The Role of Patient Activation in Preferences for Shared Decision Making: Results From a National Survey of U.S. Adults.

Studies investigating preferences for shared decision making (SDM) have focused on associations with sociodemographic variables, with few investigations exploring patient factors. We aimed to investigate the relationship between patient activation and preferences for SDM in 6 common medical decisions among a nationally representative cross-sectional survey of American adults. Adults older than 18 were recruited online (n = 2,700) and by telephone (n = 700). Respondents completed sociodemographic assessments and the Patient Activation Measure. They were also asked whether they perceived benefit (yes/no) in SDM in 6 common medical decisions. Nearly half of the sample (45.9%) reached the highest level of activation (Level 4). Activation was associated with age (p < .001), higher income (p = .001), higher education (p = .010), better self-rated health (p < .001), and fewer chronic conditions (p = .050). The proportion of people who agreed that SDM was beneficial varied from 53.1% (deciding the necessity of a diagnostic test) to 71.8% (decisions associated with making lifestyle changes). After we controlled for participant characteristics, higher activation was associated with greater perceived benefit in SDM across 4 of the 6 decisions. Preferences for SDM varied among 6 common medical scenarios. Low patient activation is an important barrier to SDM that could be ameliorated through the development of behavioral interventions.

Cost of illness for neuromuscular diseases in the United States.

INTRODUCTION: We conducted a comprehensive study of the costs associated with amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD). and myotonic dystrophy (DM) in the U.S. METHODS: We determined the total impact on the U.S. economy, including direct medical costs, nonmedical costs, and loss of income. Medical costs were calculated using a commercial insurance database and Medicare claims data. Nonmedical and indirect costs were determined through a survey of families registered with the Muscular Dystrophy Association. RESULTS: Medical costs were driven by outpatient care. Nonmedical costs were driven by the necessity to move or adapt housing for the patient and paid caregiving. Loss of income correlated significantly with the amount of care needed by the patient. CONCLUSIONS: We calculated the annual per-patient costs to be $63,693 for ALS, $50,952 for DMD, and $32,236 for DM. Population-wide national costs were $1,023 million (ALS), $787 million (DMD), and $448 million (DM).

Economic costs of excessive alcohol consumption in the U.S., 2006.

BACKGROUND: Excessive alcohol consumption causes premature death (average of 79,000 deaths annually); increased disease and injury; property damage from fire and motor vehicle crashes; alcohol-related crime; and lost productivity. However, its economic cost has not been assessed for the U.S. since 1998. PURPOSE: To update prior national estimates of the economic costs of excessive drinking. METHODS: This study (conducted 2009-2010) followed U.S. Public Health Service Guidelines to assess the economic cost of excessive alcohol consumption in 2006. Costs for health care, productivity losses, and other effects (e.g., property damage) in 2006 were obtained from national databases. Alcohol-attributable fractions were obtained from multiple sources and used to assess the proportion of costs that could be attributed to excessive alcohol consumption. RESULTS: The estimated economic cost of excessive drinking was $223.5 billion in 2006 (72.2% from lost productivity, 11.0% from healthcare costs, 9.4% from criminal justice costs, and 7.5% from other effects) or approximately $1.90 per alcoholic drink. Binge drinking resulted in costs of $170.7 billion (76.4% of the total); underage drinking $24.6 [corrected] billion; and drinking during pregnancy $5.2 billion. The cost of alcohol-attributable crime was $73.3 billion. The cost to government was $94.2 billion (42.1% of the total cost), which corresponds to about $0.80 per alcoholic drink consumed in 2006 (categories are not mutually exclusive and may overlap). CONCLUSIONS: On a per capita basis, the economic impact of excessive alcohol consumption in the U.S. is approximately $746 per person, most of which is attributable to binge drinking. Evidence-based strategies for reducing excessive drinking should be widely implemented.

The economic impact of chronic fatigue syndrome in Georgia: direct and indirect costs.

BACKGROUND: Chronic fatigue syndrome (CFS) is a debilitating chronic illness affecting at least 4 million people in the United States. Understanding its cost improves decisions regarding resource allocation that may be directed towards treatment and cure, and guides the evaluation of clinical and community interventions designed to reduce the burden of disease. METHODS: This research estimated direct and indirect costs of CFS and the impact on educational attainment using a population-based, case-control study between September 2004 and July 2005, Georgia, USA. Participants completed a clinical evaluation to confirm CFS, identify other illnesses, and report on socioeconomic factors. We estimated the effect of CFS on direct medical costs (inpatient hospitalizations, provider visits, prescription medication spending, other medical supplies and services) and loss in productivity (employment and earnings) with a stratified sample (n = 500) from metropolitan, urban, and rural Georgia. We adjusted medical costs and earnings for confounders (age, sex, race/ethnicity, education, and geographic strata) using econometric models and weighted estimates to reflect response-rate adjusted sampling rates. RESULTS: Individuals with CFS had mean annual direct medical costs of $5,683. After adjusting for confounding factors, CFS accounted for $3,286 of these costs (p < 0.01), which were driven by increased provider visits and prescription medication use. Nearly one-quarter of these expenses were paid directly out-of pocket by those with CFS. Individuals with CFS reported mean annual household income of $23,076. After adjustment, CFS accounted for $8,554 annually in lost household earnings (p < 0.01). Lower educational attainment accounted for 19% of the reduction in earnings associated with CFS. CONCLUSIONS: Study results indicate that chronic fatigue syndrome may lead to substantial increases in healthcare costs and decreases in individual earnings. Studies have estimated up to 2.5% of non-elderly adults may suffer from CFS. In Georgia, a state with roughly 5.5 million people age 18-59, illness could account for $452 million in total healthcare expenditures and $1.2 billion of lost productivity.

Maternal support for human papillomavirus vaccination in Honduras.

BACKGROUND: Cervical cancer is a leading cause of cancer death for women in Latin America, and vaccinating against human papillomavirus (HPV) has the potential to limit this disease. We sought to determine Honduran women's awareness of HPV vaccination and interest in vaccinating their daughters against HPV. METHODS: We interviewed mothers aged ≥17 at primary care clinics in Honduras. First, we collected demographic information and assessed knowledge related to cervical cancer prevention and awareness of HPV and HPV vaccination. Because most participants were not familiar with HPV, education about the relationships among HPV, sexual activity, and cervical cancer was provided before we asked participants if they would accept HPV vaccination for a 9-year-old daughter. We used multivariable logistic regression to determine predictors of vaccine acceptance. RESULTS: We interviewed 632 mothers. Only 13% had heard of HPV vaccination before the interview. After education, 91% would accept HPV vaccination for a 9-year-old daughter. Mothers who intended to vaccinate knew more at baseline about cervical cancer prevention than did those who did not endorse vaccination. Demographic characteristics did not predict vaccine acceptance. CONCLUSIONS: Few Honduran mothers were aware of HPV or HPV vaccination. However, most Honduran mothers would accept HPV vaccination for their daughters after receiving education about the relationship between HPV infection and cervical cancer. Baseline cervical cancer knowledge was associated with vaccine acceptance.

Impact of patient adherence and test performance on the cost-effectiveness of cervical cancer screening in developing countries: the case of Honduras.

OBJECTIVE: We examined the impact of patient adherence and screening test performance on the cost-effectiveness of visual inspection with acetic acid (VIA) and Pap smears when used with colposcopy for diagnosis. MATERIALS AND METHODS: Cost-effectiveness analysis was performed using computer modeling. The primary outcome was cancer prevalence in the 10 years after screening. Three hypothetical populations of 35-year-old women were compared: never-screened women, women screened with VIA, and women screened with Pap smears. We used community-based data from our screening program in Honduras to estimate screening test sensitivity and specificity, adherence to follow-up, and costs of screening and colposcopy services. Published data were used to model disease outcomes. RESULTS: VIA was more sensitive than Pap smears (70% vs. 4%), less expensive (U.S. 0.23 dollars vs. 3.17 dollars), and the 2-vist VIA system had a higher rate of adherence to follow-up than the 3-visit Pap smear system (84% vs. 38%). VIA had a higher false-positive rate than Pap smears resulting in higher colposcopy referral rates, but more dysplasia was detected and treated. Cost-effectiveness analysis revealed that screening with VIA would cost U.S. 3,198 dollars per cancer case avoided and reduce cancer cases by 42%, versus U.S. 36,802 dollars and 2% for Pap screening. Although Pap smear quality was low in Honduras, sensitivity analysis showed that VIA was more cost-effective than Pap smears, even when test accuracy was equivalent. CONCLUSION: In developing countries, systems barriers can limit the cost-effectiveness of Pap smears. VIA may be a cost-effective alternative for some resource-poor settings, although systems barriers, quality control, and feasibility issues must be considered.

A community-based education program about cervical cancer improves knowledge and screening behavior in Honduran women.

OBJECTIVES: This study examined changes in knowledge and behavior after a community-based cervical cancer education program in Honduras. METHODS: The program consisted of radio broadcasts targeting rural women and presentations to community nurses. The effectiveness of the radio broadcasts was assessed using a cross-sectional design (control groups n = 124, n = 243; intervention group n = 233). A pre-/post-test design was used to evaluate the nurses' training program (n = 32). A subset of nurses (n = 16) was retested two years later. Evaluation included t tests, chi-square and Fisher exact analyses. RESULTS: The radio broadcast increased the proportion of women who were familiar with the term "cervical cancer," who could identify means of preventing cervical cancer, and who understood the purpose of the Pap smear. In addition, older and under-screened women were successfully recruited for screening via radio. The nurses' program improved understanding of the correct use of the Pap smear, the age-related risk of dysplasia, and the proper triage of abnormal results. The nurses retained a significant amount of knowledge two years after this training. CONCLUSIONS: In developing countries, inexpensive, community-based educational programs using radio broadcasts and lecture presentations can increase cervical cancer knowledge and improve screening behavior.

A community-based education program about cervical cancer improves knowledge and screening behavior in Honduran women

OBJECTIVES: This study examined changes in knowledge and behavior after a community-based cervical cancer education program in Honduras. METHODS: The program consisted of radio broadcasts targeting rural women and presentations to community nurses. The effectiveness of the radio broadcasts was assessed using a cross-sectional design (control groups n = 124, n = 243; intervention group n = 233). A pre-/ post-test design was used to evaluate the nurses’ training program (n = 32). A subset of nurses (n = 16) was retested two years later. Evaluation included t tests, chi-square and Fisher exact analyses. RESULTS: The radio broadcast increased the proportion of women who were familiar with the term "cervical cancer," who could identify means of preventing cervical cancer, and who understood the purpose of the Pap smear. In addition, older and under-screened women were successfully recruited for screening via radio. The nurses’ program improved understanding of the correct use of the Pap smear, the age-related risk of dysplasia, and the proper triage of abnormal results. The nurses retained a significant amount of knowledge two years after this training. CONCLUSIONS: In developing countries, inexpensive, community-based educational programs using radio broadcasts and lecture presentations can increase cervical cancer knowledge and improve screening behavior.

OBJETIVOS: Examinar los cambios ocurridos en el conocimiento sobre el cáncer cervicouterino y el comportamiento ante el tamizaje después de un programa educacional basado en la comunidad en Honduras. MÉTODOS: El programa consistió en transmisiones radiales dirigidas a mujeres de zonas rurales y conferencias a enfermeros de la comunidad. La eficacia de las transmisiones radiales se evaluó mediante un diseño transversal (grupos de control: n = 124 y n = 243; grupo de intervención: n = 233). Se utilizó una prueba previa y otra posterior para evaluar el programa de entrenamiento de enfermeros (n = 32). Después de dos años se repitió la prueba a un subgrupo de enfermeros (n = 16). Se emplearon las pruebas exacta de Fisher, de la t de Student y de la ji al cuadrado. RESULTADOS: Las transmisiones radiales elevaron la proporción de mujeres familiarizadas con el término "cáncer cervicouterino", que podían identificar las vías para prevenir el cáncer cervicouterino y que comprendían los objetivos de la prueba de Papanicolau. Además, mediante el radio se reclutaron exitosamente para tamizar más mujeres de los grupos de mayor edad y menos tamizadas. Con el programa para enfermeros se mejoró la comprensión del uso correcto de la prueba de Papanicolau, del riego relativo de displasia según la edad y de la conducta apropiada a seguir ante resultados alterados. Los enfermeros retenían una cantidad importante de conocimientos dos años después del entrenamiento. CONCLUSIONES: En los países en desarrollo, el empleo de programas educacionales poco costosos basados en la comunidad mediante transmisiones radiales y conferencias puede elevar el conocimiento sobre el cáncer cervicouterino y mejorar el comportamiento ante el tamizaje.

Is managed care leading to consolidation in health-care markets?

OBJECTIVE: To determine the extent to which managed care has led to consolidation among hospitals and physicians. DATA SOURCES: We use data from the American Hospital Association, American Medical Association, and government censuses. STUDY DESIGN: Two stage least squares regression analysis examines how cross-section variation in managed care penetration affects provider consolidation, while controlling for the endogeneity of managed-care penetration. Specifically, we examine inpatient hospital markets and physician practice size in large metropolitan areas. DATA COLLECTION METHODS: All data are from secondary sources, merged at the level of the Primary Metropolitan Statistical Area. PRINCIPAL FINDINGS: We find that higher levels of local managed-care penetration are associated with substantial increases in consolidation in hospital and physician markets. In the average market (managed-care penetration equaled 34 percent in 1994), managed care was associated with an increase in the Herfindahl of .054 between 1981 and 1994, moving from .096 in 1981 to .154. This is equivalent to moving from 10.4 equal-size hospitals to 6.5 equal-sized hospitals. In the physician market place, we estimate that at the mean, managed care resulted in a 14 percentage point decrease of physicians in solo practice between 1986 and 1995. This implies a decrease in the percentage of doctors in solo practice from 38 percent in 1986 to 24 percent by 1995.