The cost of love: financial consequences of insecure attachment in antisocial youth.

BACKGROUND: Knowing that your parent or caregiver will be there for you in times of emotional need and distress is a core aspect of the human experience of feeling loved and being securely attached. In contrast, an insecure attachment pattern is found in many antisocial youth and is related to less sensitive caregiving. Such youth are often distrustful of adults and authority figures, and are at high risk of poor outcomes. As they become adults, they require extensive health, social and economic support, costing society ten times more than their well-adjusted peers. However, it is not known whether insecure attachment itself is associated with higher costs in at-risk youth, independently of potential confounders, nor whether cost differences are already beginning to emerge early in adolescence. METHODS: Sample: A total of 174 young people followed up aged 9-17 years (mean 12.1, SD 1.8): 85 recruited with moderate antisocial behaviour (80th percentile) from a school screen aged 4-6 years; 89 clinically referred with very high antisocial behaviour (98th percentile) aged 3-7 years. MEASURES: Costs by detailed health economic and service-use interview; attachment security to mother and father from interview; diagnostic interviews for oppositional and conduct problems; self-reported delinquent behaviour. RESULTS: Costs were greater for youth insecurely attached to their mothers (secure £6,743, insecure £10,199, p = .001) and more so to fathers (secure £1,353, insecure £13,978, p < .001). These differences remained significant (mother p = .019, father p < .001) after adjusting for confounders, notably family income and education, intelligence and antisocial behaviour severity. CONCLUSIONS: Attachment insecurity is a significant predictor of public cost in at-risk youth, even after accounting for covariates. Since adolescent attachment security is influenced by caregiving quality earlier in childhood, these findings add support to the public health case for early parenting interventions to improve child outcomes and reduce the financial burden on society.

Militaries and global health: peace, conflict, and disaster response.

Many countries show a growing willingness to use militaries in support of global health efforts. This Series paper summarises the varied roles, responsibilities, and approaches of militaries in global health, drawing on examples and case studies across peacetime, conflict, and disaster response environments. Militaries have many capabilities applicable to global health, ranging from research, surveillance, and medical expertise to rapidly deployable, large-scale assets for logistics, transportation, and security. Despite this large range of capabilities, militaries also have limitations when engaging in global health activities. Militaries focus on strategic, operational, and tactical objectives that support their security and defence missions, which can conflict with humanitarian and global health equity objectives. Guidelines-both within and outside militaries-for military engagement in global health are often lacking, as are structured opportunities for military and civilian organisations to engage one another. We summarise policies that can help close the gap between military and civilian actors to catalyse the contributions of all participants to enhance global health.

Reducing Metabolic Syndrome Risk Using a Personalized Wellness Program.

OBJECTIVE: The aim of this study was to determine the impact of a targeted, personalized wellness program on reducing employees' future risk of metabolic syndrome. METHODS: Aetna piloted a year-long program that included a limited genetic profile, a traditional psychosocial assessment, and high-intensity coaching in a randomized controlled study of Aetna employees with an increased risk for metabolic syndrome. RESULTS: Sustained employee engagement of 50% over the course of 1 year; 76% of participating employees lost an average of 10 pounds (4.5 kg) (P < 0.001 vs baseline weight), and there were trends in improved clinical outcomes relative to three of five metabolic factors. Average health care costs were reduced by $122 per participant per month, resulting in a positive return on investment in the program's first year. CONCLUSIONS: At scale, such programs would be expected to lead to significant downstream reduction in major clinical events and costs.

Novel predictive models for metabolic syndrome risk: a "big data" analytic approach.

OBJECTIVES: We applied a proprietary "big data" analytic platform--Reverse Engineering and Forward Simulation (REFS)--to dimensions of metabolic syndrome extracted from a large data set compiled from Aetna's databases for 1 large national customer. Our goals were to accurately predict subsequent risk of metabolic syndrome and its various factors on both a population and individual level. STUDY DESIGN: The study data set included demographic, medical claim, pharmacy claim, laboratory test, and biometric screening results for 36,944 individuals. The platform reverse-engineered functional models of systems from diverse and large data sources and provided a simulation framework for insight generation. METHODS: The platform interrogated data sets from the results of 2 Comprehensive Metabolic Syndrome Screenings (CMSSs) as well as complete coverage records; complete data from medical claims, pharmacy claims, and lab results for 2010 and 2011; and responses to health risk assessment questions. RESULTS: The platform predicted subsequent risk of metabolic syndrome, both overall and by risk factor, on population and individual levels, with ROC/AUC varying from 0.80 to 0.88. We demonstrated that improving waist circumference and blood glucose yielded the largest benefits on subsequent risk and medical costs. We also showed that adherence to prescribed medications and, particularly, adherence to routine scheduled outpatient doctor visits, reduced subsequent risk. CONCLUSIONS: The platform generated individualized insights using available heterogeneous data within 3 months. The accuracy and short speed to insight with this type of analytic platform allowed Aetna to develop targeted cost-effective care management programs for individuals with or at risk for metabolic syndrome.

The multiple meanings of global health governance: a call for conceptual clarity.

BACKGROUND: The term global health governance (GHG) is now widely used, with over one thousand works published in the scholarly literature, almost all since 2002. Amid this rapid growth there is considerable variation in how the term is defined and applied, generating confusion as to the boundaries of the subject, the perceived problems in practice, and the goals to be achieved through institutional reform. METHODOLOGY: This paper is based on the results of a separate scoping study of peer reviewed GHG research from 1990 onwards which undertook keyword searches of public health and social science databases. Additional works, notably books, book chapters and scholarly articles, not currently indexed, were identified through Web of Science citation searches. After removing duplicates, book reviews, commentaries and editorials, we reviewed the remaining 250 scholarly works in terms of how the concept of GHG is applied. More specifically, we identify what is claimed as constituting GHG, how it is problematised, the institutional features of GHG, and what forms and functions are deemed ideal. RESULTS: After examining the broader notion of global governance and increasingly ubiquitous term "global health", the paper identifies three ontological variations in GHG scholarship - the scope of institutional arrangements, strengths and weaknesses of existing institutions, and the ideal form and function of GHG. This has produced three common, yet distinct, meanings of GHG that have emerged - globalisation and health governance, global governance and health, and governance for global health. CONCLUSIONS: There is a need to clarify ontological and definitional distinctions in GHG scholarship and practice, and be critically reflexive of their normative underpinnings. This will enable greater precision in describing existing institutional arrangements, as well as serve as a prerequisite for a fuller debate about the desired nature of GHG.

Non-physician-led exercise stress testing is a safe and effective practice.

Exercise stress testing is a non-invasive procedure that provides diagnostic and prognostic information for the evaluation of several pathologies, including arrhythmia provocation, assessment of exercise capacity, and coronary heart disease. Historically, exercise tests were directly supervised by physicians; however, cost-containment issues and time constraints on physicians have encouraged the use of health professionals with specific training and experience to supervise selected exercise stress tests. Evidence suggests that non-physician-led exercise stress testing is a safe and effective practice with similar morbidity and mortality rates as those performed or supervised by a physician.

Framing global health: the governance challenge.

With the emergence of global health comes governance challenges which are equally global in nature. This article identifies some of the initial limitations in analyses of global health governance (GHG) before discussing the focus of this special supplement: the framing of global health issues and the manner in which this impacts upon GHG. Whilst not denying the importance of material factors (such as resources and institutional competencies), the article identifies how issues can be framed in different ways, thereby creating particular pathways of response which in turn affect the potential for and nature of GHG. It also identifies and discusses the key frames operating in global health: evidence-based medicine, human rights, security, economics and development.

The securitisation of pandemic influenza: framing, security and public policy.

This article examines how pandemic influenza has been framed as a security issue, threatening the functioning of both state and society, and the policy responses to this framing. Pandemic influenza has long been recognised as a threat to human health. Despite this, for much of the twentieth century it was not recognised as a security threat. In the decade surrounding the new millennium, however, the disease was successfully securitised with profound implications for public policy. This article addresses the construction of pandemic influenza as a threat. Drawing on the work of the Copenhagen School, it examines how it was successfully securitised at the turn of the millennium and with what consequences for public policy.

Exercise training in recently hospitalized heart failure patients enrolled in a disease management programme: design of the EJECTION-HF randomized controlled trial.

AIMS: The Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly-discharged Heart Failure (EJECTION-HF) study will evaluate the impact of a supervised exercise training programme (ETP) on clinical outcomes in recently hospitalized heart failure patients attending a disease management programme (DMP). Methods This multisite, pragmatic randomized controlled trial enrols patients discharged from participating hospitals with clinical evidence of heart failure who are willing and able to participate in a DMP and considered clinically safe to exercise. Enrolment includes participants with impaired and preserved left ventricular systolic function. Baseline assessment and programme commencement occur within 6 weeks of hospital discharge. The control group DMP includes individualized education and follow-up from a multidisciplinary heart failure team; a weekly education programme for 12 weeks; self-management advice; and medical follow-up. Home exercise is recommended for all participants. In addition, intervention participants are offered 36 supervised, structured gym-based 1 h exercise sessions over 24 weeks. Sessions are tailored to exercise capacity and include aerobic, resistance, and balance exercises. Enrolment target is 350 participants. Primary outcome is 12-month mortality and readmissions. Secondary outcomes include blinded evaluation of depressive symptoms, sleep quality, cognition, and functional status (activities of daily living, 6 min walk distance, grip strength) at 3 and 6 months. A cost-utility analysis will be conducted. CONCLUSION: This study will enrol a representative group of hospitalized heart failure patients and measure a range of patient and health service outcomes to inform the design of post-hospital DMPs for heart failure. Enrolment will be completed in 2013. ACTRN12608000263392.

The evolution of chest pain pathways.

Patients presenting to the emergency department with chest pain require prompt identification and referral, as early treatment of patients with an acute coronary syndrome (ACS) is crucial to decrease morbidity and mortality (Steurer et al, Emerg Med J. 2010;27:896-902). Although rule-in ACS is critical and time dependant, other difficulties arise during the rule-out ACS process (Steurer et al, Emerg Med J. 2010;27:896-902). Inappropriate discharge of patients with misdiagnosed acute myocardial infarction is associated with significant morbidity and mortality. Concerns relating to inappropriate discharge result in readmission with resultant lengthy hospital stays, high costs, and contribute to overcrowding and bed block (Amsterdam et al, J Am Coll Cardiol. 2002;40:251-256; Cardiol Clin. 2005;23:503-516; Furtado et al, Emerg Med. In press; Karlson, Am J Cardiol. 1991;68:171-175; Ng et al, Am J Cardiol. 2001;88:611-617; Ramakrishna et al, Mayo Clin Proc. 2005;80:322-329; Stowers, Crit Pathw Cardiol. 2003;2:88-94). The challenge of chest pain diagnosis has led to a number of associated problems within the health care system. The growing need for improvements in consistency of patient care, resource efficiency, and quality of patient healthcare has led to the development of chest pain pathways (Erhardt et al, Eur Heart J. 2002;23:1153-1176). The development and implementation of chest pain pathways is not without difficulties. These may arise from differences in the management approaches of health practitioners, poor adherence to guidelines, and concerns for costs. New procedures such as new cardiac injury markers, stress testing, and specialized chest pain units have led to a reduction in admission rates and length of stay, reduced costs, and a reduction of inappropriate discharge of patients with ischemic heart disease.