The Cost of Blindness in the Republic of Ireland 2010-2020.

Aims. To estimate the prevalence of blindness in the Republic of Ireland and the associated financial and total economic cost between 2010 and 2020. Methods. Estimates for the prevalence of blindness in the Republic of Ireland were based on blindness registration data from the National Council for the Blind of Ireland. Estimates for the financial and total economic cost of blindness were based on the sum of direct and indirect healthcare and nonhealthcare costs. Results. We estimate that there were 12,995 blind individuals in Ireland in 2010 and in 2020 there will be 17,997. We estimate that the financial and total economic costs of blindness in the Republic of Ireland in 2010 were €276.6 million and €809 million, respectively, and will increase in 2020 to €367 million and €1.1 billion, respectively. Conclusions. Here, ninety-eight percent of the cost of blindness is borne by the Departments of Social Protection and Finance and not by the Department of Health as might initially be expected. Cost of illness studies should play a role in public policy making as they help to quantify the indirect or "hidden" costs of disability and so help to reveal the true cost of illness.

Pharmacogenomic information in FDA-approved drug labels: Application to pediatric patients.

Pharmacogenomic (PGx) information is increasingly being incorporated into US Food and Drug Administration-approved drug labels. We reviewed the data source (adults vs. pediatrics) of PGx information in approved drug labels and assessed the suitability of applying adult-derived PGx information and related prescribing recommendations to the care of pediatric patients. We identified 65 drugs with labels containing PGx information and that have also been evaluated in children and found that in the majority of cases (56/65, 86%), the PGx information described was derived from adult studies. The application of PGx information from adults to pediatrics was deemed suitable for 71.4% (n = 40) of the drugs and unclear for 28.6% (n = 16). An ontogeny effect, limited or conflicting data regarding ontogeny of the genetic biomarker, or a difference in the pathophysiology or progression of the adult vs. pediatric disease were the primary reasons for deeming direct application from adults to pediatrics unclear.

Utilization of stored autologous PBSCs to support second autologous transplantation in multiple myeloma patients in the era of novel agent therapy.

Outcomes in multiple myeloma (MM) have improved significantly with novel agent therapy and autologous stem cell transplantation (ASCT). ASCTs are typically planned as either tandem or a single transplant with additional stored PBSCs available for a second salvage transplant. To accommodate these strategies, many centers routinely collect and store adequate PBSCs for two ASCTs. We analyzed the cost associated with this practice by determining the expenses of PBSC collection, cryopreservation and storage, and the ultimate use of additional cryopreserved PBSCs in patients who had undergone at least one ASCT. There were 889 MM patients transplanted between 1993 and 2011 at our center. Most (N=726) had residual PBSCs in storage after their first ASCT (ASCT1). Only 135 patients underwent a second ASCT within a median of 14 months after ASCT1. The percentage of patients receiving a second ASCT declined over time. The resources required to collect and store unused PBSCs added up to 336 extra patient days of apheresis and 41 587 extra patient months of cryopreservation, translating into an average extra cost per patient of US$4981.12. A reconsideration of conventional PBSC collection and storage practices would save significant cost for the majority of MM patients who never undergo a second ASCT.

Physiological assessment of the effects of changing water levels associated with reservoir management on fattening rates of neotropical migrants at a stopover site.

Riparian habitat makes up a small fraction of the landscape but provides important stopover habitat for migratory birds. Hydroelectric dam operations cause fluctuations in water levels that can change the amount or quality of riparian habitat, which in turn might affect potential fattening rates of migrant birds. Here we used plasma metabolite analysis to estimate variation in fattening rate in relationship to variable water levels associated with reservoir management in four species of neotropical migratory songbirds using riparian habitat at a dam-impacted stopover site in Revelstoke, British Columbia, Canada. Residual plasma triglyceride, our measure of estimated fattening rate, varied systematically with time of day and Julian date and varied consistently among species, but did not vary with age or sex. Controlling for potentially confounding variables, we found no inter-annual variation in estimated fattening rate, even though there were marked differences in water levels among years. Likewise, there was no relationship between daily variation in water levels and estimated fattening rate. Data on feather isotopes (δD), indicative of migratory origin, did not add explanatory power to our models. There was inter-annual variation in plasma glycerol and ß-hydroxybutyrate levels and significant, though weak, relationships between these metabolites and water level (higher metabolite levels when drier) that might indicate effects on 'body condition' independent of fattening rate. Our study suggests that, at present, although hydroelectric dam operations influence water levels in the Arrows Lake Reservoir and adjacent riparian habitats, this does not significantly impact fattening rates of migratory passerines using these habitats.

Factors associated with primary care prescription of opioids for joint pain.

BACKGROUND: Opioids are commonly prescribed in primary care and can offer pain relief but may also have adverse effects. Little is known about the characteristics of people likely to receive an opioid prescription in primary care. The aim is to identify what factors are associated with primary care prescribing of high-strength analgesics in a community sample of older people with joint pain. METHODS: A prospective two-stage postal survey completed at baseline and 3-year follow-up in a population aged 50 and over registered with eight general practitioner (GP) practices in North Staffordshire (North Staffordshire Osteoarthritis Project cohorts) linked with data from medical records. Participants were selected who reported joint pain in one or more joints at baseline. Outcome measures were the number of prescriptions for high-strength pain medication (opioids) in the following 3 years. Socio-demographic and health status factors associated with prescription were assessed using a zero-inflated Poisson model. RESULTS: 873 (19%) people were prescribed opioids (out of 4652 providing complete data) ranging from 1 to 76 prescriptions over 3 years. Baseline factors significantly associated with increased rates of prescription were younger age group [65-74 group: incidence rate ratio (IRR) = 1.26 (1.18-1.35)], male gender [IRR = 1.17 (1.12-1.23)], severe joint pain [IRR = 1.19 (1.12-1.26)] poor physical function [IRR = 0.99 (0.99-0.99)] and lower frequency of alcohol consumption [once/twice a year: IRR = 1.13 (1.06-1.21), never: IRR = 1.14 (1.06-1.22)]. Restricting the analysis to those without prior prescriptions for strong opioids showed similar results. CONCLUSION: Poor physical function and participation restrictions were strongly associated with prescriptions of stronger opioids in addition to several socio-demographic and lifestyle factors. Given the uncertainties over the effectiveness and risks of opioid use, future research could investigate decision making of GPs, exploring reasons for prescribing them.

Longitudinal assessment of fibrinogen in relation to subclinical cardiovascular disease: the CARDIA study.

OBJECTIVE: To examine the strength of the associations of fibrinogen with subclinical atherosclerosis in healthy persons. METHODS: A population-based, prospective, observational study of black and white men and women (Coronary Artery Risk Development in Young Adults [CARDIA]). Fibrinogen levels were measured at year 7 (ages 25-37, n = 2969), and again at year 20 (ages 38-50, n = 2832). Measures of subclinical atherosclerosis (coronary artery calcification [CAC] and carotid intimal-medial thickness [CIMT]) were recorded at year 20. RESULTS: Over the 13-year study interval (1992-1993 to 2005-2006), fibrinogen rose from a mean of 3.32 to 4.05 g L(-1). After adjusting for age, gender and race, fibrinogen was positively associated with greater incidence of CAC and increased CIMT cross-sectionally as well as after 13 years of follow-up (all P-trend < 0.001). After further adjustment for field center, BMI, smoking, education, systolic blood pressure, diabetes, antihypertensive medication use, total and HDL cholesterol, and CRP, significant positive relationships between fibrinogen and incidence of CAC remained for the total cohort longitudinally (P-trend = 0.037), but not cross-sectionally (P-trend = 0.147). CONCLUSION: This 13-year study demonstrates that higher levels of fibrinogen during young adulthood are positively associated with incidence of CAC and increased CIMT in middle-age, but the strength of the association declines with increasing age.

How contraceptive use patterns differ by pregnancy intention: implications for counseling.

To increase awareness of issues to include in contraceptive counseling-the objectives of this study were to evaluate: 1) how contraceptive use patterns (eg, non-use), level of effectiveness of contraceptive method, and sociodemographic characteristics may be associated with the occurrence of unintended pregnancy; 2) patterns of health care use for women with intended and unintended pregnancy; and 3) the association between contraceptive use patterns and sociodemographic characteristics. In-person interviews were conducted with 279 women enrolled in a Medicaid managed care health plan who had been pregnant in the last 5 years. Self-reported measures of pregnancy intention, contraceptive use, and health care use were collected. The relationships of pregnancy intention with contraceptive use patterns, level of effectiveness of contraceptive method used, and patterns of recent health care use were assessed. Differences in contraceptive use patterns by sociodemographic groups were assessed. Seventy-eight percent of women reported an unintended pregnancy. Non-use of birth control the month before conception was reported by 57% of women with unintended pregnancies and 84% of women with intended pregnancies. Use of birth control of low effectiveness was reported by 20% of women with unintended pregnancies and 8% of women with intended pregnancies. Non-use or use of contraceptive methods of low effectiveness did not differ for women in different sociodemographic groups regardless of pregnancy intention status. A majority of women reported recent health care use. Health care providers should be aware that women who have no intention for pregnancy may not be using an effective contraceptive method NOR have an effective pattern of contraceptive use.

Physician incentives and disclosure of payment methods to patients.

OBJECTIVE: There is increasing public discussion of the value of disclosing how physicians are paid. However, little is known about patients' awareness of and interest in physician payment information or its potential impact on patients' evaluation of their care. DESIGN: Cross-sectional survey SETTING: Managed care and indemnity plans of a large, national health insurer. PARTICIPANTS: Telephone interviews were conducted with 2,086 adult patients in Atlanta, Ga; Baltimore, Md/Washington DC; and Orlando, Fla (response rate, 54%). MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to assess perceptions of their physicians' payment method, preference for disclosure, and perceived effect of different financial incentives on quality of care. Non-managed fee-for-service patients (44%) were more likely to correctly identify how their physicians were paid than those with salaried (32%) or capitated (16%) physicians. Just over half (54%) wanted to be informed about their physicians' payment METHOD: Patients of capitated and salaried physicians were as likely to want disclosure as patients of fee-for-service physicians. College graduates were more likely to prefer disclosure than other patients. Many patients (76%) thought a bonus paid for ordering fewer than the average number of tests would adversely affect the quality of their care. About half of the patients (53%) thought a particular type of withhold would adversely affect the quality of their care. White patients, college graduates, and those who had higher incomes were more likely to think that these types of bonuses and withholds would have a negative impact on their care. Among patients who believed that these types of bonuses adversely affected care, those with non-managed fee-for-service insurance and college graduates were more willing to pay a higher deductible or co-payment in order to get tests that they thought were necessary. CONCLUSIONS: Most patients were unaware of how their physicians are paid, and only about half wanted to know. Most believed that bonuses or withholds designed to reduce the use of services would adversely affect the quality of their care. Lack of knowledge combined with strong attitudes about various financial incentives suggest that improved patient education could clarify patient understanding of the nature and rationale for different types of incentives. More public discussion of this important topic is warranted.

Referral patterns to a University-based cardiac rehabilitation program.

Referral rates to our cardiac rehabilitation program among patients hospitalized for coronary heart disease were computed over an 18-month period. Only 8.7% of eligible patients were referred, suggesting that more education targeting physicians, patients, and insurers is needed and barriers to participation must be systematically addressed.

Health literacy among Medicare enrollees in a managed care organization.

CONTEXT: Elderly patients may have limited ability to read and comprehend medical information pertinent to their health. OBJECTIVE: To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization. DESIGN: Cross-sectional survey. SETTING: Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla). PARTICIPANTS: A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults. RESULTS: Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years. CONCLUSIONS: Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.

Prenatal care in the first trimester: misleading findings from HEDIS. Health Plan Employer Data and Information Set.

OBJECTIVE: To understand factors influencing Health Plan Employer Data and Information Set (HEDIS) rates for the measure 'Prenatal care in the first trimester'. DESIGN: Telephone survey of a retrospective cohort of women with a live birth. Medical record review of a sample of both responders and non-responders to the telephone survey. Detailed review of HEDIS data collection procedures. SETTING: A managed care plan in California. STUDY PARTICIPANTS: Women aged 18-49 years at date of delivery, who delivered a live birth from 1 October 1995 through 31 March 1996, and who were continuously enrolled in a California managed care plan for 12 months prior to delivery (telephone survey, n= 1,185; medical record review, n= 465). RESULTS: Of the women participating in the telephone survey, 95% indicated that their first prenatal visit occurred during the first 3 months of pregnancy. Using HEDIS 3.0 standards, a review of medical records for a sample of these women indicated that 94% of the women initiated care during the first trimester. These results contrasted sharply with 1995 and 1996 HEDIS rates of 64% and 75%, respectively. CONCLUSION: An investigation of the discrepancy between HEDIS rates and rates from both telephone survey and medical record review led to the finding that the low HEDIS rates were due not to a true low rate of early care, but to data collection problems, including difficulty obtaining medical records. Potential solutions involving health plan activities, revisions to the official HEDIS process and revised reporting of results are proposed.

The relationship between method of physician payment and patient trust.

CONTEXT: Trust is the cornerstone of the patient-physician relationship. Payment methods that place physicians at financial risk have raised concerns about patients' trust in physicians to act in patients' best interests. OBJECTIVE: To evaluate the extent to which methods of physician payment are related to patient trust. DESIGN: Cross-sectional telephone interview survey done between January and June 1997. SETTING: Health plans of a large national insurer in Atlanta, Ga, the Baltimore, Md-Washington, DC, area, and Orlando, Fla. PARTICIPANTS: A total of 2086 adult managed care and indemnity patients. MAIN OUTCOME MEASURE: A 10-item scale (alpha = .94) assessing patients' trust in physicians. RESULTS: More fee-for-service (FFS) indemnity patients (94%) completely or mostly trust their physicians to "put their health and well-being above keeping down the health plan's costs" than salary (77%), capitated (83%), or FFS managed care patients (85%) (P<.001 for pairwise comparisons). In multivariate analyses that adjusted for potentially confounding factors, FFS indemnity patients also had higher scores on the 10-item trust scale than salary (P<.001), capitated (P<.001), or FFS managed care patients (P<.01). The effects of payment method on patient trust were reduced when a measure based on patients' reports about physician behavior (eg, Does your physician take enough time to answer your questions?) was included in the regression analyses, but the differences remained statistically significant, except for the comparison between FFS managed care and FFS indemnity patients (P=.08). Patients' perceptions of how their physicians were paid were not independently associated with trust, but the 37.7% who said they did not know how their physicians were paid had higher levels of trust than other patients (P<.01). A total of 30.2% of patients were incorrect about their physicians' method of payment. CONCLUSIONS: Most patients trusted their physicians, but FFS indemnity patients have higher levels of trust than salary, capitated, or FFS managed care patients. Patients' reports of physician behavior accounted for part of the variation in patients' trust in physicians who are paid differently. The impact of payment methods on patient trust may be mediated partly by physician behavior.

Effect of duration of treatment on treatment outcome and cost of treatment for Wilms' tumor: a report from the National Wilms' Tumor Study Group.

PURPOSE: National Wilms' Tumor Study (NWTS)-4 was designed to evaluate the efficacy, toxicity, and cost of the administration of different regimens for the treatment of Wilms' tumor (WT). PATIENTS AND METHODS: Between August 6, 1986 and September 1, 1994, 905 previously untreated children aged younger than 16 years with stage II favorable histology (FH) WT (low-risk [LR]), stages III to IV FH WT, or stages I to IV clear-cell sarcoma of the kidney (high-risk[HR]) were randomized after the completion of 6 months of chemotherapy to discontinue (short) or continue for 9 additional months (long) treatment with chemotherapy regimens that included vincristine and either divided-dose (standard [STD]) courses (5 days) or single-dose (pulse-intensive [PI]) treatment with dactinomycin. HR patients also received either divided-dose (STD) courses (3 days) or single-dose (PI) treatment with doxorubicin. RESULTS: The 4-year relapse-free survival (RFS) rates after the second randomization for LR patients were 83.7% for the 190 patients treated with short and 88.2% for the 187 patients treated with long chemotherapy (P = .11). The 4-year RFS rates after the second randomization for HR FH patients were 89.7% for the 256 patients treated with short and 88.8% for the 246 patients treated with long chemotherapy (P = .87). The charge for treatment with the short PI treatment regimens for all children with stages I through IV FH WT was approximately one half of that with the long STD treatment regimens. CONCLUSION: The short administration schedule for the treatment of children with WT is no less effective than the long administration schedule and can be administered at a substantially lower total treatment cost.

Patients' trust in their physicians: effects of choice, continuity, and payment method.

OBJECTIVE: To evaluate the extent to which physician choice, length of patient-physician relationship, and perceived physician payment method predict patients' trust in their physician. DESIGN: Survey of patients of physicians in Atlanta, Georgia. PATIENTS: Subjects were 292 patients aged 18 years and older. MEASUREMENTS AND MAIN RESULTS: Scale of patients' trust in their physician was the main outcome measure. Most patients completely trusted their physicians "to put their needs above all other considerations" (69%). Patients who reported having enough choice of physician (p < .05), a longer relationship with the physician (p < .001), and who trusted their managed care organization (p < .001) were more likely to trust their physician. Approximately two thirds of all respondents did not know the method by which their physician was paid. The majority of patients believed paying a physician each time a test is done rather than a fixed monthly amount would not affect their care (72.4%). However, 40.5% of all respondents believed paying a physician more for ordering fewer than the average number of tests would make their care worse. Of these patients, 53.3% would accept higher copayments to obtain necessary medical tests. CONCLUSIONS: Patients' trust in their physician is related to having a choice of physicians, having a longer relationship with their physician, and trusting their managed care organization. Most patients are unaware of their physician's payment method, but many are concerned about payment methods that might discourage medical use.

Breast and cervical cancer screening interventions: an assessment of the literature.

An extensive body of intervention research to promote breast and cervical cancer screening has accumulated over the last three decades, but its coverage and comprehensiveness have not been assessed. We evaluated published reports of these interventions and propose a framework of critical elements for authors and researchers to use when contributing to this literature. We identified all articles describing breast and cervical cancer screening interventions published between January 1960 and May 1997 in the United States and abstracted specified critical elements in the broad areas of: (a) needs assessment; (b) intervention study design; and (c) analysis methods and study outcomes from each article using a template developed for that purpose. Fifty-eight studies met our criteria for inclusion. Thirty-eight focused exclusively on breast cancer screening, 7 promoted cervical cancer screening, and 13 were designed to promote screening for both cancers. The amount of detail reported varied among the 58 studies. All studies reported the outcome measures used to assess the effectiveness of the intervention, yet only 40% of the studies reported the investigators' original hypotheses or research questions. Needs assessment data were reported in 84% of the studies. Data sources ranged from national surveys to local intervention baseline surveys. Population characteristics reported also varied, with most studies reporting age and race of the study population (78 and 71%, respectively), and fewer studies reporting income and education (53 and 38%, respectively). As the field of behavioral intervention research progressed, we found that more recent studies included and reported many of the parameters we had identified as critical. If this trend continues, it will enhance the reproducibility of studies, enable comparisons between interventions, and provide a reference point for measuring progress in this area. To facilitate this trend toward uniform reporting, we propose an evaluative framework of critical elements for authors to use when developing and reporting their research. The comprehensive assessment of literature that this article provides should be useful background to investigators planning and reporting cancer control interventions, to funding agencies choosing and guiding quality research, and to publishers to help them enhance the quality and utility of their publications.

From lynching to gay bashing: the elusive connection between economic conditions and hate crime.

Trends in bigoted violence are often explained by reference to frustrations arising from macroeconomic downturns. Historical and recent time-series studies have turned up significant links between economic conditions and lynchings of Blacks in the pre-Depression South (e.g., Hepworth & West, 1988; Hovland & Sears, 1940). However, replicating the time-series analyses of lynching, extending them through the Great Depression, and applying similar techniques to contemporary data fail to provide robust evidence of a link between economic performance and intolerant behavior directed against minorities. The authors speculate that the predictive force of macroeconomic fluctuation is undermined by the rapid rate of decay in the frustration-bred aggressive impulse and the absence of prominent political actors affixing economic blame on target groups.

In vivo comparison of Visualix-2 and Ektaspeed Plus in the assessment of periradicular lesion dimensions.

UNLABELLED: Accurate assessment of intraosseous lesion dimensions is useful in determining strategies for treatment of periradicular pathoses of dental causation. OBJECTIVES: To compare the efficacy of digital versus analog imaging for the measurement of mesiodistal and vertical dimensions of periapical lesions in patients that require apical surgery. METHODS: Fourteen examiners assessed the dimensions of 28 lesions with a millimeter ruler and Ektaspeed Plus radiographs (Eastman Kodak, Rochester, N.Y.), and with the Visualix-2 (Gendex/Dentsply, Milan, Italy) in unenhanced, contrast-stretched and equalized modes with proprietary software mouse-driven measurement algorithm. Impregum F (Premier Dental Products) impressions at surgery were used as the "gold standard." Ten randomly chosen images were reread 2 weeks later to assess intra-operator reliability. As the Mauchly sphericity test was significant for all tests, a multivariate analysis of variance was used to assess accuracy. To explain the exact difference between means, the Bonferroni test was applied. Intra-observer reliability was assessed with Friedman's two-way analysis of variance; inter-observer effects were determined with Cronbach's alpha. RESULTS: For accuracy in measurement, the closest to the "gold standard" were achieved with the Visualix-2 with image equalization. The contrast-stretched Visualix-2 and unenhanced Visualix-2 measurements were less accurate; conventional film was consistently the least accurate (p < 0.002). On the other hand, subjective preference placed film radiographs above the unenhanced Visualix-2 images; contrast-stretched Visualix-2 images were preferred over all other modalities. CONCLUSIONS: Charge-coupled device-based images with the Visualix-2 are preferable to film-based radiographs for measuring periapical lesion dimensions.