The nation’s health care bill

During the past 50 years, spending on health care services—by households, private businesses, and state and federal governments—increased dramatically and now approaches one out of every five dollars spent in the United States. The benefits of health care spending have not been distributed equally across the population, with less going to a growing number of uninsured people. Moreover, the United States does not realize proportional value for its spending on health care. It spends more per capita than any of six other industrialized countries but ranks below them on measures of health care quality, efficiency, and equity. Unable to sustain rising contributions to health insurance, employers are shifting more of the cost to workers, thereby increasing the number who cannot afford coverage. Federal, state, and local governments have taken on some of these costs by subsidizing the health services of elderly, disabled, and poor people. Health spending, once a small fraction of the federal budget, now exceeds spending on defense or Social Security. State and local governments now devote more of their own taxes to health care than to elementary and secondary education, despite the federal government’s paying for the majority of Medicaid spending. The data in this chartbook indicate that the financial burden of health care spending presents a disproportionate burden on uninsured and sick people, small businesses, and low-wage workers. In addition to the magnitude and maldistribution of health spending, society’s “opportunity costs” are high: Private businesses, households, and state and federal governments could have made other highly productive purchases had health spending not exceeded economy-wide growth. For the government, health care spending decreases the money available for other investments, such as education, infrastructure, and debt reduction. As health costs increase and the population ages, the historical reallocation of US productive capacity to health care is unsustainable. With pressing needs elsewhere, the country must make the health system more efficient, equitable, and affordable. Passage of the Patient Protection and Affordable Care Act (ACA) by Congress in 2010 was a comprehensive step to contain health care costs, particularly for families, while extending health care coverage to millions of uninsured people. The potential benefits of the ACA include better access to health professionals and prescription drugs, decreased medical debt and fewer subsequent bankruptcy filings, and lower labor costs for small businesses. Constrained health care spending will allow businesses and government to make more cost-effective investments elsewhere without raising prices or burdening taxpayers. With this chartbook as a baseline, users can monitor changes that result from the ACA and take future steps to enhance the cost-effectiveness of the US health care system.Publishe

Aedes aegypti Density and Risk of Dengue Virus Seroconversion

Routine entomological monitoring data are used as a surrogate for overall risk of dengue virus (DENV) infection and to trigger implementation of control interventions. Indicators that characterize Aedes aegypti abundance have not consistently been associated with an increased risk of dengue virus (DENV) seroconversion. Using longitudinal entomological and serological data from Iquitos, Peru, this dissertation estimated the risk of DENV infection for several entomological indicators to determine if any measure of Ae. aegypti abundance was associated with transmission. Entomological survey data from two longitudinal cohort studies linked with 8,153 paired serological observations were analyzed. Indicators of Ae. aegypti density were calculated from entomological. The risk ratios (RR) estimating the association between Ae. aegypti abundance at the household and block levels and the six-month risk of DENV seroconversion were obtained. Cross-sectional Ae. aegypti densities were not associated with an increased risk of DENV seroconversion. Longitudinal measures of adult stage density resulted in adjusted RRs ranging from 1.01 (95% CI: 1.01, 1.02) to 1.30 (95% CI: 1.17, 1.46) and categorical immature indices (RRs ranging from 1.21 (95% CI: 1.07, 1.37) to 1.75 (95% CI: 1.23, 2.5)). A total of 90,046 entomological monitoring observations were used to model the space/time covariance of ln(adult Ae. aegypti per m2). Mosquito density modeled using the Bayesian Maximum Entropy (BME) geostatistical framework was associated with an increased risk of DENV infection among densities ranging from 0.005 to 0.01 mosquitoes per m2 (adjusted risk ratio: 1.14; 95% CI: 1.01, 1.28). A multi-level logistic model was used to test for heterogeneity of the association between DENV risk and longitudinal measures of Ae. aegypti density. The multi-level model results suggest that the population-level risk ratios are more appropriate estimates of the Ae. aegypti-DENV seroconversion association. Ae. aegypti densities calculated from repeat entomological monitoring were associated with DENV seroconversion, whereas estimates of Ae. aegypti abundance measured cross-sectionally were not. It is possible that Ae. aegypti populations exhibit too much variability across space and time for periodic, cross-sectional measurement to adequately characterize entomological risk, in addition to having no correlation with true infection events due to human movement in space and time.Doctor of Philosoph

The nation’s health care bill: Who bears the burden? A chartbook

During the past 50 years, spending on health care services—by households, private businesses, and state and federal governments—increased dramatically and now approaches one out of every five dollars spent in the United States. The benefits of health care spending have not been distributed equally across the population, with less going to a growing number of uninsured people. Moreover, the United States does not realize proportional value for its spending on health care. It spends more per capita than any of six other industrialized countries but ranks below them on measures of health care quality, efficiency, and equity. Unable to sustain rising contributions to health insurance, employers are shifting more of the cost to workers, thereby increasing the number who cannot afford coverage. Federal, state, and local governments have taken on some of these costs by subsidizing the health services of elderly, disabled, and poor people. Health spending, once a small fraction of the federal budget, now exceeds spending on defense or Social Security. State and local governments now devote more of their own taxes to health care than to elementary and secondary education, despite the federal government’s paying for the majority of Medicaid spending. The data in this chartbook indicate that the financial burden of health care spending presents a disproportionate burden on uninsured and sick people, small businesses, and low-wage workers. In addition to the magnitude and maldistribution of health spending, society’s “opportunity costs” are high: Private businesses, households, and state and federal governments could have made other highly productive purchases had health spending not exceeded economy-wide growth. For the government, health care spending decreases the money available for other investments, such as education, infrastructure, and debt reduction. As health costs increase and the population ages, the historical reallocation of US productive capacity to health care is unsustainable. With pressing needs elsewhere, the country must make the health system more efficient, equitable, and affordable. Passage of the Patient Protection and Affordable Care Act (ACA) by Congress in 2010 was a comprehensive step to contain health care costs, particularly for families, while extending health care coverage to millions of uninsured people. The potential benefits of the ACA include better access to health professionals and prescription drugs, decreased medical debt and fewer subsequent bankruptcy filings, and lower labor costs for small businesses. Constrained health care spending will allow businesses and government to make more cost-effective investments elsewhere without raising prices or burdening taxpayers. With this chartbook as a baseline, users can monitor changes that result from the ACA and take future steps to enhance the cost-effectiveness of the US health care system

The prevalence of blinding trachoma in northern states of Sudan.

BACKGROUND: Despite historical evidence of blinding trachoma, there have been no widespread contemporary surveys of trachoma prevalence in the northern states of Sudan. We aimed to conduct district-level surveys in this vast region in order to map the extent of the problem and estimate the need for trachoma control interventions to eliminate blinding trachoma. METHODS AND FINDINGS: Separate, population based cross-sectional surveys were conducted in 88 localities (districts) in 12 northern states of Sudan between 2006 and 2010. Two-stage cluster random sampling with probability proportional to size was used to select the sample. Trachoma grading was done using the WHO simplified grading system. Key prevalence indicators were trachomatous inflammation-follicular (TF) in children aged 1-9 years and trachomatous trichiasis (TT) in adults aged 15 years and above. The sample comprised 1,260 clusters from which 25,624 households were surveyed. A total of 106,697 participants (81.6% response rate) were examined for trachoma signs. TF prevalence was above 10% in three districts and between 5% and 9% in 11 districts. TT prevalence among adults was above 1% in 20 districts (which included the three districts with TF prevalence >10%). The overall number of people with TT in the population was estimated to be 31,072 (lower and upper bounds = 26,125-36,955). CONCLUSION: Trachoma mapping is complete in the northern states of Sudan except for the Darfur States. The survey findings will facilitate programme planning and inform deployment of resources for elimination of trachoma from the northern states of Sudan by 2015, in accordance with the Sudan Federal Ministry of Health (FMOH) objectives

Predicting the environmental suitability for onchocerciasis in Africa as an aid to elimination planning

Recent evidence suggests that, in some foci, elimination of onchocerciasis from Africa may be feasible with mass drug administration (MDA) of ivermectin. To achieve continental elimination of transmission, mapping surveys will need to be conducted across all implementation units (IUs) for which endemicity status is currently unknown. Using boosted regression tree models with optimised hyperparameter selection, we estimated environmental suitability for onchocerciasis at the 5 × 5-km resolution across Africa. In order to classify IUs that include locations that are environmentally suitable, we used receiver operating characteristic (ROC) analysis to identify an optimal threshold for suitability concordant with locations where onchocerciasis has been previously detected. This threshold value was then used to classify IUs (more suitable or less suitable) based on the location within the IU with the largest mean prediction. Mean estimates of environmental suitability suggest large areas across West and Central Africa, as well as focal areas of East Africa, are suitable for onchocerciasis transmission, consistent with the presence of current control and elimination of transmission efforts. The ROC analysis identified a mean environmental suitability index of 0·71 as a threshold to classify based on the location with the largest mean prediction within the IU. Of the IUs considered for mapping surveys, 50·2% exceed this threshold for suitability in at least one 5 × 5-km location. The formidable scale of data collection required to map onchocerciasis endemicity across the African continent presents an opportunity to use spatial data to identify areas likely to be suitable for onchocerciasis transmission. National onchocerciasis elimination programmes may wish to consider prioritising these IUs for mapping surveys as human resources, laboratory capacity, and programmatic schedules may constrain survey implementation, and possibly delaying MDA initiation in areas that would ultimately qualify

Validity of US norms for the Bayley Scales of Infant Development-III in Malawian children

Most psychometric tests originate from Europe and North America and have not been validated in other populations. We assessed the validity of United States (US)-based norms for the Bayley Scales of Infant and Toddler Development-III (BSID-III), a neurodevelopmental tool developed for and commonly used in the US, in Malawian children