Comparative economic evaluation of data from the ACRIN national CT colonography trial with three cancer intervention and surveillance modeling network microsimulations

Purpose: To estimate the cost-effectiveness of computed tomographic (CT) colonography for colorectal cancer (CRC) screening in average-risk asymptomatic subjects in the United States aged 50 years. Materials and Methods: Enrollees in the American College of Radiology Imaging Network National CT Colonography Trial provided informed consent, and approval was obtained from the institutional review board at each site. CT colonography performance estimates from the trial were incorporated into three Cancer Intervention and Surveillance Modeling Network CRC microsimulations. Simulated survival and lifetime costs for screening 50-year-old subjects in the United States with CT colonography every 5 or 10 years were compared with those for guideline-concordant screening with colonoscopy, flexible sigmoidoscopy plus either sensitive unrehydrated fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT), and no screening. Perfect and reduced screening adherence scenarios were considered. Incremental cost-effectiveness and net health benefits were estimated from the U.S. health care sector perspective, assuming a 3% discount rate. Results: CT colonography at 5- and 10-year screening intervals was more costly and less effective than FOBT plus flexible sigmoidoscopy in all three models in both 100% and 50% adherence scenarios. Colonoscopy also was more costly and less effective than FOBT plus flexible sigmoidoscopy, except in the CRC-SPIN model assuming 100% adherence (incremental cost-effectiveness ratio: $26 300 per life-year gained). CT colonography at 5- and 10-year screening intervals and colonoscopy were net beneficial compared with no screening in all model scenarios. The 5-year screening interval was net beneficial over the 10-year interval except in the MISCAN model when assuming 100$50 000 per life-year gained. Conclusion: All three models predict CT colonography to be more costly and less effective than non-CT colonographic screening but net beneficial compared with no screening given model assumptions

A Late Phase of Long-Term Synaptic Depression in Cerebellar Purkinje Cells Requires Activation of MEF2

Summary: The MEF2 family of transcription factors restricts excitatory synapse number in an activity-dependent fashion during development, yet MEF2 has not been implicated in long-term synaptic depression (LTD), which is thought to initiate synapse elimination. Mutations in MEF2 pathways are implicated in autism spectrum disorders, which include cerebellar dysfunction. Here, we test the hypothesis that cerebellar LTD requires postsynaptic activation of MEF2. Knockdown of MEF2D produces suppression of the transcription-dependent late phase of LTD in cultured Purkinje cells. The late phase of LTD is also completely blocked in Purkinje cells derived from MEF2A+MEF2D null mice and rescued with plasmids that drive expression of MEF2D but not phosphatase-resistant mutant MEF2D S444D. Wild-type Purkinje cells transfected with a constitutively active form of MEF2 show no alterations of synaptic strength. Thus, postsynaptic activation of MEF2 by S444 dephosphorylation is necessary, but not sufficient, for the late phase of cerebellar LTD. : Neurodevelopmental disorders can reflect defects in synaptic pruning, which is thought to require activity-dependent weakening of synapses, a process called long-term depression. Andzelm et al. show that MEF2, which is important for neuronal development, is required for the late phase of long-term depression in the cerebellum. Keywords: Arc, MRE, cerebellum, motor learning, memory, autis

Health Behavior Change after Blood Pressure Feedback.

Better understanding is needed for antihypertensive medication initiation and lifestyle modification among younger populations with elevated blood pressure. This study aimed to assess health behavior change after receiving a report of elevated blood pressure among African Americans and Caucasians younger than 50 years old. We used the Coronary Artery Risk Development in Young Adults (CARDIA) repository dataset. By examination year twenty, 424 out of 2,478 Caucasian and 2,637 African American participants had received feedback from the CARDIA study due to elevated blood pressure readings. Blood pressure was measured by trained CARDIA researchers at the participant's home and was repeatedly recorded at seven examinations over twenty years. A feedback/referral letter was sent to participants with an elevated blood pressure reading. On average, participants first had an elevated blood pressure reading at the age of 34. After receiving the feedback letter, 44% of the previously undiagnosed participants received a formal diagnosis. In addition, 23% initiated the use of antihypertensive medication if they had not received medication treatment before. Among the participants with at-risk lifestyle behaviors, 40% reduced alcohol consumption, 14% increased exercise level, 11% stopped smoking, and 8% reached normal weight. While none of the studied patient factors were associated with lifestyle modification, age had a positive impact on antihypertensive medication initiation (p<0.05). We found no evidence of differences in health behavior change between African American and Caucasian participants after receiving the feedback letter. This research is one of the first to study what followed after receiving a feedback letter about elevated blood pressure outside of healthcare settings. Although additional referral care and behavior interventions are needed to facilitate medication initiation and lifestyle modification, our observations suggest that providing blood pressure feedback may have promise as part of a multi-method approach involving blood pressure screening and follow up

Performance measurement and management at the operational level

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Development of a novel, objective measure of health care-related financial burden for U.S. families with children.

ObjectiveTo develop and validate a theoretically based and empirically driven objective measure of financial burden for U.S. families with children.Data sourcesThe measure was developed using 149,021 families with children from the National Health Interview Survey, and it was validated using 18,488 families with children from the Medical Expenditure Panel Survey.Study designWe estimated the marginal probability of unmet health care need due to cost using a bivariate tensor product spline for family income and out-of-pocket health care costs (OOPC; e.g., deductibles, copayments), while adjusting for confounders. Recursive partitioning was performed on these probabilities, as a function of income and OOPC, to establish thresholds demarcating levels of predicted risk.Principal findingsWe successfully generated a novel measure of financial burden with four categories that were associated with unmet need (vs. low burden: midlow OR: 1.93, 95 percent CI: 1.78-2.09; midhigh OR: 2.78, 95 percent CI: 2.49-3.10; high OR: 4.38, 95 percent CI: 3.99-4.80). The novel burden measure demonstrated significantly better model fit and less underestimation of financial burden compared to an existing measure (OOPC/income ≥ 10 percent).ConclusionThe newly developed measure of financial burden establishes thresholds based on different combinations of family income and OOPC that can be applied in future studies of health care utilization and expenditures and in policy development and evaluation

Participants’ characteristics at baseline (when elevated blood pressure was observed).

<p>Have no financial hardship was defined by the answer of “not very hard” to the question of “How hard is it for you (and your family) to pay for the very basics like food and heating?” P-values were based on pair-wise chi-square test for categorical variables and pairwise t test for continuous variables.</p><p>Participants’ characteristics at baseline (when elevated blood pressure was observed).</p

Sensitivity analysis: odds ratio of behavior changes by participants’ characteristics in the subsequent examination (diagnosed patients only).

<p>*statistically significant p<0.1</p><p>**p<0.05 compared with reference group, by multiple logistic regression.</p><p>Sensitivity analysis: odds ratio of behavior changes by participants’ characteristics in the subsequent examination (diagnosed patients only).</p