Economic evaluations of system-based obesity interventions - the case for a new approach.

System-based interventions are of increasing interest as they seek to modify environments (e.g. socio-cultural system, transport system or policy system) that promote development of conditions such as obesity and its related risk factors. In our commentary, we draw attention to features of the system-based approach that may explain the relative absence of economic evaluations of the cost-effectiveness of these interventions, needed to guide decision-making on which to deploy. We present and discuss potentially applicable methods and alternative approaches based on our experiences in two major system-based interventions currently underway (in Melbourne, Australia and Gaggenau, Germany) that begin to fill this gap. We feel the issues and potential solutions outlined in this commentary are important for a broad range of stakeholders (e.g. clinicians, interventionalists, policy makers) to consider as they seek to address the issue of obesity.

Sunbed use in Germany: trends, user histories and factors associated with cessation and readiness to change.

BACKGROUND: Sunbed use is considered carcinogenic in humans. Studies that examine behavioural patterns related to sunbed use over time are needed for developing skin cancer prevention strategies. OBJECTIVES: To explore age-related trends in the initiation age, to investigate individual histories of sunbed use and to identify characteristics associated with cessation. METHODS: We analysed cross-sectional data of 4851 sunbed users and nonusers from a representative sample of Germans, aged 14-45 years, interviewed in 2011/2012. Biographical data were reconstructed based on reported tanning frequency/duration and changes in sunbed use over time. We used survival analysis to model the initiation age and created birth cohorts to assess age-related trends. Characteristics associated with sunbed use cessation were identified using logistic regression. RESULTS: Among sunbed users, median sunbed exposure was 180 min per year. Annual exposure remained constant in 85·6% of this subgroup with no changes over time during periods of sunbed use. Age at initiation decreased significantly across birth cohorts from 25 to 19 years (25th percentile; cohorts 1966-75 to 1986-93). Characteristics associated with sunbed use cessation included educational level [odds ratios (OR) 1·53 and 1·71 for medium and high education, respectively], greater awareness of skin cancer risk (OR 2·41) and immigrant background (OR 0·54; all P < 0·01). CONCLUSIONS: Initiation of sunbed use at an increasingly younger age suggests the need for interventions targeted at young adults. Approaches that increase general skin cancer risk awareness and that are sensitive to participants' educational level and immigrant background may also be helpful.

The Work-Health-Check (WHC): a brief new tool for assessing psychosocial stress in the workplace.

OBJECTIVE: Brief, psychometrically robust questionnaires assessing work-related psychosocial stressors are lacking. The purpose of the study is to evaluate the psychometric properties of a brief new questionnaire for assessing sources of work-related psychosocial stress. PARTICIPANTS: Managers, blue- and white-collar workers (n= 628 at measurement point one, n=459 at measurement point two), sampled from an online panel of a German marketing research institute. METHODS: We either developed or identified appropriate items from existing questionnaires for ten scales, which are conceptually based in work stress models and reflected either work-related demands or resources. Factorial structure was evaluated by confirmatory factor analyses (CFA). Scale reliability was assessed by Cronbach's Alpha, and test-retest; correlations with work-related efforts demonstrated convergent and discriminant validity for the demand and resource scales, respectively. Scale correlations with health indicators tested criterion validity. RESULTS: All scales had satisfactory reliability (Cronbach's Alpha: 0.74-0.93, retest reliabilities: 0.66-0.81). CFA supported the anticipated factorial structure. Significant correlations between job-related efforts and demand scales (mean r=0.44) and non-significant correlations with the resource scales (mean r=0.07) suggested good convergent and discriminant validity, respectively. Scale correlations with health indicators demonstrated good criterion validity. CONCLUSION: The WHC appears to be a brief, psychometrically robust instrument for assessing work-related psychosocial stressors.

A spatial regression analysis of German community characteristics associated with voluntary non-remunerated blood donor rates.

BACKGROUND AND OBJECTIVES: Previous studies have shown substantial geographical variation in blood donation within developed countries. To understand this issue better, we identified community characteristics associated with blood donor rates in German municipalities in an ecological analysis. MATERIALS AND METHODS: We calculated an aggregated rate of voluntary blood donors from each of 1533 municipalities in south-west Germany in 2007 from a database of the German Red Cross Blood Service. A multiple linear regression model estimated the association between the municipality-specific donor rate and several community characteristics. Finally, a spatial lag regression model was used to control for spatial autocorrelation that occurs when neighbouring units are related to each other. RESULTS: The spatial lag regression model showed that a relatively larger population, a higher percentage of inhabitants older than 30 years, a higher percentage of non-German citizens and a higher percentage of unemployed persons were associated with lower municipality-specific donor rates. Conversely, a higher donor rate was correlated with higher voter turnout, a higher percentage of inhabitants between 18 and 24 years and more frequent mobile donation sites. CONCLUSIONS: Blood donation appears to be a highly clustered regional phenomenon, suggesting the need for regionally targeted recruiting efforts and careful consideration of the value of mobile donation sites. Our model further suggests that municipalities with a decreasing percentage of 18- to 24-year-olds and an increasing percentage of older inhabitants may experience substantial declines in future blood donations.

Gender bias in clinical trials: do double standards still apply?

Differential enrollment into clinical trials by gender has been described previously. In 1993, the National Institutes of Health (NIH) Revitalization Act was enacted to promote the inclusion of women in clinical trials. The purpose of this study was to review patterns in clinical trial enrollment among studies published in a major medical journal to determine the effects of this policy. A systematic search was conducted of all articles published in the Original Articles section of The New England Journal of Medicine from 1994 to 1999. Two independent observers abstracted information from the randomized clinical trials using standardized forms. All randomized clinical trials in which the primary end point was total mortality or included mortality in a composite end point were considered for review. Trials were analyzed for enrollment of women with respect to disease state, funding source, site of trial performance, and use of gender-specific data analysis. From 1994 to 1999, 1322 original articles were published in The New England Journal of Medicine, including 442 randomized, controlled trials of which 120 met our inclusion criteria. On average, 24.6% women were enrolled. Gender-specific data analysis was performed in 14% of the trials. The NIH Revitalization Act does not appear to have improved gender-balanced enrollment or promoted the use of gender-specific analyses in clinical trials published in an influential medical journal. Overcoming this trend will require rigorous efforts on the part of funding entities, trial investigators, and journals disseminating study results.

Preoperative risk factors for postoperative delirium.

The objective of this article was to estimate the incidence of delirium in a sample of patients undergoing elective surgery and to identify the preoperative factors most closely associated with developing this complication. Consecutive patients (n=500) underwent a full preoperative medical evaluation including assessment of cognitive and functional status. Daily evaluation on postoperative days 1 through 4 included medical record review and direct standardized patient interviews. Logistic regression was used to explore the associations between preoperative factors and postoperative delirium. Delirium was detected in 57 (11.4%) patients. Univariate factors associated with delirium included age> or =70 years (RR=3.1 [1.75,5.55]), preexisting cognitive impairment (RR=3.1 [1.73, 5.43]), greater preoperative functional limitations (RR=1.57 [1.27, 1.94]), and a history of prior delirium (RR 4.1 [1.98 to 8.27]. Adjusting for other factors, previous delirium (OR=4.08 [1.85, 9.0]), age> or =70 years (OR=3.2 [1.6, 6.0], and preexisting cognitive impairment (OR=2.16 [1.15, 4.0] remained predictive of delirium. Patients' perceptions that alcohol had affected their health (OR=6.53 [1.58 to 28.1]) and use of narcotic analgesics just prior to admission (OR=2.7 [1.37 to 5.3]) were also significantly associated with delirium postoperatively. Several easily obtained preoperative clinical factors can be used to identify patients at risk for postoperative delirium. This approach, when combined with specialized delirium teams using established guidelines, may be more effective in targeting patients at risk, thus reducing the number of episodes and days of delirium.

The cost of delirium in the surgical patient.

The authors identified the added cost attributable to postoperative delirium in patients undergoing elective surgery. The authors evaluated patients (n = 500) before their elective surgery, assessing cognitive functioning, medical conditions, medication usage, and other information regarding their health status. Using DSM-IV criteria, the authors assessed patients for delirium on Postoperative Days 1-4. Medical record review provided laboratory, radiological, and pharmaceutical information. The authors analyzed length of stay (LOS), comprehensive cost data collected through the hospital, and a group practice financial database to determine differences among those developing delirium. Of the 500 patients assessed, 57 (11.4%) developed delirium during the study. Delirium is an extremely costly disorder, both to the patient in terms of morbidity and mortality and to the medical facility. A prolonged LOS increases charges to third party payors and reduces return to physicians and hospitals when delirium develops. Careful presurgical screening and targeted postoperative interventions may help contain LOS and costs while affording greater physical, emotional, and cognitive health to patients hospitalized for elective surgery.

Ending a nurse practitioner-patient relationship: uncovering patients' perceptions.

DATA SOURCES: Seventy-nine patients assigned to the care of a nurse practitioner (NP) were interviewed to explore reactions to ending a yearlong therapeutic relationship at the conclusion of a clinical trial. Three researchers identified, reviewed and CONCLUSIONS: Of the total 79 patients, 22 (28%) spontaneously discussed perceptions and feelings about the termination of their relationship with the NP, Qualitative analysis of their statements identified future concerns about continuity of care and emotional themes ranging from gratitude, regret, and anxiety to grief. IMPLICATIONS FOR PRACTICE: Changes in health care coverage often result in abrupt termination of patient-provider relationships. The involuntary termination of a patient-provider relationship may have significant negative consequences on patients with substantial influence on physical and emotional health. Awareness and anticipatory counseling may be useful in stemming these effects.

Differences in breast cancer screening rates: an issue of ethnicity or socioeconomics?

Previous reports suggest that use of preventive measures, such as screening mammography (SM), differs by ethnicity. It is unclear, however, if this is determined directly by ethnicity or indirectly by related socioeconomic factors. We studied self-reported data from 18,245 women aged 40-49 who participated in the Behavioral Risk Factor Surveillance System telephone survey in 1992 and 1993. Of these, 11,509 (63%) reported having obtained mammography within the preceding 2 years for screening purposes only. Using reports of other preventive healthcare behaviors, education level, socioeconomic status, and healthcare access problems as independent variables, bivariate associations were assessed, and a logistic regression model was developed. Models for each ethnic group were developed, with consistent results. Women who engaged in other preventive health measures, such as Pap smear (odds ratio [OR] 8.99, 95% confidence interval [CI] = 7.6-10.7), cholesterol measurement (OR 2.64, 95% CI = 2.3-3.0), and seatbelt use, were more likely to obtain SM. Women with healthcare access or insurance problems (OR 0. 59, 95% CI = 0.5-0.7) and current smokers (OR 0.71, CI = 0.6-0.8) had a lower likelihood of obtaining SM. Ethnicity, alcohol use, marital status, and education level were not significantly associated with women's reports of SM. Although ethnicity apparently does not influence a woman's likelihood of obtaining SM, access to healthcare and insurance and engaging in other healthy behaviors do. Health policy planners should consider the importance of these related factors when developing preventive health programs for women.

Returning to the bedside: using the history and physical examination to identify rotator cuff tears.

OBJECTIVES: To determine the value of elements of the bedside history and physical examination in predicting arthrography results in older patients with suspected rotator cuff tear (RCT). DESIGN: Retrospective chart review SETTING: Orthopedic practice limited to disorders of the shoulder PARTICIPANTS: 448 consecutive patients with suspected RCT referred for arthrography over a 4-year period MAIN OUTCOME MEASURE: Presence of partial or complete RCT on arthrogram RESULTS: 301 patients (67.2%) had evidence of complete or partial RCT. Clinical findings in the univariate analysis most closely associated with rotator cuff tear included infra- and supraspinatus atrophy (P < .001), weakness with either elevation (P < .001) or external rotation (P < .001), arc of pain (P = .004), and impingement sign (P = .01). Stepwise logistic regression based on a derivation dataset (n = 191) showed that weakness with external rotation (Adjusted Odds Ratio (AOR) 6.96 (3.09, 13.03)), age > or = 65 (AOR 4.05(2.47, 16.07)), and night pain (AOR 2.61 (1.004, 7.39)) best predicted the presence of RCT. A five-point scoring system developed from this model was applied in the remaining patient sample (n = 216) to test validity. No significant differences in performance were noted using ROC curve comparison. Using likelihood ratios, a clinical score = 4 was superior in predicting RCT to the diagnostic prediction of an expert clinician. This score had specificity equivalent to magnetic resonance imaging or ultrasonography in diagnosis of RCT. CONCLUSIONS: The presence of three simple features in the history and physical examination of the shoulder can identify RCT efficiently. This approach offers a valuable strategy to diagnosis at the bedside without compromising sensitivity or specificity.

Targeting lead screening: The Ohio Lead Risk Score.

OBJECTIVE: Annual blood lead (BPb) screening is recommended for children /=12% of BPb test results >/=10 microg/dL. RESULTS: Data from 897 census tracts were available. Higher risk for lead toxicity existed in areas where: 1) >/=55% of houses were built before 1950 (adjusted odds ratio [AOR]: 10.9 [6.1,19.6]); 2) >/=35% of residents were black (AOR: 3.5 [2.0,6. 3]); 3) >/=35% of residents had less than a high school education (AOR: 6.1 [3.6,10.4]); and 4) >/=50% of housing units were renter-occupied (AOR: 3.6 [2.1,6.2]). Receiver operator characteristic (ROC) curves demonstrated no significant differences after applying the model in a second dataset. CONCLUSIONS: Several community characteristics predict risk for lead toxicity in children and may provide a useful approach to focus lead screening, especially in communities where public health resources are limited. The approach described here may also prove helpful in identifying factors within a community associated with other environmental public health hazards for children.

Redefining the preoperative evaluation process and the role of the anesthesiologist.

STUDY OBJECTIVE: To assess the effects of implementing an ambulatory and same-day surgery preoperative evaluation patient triage system over a 3-year period. DESIGN: Retrospective analysis of 63,941 ambulatory surgical patients presenting for elective surgery. SETTING: Tertiary care, academic medical institution. INTERVENTIONS: The following preoperative evaluation model components were implemented over a 3-year period: HealthQuest, which is an outpatient preoperative assessment computer program developed by the Department of General Anesthesiology; a general internal medicine clinic designated specifically for preoperative evaluation and medical optimization; disease specific algorithms for both preoperative patient assessment and management; and a preoperative anesthesia clinic that no longer performs preoperative medical optimization. MEASUREMENTS AND MAIN RESULTS: During the 3-year study period ambulatory and same-day surgical case volume increased 34.7%. A total of 50,967 patients used HealthQuest as part of their preoperative evaluation. Of these patients 22,744 (35.6%) did not need to see an anesthesiologist until the day of surgery as guided by both a computer-assigned HealthQuest score and surgical classification scheme. Also, 41,197 patients were evaluated in our anesthesia preoperative clinic with a cost per evaluation of $24.86, which increased only 0.9% per year. In addition, both patient interview time and patient dissatisfaction with the preoperative process decreased over the 3-year period. There were 20, 088 patient encounters in the general internal medicine clinic for patient medical evaluation and optimization. The average monthly preoperative surgical delay rate decreased 49% during the study period. Finally, significant monetary saving resulted due to decreased unnecessary laboratory testing. CONCLUSIONS: Efficient, cost-effective patient care can be provided by using this preoperative evaluation model. Some institutions may find portions of this preoperative model applicable to their current situation.

Factors influencing the selection of general internal medicine fellowship programs: a national survey.

Although criteria are available to guide the selection of general internal medicine (GIM) fellowship programs, the factors actually used in this process are unclear. Using a survey of current GIM fellows, we determined that most received information from their residency advisors, and many viewed them as the most important source of fellowship information. Program location was the top selection factor for fellows, followed by research opportunities, availability of a mentor, and the reputation of the program. This information may be useful to both fellowship candidates as an additional selection guide and to program directors seeking to best structure and market their fellowships.

Framing procedural risks to patients: is 99% safe the same as a risk of 1 in 100?

PURPOSE: A patient's willingness to consent to a procedure may be influenced by various factors, including the patient's rapport with the physician, nonverbal cues he or she receives during the discussion of risks, and other elements of the discussion of risks. Previous reports address these influences, but the effect of the actual wording used to describe risks is unclear. The purpose of this study was to better understand how framing the risk involved in a procedure affects a patient's likelihood to consent to the procedure. METHOD: In a 1997 study at the Cleveland Clinic Foundation, the authors randomly assigned 116 patients to view one of two short videos describing angioplasty and its associated risks. Sixty-three participants viewed the first video, which framed the procedure as 99% safe, and 53 viewed the second, which framed the likelihood of complication as 1 in 100. Participants were then asked to rate their consent to two hypothetical treatment scenarios on a four-point Likert-type scale (1 = definitely, 4 = definitely not). RESULTS: When asked to consent to a treatment scenario that would relieve chest pain but offer no survival benefit, respondents who viewed the first video were more likely to consent than were those who viewed the second (p<.001). There was no significant difference in the two groups' likelihoods to consent when the potential health benefit was to reduce the risk of future heart attack. CONCLUSION: This study's finding provides evidence that how a physician describes a procedure's risks when obtaining a patient's informed consent significantly influences the likelihood of consent. This fact should be considered when teaching communication skills, including interviewing and patient education skills, so that patients will be more likely to make health care decisions that are consistent with their own values and beliefs.

The dilemma of nosocomial pneumonia: what primary care physicians should know.

Because nosocomial pneumonia is difficult to diagnose and the need to treat it is often urgent, particularly in patients on mechanical ventilation, therapy is often empiric. We review the pathogenesis, risk factors, microbiology, diagnosis, and treatment of this disease.

Surviving the prospective payment system: potential problems and solutions to ensure quality of care.

In response to diagnosis-related group payment systems and changing social structures, many hospital systems have created alternative discharge sites, thus shifting care to subacute units offering comprehensive inpatient programs of cost-effective restorative care. The growth in expenditures for these postacute services led to the implementation of the prospective payment system (PPS). This article discusses factors involved in calculating reimbursement and solutions to such problems as inadequate reimbursement, quality of care, and documentation requirements. For subacute care to succeed clinically and financially, a basis for collaboration between hospital-based referring physicians and subacute unit directors must be established; patient satisfaction and quality of care must be monitored closely; and a well-trained nursing staff with frequent in-service training in patient care should be employed. The reorganization tactics suggested in this article may help a subacute facility function in an efficient way at acceptable costs while maintaining high quality patient care.

Preoperative screening.

In screening the preoperative patient, several sources of risk, each with potentially modifiable components, must be considered. These include risks related to the proposed procedure, anesthetic, and medical illnesses present in the patient. To screen effectively, one must look for potential factors in each area that may affect perioperative morbidity and mortality. Once risk areas are identified, it is helpful to quantify them further through a focused testing approach, especially when the anticipated surgical or anesthetic risks are high. Data obtained through this process should guide the optimization of the patient's medical status to modify risks when possible. Sharing information obtained during the preoperative assessment with both anesthesiologists and surgeons helps to refine plans for management and may better ensure patient safety in the perioperative period.

Practice variation in the diagnosis and treatment of osteoporosis: a case for more effective physician education in primary care.

Bone mineral density (BMD) performed by dual energy x-ray absorptiometry (DEXA) has been used at our institution as a screening test for osteoporosis since 1986. Of 2789 bone densitometry tests done between 1992 and 1996 on women aged 51-75 years, 1743 (62.5%) were ordered by general internists (GIM), endocrinologists (ENDO), rheumatologists (RHEUM), and a metabolic bone disease specialist (MBDS). We compared the percentage of densitometry tests ordered by GIM, ENDO, RHEUM, and MBDS resulting in one of three possible diagnoses (normal, osteopenia, or osteoporosis). Applying the World Health Organization's (WHO) definition of normal (< 1 standard deviation [SD] below the mean for young, adult women), osteopenia (> or = 1 SD-< 2.5 SD below the mean), and osteoporosis (> or = 2.5 SD below the mean), we found that 34% of patients tested between 1992 and 1996 were osteoporotic, 42% were osteopenic, and 24% had normal bone density results. The rate of osteoporosis diagnosis was highest in the MBDS cohort (chi 2 = 9.19, p = 0.002) compared with patients in the other cohorts. To explore trends in management of this condition, a random sample of osteoporotic women aged 51-75 who had densitometry in 1996 (n = 82) was obtained. Review of medical records revealed that 73% were on some form of osteoporosis treatment (bisphosphonate, estrogen, or calcitonin, with or without calcium and vitamin D supplementation). Treatment rates differed significantly, however, by the ordering physician specialty (96% for MBDS, 63% for ENDO, 75% for RHEUM, and 53% for GIM, chi (2)3df = 11.37, p = 0.01). There were no significant differences in selected clinical or demographic characteristics between patients treated by GIM and MBDS. This variation in treatment rates suggests that an opportunity to enhance primary care physicians' recognition and treatment of osteoporosis exists. Making osteoporosis management an educational focus may help narrow differences in practice and improve the effectiveness of a larger number of physicians treating patients with this problem.

Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation.

BACKGROUND: In the context that special weaning units have been advocated as effective alternatives to the ICU for weaning selected patients, we initiated a Respiratory Special Care Unit (ReSCU) at the Cleveland Clinic Hospital in August 1993. The goals of the ReSCU were the following: (1) to wean ventilator-dependent patients when possible; and (2) when weaning was not possible, to optimize patient and family instruction for patients going home with ventilatory support. This study presents our 4-year experience with 212 patients managed in the ReSCU and analyzes clinical features associated with favorable clinical outcomes. METHODS: The features of the ReSCU include six private beds in a pulmonary inpatient ward staffed by nurses with special pulmonary expertise; 24-h respiratory therapy supervision; bedside and central noninvasive monitoring (i.e., continuous pulse oximetry, end tidal capnometry, and ventilator alarms); and a multidisciplinary approach involving dietitians, physical therapists, occupational therapists, social workers, and speech pathologists. All ReSCU patients were cared for primarily by a pulmonary/critical care attending physician and fellow, with consultative input solicited as deemed necessary. The criteria for admission to the ReSCU included hemodynamic stability; absence of an arrhythmia requiring telemetry; and in the attending physician's judgment, the ability to benefit from the ReSCU. RESULTS: Between August 23, 1993, and August 31, 1997, 212 patients were admitted to the ReSCU. The median age was 68 years old; 55% were women; 86% were white; and 55% were transferred from the medical ICU. Underlying reasons for ventilator dependence were ARDS from a nonsurgical cause (33%), ARDS following surgery (18%), status post-cardiothoracic surgery (13%), status post-thoracic surgery (12%), and COPD (12%). The median length of ReSCU stay was 17 days (interquartile range, 10 to 29 days). Eighteen percent (n = 38) died during the hospitalization. Among the 174 survivors, complete ventilator independence was achieved in 127 patients (60% of the 212 patient cohort), 28 patients were ventilator dependent (13% of 212 patients), and the remaining 19 patients (9%) required partial ventilatory support. Univariate analysis regarding the association of baseline characteristics with death identified lower albumin and transferrin levels, increasing age, and the physician's estimate of lower weaning likelihood as significant correlates of death. In contrast, achieving complete ventilator independence was associated with a higher serum albumin level, a nonmedical ICU referral source, a cause of respiratory failure other than COPD, and a physician's estimate of higher weaning likelihood. To analyze the financial impact of the ReSCU, we assumed that ReSCU patients would have otherwise stayed in the medical ICU and compared the charges (ICU vs ReSCU) with, for a subset of patients, the true costs of ReSCU vs. ICU care. Analyses of both charges and cost differences showed similar savings associated with ReSCU care ($13,339 per patient [charges] and $10,694 per patient [costs]). CONCLUSIONS: We conclude the following: (1) the rate of achieving complete ventilator independence in the ReSCU was high; and (2) based on our achieving clinical outcomes, which are comparable to the most favorable rates reported in other series from ventilator units, we conclude that the ReSCU can be an effective and cost-saving alternative to the ICU for carefully selected patients.

Controlling varicella in the healthcare setting: barriers to varicella vaccination among healthcare workers.

We surveyed healthcare workers to determine factors that may influence acceptance of varicella-zoster virus vaccine. Of 2,801 workers tested, 90 were susceptible to varicella; of workers offered vaccination, 68% accepted. Workers providing direct patient care were 3.7-fold more likely than other workers to accept VZV vaccination (P=.04).