Cognitive impairment and preferences for current health

<p>Abstract</p> <p>Background</p> <p>We assessed preferences for current health using the visual analogue scale (VAS), standard gamble (SG), time trade-off (TTO), and willingness to pay (WTP) in patients with cerebral aneurysms, a population vulnerable to cognitive deficits related to aneurysm bleeding or treatment.</p> <p>Methods</p> <p>We measured VAS, SG, TTO, and WTP values for current health in 165 outpatients with cerebral aneurysms. We assessed cognitive impairment with the Mini Mental State Examination (MMSE; scores < 24 = cognitive impairment). We examined the distributions of preference responses stratified by cognitive status, and the relationship between preferences and cognitive impairment, patient characteristics, and aneurysm history.</p> <p>Results</p> <p>Eleven patients (7%) had MMSE scores < 24. The distribution of preferences responses from patients with cognitive impairment had greater variance (SG, 0.39 vs. 0.21, P = 0.001; TTO, 0.36 vs. 0.24, P = 0.017) and altered morphology (VAS, P = 0.012; SG, P = 0.023) compared to the responses of unimpaired patients. There was good correlation between most preference measures for unimpaired patients (VAS:TTO, rho = 0.19, P = 0.018; SG:TTO, rho = 0.36, P < 0.001; SG:WTP, rho = -0.33, P < 0.001) and a trend towards significance with another pairing (VAS:WTP, rho = 0.16, P = 0.054). In subjects with cognitive impairment, there was a significant correlation only between VAS and TTO scores (rho = 0.76, P = 0.023). Separate regression models showed that cognitive impairment was associated with lower preferences on the VAS (β = -0.12, P = 0.048), SG (β = -0.23, P = 0.002), and TTO (β = -0.17, P = 0.035).</p> <p>Conclusion</p> <p>Cognitive impairment is associated with lower preferences for current health in patients with cerebral aneurysms. Cognitively impaired patients have poor inter-preference test correlations and different response distributions compared to unimpaired patients.</p

Do medical house officers value the health of veterans differently from the health of non-veterans?

BACKGROUND: Little information is available regarding medical residents' perceptions of patients' health-related quality of life. Patients cared for by residents have been shown to receive differing patterns of care at Veterans Affairs facilities than at community or university settings. We therefore examined: 1) how resident physicians value the health of patients; 2) whether values differ if the patient is described as a veteran; and 3) whether residency-associated variables impact values. METHODS: All medicine residents in a teaching hospital were asked to watch a digital video of an actor depicting a 72-year-old patient with mild-moderate congestive heart failure. Residents were randomized to 2 groups: in one group, the patient was described as a veteran of the Korean War, and in the other, he was referred to only as a male. The respondents assessed the patient's health state using 4 measures: rating scale (RS), time tradeoff (TTO), standard gamble (SG), and willingness to pay (WTP). We also ascertained residents' demographics, risk attitudes, residency program type, post-graduate year level, current rotation, experience in a Veterans Affairs hospital, and how many days it had been since they were last on call. We performed univariate and multivariable analyses using the RS, TTO, SG and WTP as dependent variables. RESULTS: Eighty-one residents (89.0% of eligible) participated, with 36 (44.4%) viewing the video of the veteran and 45 (55.6%) viewing the video of the non-veteran. Their mean (SD) age was 28.7 (3.1) years; 51.3% were female; and 67.5% were white. There were no differences in residents' characteristics or in RS, TTO, SG and WTP scores between the veteran and non-veteran groups. The mean RS score was 0.60 (0.14); the mean TTO score was 0.80 (0.20); the mean SG score was 0.91 (0.10); and the median (25th, 75th percentile) WTP was $10,000 ($7600, $20,000) per year. In multivariable analyses, being a resident in the categorical program was associated with assigning higher RS scores, but no residency-associated variables were associated with the TTO, SG or WTP scores. CONCLUSION: Physicians in training appear not to be biased either in favor of or against military veterans when judging the value of a patient's health

Is Antiretroviral Therapy Cost-Effective in South Africa?

Braithwaite and Tsevat discuss a new study that suggests that antiretroviral treatment is indeed cost-effective

Cost-effectiveness of a smoking cessation program after myocardial infarction

AbstractObjectives. The purpose of this study was to evaluate the cost-effectiveness of a smoking cessation program initiated after acute myocardial infarction.Background. The value of allocating health care resources to smoking cessation programs after myocardial infarction has not been compared with the value of other currently accepted interventions.Methods. A model was developed to examine the cost-effectiveness of a recently reported smoking cessation program after an acute myocardial infarction. The cost was estimated by considering the resources necessary to implement the program, and the effectiveness was expressed as discounted years of life saved. Years of life saved were estimated by modeling life expectancy using a single declining exponential approximation of life expectancy based on data from published reports.Results. The cost-effectiveness of the nurse-managed smoking cessation program was estimated to be $220/year of life saved. In a one-way sensitivity analysis, the cost-effectiveness of the program remained <$20,000/year of life saved if the program decreased the smoking rate by only 3/1,000 smokers (baseline assumption 26/100 smokers), or if the program cost as much as $8,840/smoker (baseline assumption$100). In a two-way sensitivity analysis, even if the cost of the program were as high as $2,000/participant, the cost-effectiveness of the program would be <$10,000/year of life saved so as the an program helped an additional 12 smokers quit for every 100 enrolled.Conclusions. Over a wide range of estimates of costs and effectiveness, a nurse-managed smoking cessation program after acute myocardial infarction is an extremely cost-effective intervention. This program is more cost-elective than beta-adrenergic antagonist therapy after myocardial infarction

Gender differences in health-related quality of life of adolescents with cystic fibrosis

BACKGROUND: Female patients with cystic fibrosis (CF) have consistently poorer survival rates than males across all ages. To determine if gender differences exist in health-related quality of life (HRQOL) of adolescent patients with CF, we performed a cross-section analysis of CF patients recruited from 2 medical centers in 2 cities during 1997–2001. METHODS: We used the 87-item child self-report form of the Child Health Questionnaire to measure 12 health domains. Data was also collected on age and forced expiratory volume in 1 second (FEV(1)). We analyzed data from 98 subjects and performed univariate analyses and linear regression or ordinal logistic regression for multivariable analyses. RESULTS: The mean (SD) age was 14.6 (2.5) years; 50 (51.0%) were female; and mean FEV(1 )was 71.6% (25.6%) of predicted. There were no statistically significant gender differences in age or FEV(1). In univariate analyses, females reported significantly poorer HRQOL in 5 of the 12 domains. In multivariable analyses controlling for FEV(1 )and age, we found that female gender was associated with significantly lower global health (p < 0.05), mental health (p < 0.01), and general health perceptions (p < 0.05) scores. CONCLUSION: Further research will need to focus on the causes of these differences in HRQOL and on potential interventions to improve HRQOL of adolescent patients with CF

Valuation of scleroderma and psoriatic arthritis health states by the general public

<p>Abstract</p> <p>Objective</p> <p>Psoriatic arthritis (PsA) and scleroderma (SSc) are chronic rheumatic disorders with detrimental effects on health-related quality of life. Our objective was to assess health values (utilities) from the general public for health states common to people with PsA and SSc for economic evaluations.</p> <p>Methods</p> <p>Adult subjects from the general population in a Midwestern city (N = 218) completed the SF-12 Health Survey and computer-assisted 0-100 rating scale (RS), time trade-off (TTO, range: 0.0-1.0) and standard gamble (SG, range: 0.0-1.0) utility assessments for several hypothetical PsA and SSc health states.</p> <p>Results</p> <p>Subjects included 135 (62%) females, 143 (66%) Caucasians, and 62 (28%) African-Americans. The mean (SD) scores for the SF-12 Physical Component Summary scale were 52.9 (8.3) and for the SF-12 Mental Component Summary scale were 49.0 (9.1), close to population norms. The mean RS, TTO, and SG scores for PsA health states varied with severity, ranging from 20.2 to 63.7 (14.4-20.3) for the RS 0.29 to 0.78 (0.24-0.31) for the TTO, and 0.48 to 0.82 (0.24-0.34) for the SG. The mean RS, TTO, and SG scores for SSc health states were 25.3-69.7 (15.2-16.3) for the RS, 0.36-0.80 (0.25-0.31) for the TTO, and 0.50-0.81 (0.26-0.32) for the SG, depending on disease severity.</p> <p>Conclusion</p> <p>Health utilities for PsA and SSc health states as assessed from the general public reflect the severity of the diseases. These descriptive findings could have implications regarding comparative effectiveness research for tests and treatments for PsA and SSc.</p

Self-rated health of primary care house officers and its relationship to psychological and spiritual well-being

<p/> <p>Background</p> <p>The stress associated with residency training may place house officers at risk for poorer health. We sought to determine the level of self-reported health among resident physicians and to ascertain factors that are associated with their reported health.</p> <p>Methods</p> <p>A questionnaire was administered to house officers in 4 residency programs at a large Midwestern medical center. Self-rated health was determined by using a health rating scale (ranging from 0 = death to 100 = perfect health) and a Likert scale (ranging from "poor" health to "excellent" health). Independent variables included demographics, residency program type, post-graduate year level, current rotation, depressive symptoms, religious affiliation, religiosity, religious coping, and spirituality.</p> <p>Results</p> <p>We collected data from 227 subjects (92% response rate). The overall mean (SD) health rating score was 87 (10; range, 40–100), with only 4 (2%) subjects reporting a score of 100; on the Likert scale, only 88 (39%) reported excellent health. Lower health rating scores were significantly associated (P < 0.05) with internal medicine residency program, post-graduate year level, depressive symptoms, and poorer spiritual well-being. In multivariable analyses, lower health rating scores were associated with internal medicine residency program, depressive symptoms, and poorer spiritual well-being.</p> <p>Conclusion</p> <p>Residents' self-rated health was poorer than might be expected in a cohort of relatively young physicians and was related to program type, depressive symptoms, and spiritual well-being. Future studies should examine whether treating depressive symptoms and attending to spiritual needs can improve the overall health and well-being of primary care house officers.</p