Reducing health care costs by reducing the need and demand for medical services. The Health Project Consortium

Midlife fitness and the development of chronic conditions in later life

BACKGROUND The association between cardiorespiratory fitness (fitness) and mortality is well described. However, the association between midlife fitness and the development of nonfatal chronic conditions in older age has not been studied. METHODS To examine the association between midlife fitness and chronic disease outcomes in later life, participant data from the Cooper Center Longitudinal Study were linked with Medicare claims. We studied 18 670 healthy participants (21.1% women; median age, 49 years) who survived to receive Medicare coverage from January 1, 1999, to December 31, 2009. Fitness estimated by Balke treadmill time was analyzed as a continuous variable (in metabolic equivalents [METs]) and according to age- and sex-specific quintiles. Eight common chronic conditions were defined using validated algorithms, and associations between midlife fitness and the number of conditions were assessed using a modified Cox proportional hazards model that stratified the at-risk population by the number of conditions while adjusting for age, body mass index, blood pressure, cholesterol and glucose levels, alcohol use, and smoking. RESULTS After 120 780 person-years of Medicare exposure with a median follow-up of 26 years, the highest quintile of fitness (quintile 5) was associated with a lower incidence of chronic conditions compared with the lowest quintile (quintile 1) in men (15.6 [95% CI, 15.0-16.2] vs 28.2 [27.4-29.0] per 100 person-years) and women (11.4 [10.5-12.3] vs 20.1 [18.7 vs 21.6] per 100 person-years). After multivariate adjustment, higher fitness (in METs) was associated with a lower risk of developing chronic conditions in men (hazard ratio, 0.95 [95% CI, 0.94-0.96] per MET) and women (0.94 [0.91-0.96] per MET). Among decedents (2406 [12.9%]), higher fitness was associated with lower risk of developing chronic conditions relative to survival (compression hazard ratio, 0.90 [95% CI, 0.88-0.92] per MET), suggesting morbidity compression. CONCLUSIONS In this cohort of healthy middle-aged adults, fitness was significantly associated with a lower risk of developing chronic disease outcomes during 26 years of follow-up. These findings suggest that higher midlife fitness may be associated with the compression of morbidity in older age.

[Paediatric emergency triage in Spanish primary care using mobile phones. Analysis of a model in a health area]

OBJECTIVES

To conduct a pilot study of telephone consultation in the paediatric population of an urban health centre. To evaluate the telephone consultation as an effective tool when it comes to exercising prior triage of patients requiring urgent attention.

MATERIAL AND METHODS

The study was conducted in two phases. In the first, data were collected from all calls received for six months. In a second phase, we conducted a telephone intervention study to analyse what a random sample of users remembered of the care provided. All those who requested a telephone consultation were included in the study. Demographic, social-welfare, epidemiological, and clinical features, of each patient were recorded. Data were processed using a statistical package SPSS version 17.0 for Windows.

RESULTS

There were 439 telephone inquiries in our pilot project, of which 35.1% were attended by residents, 36% by paediatricians, and 28.9% by paediatric nurses. There were more telephone calls in the afternoons and on weekends. Patients less than or equal to 2 years accounted for 57.9% of cases handled, and there were no differences between sexes. The most frequent reasons for consultation were gastrointestinal symptoms, fever and respiratory problems. The health problem was resolved in 85.8% of cases, requiring only home care instructions, and only 13.3% of children were referred to emergency services. We obtained a mean score of satisfaction of 9.2.

CONCLUSIONS

The pilot project had a high level of satisfaction and resolution, demonstrating cost savings by reducing 55% of face to face visits, with a saving of 35.2 euros per telephone consultation. A teleconsultation model for dealing with emergencies in primary care by telephone would be comparable to a practice staffed by trained paediatric nurses.

Patient-centered medical home: how it affects psychosocial outcomes for diabetes

Fragmentation of the current U.S. health care system and the increased prevalence of chronic diseases in the U.S. have led to the recognition that new models of care are needed. Chronic disease management, including diabetes, is often accompanied by a myriad of associated psychosocial issues that need to be addressed as part of a comprehensive treatment plan. Diabetes care should be aligned with comprehensive whole-person health care. The patient-centered medical home (PCMH) has emerged as a model for enhanced primary care that focuses on comprehensive integrated care. PCMH demonstration projects have shown improvements in quality of care, patient experience, care coordination, access to care, and quality measures for diabetes. Key PCMH transformative features associated with psychosocial issues related to diabetes reviewed in this article include integration of mental and behavioral health, care management/coordination, payment reform, advanced access, and putting the patient at the center of health care. This article also reviews the evidence supporting comprehensive and integrated care for addressing psychosocial issues associated with diabetes in the medical home.

The theory and practice of active aging

“Active aging” connotes a radically nontraditional paradigm of aging which posits possible improvement in health despite increasing longevity. The new paradigm is based upon postponing functional declines more than mortality declines and compressing morbidity into a shorter period later in life. This paradigm (Compression of Morbidity) contrasts with the old, where increasing longevity inevitably leads to increasing morbidity. We have focused our research on controlled longitudinal studies of aging. The Runners and Community Controls study began at age 58 in 1984 and the Health Risk Cohorts study at age 70 in 1986. We noted that disability was postponed by 14 to 16 years in vigorous exercisers compared with controls and postponed by 10 years in low-risk cohorts compared with higher risk. Mortality was also postponed, but too few persons had died for valid comparison of mortality and morbidity. With the new data presented here, age at death at 30% mortality is postponed by 7 years in Runners and age at death at 50% (median) mortality by 3.3 years compared to controls. Postponement of disability is more than double that of mortality in both studies. These differences increase over time, occur in all subgroups, and persist after statistical adjustment.

Advance care treatment plan (ACT-Plan) for African American family caregivers: a pilot study

Research is limited on end-of-life treatment decisions made by African American family caregivers. In a pilot study, we examined the feasibility of implementing an advance care treatment plan (ACT-Plan), a group-based education intervention, with African American dementia caregivers. Theoretically based, the ACT-Plan included strategies to enhance knowledge, self-efficacy, and behavioral skills to make end-of-life treatment plans in advance. Cardiopulmonary resuscitation, mechanical ventilation, and tube feeding were end-of-life treatments discussed in the ACT-Plan. In a four-week pre/posttest two-group design at urban adult day care centers, 68 caregivers were assigned to the ACT-Plan or attention-control health promotion conditions. Findings strongly suggest that the ACT-Plan intervention is feasible and appropriate for African American caregivers. Self-efficacy and knowledge about dementia, cardiopulmonary resuscitation, mechanical ventilation, and tube feeding increased for ACT-Plan participants but not for the attention-control. More ACT-Plan than attention-control participants developed advance care plans for demented relatives. Findings warrant a randomized efficacy trial.

Making the economic case for prevention--a view from Wales

BACKGROUND

It is widely acknowledged that adverse lifestyle behaviours in the population now will place an unsustainable burden on health service resources in the future. It has been estimated that the combined cost to the NHS in Wales of overweight and obesity, alcohol and tobacco is in excess of £540 million.In the current climate of financial austerity, there can be a tendency for the case for prevention efforts to be judged on the basis of their scope for cost savings. This paper was prompted by discussion in Wales about the evidence for the cost savings from prevention and early intervention and a resulting concern that these programmes were thus being evaluated in policy terms using an incorrect metric. Following a review of the literature, this paper contributes to the discussion of the potential role that economics can play in informing decisions in this area.

DISCUSSION

This paper argues that whilst studies of the economic burden of diseases provide information about the magnitude of the problem faced, they should not be used as a means of priority setting. Similarly, studies discussing the likelihood of savings as a result of prevention programmes may be distorting the arguments for public health.Prevention spend needs to be considered purposefully, resulting in a strategic commitment to spending. The role of economics in this process is to provide evidence demonstrating that information and support can be provided cost effectively to individuals to change their lifestyles thus avoiding lifestyle related morbidity and mortality. There is growing evidence that prevention programmes represent value for money using the currently accepted techniques and decision making metrics such as those advocated by NICE.

SUMMARY

The issue here is not one of arguing that the economic evaluation of prevention and early intervention should be treated differently, although in some instances that may be appropriate, rather it is about making the case for these interventions to be treated and evaluated to the same standard. The difficulty arises when a higher standard of cost saving may be expected from prevention and public health programmes.The paper concludes that it is of vital importance that during times of budget constraints, as currently faced, the public health budgets are not eroded to fund secondary care budget shortfalls, which are more easily identifiable. To do so would diminish any possibility of reducing the future burden faced by the NHS of lifestyle-related illnesses.

Neuroprotective Effects ofHypericum perforatumon Trauma Induced by Hydrogen Peroxide in PC12 Cells

The standard extracts of Hypericum perforatum L. (SEHP), a well-known medicinal plant, are used for the treatment of depression, exhibited upgrading and significant protective effects on the trauma of PC12 cells induced by 200 μM H2O2in a dose-dependent manner within 24-hour treatment. Cell viability was assessed by the MTT method, and in situ cellular hydrogen peroxide ( H2O2)-induced oxidative stress was examined by measurement of reactive oxygen species (ROS) formation using CDCFH procedures. Intra- and extra-cellular ROS levels decreased significantly to 71.9% and 50.0% of the control at a moderate concentration of 20 μg/ml, respectively, suggesting that SEHP could easily enter the cells and play important roles in reducing ROS levels. Our results were proved by detection of DNA fragmentation and inspection of cell morphology of PC12 cells. SEHP can obviously block DNA fragmentation and prevent the cells from shrinking and turning round of H2O2-induced apoptosis in PC12 cells at concentrations of 10~100 μg/ml. This data suggests SEHP may be a candidate for application in neurodegenerative diseases such as Alzheimer's disease or Parkinson's disease.

Less exercise and more TV: leisure-time physical activity trends of Shanghai elders, 1998-2008

BACKGROUND

Surveillance of physical activity trends in older adults is limited in developing nations. This study examined 10-year leisure-time physical activity trends of elderly residents of Shanghai, the largest Chinese city with the nation's highest proportion of senior citizens.

METHODS

The study used panel data from the Shanghai Longitudinal Survey of Elderly Life and Opinion (1998, 2003, 2005 and 2008). Leisure-time physical activity questions included (i) 16 major leisure-time habitual activities and (ii) regular exercise in the previous 6 months.

RESULTS

In comparison to 1998, for Shanghai elders, the trend for engaging in leisure-time habits not related to physical activity increased over time, becoming statistically significant in 2005 and 2008 (e.g. OR for watching TV in 2003, 2005 and 2008 is 1.04 [0.91, 1.19], 1.17 [1.00, 1.38] and 1.78 [1.51, 2.09], respectively). Simultaneously, the trend for engaging in regular exercise declined significantly in each observation year in comparison to 1998 (OR in 2003, 2005 and 2008 is 0.70 [0.61, 0.80], 0.36 [0.30, 0.42] and 0.28 [0.24, 0.33], respectively). Discussion An increasingly sedentary lifestyle has evolved over the past decade in Shanghai. This highlights a need for public health agencies to develop effective active lifestyle interventions and physical activity promotion programs for local elders.

Making the case for talking to patients about the costs of end-of-life care

Costs at the end of life disproportionately contribute to health care costs in the United States. Addressing these costs will therefore be an important component in making the U.S. health care system more financially sustainable. In this paper, we explore the moral justifications for having discussions of end-of-life costs in the doctor-patient encounter as part of an effort to control costs. As health care costs are partly shared through pooled resources, such as insurance and taxation, and partly borne by individuals through out-of-pocket expenses, we separate our defense for, and approach to, discussing both pooled and individual aspects of cost. We argue that there needs to be a shift away from formulating the options as a dichotomous choice of paying attention to end-of-life costs versus ignoring such costs. The question should be how personal costs will be managed and how societal expenditures should be allocated. These are issues that we believe patients care about and need to have addressed in a manner with which they are comfortable. Conversations about how money will be spent at the end of life should begin before the end is near. We propose discussing costs from the onset of chronic illness and incorporating financial issues in advance care planning. Through these approaches one can avoid abruptly and insensitively introducing financial issues at the very conclusion of a person's life when one would prefer to address the painful and important issues of spiritual and existential loss that are appropriately the focus when a person is dying.

Predictive health: the imminent revolution in health care

Increasing social, economic, and political pressures to reform the U.S. approach to medical care makes change likely. A fundamental premise of predictive health is that it should be cheaper (at least per person life-year) and more efficient and have a greater return on the investment of keeping people healthy as opposed to waiting for disease to intervene. The Emory Predictive Health and Society Strategic Initiative and its Center for Health Discovery and Well Being have embarked on a program to define health to the extent that modern science permits in the context of the entire human experience, to identify measurable variables that describe and predict a healthy state, and to use that knowledge to design health-focused interventions that are affordable and effective. Initial results from a study of a randomly selected "essentially healthy" cohort, using extensive assessments and a health partner, are promising. Studies of healthy aging over the entire life spectrum promise valuable normative data for age-specific assessments of health and the setting of realistic health goals.

The opportunities for and obstacles against prevention: the example of Germany in the areas of tobacco and alcohol

BACKGROUND

Recent years have seen a growing research and policy interest in prevention in many developed countries. However, the actual efforts and resources devoted to prevention appear to have lagged well behind the lip service paid to the topic.

DISCUSSION

We review the evidence on the considerable existing scope for health gains from prevention as well as for greater prevention policy efforts in Germany. We also discuss the barriers to "more and better" prevention and provide modest suggestions about how some of the obstacles could be overcome.

SUMMARY

In Germany, there are substantial health gains to be reaped from the implementation of evidence-based, cost-effective preventive interventions and policies. Barriers to more prevention include social, historical, political, legal and economic factors. While there is sufficient evidence to scale up prevention efforts in some public health domains in Germany, in general there is a comparative shortage of research on non-clinical preventive interventions. Some of the existing barriers in Germany are at least in principle amenable to change, provided sufficient political will exists. More research on prevention by itself is no panacea, but could help facilitate more policy action. In particular, there is an economic efficiency-based case for public funding and promotion of research on non-clinical preventive interventions, in Germany and beyond, to confront the peculiar challenges that set this research apart from its clinical counterpart.

Difference in lifetime medical expenditures between male smokers and non-smokers

OBJECTIVES

It is controversial whether smokers have higher lifetime medical expenditures than non-smokers, because smokers have high annual medical expenditures but comparatively short lives. We examined differences in lifetime medical expenditures between them.

METHODS

We constructed life tables for male smokers and non-smokers from 40 years of age. We calculated average annual medical expenditures of them categorized by survivors and deceased, which were used to examine differences in lifetime medical expenditures between them and perform sensitivity analyses.

RESULTS

Smokers had a higher mortality rate, shorter life expectancy, and generally higher annual medical expenditures than non-smokers. We also observed tendencies for smokers to have higher inpatient expenditures, but non-smokers to have higher outpatient expenditures. Although non-smokers had lower long-term cumulative medical expenditures between 64 and 81 years of age, their lifetime medical expenditures were higher by a minimal amount. Sensitivity analyses did not change this result.

CONCLUSIONS

Smoking may not cause increases in lifetime medical expenditures because smokers had lower lifetime medical expenditures than non-smokers. However, it was clear that smokers, especially survivors, often had higher annual medical expenditures than non-smokers. The importance of tobacco control is still relevant.

Identifying and screening for psychological and comorbid medical and psychological disorders in medical settings

There is increased attention to the medical and economic consequences of psychological problems comorbid with medical issues. There is also a clear awareness that most psychological problems are assessed and responded to in nonpsychiatric medical settings. This has furthered interest and attention in implementing screening procedures to better identify psychological, behavioral, and substance abuse problems in medical settings. Such interest is taking the form of recommendations from federal government task forces, and the funding of large projects to include screening in medical settings. At the same time there has been further attention to brief, valid, and reliable measures with which to capture psychological comorbidities. However, there have been multiple concerns raised about a variety of issues concerning the utility and effectiveness of such screening procedures and the identification of multiple issues to be considered in screening design. The author outlines and reviews the rationale and concerns about screening, identifies the issues that need to be considered in screening program development, and describes the efforts to develop a screening capacity in a rural family practice.

Health care costs in the last week of life: associations with end-of-life conversations

BACKGROUND

Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions.

METHODS

Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases.

RESULTS

Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006).

CONCLUSIONS

Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Clinical nihilism in neuroemergencies

Mortality and morbidity remain high from neurologic emergencies, such as acute stroke, traumatic brain injury, and hypoxic-ischemic encephalopathy after cardiac arrest. Decisions regarding initial aggressiveness of care must be made at the time of presentation, and perceived prognosis is often used as part of this decision-making process. These decisions are predicated on the accuracy of early outcome prediction, however. Decisions to limit treatment early after neuroemergencies must be balanced with avoidance of self-fulfilling prophecies of poor outcome attributable to clinical nihilism. This article examines the role of prognostication early after neuroemergencies, the potential impact of early treatment limitations, and how these may relate to communication with patients and surrogate decision makers in the context of these acute neurologic events.

Managers' Perceptions of the Current and Future Role of Occupational Health Nurses in Australia

Occupational health nurses face competition from other professionals in the field of occupational health and safety. This study investigated managers' perceptions of Australian occupational health nurses' roles. Managers were asked to rate the importance of occupational health nurses' activities and the time they believe occupational health nurses do or should dedicate to each activity now and in the future. The questionnaire included 22 activity statements grouped into eight areas of practice that were thought to constitute the occupational health nurse role, based on the Australian College of Occupational Health Nurses standards. Data revealed that emergent roles focused on injury prevention, health promotion, management, and research were of increasing importance, with more time being needed for them in the future. Fulfilling these expectations may place occupational health nurses in competition with other occupational health and safety personnel for particular responsibilities and may require negotiation to gain support for taking on these role activities. Fulfilling these emergent role activities effectively will require appropriate professional development and advanced education.

Correlates of improvement in walking ability in older persons in the United States

OBJECTIVES

We analyzed factors associated with improvement in walking ability among respondents to the nationally representative Health and Retirement Study.

METHODS

We analyzed data from 6574 respondents aged 53 years or older who reported difficulty walking several blocks, 1 block, or across the room in 2000 or 2002. We examined associations between improvement (versus no change, deterioration, or death) and baseline health status, chronic conditions, baseline walking difficulty, demographic characteristics, socioeconomic status, and behavioral risk factors.

RESULTS

Among the 25% of the study population with baseline walking limitations, 29% experienced improved walking ability, 40% experienced no change in walking ability, and 31% experienced deteriorated walking ability or died. In a multivariate analysis, we found positive associations between walking improvement and more recent onset and more severe walking difficulty, being overweight, and engaging in vigorous physical activity. A history of diabetes, having any difficulty with activities of daily living, and being a current smoker were all negatively associated with improvement in walking ability. After we controlled for baseline health, improvement in walking ability was equally likely among racial and ethnic minorities and those with lower socioeconomic status.

CONCLUSIONS

Interventions to reduce smoking and to increase physical activity may help improve walking ability in older Americans.

Integrated primary care: an inclusive three-world view through process metrics and empirical discrimination

Integrating behavioral health services within the primary care setting drives higher levels of collaborative care, and is proving to be an essential part of the solution for our struggling American healthcare system. However, justification for implementing and sustaining integrated and collaborative care has shown to be a formidable task. In an attempt to move beyond conflicting terminology found in the literature, we delineate terms and suggest a standardized nomenclature. Further, we maintain that addressing the three principal worlds of healthcare (clinical, operational, financial) is requisite in making sense of the spectrum of available implementations and ultimately transitioning collaborative care into the mainstream. Using a model that deconstructs process metrics into factors/barriers and generalizes behavioral health provider roles into major categories provides a framework to empirically discriminate between implementations across specific settings. This approach offers practical guidelines for care sites implementing integrated and collaborative care and defines a research framework to produce the evidence required for the aforementioned clinical, operational and financial worlds of this important movement.

Chronic disease risk factors associated with health service use in the elderly

Background

To examine the association between number and combination of chronic disease risk factors on health service use.

Methods

Data from the 1995 Nova Scotia Health Survey (n = 2,653) was linked to provincial health services administrative databases. Multivariate regression models were developed that included important interactions between risk factors and were stratified by sex and at age 50. Negative-binomial regression models were estimated using generalized estimating equations assuming an autoregressive covariance structure.

Results

As the number of chronic disease risk factors increased so did the number of annual general practitioner visits, specialist visits and days spent in hospital in people aged 50 and older. This was not seen among individuals under age 50. Comparison of smokers, people with high blood pressure and people with high cholesterol showed no significantly different impact on health service use.

Conclusion

As the number of chronic disease risk factors increased so did health service use among individuals over age 50 but risk factor combination had no impact.

Ageing, Meaning and the Allocation of Resources

Different scenarios for an ageing society presume different approaches to the meaning of old age. One scenario anticipates a Prolongation of Morbidity, where quality of life concerns might permit active euthanasia or suicide as a means of saving money. Those who believe in a Compression of Morbidity opt for health promotion to delay morbidity in favour of productive ageing. Optimists look to a scenario of Lifespan Extension, where scarce health resources are not expended for incremental gains in life expectancy but rather for basic research to postpone or eliminate ageing. Finally, those who emphasize Voluntary Acceptance of Limits identify the meaning of old age with voluntary acceptance of finitude, where claims of future generations might limit longevity for any one generation. Thus, contrasting meanings such as quality of life, productive ageing, indefinite survival and voluntary limits entail very different consequences for the allocation of scarce resources across age-groups and among sub-groups of the elderly population.

Peer support telephone calls for improving health

BACKGROUND

Peer support telephone calls have been used for a wide range of health-related concerns. However, little is known about their effects.

OBJECTIVES

To assess the effects of peer support telephone calls in terms of physical (e.g. blood pressure), psychological (e.g. depressive symptoms), and behavioural health outcomes (e.g. uptake of mammography) and other outcomes.

SEARCH STRATEGY

We searched: The Cochrane Library databases (CENTRAL, DARE, CDSR) (issue 4 2007); MEDLINE (OVID) (January 1966 to December 2007); EMBASE (OVID) (January 1985 to December 2007); CINAHL (Athens) (January 1966 to December 2007), trials registers and reference lists of articles, with no language restrictions.

SELECTION CRITERIA

Randomised controlled trials of peer support interventions delivered by telephone call.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. We present results narratively and in tabular format. Meta-analysis was not possible due to heterogeneity between studies.

MAIN RESULTS

We included seven studies involving 2492 participants.Peer support telephone calls were associated with an increase in mammography screening, with 49% of women in the intervention group and 34% of women in the control group receiving a mammogram since the start of the intervention (P </ = 0.001). In another study, peer telephone support calls were found to maintain mammography screening uptake for baseline adherent women (P = 0.029).Peer support telephone calls for post myocardial infarction patients were associated at six months with a change in diet in the intervention and usual care groups of 54% and 44% respectively (P = 0.03). In another study for post myocardial infarction patients there were no significant differences between groups for self-efficacy, health status and mental health outcomes.Peer support telephone calls were associated with greater continuation of breastfeeding in mothers at 3 months post partum (P = 0.01).Peer support telephone calls were associated with reduced depressive symptoms in mothers with postnatal depression (Edinburgh Postnatal Depression Scale (EPDS) > 12). The peer support intervention significantly decreased depressive symptomatology at the 4-week assessment (odds ratio (OR) 6.23 (95% confidence interval (CI) 1.15 to 33.77; P = 0.02)) and 8-week assessment (OR 6.23 (95% CI 1.40 to 27.84; P = 0.01). One study investigated the use of peer support for patients with poorly controlled diabetes. There were no significant differences between groups for self-efficacy, HbA1C, cholesterol level and body mass index.

AUTHORS' CONCLUSIONS

Whilst this review provides some evidence that peer support telephone calls can be effective for certain health-related concerns, few of the studies were of high quality and so results should be interpreted cautiously. There were many methodological limitations thus limiting the generalisability of findings. Overall, there is a need for further well designed randomised controlled studies to clarify the cost and clinical effectiveness of peer support telephone calls for improvement in health and health-related behaviour.

Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest

Introduction

The purpose of this study was to investigate the costs and health status outcomes of intensive care unit (ICU) admission in patients who present after sudden cardiac arrest with in-hospital or out-of-hospital cardiopulmonary resuscitation.

Methods

Five-year survival, health-related quality of life (Medical Outcome Survey Short Form-36 questionnaire, SF-36), ICU costs, hospital costs and post-hospital health care costs per survivor, costs per life year gained, and costs per quality-adjusted life year gained of patients admitted to a single ICU were assessed.

Results

One hundred ten of 354 patients (31%) were alive 5 years after hospital discharge. The mean health status index of 5-year survivors was 0.77 (95% confidence interval 0.70 to 0.85). Women rated their health-related quality of life significantly better than men did (0.87 versus 0.74; P < 0.05). Costs per hospital discharge survivor were 49,952 €. Including the costs of post-hospital discharge health care incurred during their remaining life span, the total costs per life year gained were 10,107 €. Considering 5-year survivors only, the costs per life year gained were calculated as 9,816 € or 14,487 € per quality-adjusted life year gained. Including seven patients with severe neurological sequelae, costs per life year gained in 5-year survivors increased by 18% to 11,566 €.

Conclusion

Patients who leave the hospital following cardiac arrest without severe neurological disabilities may expect a reasonable quality of life compared with age- and gender-matched controls. Quality-adjusted costs for this patient group appear to be within ranges considered reasonable for other groups of patients.

Lifetime medical costs of obesity: prevention no cure for increasing health expenditure

BACKGROUND

Obesity is a major cause of morbidity and mortality and is associated with high medical expenditures. It has been suggested that obesity prevention could result in cost savings. The objective of this study was to estimate the annual and lifetime medical costs attributable to obesity, to compare those to similar costs attributable to smoking, and to discuss the implications for prevention.

METHODS AND FINDINGS

With a simulation model, lifetime health-care costs were estimated for a cohort of obese people aged 20 y at baseline. To assess the impact of obesity, comparisons were made with similar cohorts of smokers and "healthy-living" persons (defined as nonsmokers with a body mass index between 18.5 and 25). Except for relative risk values, all input parameters of the simulation model were based on data from The Netherlands. In sensitivity analyses the effects of epidemiologic parameters and cost definitions were assessed. Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions.

CONCLUSIONS

Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.

Impact of fatty liver disease on health care utilization and costs in a general population: a 5-year observation

BACKGROUND & AIMS

Fatty liver disease is a common condition in the Western world. Fatty liver may progress to steatohepatitis and cirrhosis. It is not yet known whether fatty liver disease results in higher health care utilization and costs.

METHODS

We used data from the Study of Health in Pomerania (SHIP), Germany, to assess the relation of fatty liver disease to self-reported health care utilization and costs at baseline and 5 years. The SHIP is a general population cohort study of 4310 adults aged 20 to 79 years at baseline in Pomerania. Fatty liver disease was defined as the presence of a hyperechogenic pattern of the liver and elevated serum alanine aminotransferase (ALT) levels.

RESULTS

In multivariable analyses, average annual overall health care costs at baseline and follow-up measurement were significantly higher for individuals with sonographic fatty liver and increased serum ALT levels. For example, controlling for comorbid conditions, subjects with sonographic fatty liver disease and increased serum ALT levels had 26% higher overall health care costs at 5-year follow-up. Analyses also suggest that diabetes and cardiovascular disease might mediate the relation of fatty liver disease and health care utilization and costs.

CONCLUSIONS

Policies seeking to minimize costs associated with fatty liver disease might want to consider addressing behavioral risk factors of fatty liver disease.

[Preventing dependency in the elderly.]

INTRODUCTION

dependency, i.e. the need to depend on another person to perform activities of daily living, is the main concern and cause of suffering and poor quality of life in the elderly. The prevalence of dependency increases with age and is related to the presence of prior disease and fragility. Dependency is associated with increased morbidity, mortality and institutionalization, as well as with greater health and social resource utilization, all of which increases health costs.

OBJECTIVE

to create a consensus document on the main health recommendations for the prevention of dependency in the elderly, based on the scientific evidence available to date, with the collaboration of scientific societies and public health administrations (the Spanish Ministry of Health, Autonomous Communities and Cities).

METHODS

a) a preliminary consensus document was drafted by an expert group composed of representatives of various scientific societies and health administrations. This document was based on a review of the recommendations and guidelines published by the main organizations involved in health promotion and the prevention of disease, functional deterioration and dependency in the elderly; b) the consensus document was reviewed by the remaining experts assigned by the scientific societies and central and autonomous administrations; c) the final document was approved after a session in which the text was discussed and reviewed by all the experts participating in the working group (including the academic committee); d) the document was presented and discussed in the First National Conference on Prevention and Health Promotion in Clinical Practice in Spain. All participating experts signed a conflicts of interest statement.

RESULTS

the document provides recommendations, with their grades of evidence, grouped in the following three categories: a) health promotion and disease prevention, with specific preventive activities for the elderly, including prevention of geriatric syndromes; b) prevention of functional deterioration, with clinical recommendations that can be applied in primary and specialized care; c) prevention of iatrogeny (drug prescription, inappropriate use of diagnostic and therapeutic modalities and healthcare). These recommendations were tailored to the characteristics of the older person (OP), categorized in five groups: healthy OP, OP with chronic disease, fragile or at risk OP, dependent OP, and OP at the end of life.

CONCLUSION

these recommendations should be implemented by public health administrations to improve strategies for the prevention of dependency in the elderly in the XXI century.

Improving delivery of clinical preventive services: a multi-year journey

BACKGROUND

Adults in the United States typically do not receive all recommended clinical preventive services (CPS) for which they are eligible, missing opportunities for prevention and/or early detection. A multi-year quality improvement initiative targeting CPS delivery in a fee-for-service ambulatory care network is described.

METHODS

Since 1999, HealthTexas Provider Network (HTPN) has implemented multiple initiatives to increase CPS delivery, including a flowsheet, a physician champion model, physician- and practice-level audit and feedback, and rapid-cycle quality improvement training.

RESULTS

From 2000 to 2006, "recommended or done" CPS delivery increased from 68% to 92%, and "done" from 70% to 86% (2001 to 2006). "Perfect care" composite performance increased from 0.19 to 0.51 (2001 to 2006).

CONCLUSIONS

Long-term, multistrategy approaches can achieve substantial sustained improvement in CPS delivery throughout a large ambulatory care provider network.

Untangling the web: the need to clarify care co-ordinating models for people with chronic and complex conditions

OBJECTIVE

In order to clarify the expanding care co-ordinating field and stimulate debate, a descriptive typology is developed suitable for a range of stakeholders and purposes.

METHODS

The strategy for development of the typology involved a literature review of the most commonly used care coordinating models and the utilisation of select government publications that verified diverse ways of classifying care co-ordinating needs. A descriptive typology is proposed to better communicate similarities and differences.

RESULTS

The typology delineates similarities and differences among care co-ordinating models that stakeholders can use as a step towards determining the most effective model to meet the varied needs of individuals and populations.

CONCLUSIONS AND IMPLICATIONS

Stakeholders can more informatively communicate about care co-ordinating models and their place in the service delivery system. The typology may be used in comparing the effectiveness of the models. A clearer understanding of the field is both timely and warranted.

Determinants of preventive services in general practice

BACKGROUND

France is in Europe, the country in which the mortality due to potentially preventable causes is the highest. At the same time, French doctors receive no incentives to undertake prevention activities. This article examined the general practitioners' (GPs) determinants (characteristics, patient list and contextual factors) of cardiovascular prevention and vaccination carried out by GPs in their offices.

METHODS

Data were collected from 105,726 patients followed by 86 GPs (observational study). A multilevel analysis with two levels: GP and patient (HLM) was performed.

RESULTS

A high between-GP variability of the prevention activity is underlined in both domains. After controlling for patient characteristics, we observed a positive effect of the GP's workload (ORa=1.03) and of an elderly GP's patient list (ORa=1.04) on cardiovascular prevention, a positive effect of a patient list with a high level of health care consumption on vaccination activity (ORa=1.04). The significant influence of contextual factors is ever more demonstrative: the ORa is 1.3 times lower in cardiovascular prevention and 1.6 in vaccination when the density of GPs in the local community of the doctor's practice grows of one-point (1/1000); the ORa is two times lower in both cardiovascular prevention and vaccination for GPs having an urban practice.

CONCLUSION

These results emphasize the need for taking into account contextual factors to implement prevention policies in primary care. But further studies of this type should be conducted by taking other variables into account in order to improve the proportion of variance explained in our models.

The joint impact of cardiovascular risk factors upon medical costs

OBJECTIVE

The joint impact of obesity, hypertension, and hyperglycemia upon medical costs is not well known. Our objective was to evaluate the joint impact of these cardiovascular risk factors upon medical costs in the rural Japanese population.

METHODS

The data were derived from a 6-year prospective observation of National Health Insurance beneficiaries in rural Japan. Data on blood chemistry tests, blood pressure, weight, and height were obtained from an annual health check-up provided by the local municipalities in 1995. We prospectively collected data on medical costs over a 6-year period for 12,340 subjects (5306 men and 7034 women) without prior histories of cardiovascular disease or cancer.

RESULTS

Mean medical costs for individuals being overweight/obese, hypertensive, and hyperglycemic were 91.0% higher than those for individuals without any of these three cardiovascular risk factors. In this cohort, 17.2% of total medical costs were attributable to these three risk factors.

CONCLUSION

Overweight/obesity, hypertension, and hyperglycemia could have a large impact on health care resources in rural Japan.

Drivers and challenges of personal health systems in workplace health promotion

Novel technologies such as wearable sensors, electronic health diaries and personalized web services are thought to have the potential to improve population health in a cost- efficient manner. The use of personal health systems in workplace health promotion is of particular interest, since the workplace often provides an excellent setting and infrastructure to support health- related interventions. Compared to the elderly or those already debilitated by disease, working people are also generally more capable of taking advantage of information technology. Extant research on the use of ICT in health promotion has recognized several functional and technological requirements, but relatively little is known about other factors that affect the commercialization and adoption of such systems. This paper attempts to identify some economic and structural drivers and challenges that may be relevant to the success of personal health systems in workplace health promotion.

A low tension between individual and societal time aspects in health improved outcomes

OBJECTIVES

To review intertemporal choices, involving decisions with a trade-off between something now and something later. These choices are common in health both at an individual and societal level.

METHODS

The present value of an outcome, for example, the amount of money or the health outcomes in various aspects, is equivalent to the value of a future outcome discounted with the delay of time. The concept of diminishing value over time is positive discounting. Economic forecasts generally use discount rates in which the value of a future dollar is less than the value of a present dollar, and where the discount rates are similar for the individual investor and society. The value of future health is commonly thought of as similar to the value of future money. Yet, the individual may rationally choose a discount rate that is exceedingly low or even negative. This paradox is particularly relevant when considering primary and secondary prevention, where initial and continuing costs may precede beneficent outcomes by decades, making discount rate selections the dominant factor in determining decisions.

CONCLUSION

We suggest that the societal perspective should also recognize that discount rates for health outcomes are largely irrelevant and that even negative discount rates have crucial relevance.

A Sustainable Behavioral Health Program Integrated With Public Health Primary Care

The need for behavioral healthcare for the poor and indigent is well documented in rural North Carolina, and integrated behavioral healthcare--that is, mental health screening and treatment offered as part of primary care services--has proven a very effective and efficient method to improve patients' health. In 2000, the Buncombe County Health Center (BCHC) began a grant-funded program treating depressed patients in its public health clinics and school health programs. The Health Center used the opportunity to send a team to the Management Academy for Public Health to learn business principles that could be applied to the challenge of sustaining this program as part of its ongoing public health service delivery for the county. Using their business plan from the Management Academy, the BCHC sought funding from various stakeholders, and, through their support, was able to institute a fully integrated behavioral health program in 2004. The BCHC has now joined forces with other partners in the state to address statewide policy changes in support of such programs. These efforts are an example of how a community health center can apply entrepreneurial thinking and strategic business planning to improve healthcare and effect wide-ranging change.

Neuropsychological outcomes research: a necessity and an opportunity

Clinical neuropsychology is subject to the same pressures and demands as other aspects of health care. Increasingly, this means being able to document the usefulness of services and interventions. This special issue of Applied Neuropsychology on neuropsychological outcomes research provides preliminary data on the effectiveness of neuropsychological services in various clinical and medicolegal settings. To date, clinical neuropsychology has devoted little time and energy to such outcomes research. It is hoped that this special issue will challenge neuropsychologists to conduct additional outcomes research that in turn will stimulate the development of increasingly better and more cost-effective services. Such outcomes research is one mark of a maturing and responsible clinical profession.