Factors predicting health-related quality of life in pediatric liver transplant recipients in the functional outcomes group.

Data from 997 pediatric LT recipients were used to model demographic and medical variables as predictors of lower levels of HRQOL. Data were collected through SPLIT FOG project. Patients were between 2 and 18 yr of age and survived LT by at least 12 months. Parents and children (age ≥ 8 yr) completed PedsQL™ 4.0 Generic Core and CF Scales at one time point. Demographic and medical variables were obtained from SPLIT. HRQOL scores were categorized as "poor" based on lower 25% of scores for each measure. Logistic regression models were generated. Single-parent households (OR 1.94, CI 1.13-3.33, p = 0.017), anti-seizure medications (OR 3.99, CI 1.26-12.70, p = 0.019), and number of days hospitalized (OR 1.03, CI 1.01-1.06, p = 0.0067) were associated with lower self-reported HRQOL. Parent data identified increasing age at transplant, age 5-12 yr at survey, hospitalization >21 days at LT, re-operations, diabetes, and growth failure at LT as additional predictors of generic HRQOL. Male gender, single-parent households, higher bilirubin levels at LT, and use of anti-seizure medication predicted lower cognitive function scores. HRQOL following pediatric LT is related to medical and demographic variables.

A conceptual model of physician work intensity: guidance for evaluating policies and practices to improve health care delivery.

BACKGROUND: Physician work intensity, although a major factor in determining the payment for medical services, may potentially affect patient health outcomes including quality of care and patient safety, and has implications for the redesign of medical practice to improve health care delivery. However, to date, there has been minimal research regarding the relationship between physician work intensity and either patient outcomes or the organization and management of medical practices. A theoretical model on physician work intensity will provide useful guidance to such inquiries. OBJECTIVE: To describe an initial conceptual model to facilitate further investigations of physician work intensity. RESEARCH DESIGN: A conceptual model of physician work intensity is described using as its theoretical base human performance science relating to work intensity. For each of the theoretical components, we present relevant empirical evidence derived from a review of the current literature. RESULTS: The proposed model specifies that the level of work intensity experienced by a physician is a consequence of the physician performing the set of tasks (ie, demands) relating to a medical service. It is conceptualized that each medical service has an inherent level of intensity that is experienced by a physician as a function of factors relating to the physician, patient, and medical practice environment. CONCLUSIONS: The proposed conceptual model provides guidance to researchers as to the factors to consider in studies of how physician work intensity impacts patient health outcomes and how work intensity may be affected by proposed policies and approaches to health care delivery.

Complementary and alternative medicine use and psychosocial outcomes among urban adolescents with asthma.

Objective. Many adolescents with asthma use complementary and alternative medicine (CAM) for asthma symptom management. The purpose of this study was to investigate cross-sectional and longitudinal differences in psychosocial health outcomes between high and low CAM users among urban adolescents with asthma. Methods. Adolescents (Time 1: N = 151, Time 2: N = 131) completed self-report measures regarding the use of 10 CAM modalities, mental health, and health-related quality of life (HRQoL) following two clinic visits 1 year apart as part of a larger observational study. Multivariable regression analyses using backward elimination examined relationships between CAM use at Time 1 and outcomes at Time 1 and Time 2, controlling for key covariates and, in longitudinal analyses, Time 1 functioning. Results. Participants (M(age) = 15.8, SD = 1.85) were primarily African-American (n = 129 [85%]) and female (n = 91 [60%]) adolescents with asthma. High and low CAM users differed significantly in terms of several psychosocial health outcomes, both cross-sectionally and longitudinally. In cross-sectional multivariable analyses, greater frequency of praying was associated with better psychosocial HRQoL (R(2) = 0.22). No longitudinal relationships remained significant in multivariable analyses. Conclusions. Specific CAM techniques are differentially associated with psychosocial outcomes, indicating the importance of examining CAM modalities individually. Greater frequency of praying was cross-sectionally associated with better psychosocial HRQoL. When controlling for key covariates, CAM use was not associated with psychosocial outcomes over time. Further research should examine the effects of CAM use in controlled research settings.

Spirituality and religiosity in urban adolescents with asthma.

Predictors of multiple dimensions of spirituality/religiosity (S/R) and adolescents' preferences for having S/R (e.g., prayer) addressed in hypothetical medical settings were assessed in a sample of urban adolescents with asthma. Of the 151 adolescents (mean age = 15.8, 60% female, 85% African-American), 81% said that they were religious and spiritual, 58% attended religious services in the past month, and 49% prayed daily. In multivariable models, African-American race/ethnicity and having a religious preference were associated with higher levels of S/R (R (2) = 0.07-0.25, P < .05). Adolescents' preferences for including S/R in the medical setting increased with the severity of the clinical situation (P < .05).

Overestimation of impairment-related asthma control by adolescents.

We investigated the concordance between adolescents' perceived and impairment-related asthma control. Based on self-reported medication use, symptoms, and activity limitations, most overestimated their impairment-related control (73.8%). Providers should ask detailed, structured questions to get the most comprehensive picture of a patient's impairment-related control so they can ultimately improve disease outcomes.

Complementary and alternative medicine behaviors and beliefs in urban adolescents with asthma.

BACKGROUND/PURPOSE: Up to 80% of adolescents with asthma have used complementary and alternative medicine (CAM) for symptom management. However, little is known about patient characteristics associated with CAM factors other than use. Previous studies recommend provider-patient discussion of CAM use, although few adolescents with asthma disclose their CAM use to their providers. To inform clinical interactions, this study examined prevalence and predictors of CAM use, consideration of use, disclosure of use, and perceived efficacy of use, in urban adolescents with asthma. METHODS: Adolescents with asthma (N = 151) recruited from a children's hospital completed questionnaires addressing demographic and clinical variables and 10 CAM modalities. Response frequencies to four questions assessing CAM use, consideration of use, disclosure, and perceived efficacy were calculated for each modality. Multivariable logistic regression analyses examined characteristics associated with responses to each question for the two most commonly used CAM modalities. RESULTS: Participants' mean age was 15.8 (SD = 1.8), 60% were female and 85% were African-American. Seventy-one percent reported using CAM for symptom management in the past month. Relaxation (64%) and prayer (61%) were the most frequently reported modalities and were perceived to be the most efficacious. Adolescents most commonly reported considering using relaxation (85%) and prayer (80%) for future symptom management. Participants were most likely to disclose their use of yoga (59%) and diet (57%), and least likely to disclose prayer (33%) and guided imagery (36%) to providers. In multivariable analyses, older adolescents (OR = 1.27, p < .05) and African-Americans (OR = 2.76, p < .05) were more likely to use relaxation. Adolescents with more frequent asthma symptoms (OR = 0.98, p < .05) were more likely to use prayer. African-Americans were more likely to report using prayer (OR = 3.47, p < .05) and consider using prayer (OR = 7.98, p < .01) in the future for symptom management. CONCLUSIONS: Many urban adolescents used and would consider using CAM, specifically relaxation and prayer, for asthma symptom management. African-Americans, older adolescents, and those with more frequent symptoms were more likely to use and/or consider using CAM. Providers caring for urban adolescents with asthma should discuss CAM with patients, particularly those identified as likely to use CAM. Future studies should examine relationships between CAM use and health outcomes.

Anxiety and asthma symptoms in urban adolescents with asthma: the mediating role of illness perceptions.

Twenty to 40% of adolescents with asthma experience significant symptoms of anxiety. This study examined the mediational role of illness perceptions in the relationship between anxiety and asthma symptoms in adolescents. One hundred fifty-one urban adolescents (ages 11-18) with asthma completed measures of illness perceptions, and anxiety and asthma symptoms. Using the Baron and Kenny approach and Sobel tests, we examined whether illness perceptions mediated the anxiety-asthma symptom relationship. Three illness perceptions significantly mediated the relationship between anxiety and asthma symptoms, z = 1.97-2.13, p < .05; adjusted R(2) = 0.42-0.51, p < .05. Greater anxiety symptoms were associated with perceptions that asthma negatively impacted one's life and emotions and was difficult to control. These negative illness perceptions were, in turn, related to greater asthma symptoms. Illness perceptions helped explain the anxiety-asthma symptoms link in adolescents. Results suggest that targeting illness perceptions in adolescents with asthma and anxiety may help reduce asthma symptoms.

Health values in adolescents with or without inflammatory bowel disease.

OBJECTIVE: To examine for differences in and predictors of health value/utility scores in adolescents with or without inflammatory bowel disease (IBD). STUDY DESIGN: Adolescents with IBD and healthy control subjects were interviewed in an academic health center. We collected sociodemographic data and measured health status, personal, family, and social characteristics, and spiritual well-being. We assessed time tradeoff (TTO) and standard gamble (SG) utility scores for current health. We performed bivariate and multivariable analyses with utility scores used as outcomes. RESULTS: Sixty-seven patients with IBD and 88 healthy control subjects 11 to 19 years of age participated. Among subjects with IBD, mean (SD) TTO scores were 0.92 (0.17), and mean (SD) SG scores were 0.97 (0.07). Among healthy control subjects, mean (SD) TTO scores were 0.99 (0.03) and mean (SD) SG scores were 0.98 (0.03). TTO scores were significantly lower (P= .001), and SG scores trended lower (P= .065) in patients with IBD when compared with healthy control subjects. In multivariable analyses controlling for IBD status, poorer emotional functioning and spiritual well-being were associated with lower TTO (R(2)=0.17) and lower SG (R(2)=0.22) scores. CONCLUSION: Direct utility assessment in adolescents with or without IBD is feasible and may be used to assess outcomes. Adolescents with IBD value their health state highly, although less so than healthy control subjects. Emotional functioning and spiritual well-being appear to influence utility scores most strongly.

Religious/Spiritual coping in adolescents with sickle cell disease: a pilot study.

Religious/spiritual (R/S) coping has been associated with health outcomes in chronically ill adults; however, little is known about how adolescents use R/S to cope with a chronic illness such as sickle cell disease (SCD). Using a mixed method approach (quantitative surveys and qualitative interviews), we examined R/S coping, spirituality, and health-related quality of life in 48 adolescents with SCD and 42 parents of adolescents with SCD. Adolescents reported high rates of religious attendance and belief in God, prayed often, and had high levels of spirituality (eg, finding meaning/peace in their lives and deriving comfort from faith). Thirty-five percent of adolescents reported praying once or more a day for symptom management. The most common positive R/S coping strategies used by adolescents were: "Asked forgiveness for my sins" (73% of surveys) and "Sought God's love and care" (73% of surveys). Most parents used R/S coping strategies to cope with their child's illness. R/S coping was not significantly associated with HRQOL (P=NS). R/S coping, particularly prayer, was relevant for adolescents with SCD and their parents. Future studies should assess adolescents' preferences for discussing R/S in the medical setting and whether R/S coping is related to HRQOL in larger samples.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

How do patients with HIV/AIDS understand and respond to health value questions?

BACKGROUND: Utility assessment involves assigning values to experienced or unfamiliar health states. Pivotal to utility assessment, then, is how one conceptualizes health states such as "current health" and "perfect health." The purpose of this study was to ascertain how patients with HIV think about and value health and health states. METHODS: We conducted open-ended in-depth interviews with 32 patients with HIV infection purposefully sampled from a multicenter study of quality of life in HIV. After undergoing computer-assisted utility assessment using the rating scale, time tradeoff, and standard gamble methods, patients were asked how they thought about the utility tasks and about the terms "current health" and "perfect health." RESULTS: Patients understood the health valuation tasks but conceptualized health states in different ways. Many patients believed that "perfect health" was a mythical health state, and some questioned whether it was even desirable. "Current health" was variably interpreted as the status quo; deteriorating over time; or potentially improving with the hope of a cure. CONCLUSION: Patients with HIV infection vary in the way they conceptualize health states central to utility assessment, such as perfect health and current health. Better understanding of these issues could make important methodologic and policy-level contributions.

Religion, spirituality, and depressive symptoms in patients with HIV/AIDS.

BACKGROUND: Depression has been linked to immune function and mortality in patients with chronic illnesses. Factors such as poorer spiritual well-being has been linked to increased risk for depression and other mood disorders in patients with HIV. OBJECTIVE: We sought to determine how specific dimensions of religion, spirituality, and other factors relate to depressive symptoms in a contemporary, multi-center cohort of patients with HIV/AIDS. DESIGN: Patients were recruited from 4 medical centers in 3 cities in 2002 to 2003, and trained interviewers administered the questionnaires. The level of depressive symptoms was measured with the 10-item Center for Epidemiologic Studies Depression (CESD-10) Scale. Independent variables included socio-demographics, clinical information, 8 dimensions of health status and concerns, symptoms, social support, risk attitudes, self-esteem, spirituality, religious affiliation, religiosity, and religious coping. We examined the bivariate and multivariable associations of religiosity, spirituality, and depressive symptoms. MEASUREMENTS AND MAIN RESULTS: We collected data from 450 subjects. Their mean (SD) age was 43.8 (8.4) years; 387 (86.0%) were male; 204 (45.3%) were white; and their mean CD4 count was 420.5 (301.0). Two hundred forty-one (53.6%) fit the criteria for significant depressive symptoms (CESD-10 score > or = 10). In multivariable analyses, having greater health worries, less comfort with how one contracted HIV, more HIV-related symptoms, less social support, and lower spiritual well-being was associated with significant depressive symptoms (P<.05). CONCLUSION: A majority of patients with HIV reported having significant depressive symptoms. Poorer health status and perceptions, less social support, and lower spiritual well-being were related to significant depressive symptoms, while personal religiosity and having a religious affiliation was not associated when controlling for other factors. Helping to address the spiritual needs of patients in the medical or community setting may be one way to decrease depressive symptoms in patients with HIV/AIDS.

Health-related quality of life in veterans and nonveterans with HIV/AIDS.

PURPOSE: To compare health-related quality of life (HRQoL) between patients receiving care in Veterans Administration (VA) settings (veterans) and non-VA settings (nonveterans), and to explore determinants of HRQoL and change in HRQoL over time in subjects living with HIV/AIDS. SUBJECTS: One hundred veterans and 350 nonveterans with HIV/AIDS from 2 VA and 2 university-based sites in 3 cities interviewed in 2002 to 2003 and again 12 to 18 months later. METHODS: We assessed health status (functional status and symptom bother), health ratings, and health values (time tradeoff [TTO] and standard gamble [SG] utilities). We also explored bivariate and multivariable associations of HRQoL measures with a number of demographic, clinical, spiritual/religious, and psychosocial characteristics. RESULTS: Compared with nonveterans, the veteran population was older (47.7 vs 42.0 years) and consisted of a higher proportion of males (97% vs 83%), of participants with a history of injection drug use (23% vs 15%), and of subjects with unstable housing situations (14% vs 6%; P<.05 for all comparisons). On scales ranging from 0 (worst) to 100 (best), veterans reported significantly poorer overall function (mean [SD]; 65.9 [17.2] vs 71.9 [16.8]); lower rating scale scores (67.6 [21.7] vs 73.5 [21.0]), lower TTO values (75.7 [37.4] vs 89.0 [23.2]), and lower SG values (75.0 [35.8] vs 83.2 [28.3]) than nonveterans (P<.05 for all comparisons); however, in multivariable models, veteran status was only a significant determinant of SG and TTO values at baseline. Among other determinants that were associated with multiple HRQoL outcomes in baseline and follow-up multivariable analyses were: symptom bother, overall function, religiosity/spirituality, depressive symptoms, and financial worries. CONCLUSIONS: Veterans reported significantly poorer HRQoL than nonveterans, but when controlling for other factors, veteran status was only a significant determinant of TTO and SG health values at baseline. Correlates of HRQoL such as symptom bother, spirituality/religiosity, and depressive symptoms could be fruitful potential targets for interventions to improve HRQoL in patients with HIV/AIDS.

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 (FEV1). 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 FEV1 was 71.6% (25.6%) of predicted. There were no statistically significant gender differences in age or FEV1. In univariate analyses, females reported significantly poorer HRQOL in 5 of the 12 domains. In multivariable analyses controlling for FEV1 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.

Religion, spirituality, and depressive symptoms in primary care house officers.

OBJECTIVE: The arduous nature of residency training places house officers at risk for depression. We sought to determine the prevalence of depressive symptoms in pediatric (PED), internal medicine (IM), family medicine (FM), and combined internal medicine-pediatric (IMPED) house staff, and spiritual/religious factors that are associated with prevalence of depressive symptoms. METHODS: PED, IM, FM, and IMPED residents at a major teaching program were asked to complete a questionnaire during their In-Training Examination. Depressive symptoms were measured with the 10-item Center for Epidemiologic Studies Depression Scale. Independent variables included demographics, residency program type, postgraduate level, current rotation, health status, religious affiliation, religiosity, religious coping, and spirituality. RESULTS: We collected data from 227 subjects. Their mean (SD) age was 28.7 (3.8) years; 131 (58%) were women; 167 (74%) were white; and 112 (49%) were PED, 62 (27%) were IM, 27 (12%) were FM, and 26 (12%) were IMPED residents. Fifty-seven house officers (25%) met the criteria for having significant depressive symptoms. Having depressive symptoms was significantly associated (P< .05) with residency program type, inpatient rotation status, poorer health status, poorer religious coping, and worse spiritual well-being. In multivariable analyses, having significant depressive symptoms was associated with program type, poorer religious coping, greater spiritual support seeking, and worse spiritual well-being. CONCLUSIONS: Depressive symptoms are prevalent among house officers and are associated with certain residency program types and with residents' spiritual and religious characteristics. Identifying residents with depressive symptoms and potentially attending to their spiritual needs may improve their well-being.

Beliefs of primary care residents regarding spirituality and religion in clinical encounters with patients: a study at a midwestern U.S. teaching institution.

PURPOSE: To assess primary care residents' beliefs regarding the role of spirituality and religion in the clinical encounter with patients. METHOD: In 2003, at a major midwestern U.S. teaching institution, 247 primary care residents were administered a questionnaire adapted from that used in the Religion and Spirituality in the Medical Encounter Study to assess whether primary care house officers feel they should discuss religious and spiritual issues with patients, pray with patients, or both, and whether personal characteristics of residents, including their own spiritual well-being, religiosity, and tendency to use spiritual and religious coping mechanisms, are related to their sentiments regarding spirituality and religion in health care. Simple descriptive, univariate, and two types of multivariable analyses were performed. RESULTS: Data were collected from 227 residents (92%) in internal medicine, pediatrics, internal medicine/pediatrics, and family medicine. One hundred four (46%) respondents felt that they should play a role in patients' spiritual or religious lives. In multivariable analysis, this sentiment was associated with greater frequency of participating in organized religious activity (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.20-1.99), a higher level of personal spirituality (OR 1.05, 95% CI 1.02-1.08), and older resident age (OR 1.11, 95% CI 1.02-1.21; C-statistic 0.76). In general, advocating spiritual and religious involvement was most often associated with high personal levels of spiritual and religious coping and with the family medicine training program. Residents were more likely to agree with incorporating spirituality and religion into patient encounters as the gravity of the patient's condition increased (p < .0001). CONCLUSIONS: Approximately half of primary care residents felt that they should play a role in their patients' spiritual or religious lives. Residents' agreement with specific spiritual and religious activities depended on both the patient's condition and the resident's personal characteristics.

Impact of HIV/AIDS on care and outcomes of severe sepsis.

INTRODUCTION: There has been dramatic improvement in survival for patients with HIV/AIDS; however, some studies on patients with HIV/AIDS and serious illness have reported continued low rates of intensive care. The purpose of this study was to examine patterns of care and outcomes for patients with severe sepsis and HIV/AIDS and compare them with those of patients with severe sepsis without HIV/AIDS. METHODS: We assessed data from all 1999 discharge abstracts from all non-federal hospitals in six US states. Patient demographic characteristics, discharge diagnoses, resource use, and outcomes were extracted. Analyses were performed using chi-square, Wilcoxon rank sum, or regression techniques, as appropriate. RESULTS: We identified 74,020 patients with severe sepsis (7,638 (10.3%) had HIV/AIDS) using ICD-9-CM codes. Patients with severe sepsis and HIV/AIDS had a similar mean length of stay (16.9 days versus 17.7 days; p = 0.0669), had lower mean hospitalization cost (24,382 dollars versus 30,537 dollars; p < 0.0001), were less likely to be admitted to the intensive care unit (37% versus 56%; p < 0.0001), and had a greater mortality (29% versus 20%; p < 0.0001) than those without HIV/AIDS. After adjustment for cohort differences, patients with severe sepsis and HIV/AIDS had increased likelihood of death (OR (95% CI) = 2.41 (2.23-2.61)) and were substantially less likely to be admitted to the intensive care unit (OR (95% CI) = 0.54 (0.51-0.59)). When compared with those with severe sepsis and HIV/AIDS, patients with severe sepsis without HIV/AIDS were universally more likely to be admitted to the intensive care unit, even when they had comorbid illnesses with equal or worse expected in-hospital mortality (e.g., metastatic cancer). CONCLUSION: For patients with severe sepsis, there are differences in care and outcomes for those with HIV/AIDS. Further research is needed to examine the delivery of care for patients with severe sepsis and HIV/AIDS.

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 dollars (7600 dollars, 20,000 dollars) 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.

The impact of expected HIV transmission rates on the effectiveness and cost of ruling out HIV infection in infants.

OBJECTIVE: To quantify the costs and effectiveness of different strategies for ruling out HIV infection in infants born to HIV-infected mothers in the United States. METHODS: The authors assessed 4 different testing strategies that incorporated serial HIV DNA polymerase chain reaction (PCR) testing with or without enzyme-linked immunosorbent assay (ELISA) antibody testing. Testing costs, false reassurance rates, and incremental cost-effectiveness ratios were compared for the 4 strategies. RESULTS: In HIV-exposed infants, HIV DNA PCR testing at birth, 1 month, and 4 months of age results in a false reassurance rate of 21 per million (at a 2% transmission rate). Adding an ELISA test lowers the false reassurance rate to 0.052 per million at a cost of $570,000 per additional case detected; adding another PCR lowers the false reassurance rate to 1.49 per million at a cost of $720,000 per additional case detected compared with the 3-PCR strategy. At a high transmission rate (20%), there would be substantially more erroneously negative results (false reassurance rate is 256 per million with PCR testing at birth, 1 month, and 4 months) and consequently more favorable cost-effectiveness ratios with additional testing: $47,000 per additional case detected by adding 1 ELISA test and $59,000 per additional case detected by adding another PCR test. CONCLUSIONS: False-negative HIV results after serial testing in exposed infants are rare, and the incremental cost-effectiveness ratios of additional tests are substantial at low transmission rates. However, the false reassurance rate increases considerably with a 3-PCR strategy and additional testing becomes more cost-effective at greater transmission rates; therefore, additional testing may be warranted in infants at greater risk of infection.

Utilities derived from visual analog scale scores in patients with HIV/AIDS.

BACKGROUND: Visual analog scale (VAS) scores are used as global quality-of-life indicators and, unlike true utilities (which assess the desirability of health states v. an external metric), are often collected in HIV-related clinical trials. The purpose of this study was to derive and evaluate transformations relating aggregate VAS scores to utilities for current health in patients with HIV/AIDS. METHODS: HIV-specific transformations were developed using linear and nonlinear regression to attain models that best fit mean VAS and standard gamble (SG) utility values directly derived from 299 patients with HIV/AIDS participating in a multicenter study of health values. The authors evaluated the transformations using VAS and SG utility values derived directly from patients in other HIV/AIDS studies. Derived transformations were also compared with published transformations. RESULTS: A simple linear transformation was derived (u = 0.44v + 0.49), as was the exponent for a curvilinear model (u = 1 - [1 - v]1.6), where u = the sample mean utility and v the sample mean VAS score. The curvilinear transformation predicted values within 0.10 of the actual SG utility in 5 of 8 estimates and within 0.05 in 3 of 8 estimates (absolute error ranged from -0.01 to +0.21). The linear transformation performed somewhat better, predicting within 0.10 of the actual SG value in 6 of 8 cases and within 0.05 in 5 of 8 estimates (absolute error ranged from -0.05 to +0.13). An alternative linear model (u = v + 0.018) derived from the literature performed similarly to our linear model (7 of 8 predictions within 0.10, 1 of 8 estimates within 0.05, and absolute error ranging from -0.15 to +0.10), whereas an alternative published curvilinear model (u = 1 - [1 - v]2.3) performed the least well (2 of 8 estimates within 0.10 of the actual values and no estimates within 0.05). CONCLUSIONS: Predicted utilities are a reasonable alternative for use in HIV/AIDS decision analyses and cost-effectiveness analyses. Linear transformations performed better than curvilinear transformations in this context and can be used to convert aggregate VAS scores to aggregate SG values in large HIV/AIDS studies that collect VAS data but not utilities.