Implications of cost-effectiveness analyses of lipid-lowering therapies: From the policy-maker's desk to the patient's bedside.

In our increasingly cost-conscious health system, patients, clinicians, hospitals, and payers all agree about the urgent need to rein in runaway healthcare costs. High pharmaceutical costs make drugs unaffordable to many patients who may benefit from them, including some insured patients who face prohibitive out-of-pocket costs. Health systems and payers can use the systematic framework of cost-effectiveness analysis and estimated budgetary impact to prioritize the adoption of new therapies and technologies. In this review article, we discuss basic principles of cost-effectiveness research for practicing clinicians, the concept of cost-effectiveness versus affordability, other considerations relevant to resource allocation, and limitations of cost-effectiveness research. We use the example of lipid lowering therapies to discuss application of cost-effectiveness research in informing health care policy, its use for health care systems and in the development of clinical practice guidelines, and its implications for clinicians and patients. As clinicians and patients become more cognizant of the cost-implications of new therapies, professional societies can help improve the quality of decision-making by incorporating unbiased value statements into their expert guidelines.

Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities.

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

[Treatment structures for men with pedosexual problems]. / Versorgungsstrukturen für Männer mit pädosexueller Problematik.

Pedophilia is defined as a persistent or dominating sexual preference for prepubescent children characterized by persistent thoughts, fantasies, urges, sexual arousal and behavior. Less than 50% of all child abusers fulfill the diagnostic criteria and an even smaller part exclusively has a preference for children. Following psychiatric classification systems, pedophilia must be distinguished from child sexual abuse. Outpatient treatment and treatment in forensic psychiatry clinics, sociotherapeutic facilities and in correction facilities are different aspects of prevention. So-called grey area projects (Dunkelfeldprojekte) are special facilities of primary and secondary prevention. The aim is to prevent sexual abuse by reducing and controlling of risk factors.

[The risk of reoffending, a major concern of the doctor-coordinator]. / Le risque de récidive, une préoccupation majeure du médecin coordonnateur.

Doctor-coordinators are nominated by the judge for the enforcement of sentences as soon as socio-judicial supervision with court-ordered therapy is to be implemented. Their mission is to facilitate the contact between offenders and the general practitioner likely to be working with them on the therapeutic level. The experience of the doctor-coordinator in Bordeaux sheds light on the conditions in which this function is performed. Identifying elements which may be considered as indicators of the risk of reoffending is, in daily practice, a constant concern for this specialist.

Prevention of Anaphylaxis: The Role of the Epinephrine Auto-Injector.

Anaphylaxis is a life-threatening condition, with at-risk individuals remaining at chronic high risk of recurrence. Anaphylaxis is frequently underrecognized and undertreated by healthcare providers. The first-line pharmacologic intervention for anaphylaxis is epinephrine, and guidelines uniformly agree that its prompt administration is vital to prevent progression, improve patient outcomes, and reduce hospitalizations and fatalities. Healthcare costs potentially associated with failure to provide epinephrine (hospitalizations and emergency department visits) generally exceed those of its provision. At-risk patients are prescribed epinephrine auto-injectors to facilitate timely administration in the event of an anaphylactic episode. Despite guideline recommendations that patients carry 2 auto-injectors at all times, a significant proportion of patients fail to do so, with cost of medicine cited as one reason for this lack of adherence. With the increase of high-deductible healthcare plans, patient adherence to recommendations may be further affected by increased cost sharing. The recognition and classification of epinephrine as a preventive medicine by both the US Preventive Services Task Force and insurers could increase patient access, improve outcomes, and save lives.

Community Protection Policies and Repeat Sexual Offenses in Florida.

The purpose of this study was to investigate the impact of sexual offender management policies on sex crime repeat arrest rates in Florida. Aggregate data for the period 1990 to 2010 were provided by the Florida Department of Law Enforcement. The repeat offense rate was defined as the proportion of arrests each year that were committed by individuals with a previous conviction in the same crime category. The average yearly repeat offense rate for sex crimes was 6.5%, which was consistently and significantly lower than rates for other crimes: 8.3% for non-sex assaults, 15.1% for robbery, 29.8% for drug offenses, and 11.6% for DUI. The average annual sexual repeat arrest rate prior to and after the implementation of sexual offender registration laws in 1997 was 4.9% and 7.5%, respectively, indicating a statistically significant increase. The average annual repeat arrest rates for non-sex assaults, robberies, drug crimes, and DUIs also increased after 1997. No significant differences were found when comparing the average annual percent change for sexual re-arrest (+3.47%) with non-sexual assault (+3.93%), robbery (-.73%), drug offenses (+1.59%), and DUI (+1.14). Sex crime repeat arrests in Florida do not appear to show a decline attributable to sex offender management policies implemented since 1997.

[Impact of a Decree on ACE inhibitors/ARBs in cardiovascular secondary prevention in the Lazio Region (Central Italy): a pre-post analysis]. / Impatto di un decreto su ACE-Inibitori e Sartani in prevenzione secondaria nel Lazio: un'analisi pre-post.

OBJECTIVES: to evaluate the effect of the 2010 legal decree (DCA) in the Lazio Region (Central Italy), promoting appropriateness on use of agents acting on the renin-angiotensin system, and limiting use of angiotensin II receptor blockers (ARBs) within this drug group to levels below 30%. SETTING AND PARTICIPANTS: two cohorts of incident patients with diagnosis of cardiovascular disease (CVD) were enrolled from the regional hospital information system: the first cohort included patients discharged during the 12 months before DCA (35,917 patients), and the second one patients discharged during the 12 months after DCA (35,491 patients). DESIGN: the first prescriptions of angiotensin- converting enzyme inhibitors (ACEIs) and ARBs in the 30 days after discharge were collected from the drug claims registry. The trends of monthly prescription proportions for the two drug groups were compared through a segmented regression analysis. MAIN OUTCOMES MEASURES: comparison between the pre- and post-DCA periods, distinguishing between prescription made by hospital physicians and by general practitioners, and between naïve and prevalent users. RESULTS: proportion of patients with CVD treated with ACEIs/ARBs after discharge was 50% in both pre-DCA (35,917 patients) and post-DCA (35,491 patients) cohorts, with the same share of ACEIs (60%) and ARBs (40%). ARB proportions met the threshold only for hospital prescriptions. Among naïve users, the target was met for both hospital physicians and general practitioners. CONCLUSIONS: the specific DCA has not led to an overall improvement in the appropriateness of prescribing of ACEIs/ARBs in secondary cardiovascular prevention. However, there is a suitable prescription choice for naïve patients and when the drug is dispensed in hospital pharmacies.

Substance use: determinants and opportunities for prevention in the family and school context.

During adolescence, teenagers try a range of risk behaviors including smoking, drinking, and the use of soft drugs. Because substance use contributes to an unhealthy lifestyle of teenagers on the short term and can lead to serious health problems on the longer term, prevention in this target group is important. This chapter provides an overview of the determinants of substance use on the one hand, and primary and secondary prevention opportunities on the other hand, especially in the school context. At the end, future directions and recommendations for school, youth, and family are discussed.

Worksite wellness for the primary and secondary prevention of cardiovascular disease in Japan: the current delivery system and future directions.

In the Japanese workplace, employers are required to provide annual health checkups for workers in accordance with the "Industrial Safety and Health Law," which also mandates that an occupational physician be assigned to companies employing at least 50 workers. The annual medical examination includes testing for the early detection of cardiovascular risk factors such as hypertension, dyslipidemia, diabetes, and the metabolic syndrome. This approach has successfully contributed to the extremely low incidence of coronary artery disease among Japanese workers. However, problems such as poor health and the low rate of participation in health checkups among small-scale companies still persist. Furthermore, although most wellness delivery systems in Japan employ strategies targeting high-risk individuals, instituting a strategy addressing the broader population irrespective of screening may be effective in reducing disease risk in the overall population. As a future direction, we should therefore develop practical methods for implementing a population strategy.

System barriers to the evidence-based care of acute coronary syndrome patients in China: qualitative analysis.

BACKGROUND: Organizational and wider health system factors influence the implementation and success of interventions. Clinical Pathways in Acute Coronary Syndromes 2 is a cluster randomized trial of a clinical pathway-based intervention to improve acute coronary syndrome care in hospitals in China. We performed a qualitative evaluation to examine the system-level barriers to implementing clinical pathways in the dynamic healthcare environment of China. METHODS AND RESULTS: A qualitative descriptive analysis of 40 in-depth interviews with health professionals conducted in a sample of 10 hospitals purposively selected to explore barriers to implementation of the intervention. Qualitative data were analyzed using the Framework method. In-depth interviews identified 5 key system-level barriers to effective implementation: (1) leadership support for implementing quality improvement, (2) variation in the capacity of clinical services and quality improvement resources, (3) fears of patient disputes and litigation, (4) healthcare funding constraints and high out-of-pocket expenses, and (5) patient-related factors. CONCLUSIONS: System-level barriers affect the ability of acute coronary syndrome clinical pathways to change practice. Addressing these barriers in the context of current and planned national health system reform will be critical for future improvements in the management of acute coronary syndromes, and potentially other hospitalized conditions, in China. Clinical Trial Registration- URL: http://www.anzctr.org.au/default.aspx. Register. Unique identifier: ACTRN12609000491268.

UV-induced occupational skin cancer: possibilities of secondary individual prevention in the "Dermatologist's Procedure".

Invasive squamous cell carcinoma (SCC) as a "quasi occupational disease" according to §9 Section 2 of the German Social Code Book (SGB) VII typically develops on chronically UV-damaged skin from actinic keratoses. After the Medical Scientific Committee of the Federal Ministry of Labor and Social Affairs has confirmed the legal criteria for acknowledging UV-induced SCC as an occupational disease, it is expected that the condition will be added to the official list of occupational diseases issued by the Federal Government in the near future. The Social Accident Insurance is required by law (§3 Occupational Disease Regulation) to prevent these tumors by "all appropriate means". There are excellent therapeutic and preventive measures for the management of actinic keratoses to avoid the development of SCC. The "Dermatologist's Procedure" according to §§ 41-43 of the agreement between the Social Accident Insurance and the Federal Medical Association was established in Germany in 1972 to take preventive measures in insured persons with skin lesions possibly developing into an occupational disease, or worsening it, or leading to a recurrence of it This procedure proved to be very successful in the prevention of severe and/or recurring skin diseases forcing a worker to leave his job. On the basis of this agreement, the Social Accident Insurance has the instruments to independently provide preventive measures for the new occupational skin disease SCC induced by natural UV light according to §9 Section 2 of the German Social Code Book (SGB) VII.

Medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: 2012 update: a statement for health care professionals from the American Association for Cardiovascular and Pulmonary Rehabilitation and the American Heart Association.

Medical directors of cardiac rehabilitation/secondary prevention (CR/SP) programs are responsible for the safe and effective delivery of high-quality CR/SP services to eligible patients. Yet, the training and resources for CR/SP medical directors are limited. As a result, there appears to be considerable variability throughout CR/SP programs in the United States in the roles, responsibilities, and engagement of CR/SP medical directors. Since the publication of the 2005 scientific statement from the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation regarding medical director responsibilities for outpatient CR/SP programs, significant changes have occurred. This statement updates the responsibilities of CR/SP medical directors, in view of changes in federal legislation and regulations and changes in health care delivery and clinical practice that impact the roles and responsibilities of CR/SP medical directors.