[show abstract][hide abstract] ABSTRACT: Early onset disruptive behavior disorders are overrepresented in low-income families; yet these families are less likely to engage in behavioral parent training (BPT) than other groups. This project aimed to develop and pilot test a technology-enhanced version of one evidence-based BPT program, Helping the Noncompliant Child (HNC). The aim was to increase engagement of low-income families and, in turn, child behavior outcomes, with potential cost-savings associated with greater treatment efficiency. Low-income families of 3- to 8-year-old children with clinically significant disruptive behaviors were randomized to and completed standard HNC (n = 8) or Technology-Enhanced HNC (TE-HNC; n = 7). On average, caregivers were 37 years old; 87% were female, and 80% worked at least part-time. More than half (53%) of the youth were boys; the average age of the sample was 5.67 years. All families received the standard HNC program; however, TE-HNC also included the following smartphone enhancements: (a) skills video series, (b) brief daily surveys, (c) text message reminders, (d) video recording home practice, and (e) midweek video calls. TE-HNC yielded larger effect sizes than HNC for all engagement outcomes. Both groups yielded clinically significant improvements in disruptive behavior; however, findings suggest that the greater program engagement associated with TE-HNC boosted child treatment outcome. Further evidence for the boost afforded by the technology is revealed in family responses to postassessment interviews. Finally, cost analysis suggests that TE-HNC families also required fewer sessions than HNC families to complete the program, an efficiency that did not compromise family satisfaction. TE-HNC shows promise as an innovative approach to engaging low-income families in BPT with potential cost-savings and, therefore, merits further investigation on a larger scale.
[show abstract][hide abstract] ABSTRACT: Estimates of the medical costs associated with different stages of CKD are needed to assess the economic benefits of interventions that slow the progression of kidney disease. We combined laboratory data from the National Health and Nutrition Examination Survey with expenditure data from Medicare claims to estimate the Medicare program's annual costs that were attributable to CKD stage 1-4. The Medicare costs for persons who have stage 1 kidney disease were not significantly different from zero. Per person annual Medicare expenses attributable to CKD were $1700 for stage 2, $3500 for stage 3, and $12,700 for stage 4, adjusted to 2010 dollars. Our findings suggest that the medical costs attributable to CKD are substantial among Medicare beneficiaries, even during the early stages; moreover, costs increase as disease severity worsens. These cost estimates may facilitate the assessment of the net economic benefits of interventions that prevent or slow the progression of CKD.
Journal of the American Society of Nephrology 08/2013; · 8.99 Impact Factor
[show abstract][hide abstract] ABSTRACT: Disruptive behavior disorders (DBD) in children can lead to delinquency in adolescence and antisocial behavior in adulthood. Several evidence-based behavioral parent training (BPT) programs have been created to treat early onset DBD. This paper focuses on one such program, helping the noncompliant child (HNC), and provides detailed cost estimates from a recently completed pilot study for the HNC program. The study also assesses the average cost-effectiveness of the HNC program by combining program cost estimates with data on improvements in child participants’ disruptive behavior. The cost and effectiveness estimates are based on implementation of HNC with low-income families. Investigators developed a Microsoft Excel-based costing instrument to collect data from therapists on their time spent delivering the HNC program. The instrument was designed using an activity-based costing approach, where each therapist reported program time by family, by date, and for each skill that the family was working to master. Combining labor and non-labor costs, it is estimated that delivering the HNC program costs an average of $501 per family from a payer perspective. It also costs an average of $13 to improve the Eyberg Child Behavior Inventory intensity score by 1-point for children whose families participated in the HNC pilot program. The cost of delivering the HNC program appears to compare favorably with the costs of similar BPT programs. These cost estimates are the first to be collected systematically and prospectively for HNC. Program managers may use these estimates to plan for the resources needed to fully implement HNC.
Journal of Child and Family Studies 01/2013; · 1.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: We conducted a systematic review on outcomes and costs of community health worker (CHW) interventions. CHWs are increasingly expected to improve health outcomes cost-effectively for the underserved.
We searched Medline, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature for studies conducted in the United States and published in English from 1980 through November 2008. We dually reviewed abstracts, full-text articles, data abstractions, quality ratings, and strength of evidence grades and resolved disagreements by consensus.
We included 53 studies on outcomes of CHW interventions and 6 on cost or cost-effectiveness. For outcomes, limited evidence (5 studies) suggests that CHW interventions can improve participant knowledge compared with alternative approaches or no intervention. We found mixed evidence for participant behavior change (22 studies) and health outcomes (27 studies). Some studies suggested that CHW interventions can result in greater improvements in participant behavior and health outcomes compared with various alternatives, but other studies suggested that CHW interventions provide no statistically different benefits than alternatives. We found low or moderate strength of evidence suggesting that CHWs can increase appropriate health care utilization for some interventions (30 studies). Six studies with economic information yielded insufficient data to evaluate the cost-effectiveness of CHW interventions relative to other interventions.
CHWs can improve outcomes for underserved populations for some health conditions. The effectiveness of CHWs in many health care areas requires further research that addresses the methodologic limitations of prior studies and that contributes to translating research into practice.
Medical care 09/2010; 48(9):792-808. · 3.24 Impact Factor
[show abstract][hide abstract] ABSTRACT: The 2009 H1N1 influenza virus is estimated to have caused over 47 million cases of influenza, 213,000 hospitalizations, and at least 9820 deaths. In July 2009, the Advisory Committee on Immunization Practices (ACIP) made recommendations for using 2009 influenza A (H1N1) monovalent vaccine. Recognizing that vaccine supply would grow over time, the ACIP targeted groups at higher risk for H1N1 influenza or its complications or for transmitting influenza to others (159 million persons) for initial vaccination; a subset of this group was prioritized for vaccination in case of limited supply (42 million persons). The ACIP also recommended that vaccination be expanded to the rest of the population as vaccine supplies increased. Mass vaccination clinics were tasked with establishing and operating clinics with the capacity to vaccinate a thousand people or more per day. Although guidelines are available to help clinic managers develop plans for running large-scale H1N1 influenza vaccination clinics, limited information is available to budget for vaccination clinic operations costs. To assist with clinic budgeting, we developed a spreadsheet-based tool that is flexible enough to address the particular budget-related features of any mass prophylaxis campaign. It estimates costs by activity, which allows users to assess the effect on costs of scaling up or down specific activities. We pilot tested the tool with public health clinics in North Carolina and South Carolina and with private clinics in those states (e.g., doctor’s offices, pharmacies). Although we focused on collecting data on costs and clinic outcomes, we also collected information about clinic planning and the process for distributing H1N1 vaccine within each state from October 2009 through the spring of 2010. Results suggest that, from the clinic perspective, the cost of setting up and running H1N1 vaccination clinics was minimal. Vaccination supplies (vaccine, needles, alcohol swabs, etc.) were provided at no cost to both public and private H1N1 vaccination clinics; public health clinics were reimbursed by the federal government for all other clinic-related expenditures. Costs to public health departments consisted only of the opportunity costs associated with staff time spent working on H1N1 vaccination and the loss of clinic space for other uses. We also estimated clinic costs from the societal perspective, calculating costs using ex-ante assumptions about the number of people expected to show for vaccination. These budgeted costs were similar to estimates in the literature for seasonal influenza mass vaccination clinic costs, or about $15 per person vaccinated. However, costs per person varied widely depending on the number and characteristics of people who actually showed for vaccination and on clinic structure (i.e., walk-in versus scheduled appointments). Our findings suggest that the cost of operating mass vaccination clinics varies depending on the analytical perspective and target population characteristics. When planning for the set-up of mass vaccination clinics, managers should consider what clinic costs would be if free resources (e.g., volunteers) were not available and should assess the range of clinic costs across a range of clinic operations, target population, and utilization assumptions.
[show abstract][hide abstract] ABSTRACT: To conduct a systematic review of the evidence on characteristics of community health workers (CHWs) and CHW interventions, outcomes of such interventions, costs and cost-effectiveness of CHW interventions, and characteristics of CHW training.
We searched MEDLINE, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature for studies published in English from 1980 through November 2008.
We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grades. We resolved disagreements by consensus.
We included 53 studies on characteristics and outcomes of CHW interventions, 6 on cost-effectiveness, and 9 on training. CHWs interacted with participants in a broad array of locations, using a spectrum of materials at varying levels of intensity. We classified 8 studies as low intensity, 18 as moderate intensity, and 27 as high intensity, based on the type and duration of interaction. Regarding outcomes, limited evidence (five studies) suggests that CHW interventions can improve participant knowledge when compared with alternative approaches such as no intervention, media, mail, or usual care plus pamphlets. We found mixed evidence for CHW effectiveness on participant behavior change (22 studies) and health outcomes (27 studies): some studies suggested that CHW interventions can result in greater improvements in participant behavior and health outcomes when compared with various alternatives, but other studies suggested that CHW interventions provide no statistically different benefits than alternatives. Low or moderate strength of evidence suggests that CHWs can increase appropriate health care utilization for some interventions (30 studies). The literature showed mixed results of effectiveness when analyzed by clinical context: CHW interventions had the greatest effectiveness relative to alternatives for some disease prevention, asthma management, cervical cancer screening, and mammography screening outcomes. CHW interventions were not significantly different from alternatives for clinical breast examination, breast self-examination, colorectal cancer screening, chronic disease management, or most maternal and child health interventions. Six studies with economic and cost information yielded insufficient data to evaluate the cost-effectiveness of CHW interventions relative to other community health interventions. Limited evidence described characteristics of CHW training; no studies examined the impact of CHW training on health outcomes.
CHWs can serve as a means of improving outcomes for underserved populations for some health conditions. The effectiveness of CHWs in numerous areas requires further research that addresses the methodological limitations of prior studies and that contributes to translating research into practice.
[show abstract][hide abstract] ABSTRACT: To forecast age-related macular degeneration (AMD) and its consequences in the United States through the year 2050 with different treatment scenarios.
We simulated cases of early AMD, choroidal neovascularization (CNV), geographic atrophy (GA), and AMD-attributable visual impairment and blindness with 5 universal treatment scenarios: (1) no treatment; (2) focal laser and photodynamic therapy (PDT) for CNV; (3) vitamin prophylaxis at early-AMD incidence with focal laser/PDT for CNV; (4) no vitamin prophylaxis followed by focal laser treatment for extra and juxtafoveal CNV and anti-vascular endothelial growth factor treatment; and (5) vitamin prophylaxis at early-AMD incidence followed by CNV treatment, as in scenario 4.
Cases of early AMD increased from 9.1 million in 2010 to 17.8 million in 2050 across all scenarios. In non-vitamin-receiving scenarios, cases of CNV and GA increased from 1.7 million in 2010 to 3.8 million in 2050 (25% lower in vitamin-receiving scenarios). Cases of visual impairment and blindness increased from 620 000 in 2010 to 1.6 million in 2050 when given no treatment and were 2.4%, 22.0%, 16.9%, and 34.5% lower in scenarios 2, 3, 4, and 5, respectively.
Prevalence of AMD will increase substantially by 2050, but the use of new therapies can mitigate its effects.
Archives of ophthalmology 05/2009; 127(4):533-40. · 3.86 Impact Factor
[show abstract][hide abstract] ABSTRACT: To compare disease cost estimates from two commonly used approaches.
Pooled Medical Expenditure Panel Survey (MEPS) data for 1998-2003.
We compared regression-based (RB) and attributable fraction (AF) approaches for estimating disease-attributable costs with an application to diabetes. The RB approach used results from econometric models of disease costs, while the AF approach used epidemiologic formulas for diabetes-attributable fractions combined with the total costs for seven conditions that result from diabetes.
We used SAS version 9.1 to create a dataset that combined data from six consecutive years of MEPS.
The RB approach produced higher estimates of diabetes-attributable medical spending ($52.9 billion in 2004 dollars) than the AF approach ($37.1 billion in 2004 dollars). RB model estimates may in part be higher because of the challenges of implementing the two approaches in a similar manner, but may also be higher because they capture the costs of increased treatment intensity for those with the disease.
We recommend using the RB approach for estimating disease costs whenever individual-level data on health care spending are available and when the presence of the disease affects treatment costs for other conditions, as in the case of diabetes.
Health Services Research 03/2009; 44(1):303-20. · 2.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: To estimate the number of people with diabetic retinopathy (DR), vision-threatening DR (VTDR), glaucoma, and cataracts among Americans 40 years or older with diagnosed diabetes mellitus for the years 2005-2050.
Using published prevalence data of DR, VTDR, glaucoma, and cataracts and data from the National Health Interview Survey and the US Census Bureau, we projected the number of Americans with diabetes with these eye conditions.
The number of Americans 40 years or older with DR and VTDR will triple in 2050, from 5.5 million in 2005 to 16.0 million for DR and from 1.2 million in 2005 to 3.4 million for VTDR. Increases among those 65 years or older will be more pronounced (2.5 million to 9.9 million for DR and 0.5 million to 1.9 million for VTDR). The number of cataract cases among whites and blacks 40 years or older with diabetes will likely increase 235% by 2050, and the number of glaucoma cases among Hispanics with diabetes 65 years or older will increase 12-fold.
Future increases in the number of Americans with diabetes will likely lead to significant increases in the number with DR, glaucoma, and cataracts. Our projections may help policy makers anticipate future demands for health care resources and possibly guide the development of targeted interventions.
Efforts to prevent diabetes and to optimally manage diabetes and its complications are needed.
Archives of ophthalmology 01/2009; 126(12):1740-7. · 3.86 Impact Factor
[show abstract][hide abstract] ABSTRACT: The CDC provides funding for HIV prevention activities and state and local decision-makers must allocate these funds. The implementation of a resource allocation tool designed to facilitate this process that incorporates concepts of efficiency and equity as well as CDC mandates on the use of community planning groups is demonstrated, showing how information obtained from the resource allocation tool can be used to guide the policy analysis. The demonstration uses a simplified example based on data from Florida. The tool quantifies the inherent trade-offs associated with efficiency and equity and allows decision-makers to explore different ways of achieving equity. Given the underlying epidemiological model, results are not necessarily linear so common proportionality assumptions do not hold. However, a sense of equity can be provided by implementing various metrics allowing the policy maker flexibility in their decision process. By quantifying the impact of policy choices in terms of efficiency, cost, and distribution, the resource allocation tool makes the decision process more transparent and permits more informed choices.
Health Policy 04/2008; 87(3):342-9. · 1.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: Given the initiatives to improve resource allocation decisions for HIV prevention activities, a linear programming model was designed specifically for use by state and local decision-makers. A pilot study using information from the state of Florida was conducted and studied under a series of scenarios depicting the impact of common resource allocation constraints. Improvements over the past allocation strategy in the number of potential infections averted were observed in all scenarios with a maximal improvement of 73%. When allocating limited resources, policymakers must balance efficiency and equity. In this pilot study, the optimal allocation (i.e., most-efficient strategy) would not distribute resources in an equitable manner. Instead, only 12% of at-risk people would receive prevention funds. We find that less efficient strategies, where 58% fewer infections are averted, result in significantly more equitable allocations. This tool serves as a guide for allocating funds for prevention activities.
Health Care Management Science 10/2007; 10(3):239-52. · 1.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: Although influenza and pneumonia are largely vaccine-preventable, vaccination coverage rates are well below Healthy People 2010 goals. The aim of this study was to examine the costs and cost-effectiveness of three provider-based vaccination interventions in the hospital setting: standing orders programs (SOPs), physician reminders (PRs), and pre-printed orders (PPOs). Data on program operating costs and the numbers of patients who received influenza or pneumococcal vaccinations were collected from nine North Carolina hospitals. Results demonstrated that the additional cost per patient vaccinated in 2004 was US dollars 58 for SOPs, US dollars 90 for PRs, and US dollars 412 for PPOs. These findings suggest that SOPs are a cost-effective approach for increasing adult vaccination coverage rates in hospital settings.
[show abstract][hide abstract] ABSTRACT: To estimate the cost and cost-effectiveness of testing sexually transmitted disease (STD) clinic subgroups for antibodies to hepatitis C virus (HCV).
HCV counseling, testing, and referral (CTR) costs were estimated using data from two STD clinics and the literature, and are reported in 2006 dollars. Effectiveness of HCV CTR was defined as the estimated percentage of clinic clients in subgroups targeted for HCV antibody (anti-HCV) testing who had a true positive test and returned for their test results. We estimated the cost per true positive injection drug user (IDU) who returned for anti-HCV test results and the cost-effectiveness of expanding HCV CTR to non-IDU subgroups.
The estimated cost per true positive IDU who returned for test results was $54. The cost-effectiveness of expanding HCV CTR to non-IDU subgroups ranged from $179 to $2,986. Our estimates were most sensitive to variations in HCV prevalence, the cost of testing, and the rate of client return.
Based on national data, testing IDUs in the STD clinic setting is highly cost-effective. Some clinics may find that it is cost-effective to expand testing to non-IDU men older than 40 who report more than 100 lifetime sex partners. STD clinics can use study estimates to assess the feasibility and desirability of expanding HCV CTR beyond IDUs.
Public Health Reports 02/2007; 122 Suppl 2:55-62. · 1.42 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Centers for Disease Control and Prevention's Section 317 Grants Program is the main source of funding for state and jurisdictional immunization programs, yet no study has evaluated its direct impact on vaccination coverage rates. Therefore, we used a fixed-effects model and data collected from 56 US jurisdictions to estimate the impact of Section 317 financial assistance immunization grants on childhood vaccination coverage rates from 1997 to 2003. Our results showed that increases in Section 317 funding were significantly and meaningfully associated with higher rates of vaccination coverage; a 10 dollars increase in per capita funding corresponded with a 1.6-percentage-point increase in vaccination coverage. Policymakers charged with funding public health programs should consider this study's findings, which indicate that money allocated to vaccine activities translates directly into higher vaccine coverage rates.
American Journal of Public Health 10/2006; 96(9):1548-53. · 3.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: This study develops forecasts of the number of people with diagnosed diabetes and diagnosed diabetes prevalence in the United States through the year 2050. A Markov modeling framework is used to generate forecasts by age, race and ethnicity, and sex. The model forecasts the number of individuals in each of three states (diagnosed with diabetes, not diagnosed with diabetes, and death) in each year using inputs of estimated diagnosed diabetes prevalence and incidence; the relative risk of mortality from diabetes compared with no diabetes; and U.S. Census Bureau estimates of current population, live births, net migration, and the mortality rate of the general population. The projected number of people with diagnosed diabetes rises from 12.0 million in 2000 to 39.0 million in 2050, implying an increase in diagnosed diabetes prevalence from 4.4% in 2000 to 9.7% in 2050.
Health Care Management Science 09/2003; 6(3):155-64. · 1.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: To project the number of people with diagnosed diabetes in the U.S. through 2050, accounting for changing demography and diabetes prevalence rates.
We combined age-, sex-, and race-specific diagnosed diabetes prevalence rates-predicted from 1980-1998 trends in prevalence data from the National Health Interview Survey-with Bureau of Census population demographic projections. Sensitivity analyses were performed by varying both prevalence rate and population projections.
The number of Americans with diagnosed diabetes is projected to increase 165%, from 11 million in 2000 (prevalence of 4.0%) to 29 million in 2050 (prevalence of 7.2%). The largest percent increase in diagnosed diabetes will be among those aged > or =75 years (+271% in women and +437% in men). The fastest growing ethnic group with diagnosed diabetes is expected to be black males (+363% from 2000-2050), with black females (+217%), white males (+148%), and white females (+107%) following. Of the projected 18 million increase in the number of cases of diabetes in 2050, 37% are due to changes in demographic composition, 27% are due to population growth, and 36% are due to increasing prevalence rates.
If recent trends in diabetes prevalence rates continue linearly over the next 50 years, future changes in the size and demographic characteristics of the U.S. population will lead to dramatic increases in the number of Americans with diagnosed diabetes.
Diabetes Care 01/2001; 24(11):1936-1940. · 7.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: This article uses the 2009 H1N1 influenza vaccination program experience to introduce a cost analysis approach that may be relevant for planning mass prophylaxis operations, such as vaccination clinics at public health centers, work sites, schools, or pharmacy-based clinics. These costs are important for planning mass influenza vaccination activities and are relevant for all public health emergency preparedness scenarios requiring countermeasure dispensing. We demonstrate how costs vary depending on accounting perspective, staffing composition, and other factors. We also describe a mass vaccination clinic budgeting tool that clinic managers may use to estimate clinic costs and to examine how costs vary depending on the availability of volunteers or donated supplies and on the number of patients vaccinated per hour. Results from pilot tests with school-based H1N1 influenza vaccination clinic managers are described. The tool can also contribute to planning efforts for universal seasonal influenza vaccination.
Journal of public health management and practice: JPHMP 17(1):E22-8. · 0.96 Impact Factor