quick and user-friendly tool for detecting and mapping oral lesions, and that it can enhance diagnostic accuracy when using high resolution diagnostic techniques such as in vivo microscopy. Therefore OCT can potentially provide a means of improving the clinical usefulness of novel diagnostic approaches such as proteomics by identifying sites that need to be sampled

Oral White Lesions Associated with Chewing Khat

<p>Abstract</p> <p>Introduction</p> <p>Khat is a cultivated plant whose leaves when chewed elevate mood. Unlike the chewing of betel nut, no association between the white oral mucosal lesions in khat users and oral malignancies has been reported. Chewing of khat has been documented in many countries and has increased with worldwide migration. The impact of chewing khat upon the oral mucosa is essentially unknown.</p> <p>Purpose</p> <p>The purpose of this study was to assess the occurrence of oral white changes in chronic khat chewers. Oral mucosal changes in a group of 47 Yemenite Israeli men over 30 years of age, who had chewed khat more than 3 years, were compared to those of 55 Yemenite men who did not chew.</p> <p>Results</p> <p>White lesions were significantly more prevalent in the khat chewers (83%) compared to the non chewing individuals (16%) (P < 0.001). White oral lesions were identified primarily on the lower buccal attached gingival mucosa, the alveolar mucosa and the lower mucobuccal fold on the chewing side (p < 0.001). There was no significant association between the occurrence of the white lesions and smoking. Even though the majority of the white lesions (85.4%) were homogenous, 71.4% of the non homogenous lesions were identified in khat chewers. Vital staining with toluidine blue and exfoliative cytology was conducted on a subset of patients with homogenous and non-homogenous oral lesions, and there were no findings suspicious for pre-malignant or malignant changes.</p> <p>Discussion</p> <p>This study demonstrated a relationship between khat chewing and oral white lesions, which we attribute to chronic local mechanical and chemical irritation of the mucosa. Our findings also suggest that mucosal changes associated with khat are benign, however, this initial study requires further studies including follow-up of khat users to confirm the current findings, including the likely benign changes associated with chronic use and histologic findings of clinical lesions.</p

The Sandwich Generation Diner: Development of a Web-Based Health Intervention for Intergenerational Caregivers

Background: Women are disproportionately likely to assist aging family members; approximately 53 million in the United States are involved with the health care of aging parents, in-laws, or other relatives. The busy schedules of “sandwich generation” women who care for older relatives require accessible and flexible health education, including Web-based approaches. Objective: This paper describes the development and implementation of a Web-based health education intervention, The Sandwich Generation Diner, as a tool for intergenerational caregivers of older adults with physical and cognitive impairments. Methods: We used Bartholomew’s Intervention Mapping (IM) process to develop our theory-based health education program. Bandura’s (1997) self-efficacy theory provided the overarching theoretical model. Results: The Sandwich Generation Diner website features four modules that address specific health care concerns. Our research involves randomly assigning caregiver participants to one of two experimental conditions that are identical in the type of information provided, but vary significantly in the presentation. In addition to structured Web-based assessments, specific website usage data are recorded. Conclusions: The Sandwich Generation Diner was developed to address some of the informational and self-efficacy needs of intergenerational female caregivers. The next step is to demonstrate that this intervention is: (1) attractive and effective with families assisting older adults, and (2) feasible to embed within routine home health services for older adults

Smoking Habits Among Patients Diagnosed with Oral Lichen Planus

<p>Abstract</p> <p>Introduction</p> <p>Oral lichen planus (OLP) is one of the most common dermatologic diseases that manifests in the oral cavity. The purpose of this study was to evaluate the association between smoking habits and the clinical subtypes of OLP.</p> <p>Methods</p> <p>Oral findings and smoking data from 187 charts of OLP patients from an oral medicine clinic was reviewed and compared to data from 76 matched control patients.</p> <p>Results and Discussion</p> <p>Ninety-three patients were diagnosed with reticular OLP, 55 with atrophic and 39 with erosive forms of the disease. Symptomatic OLP occurred in 63.6% of patients. Fewer cases of reticular OLP were symptomatic than erosive OLP (p < 0.001). Significantly fewer OLP patients smoked than the control group (16% versus 25%) (p = 0.04). More patients with reticular OLP smoked than those with atrophic and erosive OLP (p = 0.002). It is hypothesized that the heat and irritation of smoking may aggravate symptomatic OLP lesions, and the risk of malignant transformation associated with tobacco use may play a role in patients stopping tobacco use. Because there were fewer smokers in patients with OLP, and because OLP carries an increased malignant risk, transformation of OLP may be due to a different etiology and of a different pathogenesis than squamous cell carcinoma not arising from lichen planus. Close follow-up of patients with OLP is indicated.</p

Neuropathic and nociceptive pain in head and neck cancer patients receiving radiation therapy

BACKGROUND: Pain is common in head and neck cancer (HNC) patients and may be attributed to the malignancy and/or cancer treatment. Pain mechanisms and patient report of pain in HNC are expected to include both nociceptive and neuropathic components. The purpose of this study was to assess the trajectory of orofacial and other pain during and following treatment, using patient reports of neuropathic pain and nociceptive pain and pain impact. METHODS: 124 consecutive HNC patients receiving radiation therapy (RT) (95 men, 29 women; mean age: 54.7 ± 12.3 years) participated in a patient-reported outcome (PRO) assessment. Patients completed the McGill Pain Questionnaire three times during therapy and 3 months following study entry. RESULTS: The majority of patients related their pain to the tumor and/or cancer treatment. Whereas 59% reported their pain to be less severe than they expected, 29% were not satisfied with their level of pain despite pain management during cancer therapy. Worst pain was 3.0 ± 1.3 on a 0- to 5-point verbal descriptor scale. Pain intensity was present at entry, highest at 2-week follow-up, declining towards the end of treatment and persisting at 3-month follow-up. The most common neuropathic pain descriptors chosen were aching (20%) and burning (27%); nociceptive words chosen were dull (22%), sore (32%), tender (35%), and throbbing (23%), and affective/evaluative descriptors were tiring (25%) and annoying (41%). 57% of patients reported continuous pain, and combined continuous and intermittent pain was reported by 79% of patients. DISCUSSION: This study provides evidence that patients with HNC experience nociceptive and neuropathic pain during RT despite ongoing pain management. The affective and evaluative descriptors chosen for head and neck pain indicate considerable impact on quality of life even with low to moderate levels of pain intensity. These findings suggest that clinicians should consider contemporary management for both nociceptive and neuropathic pain in head and neck cancer patients

Comparison of Fenoterol, Isoproterenol, and Isoetharine with Phenylephrine Aerosol in Asthma

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97253/1/j.1552-4604.1983.tb02708.x.pd