Cost-benefit analysis of home blood pressure monitoring in hypertension diagnosis and treatment: an insurer perspective.

Home blood pressure (BP) monitoring has been shown to be more effective than clinic BP monitoring for diagnosing and treating hypertension. However, reimbursement of home BP monitoring is uncommon in the United States because of a lack of evidence that it is cost beneficial for insurers. We develop a decision-analytic model, which we use to conduct a cost-benefit analysis from the perspective of the insurer. Model inputs are derived from the 2008 to 2011 claims data of a private health insurer in the United States, from 2009 to 2010 National Health and the Nutrition Examination Survey data, and from published meta-analyses. The model simulates the transitions among health states from initial physician visit to hypertension diagnosis, to treatment, to hypertension-related cardiovascular diseases, and patient death or resignation from the plan. We use the model to estimate cost-benefit ratios and both short- and long-run return on investment for home BP monitoring compared with clinic BP monitoring. Our results suggest that reimbursement of home BP monitoring is cost beneficial from an insurer's perspective for diagnosing and treating hypertension. Depending on the insurance plan and age group categories considered, estimated net savings associated with the use of home BP monitoring range from $33 to $166 per member in the first year and from $415 to $1364 in the long run (10 years). Return on investment ranges from $0.85 to $3.75 per dollar invested in the first year and from $7.50 to $19.34 per dollar invested in the long run.

A model for estimating the economic impact of secondhand smoke exposure: a study in Indiana.

OBJECTIVE: This study estimated the economic cost of health services and premature loss-of-life costs from secondhand smoke (SHS) exposure in Indiana. DESIGN AND SETTING: Costs of SHS-related mortality and morbidity were estimated using national attributable risk values for diseases that are causally related to SHS exposure both for adults and children. Estimated direct costs included hospital inpatient costs, loss-of-life costs, and ambulatory care costs where available, based on the most currently available Indiana hospital discharge data, vital statistics, census data, and nationally published research. PARTICIPANTS: Attributable risk values were applied to the number of deaths and hospital discharges in Indiana in 2008 and 2010, respectively, to estimate the number of individuals impacted by SHS exposure. All cost estimates were adjusted to 2010 US dollar values. RESULTS: The direct cost of health care and premature loss of life in Indiana attributed to SHS was estimated to be $1.3 billion in 2010--$237.8 million in health care costs and $879.0 million in premature loss of life for adults and $89.4 million in health care costs and $98.6 million in premature loss of life for children. The estimated population for Indiana in 2010 was 6 483 802 resulting in SHS-related costs of $201 per capita. DISCUSSION: This study demonstrated a model that could be used to estimate the costs of health care and premature mortality from exposure to SHS at a state or local level. These data may be used to support the education of the public, community leaders, and state policy makers regarding the magnitude of the problem and the compelling need to implement interventions to better protect the health of citizens and their economic prosperity.

Effect of personal characteristics on individual support for indoor smoke-free air laws, Indiana, 2008.

INTRODUCTION: Policy makers should understand the attitudes and beliefs of their constituents regarding smoke-free air legislation. The purpose of this study was to evaluate the effect of selected personal characteristics on attitudes and beliefs about secondhand smoke in Indiana and on support for smoke-free air laws. METHODS: Data were obtained from the 2008 Indiana Adult Tobacco Survey of 2,140 adults and included 11 sociodemographic variables. Chi-square and multiple logistic regression analyses were used to test for significant associations between sociodemographic characteristics and support for statewide or community smoke-free air legislation. RESULTS: Most respondents (72.3%) indicated that they supported laws making work places smoke-free. After adjusting for the effects of the other variables, 3 were found to be significant predictors of support: being a never or former smoker, being female, and being aware of the health hazards of secondhand smoke. Age, race/ethnicity, income, urban or rural county of residence, employment status, and having children in the household were not significant when adjusting for the other characteristics. CONCLUSION: Most Indiana residents support smoke-free air legislation for workplaces. The support was constant among most groups across the state, suggesting policy makers would have the backing of their constituents to pass such legislation. The results of this study suggest that efforts to gain support for smoke-free air laws should focus on men, people unaware of the health hazards from secondhand smoke, and smokers and former smokers.

Perspective: is it time for advocacy training in medical education?

As the modern medical system becomes increasingly complex, a debate has arisen over the place of advocacy efforts within the medical profession. The authors argue that advocacy can help physicians fulfill their social contract. For physicians to become competent in patient-centered, clinical, administrative, or legislative advocacy, they require professional training. Many professional organizations have called for curricular reform to meet society's health needs during the past 30 years, and the inclusion of advocacy training in undergraduate, graduate, and continuing medical education is supported on both pragmatic and ethical grounds. Undergraduate medical education, especially, is an ideal time for this training because a standard competency can be instilled across all specialties. Although the Accreditation Council for Graduate Medical Education includes advocacy training in curricula for residency programs, few medical schools or residency programs have advocacy electives. By understanding the challenges of the health care system and how to change it for the better, physicians can experience increased professional satisfaction and effectiveness in improving patient care, systems-based practice, and public health.

A decade of sustaining best practices for tobacco control: Indiana's story.

The Indiana Tobacco Prevention and Cessation Agency (ITPC) was created in 2000 to address high tobacco use rates. This independent state agency, using Centers for Disease Control and Prevention (CDC) Best Practices for Comprehensive Tobacco Control Programs, administered a comprehensive program that supported community health coalitions and evidence-based public policy changes. From 2000 to 2011, ITPC operated in difficult budgetary and political environments and with less than 20% of the funding recommended by CDC. ITPC and its partners enabled social and cultural changes, reduced cigarette use rates, and increased the number of community smoke-free environments. Public health leaders in Indiana agreed that the independent agency model was effective in reducing the costs associated with tobacco-use-related disease and death. Despite broad public support for ITPC and its work, on April 29, 2011, the Indiana legislature passed a controversial budget bill that abolished the ITPC executive board and transferred its budget and function to the Indiana State Department of Health (ISDH). Although the tobacco control program is not insulated from political interference, the ISDH commissioner has created a new Tobacco Prevention and Cessation Commission, whose members report directly to him, with commitment to continue the programmatic focus of the former ITPC. Restoring full funding to the tobacco control program is necessary if Indiana's goal of decreasing the health care and business costs of tobacco use-related diseases are to be achieved.

Applying the theory of planned behavior to explore the relation between smoke-free air laws and quitting intentions.

Smoke-free air policies have been shown to reduce smoking, but the mechanism of behavior change is not well understood. The authors used structural equation modeling to conduct a theory of planned behavior analysis with data from 395 smokers living in seven Texas cities, three with a comprehensive smoke-free air law and four without a comprehensive law. Agreement with regulating smoking in public places was significantly associated with attitudes and perceived normative pressure about quitting. Nicotine dependence was significantly associated with attitudes and perceived behavioral control. There was also a direct effect of nicotine dependence on intention to take measures to quit smoking. Smoke-free air laws appear to influence quitting intentions through the formation of positive attitudes about regulating smoking in public places and the perception of normative pressure to take measures to quit. Implications for smoke-free air policy campaigns and challenges in evaluating their effectiveness are discussed.

The combined effect of behavioral intention and exposure to a smoke-free air law on taking measures to quit smoking.

Because of the large burden of disease attributable to cigarette smoking, a variety of tobacco control interventions, some focused on changing individual behavior and others focused on influencing societal norms, have been introduced. The current study tested the combined effect of behavioral intention and exposure to a comprehensive smoke-free air law as a prospective predictor of taking measures to quit smoking. Participants were 187 adults living in 7 Texas cities, 3 with a comprehensive smoke-free air law and 4 without such a law, who reported current cigarette smoking at baseline and completed a 1-month follow-up interview. Data were collected by telephone administration of a questionnaire. Results showed that, compared with smokers with low behavioral intention to take measures to quit smoking and no exposure to a comprehensive smoke-free air law, the smokers with high behavioral intention and exposure to a comprehensive law had the greatest odds of taking measures to quit smoking. This longitudinal study provides further evidence that the most successful smoking cessation campaigns will be multifaceted addressing individual factors with educational strategies designed to change beliefs and intentions and environmental factors with policy-based interventions.

A cross-sectional survey on the inclusion of tobacco prevention/cessation, nutrition/ diet, and exercise physiology/fitness education in medical school curricula.

Chronic diseases are currently the major cause of death and disability worldwide. Addressing the main causes of chronic diseases from a preventive perspective is imperative for half ing a continual increase in premature deaths. Physicians occupy a unique position to assist individuals with chronic disease prevention. Hence, medical school is an opportunity to prepare physicians for preventive interventions with patients at risk for developing chronic diseases. This study asserts that education on chronic disease prevention that targets tobacco cessation/prevention, nutrition/ diet, and exercise physiology/fitness is a key aspect of medical school curricula. However, many US medical schools do not include all 3 components in their curricula. This study investigates the extent to which medical school curricula include the above 3 areas. Two methods were utilized for the study: (1) a cross-sectional survey was given to the associate dean of academic affairs of 129 US medical schools and (2) relevant data were retrieved from the Association of American Medical Colleges. Findings support the notion that medical schools are in need of increased curricula covering tobacco prevention/cessation, nutrition/diet, and exercise physiology/fitness. Results indicate that exercise physiology/fitness was the area receiving the least attention in medical schools. Ultimately, this study's purpose was to provide a basis for determining whether inclusion of these 3 subjects in medical school curricula has any significant effect on training future doctors to meet the needs of growing numbers of individuals with chronic disease.

Trends in adult attitudes toward secondhand smoke in Indiana, 2002-2007: the impact of smoking status.

PURPOSE: As more research has been distributed through the media about the negative health impact of exposure to secondhand smoke (SHS), the public's support for smoke-free policies has increased. The purpose of this study was to evaluate trends in knowledge and attitudes about SHS exposure among Indiana adults by smoking status. METHODS: Study data were from four cross-sectional studies previously conducted by the Indiana Tobacco Prevention and Cessation Agency using the Adult Tobacco Survey protocol between the years 2002 and 2007. RESULTS: Eighteen questions were identified as addressing SHS, 16 of which were available for more than 1 year and were evaluated for time trends. Significant overall trends toward increased awareness of SHS's health effects and support for smoking bans were noted in 10 of the 16 questions analyzed. No significant overall change, positive or negative, occurred in the remaining six questions. When responses were analyzed by smoking status, never smokers and former smokers consistently exhibited higher rates of anti-SHS sentiments and knowledge of SHS than did current smokers. CONCLUSIONS: In general, the trends are encouraging to public health efforts to raise awareness about SHS, but there remains much room for improvement, particularly among current smokers.

Leroy E. Burney, MD, MPH: quiet champion of American dentistry and dental research at mid-century.

Leroy E. Burney was a preeminent Surgeon General and was recognized for modernizing the Public Health Service. He promoted environmental public health and access to health care for the poor. He oversaw major expansion of health professions' education and research, and he was the first public official to alert America to the link between cigarette smoking and lung cancer. Historical accounts of Burney's legacy have not focused on his remarkable contributions to dental public health. The aim of this study was to elucidate Burney's role over four decades in promoting the interests of dentistry in America, through his support of dental science, dental education, and public access to dental health services. Burney engaged in dental research and developed a model dental public health program for Indiana. As Surgeon General, he oversaw dramatic expansion of dental research and education and the building of the National Institute for Dental Research. A skillful collaborator, Burney worked toward common goals with leaders of American dentistry and Congress. He was one of the few physician members of the Trustees of the American Fund for Dental Education. A humble man, Burney was a quiet champion of American dentistry and dental research for almost forty years.

Estimating the economic impact of secondhand smoke on the health of a community.

PURPOSE: This study provides a model to estimate the health-related costs of secondhand smoke exposure at a community level. MODEL DEVELOPMENT: Costs of secondhand smoke-related mortality and morbidity were estimated using national attributable risk values for diseases that are causally related to secondhand smoke exposure for adults and children. Estimated costs included ambulatory care costs, hospital inpatient costs, and loss of life costs based on vital statistics, hospital discharge data, and census data. APPLICATION OF THE MODEL: The model was used to estimate health-related costs estimates of secondhand smoke exposure for Marion County, Indiana. Attributable risk values were applied to the number of deaths and hospital discharges to determine the number of individuals impacted by secondhand smoke exposure. RESULTS: The overall cost of health care and premature loss of life attributed to secondhand smoke for the study county was estimated to be $53.9 million in 2000-$10.5 million in health care costs and $20.3 million in loss of life for children compared with $6.2 million in health care costs and $16.9 million in loss of life for adults. This amounted to $62.68 per capita. CONCLUSIONS: This method may be replicated in other counties to provide data needed to educate the public and community leaders about the health effects and costs of secondhand smoke exposure.

Tobacco cessation and nicotine replacement therapy for dental practice.

Addictive tobacco use is the single greatest cause of disease and premature death in America today, responsible for more than 430,000 deaths annually. Smoked and smokeless tobacco intake have profound ill effects on oral tissues, especially those tissues associated with periodontal structures. This article describes the interactive aspects of addictive cigarette smoking and presents specific clinical and systems-based tobacco cessation interventions that can be utilized by health care providers. These programs offer a structured, multifaceted, and behavioral-based approach that includes the utilization of nicotine replacement therapy (NRT), monitoring and follow-up. The health care professional must consider all medical contraindications before using tobacco cessation medications.

Evaluating the capability of information technology to prevent adverse drug events: a computer simulation approach.

BACKGROUND: The annual cost of morbidity and mortality due to medication errors in the U.S. has been estimated at $76.6 billion. Information technology implemented systematically has the potential to significantly reduce medication errors that result in adverse drug events (ADEs). OBJECTIVE: To develop a computer simulation model that can be used to evaluate the effectiveness of information technology applications designed to detect and prevent medication errors that result in adverse drug effects. METHODS: A computer simulation model was constructed representing the medication delivery system in a hospital. STELLA, a continuous simulation software package, was used to construct the model. Parameters of the model were estimated from a study of prescription errors on two hospital medical/surgical units and used in the baseline simulation. Five prevention strategies were simulated based on information obtained from the literature. RESULTS: The model simulates the four stages of the medication delivery system: prescribing, transcribing, dispensing, and administering drugs. We simulated interventions that have been demonstrated in prior studies to decrease error rates. The results suggest that an integrated medication delivery system can save up to 1,226 days of excess hospitalization and $1.4 million in associated costs annually in a large hospital. The results of the analyses regarding the effects of the interventions on the additional hospital costs associated with ADEs are somewhat sensitive to the distribution of errors in the hospital, more sensitive to the costs of an ADE, and most sensitive to the proportion of medication errors resulting in ADEs. CONCLUSIONS: The results suggest that clinical information systems are potentially a cost-effective means of preventing ADEs in hospitals and demonstrate the importance of viewing medication errors from a systems perspective. Prevention efforts that focus on a single stage of the process had limited impact on the overall error rate. This study suggests that system-wide changes to the medication delivery system are required to drastically reduce mediation errors that may result in ADEs in a hospital setting.

Modeling the costs and outcomes of cardiovascular surgery.

Coronary artery bypass graft (CABG) operations consume more health care resources than any other single procedure. The objective of this study was to develop a computer simulation model that can be used to predict costs and patient outcomes of CABG surgery. The analysis is based on a systems dynamic model developed using STELLA software. Two sets of data from Medicare patients who underwent CABG operations at Methodist Hospital of Indiana were used to construct and validate the model. The model predictions of length of hospital stay, use of specialists in caring for patients, costs and postoperative functional status are reasonably close to actual data on patients who underwent CABG surgery. The analysis indicates the most important factors affecting costs and outcomes are gender, age, whether or not the surgery is a reoperation and whether the patient experiences postoperative complications. The model can be used to predict costs and outcomes for a patient population from a small set of preoperative characteristics (i.e., age, gender, DRG, whether the surgery is a reoperation, and the patient's operative status). A second potential use of the model is to answer clinical questions such as do the costs and risks of CABG operations outweigh the benefits for patients with certain risk factors.