Investigating racial differences in coping with chronic osteoarthritis pain.

Osteoarthritis is a prevalent disease in older patients of all racial groups, and it is known to cause significant pain and functional disability. Racial differences in how patients cope with the chronic pain of knee or hip osteoarthritis may have implications for utilization of treatment modalities such as joint replacement. Therefore, we examined the relationships between patient race and pain coping strategies (diverting attention, reinterpreting pain, catastrophizing, ignoring sensations, hoping and praying, coping self-statements, and increasing behavior activities) for hip and knee osteoarthritis. This is a cross-sectional survey of 939 veterans 50 to 79 years old with chronic hip or knee osteoarthritis pain recruited from VA primary care clinics in Philadelphia and Pittsburgh. Patients had to have moderate to severe hip or knee osteoarthritis symptoms as measured by the WOMAC index. Standard, validated instruments were used to obtain information on attitudes and use of prayer, pain coping strategies, and arthritis self-efficacy. Analysis included separate multivariable models adjusting for demographic and clinical characteristics. Attitudes on prayer differed, with African Americans being more likely to perceive prayer as helpful (adjusted OR = 3.38, 95% CI 2.35 to 4.86) and to have tried prayer (adjusted OR = 2.28, 95% 1.66 to 3.13) to manage their osteoarthritis pain. Upon evaluating the coping strategies, we found that, compared to whites, African Americans had greater use of the hoping and praying method (beta = 0.74, 95% CI 0.50 to 0.99). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies. This increased use of the hoping and praying coping strategy by African Americans may play a role in the decreased utilization of total joint arthroplasty among African Americans compared to whites. Further investigation of the role this coping strategy has on the decision making process for total joint arthroplasty should be explored.

Cost-effectiveness of automated external defibrillators on airlines.

CONTEXT: Installation of automated external defibrillators (AEDs) on passenger aircraft has been shown to improve survival of cardiac arrest in that setting, but the cost-effectiveness of such measures has not been proven. OBJECTIVE: To examine the costs and effectiveness of several different options for AED deployment in the US commercial air transportation system. DESIGN, SETTING, AND SUBJECTS: Decision and cost-effectiveness analysis of a strategy of full deployment on all aircraft as well as several strategies of partial deployment only on larger aircraft, compared with a baseline strategy of no AEDs on aircraft (but training flight attendants in basic life support) for a hypothetical cohort of persons experiencing cardiac arrest aboard US commercial aircraft. Estimates for costs and outcomes were obtained from the medical literature, the Federal Aviation Administration, the Air Transport Association of America, a population-based cohort of Medicare patients, AED manufacturers, and the Bureau of Labor Statistics. MAIN OUTCOME MEASURES: Quality-adjusted survival after cardiac arrest; costs of AED deployment on aircraft and of medical care for cardiac arrest survivors. RESULTS: Adding AEDs on passenger aircraft with more than 200 passengers would cost $35 300 per quality-adjusted life-year (QALY) gained. Additional AEDs on aircraft with capacities between 100 and 200 persons would cost an additional $40 800 per added QALY compared with deployment on large-capacity aircraft only, and full deployment on all passenger aircraft would cost an additional $94 700 per QALY gained compared with limited deployment on aircraft with capacity greater than 100. Sensitivity analyses indicated that the quality of life, annual mortality rate, and the effectiveness of AEDs in improving survival were the most influential factors in the model. In 85% of Monte Carlo simulations, AED placement on large-capacity aircraft produced cost-effectiveness ratios of less than $50 000 per QALY. CONCLUSION: The cost-effectiveness of placing AEDs on commercial aircraft compares favorably with the cost-effectiveness of widely accepted medical interventions and health policy regulations, but is critically dependent on the passenger capacity of the aircraft. Placing AEDs on most US commercial aircraft would meet conventional standards of cost-effectiveness.

Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia.

OBJECTIVES: Previous economic studies of Helicobacter pylori eradication in dyspepsia and peptic ulcer disease have not measured quality of life using utilities (preference probabilities), which are needed to compare the cost-effectiveness of such treatment to other health care interventions. The goals of this study were to measure quality of life in patients with dyspepsia or peptic ulcer and apply these measurements to published models of disease management to determine cost-effectiveness in dollars per quality-adjusted life year (QALY) gained. METHODS: Utilities for dyspepsia and peptic ulcer disease were measured in adult patients (n = 73) on chronic acid suppression for peptic ulcer or ulcer-like dyspepsia. Median utility values were applied to the results of published cost-effectiveness analyses and a previously validated dyspepsia model. Cost-utility ratios for early H. pylori eradication in uninvestigated dyspepsia and peptic ulcer disease were then computed. RESULTS: The total disutility, or lost quality of life, for an ulcer was 0.11 QALY, of which 0.09 QALY was attributed to dyspeptic symptoms. After these results were incorporated into published studies, cost-utility ratios for ulcer treatment varied from $3,100 to $12,500 per QALY gained, whereas estimates for uninvestigated dyspepsia management ranged from $26,800 to $59,400 per QALY. Sensitivity analyses indicated a range of $1,300 to $27,300 per QALY for management of duodenal ulcer and $15,000 to $129,700 per QALY for dyspepsia. CONCLUSIONS: Strategies that emphasize early H. pylori eradication were cost-effective for patients with peptic ulcer and possibly cost-effective for patients with uninvestigated dyspepsia, relative to other medical interventions. Dyspeptic symptoms cause significant disutility that should be incorporated in future cost-effectiveness analyses of treatment strategies.

Intracardiac echocardiographic guidance during microwave catheter ablation.

The purpose of this study was to explore the potential of intracardiac echocardiography in monitoring lesion formation and assisting with the assessment of ablative lesions using microwave energy. Microwave energy is a promising modality for catheter ablation. Because microwave lesions may have considerable variability in dimension, the ability to assess them may be particularly useful. One hundred twenty-five microwave lesions were created in vitro in ovine left ventricles. Correct assessment of catheter-endocardial contact was possible in virtually all cases. Intracardiac imaging always identified correctly whether or not an ablation was performed. During ablation, gas formation was observed in all instances. Sensitivity, specificity, and predictive values for identification of ablation lesions were 88% to 92%. Although the correlations with pathology for lesion dimensions were relatively poor, intracardiac imaging had a predictive accuracy of 80% to 85% to discriminate small from large lesions. Intracardiac guidance for microwave ablation is useful for verifying tissue-electrode contact, monitoring lesion formation, and localizing lesions. It is also a useful tool for the assessment of lesion size. These attributes, combined with the ability to facilitate transseptal catheterization and to identify complications such as hemopericardium, make intracardiac echocardiography a potentially useful method for guiding microwave ablation of arrhythmic foci.