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Among the 14.6% of American households experiencing food insecurity, approximately 2 million are occupied by older adults. Food insecurity among older adults has been linked to poor health, lower cognitive function, and poor mental health outcomes. While evidence of the association between individual or household-level factors and food insecurity has been documented, the role of neighborhood-level factors is largely understudied. This study uses data from a representative sample of 1,870 New York City senior center participants in 2008 to investigate the relationship between three neighborhood-level factors (walkability, safety, and social cohesion) and food insecurity among the elderly. Issues relating to food security were measured by three separate outcome measures: whether the participant had a concern about having enough to eat this past month (concern about food security), whether the participant was unable to afford food during the past year (insufficient food intake related to financial resources), and whether the participant experienced hunger in the past year related to not being able to leave home (mobility-related food insufficiency). Unadjusted and adjusted logistic regression was performed for each measure of food insecurity. Results indicate that neighborhood walkability is an important correlate of mobility-related food insufficiency and concern about food insecurity, even after controlling the effects of other relevant factors. [ABSTRACT FROM AUTHOR]

The development of cost effective models of hospital care and discharge planning for people with HIV is a vital policy issue. However, almost no data exist evaluating cost and quality differences in alternate hospital models of care. This empirical study retrospectively evaluates social work discharge planning for patients with HIV disease in two hospital care models: a cluster AIDS unit and general inpatient site beds. The independent effect of each hospital model of care on length of stay is assessed in a multivariate analysis, controlling for level of care needs and other social and clinical factors. Results reveal that the cluster AIDS unit, where a specialized AIDS social work staff works in collaboration with the interdisciplinary AIDS team, is associated with a significant reduction in hospital length of stay for persons with HIV disease and complex discharge planning needs. These results support the hypothesis that discharge planning services, performed by specialized social workers, are a cost effective investment for hospitals treating patients with complex chronic conditions, such as AIDS. Further research should be developed to systematically evaluate the cost effectiveness of hospital-based social workers, using prospective experimental designs, in order to establish the net impact of social work discharge planning services on patient and family outcomes and institutional and social costs. [ABSTRACT FROM AUTHOR]

Pediatric AIDS is a continuing problem because of maternal transmission. Medical management is often complicated by the loss of one or both parents and adverse home environments. This study explores the cost of inpatient and clinic care of children admitted with AIDS in 1988 or 1989 at Mount Sinai Medical Center in New York City, and also examines the social severity of the cases. Blue Shield allowances were used to price clinic visits and tests, and prices in a drug trade publication were used to determine medication costs. Inpatient costs calculated per person-month at risk amounted to $48,000 per year. Costs per person-month of clinic care averaged $461 (38% of which was for drugs), annualized to around $5,500. These costs are higher than those shown by previous studies. A few cases requiring intensive inpatient services accounted for a large percentage of costs. The social severity analysis, based on the family environment at first admission and later, revealed that households were often stressed by chronic illnesses, drug abuse, marital problems and poor residential quality. Given the circumstances in which pediatric AIDS develops, the activities of social workers to strengthen families are essential to facilitating compliance, maintaining health and minimizing use of the hospital. [ABSTRACT FROM AUTHOR]

We examined the prevalence of, and factors associated with unmet health service needs among persons with HIV disease. Data were examined from 1,851 participants in the U.S. AIDS Cost and Service Utilization Study, drawn from 26 medical care providers in 10 cities. Geographic areas with large numbers of AIDS cases, and health care providers within them were chosen as study sites. After completing a screener questionnaire, potential participants at each site were stratified by illness stage, HIV exposure route, and insurance status; a systematic random sample within those strata were selected for the study. Participants completed a comprehensive survey of HIV-related service use and costs, which also asked them to identify unmet health service needs. Analyses identified the relationship between unmet needs and: stage of illness, type of insurance, source of care, living arrangement, and AIDS prevalence of respondents' geographic region. At least one unmet need was reported by 20% of the sample. Needs for non-institutional services, e.g., dental care, mental health, and medications were more likely to be unmet than need for emergency room and hospital care. While most factors significantly affected the odds of having an unmet need, the greatest effects were found for private insurance and HIV asymptomatic status, both of which decreased the odds of unmet needs by approximately 50%. These findings suggest that insurance coverage for services required during the chronic phase of HIV illness is inadequate and should be augmented. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the potential benefits, harms, and economic consequences of digital rectal examination and measurement of prostate-specific antigen (PSA) for the early detection of prostate cancer.Data Sources: Relevant studies were identified from a MEDLINE search (1966 to 1995), reviews, bibliographies of retrieved articles, author files, and abstracts.Study Selection: Probabilities for individual clinical outcomes were derived from various sources, including the largest screening study of community volunteers to data, analyses of Medicare claims, and recently published meta-analyses of the outcomes of alternative treatment strategies. Cost estimates were based on the 1992 Medicare fee schedule.Data Extraction: A cost-effectiveness model for one-time digital rectal examination and PSA measurement was constructed to examine the possible outcomes.Results: If a favorable set of assumptions is used, one-time digital rectal examination and PSA measurement may increase average life expectancy by approximately 2 weeks at a reasonable marginal cost for men who are between 50 and 69 years of age. Considerable iatrogenic illness would occur. If less favorable assumptions are used, the estimated net benefit would decrease and cost-effectiveness ratios would dramatically increase. Even if favorable assumptions are used, the model suggests that screening adds only a few days to the average life expectancy of men who are older than 69 years of age. If the assumptions are less favorable, older men are harmed.Conclusions: The model suggests that screening may be reasonable in younger men if optimistic assumptions consistent with existing observational data are made. The lack of direct evidence showing a net benefit of screening for prostate cancer seems to mandate more clinician-patient discussion for this procedure than for many other routine tests. [ABSTRACT FROM AUTHOR]

As the older adult population grows and becomes more diverse, more of its members are turning to complementary and alternative medicine (CAM). There are mixed findings regarding racial and ethnic differences in the use of CAM. This article explores racial and ethnic differences in use of a category of CAM known as mind-body techniques (MBT) among senior center participants with symptoms of depression. It also examines the relationship between use of MBT and depression severity. A cross-sectional survey was conducted with a representative sample of senior center participants in New York City, from which a subsample of those with depressive symptoms was drawn. Racial and ethnic differences in MBT use were identified, as was a significant negative relationship between MBT use and depression severity. African American elders were more likely to have used MBT than other racial or ethnic groups. When controlling for race or ethnicity, health status, and barriers to medical care, predictors of depression severity included health status, experiencing barriers to medical care, and Hispanic identity. Findings suggest that being female or younger is associated with a higher likelihood of using CAM. Contrary to some prior research, education level was not associated with use of MBT.

Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors - in particular, the primary care infrastructure - inform older adults' primary care use. Using geographic data on primary care physician supply and surveys from 1260 senior center attendees in New York City, we examined factors that facilitate and hinder primary care use for individuals living in service areas with different supply levels. Supply quartiles varied in primary care use (visit within the past 12 months), racial and socio-economic composition, and perceived neighborhood safety and social cohesion. Primary care use did not differ significantly after controlling for compositional factors. Individuals who used a community clinic or hospital outpatient department for most of their care were less likely to have had a primary care visit than those who used a private doctor's office. Stratified multivariate models showed that within the lowest-supply quartile, public transit users had a higher odds of primary care use than non-transit users. Moreover, a higher score on the perceived neighborhood social cohesion scale was associated with a higher odds of primary care use. Within the second-lowest quartile, nonwhites had a lower odds of primary care use compared to whites. Different patterns of disadvantage in primary care access exist that may be associated with - but not fully explained by - local primary care supply. In lower-supply areas, racial disparities and inadequate primary care infrastructure hinder access to care. However, accessibility and elder-friendliness of public transit, as well as efforts to improve social cohesion and support, may facilitate primary care access for individuals living in low-supply areas., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: To examine the association between self-assessed quality of life (QOL) and perceived neighborhood safety, social cohesion, and walkability among older adults in New York City (NYC)., Methods: We used data from the 2008 Health Indicators Project, a cross-sectional survey of 1,870 older adults attending 56 NYC senior centers. QOL, a binary measure, was created by dichotomizing a 5-point Likert-scaled global assessment. Neighborhood safety, social cohesion, and walkability were multi-component scale variables that were standardized due to varying response metrics. Multivariate binomial logistic regression analysis was performed on 1,660 participants with complete data., Results: After adjusting for covariates, QOL was significantly associated with neighborhood safety and social cohesion. A one-standard deviation increase in neighborhood safety and social cohesion increased the log odds of having higher QOL by 30% (odds ratio (OR) = 1.30; 95% confidence interval (CI) = 1.14, 1.48; P ≤ 0.001) and 36% (OR = 1.36; 95% CI = 1.16, 1.59; P ≤ 0.001), respectively. Higher QOL was not significantly associated with neighborhood walkability., Conclusion: The results of this study underscore the need for initiatives that focus on enhancing age-friendly neighborhood features in large urban centers such as NYC and beyond.

Diabetes with comorbid depression increases healthcare use, expenditures, and risk for complications. This study investigated current practice patterns for diabetic management as measured by HbA1C (A1C). Results indicated significant increases in Patient Health Questionnaire (PHQ)-9 and HbA1C scores among patients with diabetes who take antidepressant drugs.

The 2008 Health Indicators Project surveyed a probability sample (N = 1,870) of New York City senior center participants. Attendees of racially and ethnically diverse and nondiverse senior centers were compared across 5 domains: demographics; health and quality of life; social support networks; neighborhood perceptions and engagement; health service access/utilization. Although homogeneous and diverse center participants demonstrate similar health and quality-of-life outcomes, those from diverse centers demonstrate greater risk of social isolation, receive less family support, and more likely seek medical care from hospitals or community clinics. Implications and future directions for research, practice and policy are discussed.

For vulnerable and frail older adults, management of daily financial obligations can become an overwhelming burden spiraling into at-risk situations. Social service agencies have developed community-based Daily Money Management programs to assist these adults in protecting their financial security. Through this study the authors present the first economic estimates of the costs of Daily Money Management programs which, along with case management programs, save $60,000 per individual when compared with the cost of nursing home placement, making them highly cost effective. Most importantly, individuals are able to remain in their homes. The authors address the current gap between cost-effective community-based practice and public policy support.

The dramatic increase in the number of older immigrants living in the U.S. presents new challenges to policy makers concerned with promoting healthy aging. To date, however, strikingly little is known regarding the health and health trajectories of older immigrants. This paper examines the prevalence and predictors of important health behaviors associated with chronic disease prevention, including current smoking status, physical activity, alcohol use, and body mass index (BMI). We analyzed data from the 2003 New York City Chinese Health Survey (NYC CHS), the largest probability-based sample of Chinese immigrants residing in two distinct communities. In-person interviews were conducted with 517 representative men and women aged 55-75. Logistic regression modeling was used to test the influence of demographic, socioeconomic status, acculturation, and health characteristics on selected health behaviors. Results revealed that having more education and better physical health status were associated with greater participation in physical activity. Gender-specific analyses indicated that the effect of selected predictors varied between the sexes. For example, among older Chinese women, acculturation was negatively associated with alcohol use. This study provides some of the first evidence on health behaviors of one of the fastest growing older immigrant groups in the U.S. Study results add to the emerging literature on the complex nature of immigrant health trajectories, and demonstrate that contrary to prior research, living a greater proportion of time in the U.S. can be associated with selected positive health behaviors. Further longitudinal studies are needed to help inform policy initiatives to encourage healthy aging among diverse older immigrant groups.

Objectives: Tobacco taxes are one of the most effective policy interventions to reduce tobacco use. Tax avoidance, however, lessens the public health benefits of higher-priced cigarettes. Few studies examine responses to cigarette tax policies, particularly among high-risk minority populations. This study examined the prevalence and correlates of tax avoidance and changes in smoking behaviors among Chinese American smokers in New York City after a large tax increase., Methods: We conducted a cross-sectional study with data for 614 male smokers from in-person and telephone interviews using a comprehensive household-based survey of 2,537 adults aged 18-74 years. Interviews were conducted in multiple Chinese dialects., Results: A total of 54.7% of respondents reported engaging in at least one low- or no-tax strategy after the New York City and New York State tax increases. The more common strategies for tax avoidance were purchasing cigarettes from a private supplier/importer and purchasing duty free/overseas. Higher consumption, younger age, and number of years in the U.S. were consistently associated with engaging in tax avoidance. Younger and heavier continuing smokers were less likely to make a change in smoking behavior in response to the tax increase. Despite high levels of tax avoidance and varying prices, nearly half of continuing smokers made a positive change in smoking behavior after the tax increase., Conclusions: Expanded legislation and enforcement must be directed toward minimizing the availability of legal and illegal low- or no-tax cigarette outlets. Public education and cessation assistance customized for the Chinese American community is key to maximizing the effectiveness of tobacco tax policies in this population.

No population-based data are available on the degree to which Chinese Americans have adopted smoke-free household policies and whether these policies are effective in reducing environmental tobacco smoke (ETS) exposure. The present study examines the prevalence of smoke-free home rules among Chinese Americans living in New York City, describes predictors of adopting full smoking bans in the home, and explores the association between household smoking restrictions and ETS exposure at home. In-person interviews using a comprehensive household-based survey were conducted with 2,537 adults aged 18-74 years. Interviews were conducted in Mandarin, Cantonese, and other Chinese dialects. A total of 66% of respondents reported that smoking was not allowed inside the home, 22% reported a partial ban on smoking in the home, and 12% reported no smoking ban. Among current smokers, 38% reported a full household smoking ban. Current smoking status was the strongest predictor of less restrictive household smoking policies. Knowledge of the dangers of ETS, support of smoke-free air legislation, years in the United States, gender, income, and marital status also were associated with household smoking bans. Those living with a total household smoking ban were significantly less likely to report 30-day exposure to ETS than were those living in homes with a partial ban or no ban (7% vs. 68% and 73%, respectively). In homes of smokers and nonsmokers alike, exposure to ETS remains high. Smoke-free home rules and interventions among smokers and nonsmokers to raise awareness of the dangers of ETS have the potential to significantly reduce exposure to household ETS among this immigrant population.

Mathematical modeling is an effective tool for guiding cervical cancer screening, diagnosis, and treatment decisions for patients and policymakers. This article describes the use of mathematical modeling as outlined in five presentations from the Decision Science and Cervical Cancer session of the Second International Conference on Cervical Cancer held at The University of Texas M. D. Anderson Cancer Center, April 11-14, 2002. The authors provide an overview of mathematical modeling, especially decision analysis and cost-effectiveness analysis, and examples of how it can be used for clinical decision making regarding the prevention, diagnosis, and treatment of cervical cancer. Included are applications as well as theory regarding decision science and cervical cancer. Mathematical modeling can answer such questions as the optimal frequency for screening, the optimal age to stop screening, and the optimal way to diagnose cervical cancer. Results from one mathematical model demonstrated that a vaccine against high-risk strains of human papillomavirus was a cost-effective use of resources, and discussion of another model demonstrated the importance of collecting direct non-health care costs and time costs for cost-effectiveness analysis. Research presented indicated that care must be taken when applying the results of population-wide, cost-effectiveness analyses to reduce health disparities. Mathematical modeling can encompass a variety of theoretical and applied issues regarding decision science and cervical cancer. The ultimate objective of using decision-analytic and cost-effectiveness models is to identify ways to improve women's health at an economically reasonable cost., (Copyright 2003 American Cancer Society.)

Background: This paper examines hospital utilization, estimated hospital costs, and mortality rates for U.S.-born, foreign-born, and Puerto Rican-born persons residing in New York City., Methods: We conducted a multivariate regression analysis using New York City neighborhoods as the unit of analysis. We utilized data from the Statewide Planning and Research Cooperative System data set and from the 1997 Housing and Vacancy Survey. We also examined mortality rates using 1990 death certificate data and decennial census data., Results: The foreign-born are much less likely to be hospitalized for most major categories of illness and have lower mortality rates than either U.S.-born or Puerto Rican-born New Yorkers. The life expectancy at 1 year of age of the foreign-born is 4 years longer than for U.S.-born persons and 6 years longer than Puerto Rican-born persons. We estimate that the overall cost of providing hospital-based care to the foreign-born was $611 million US dollars less than the cost of providing hospital-based care to an equivalent number of U.S.-born persons in 1996., Conclusion: The foreign-born in New York City appear to be healthier and consume fewer hospital resources than U.S.-born populations. It is possible that the cost of hospital utilization would be lower still if the foreign-born population had better access to ambulatory and preventive services.

In this study, we aimed to estimate the contribution of environmental pollutants to the incidence, prevalence, mortality, and costs of pediatric disease in American children. We examined four categories of illness: lead poisoning, asthma, cancer, and neurobehavioral disorders. To estimate the proportion of each attributable to toxins in the environment, we used an environmentally attributable fraction (EAF) model. EAFs for lead poisoning, asthma, and cancer were developed by panels of experts through a Delphi process, whereas that for neurobehavioral disorders was based on data from the National Academy of Sciences. We define environmental pollutants as toxic chemicals of human origin in air, food, water, and communities. To develop estimates of costs, we relied on data from the U.S. Environmental Protection Agency, Centers for Disease Control and Prevention, National Center for Health Statistics, the Bureau of Labor Statistics, the Health Care Financing Agency, and the Practice Management Information Corporation. EAFs were judged to be 100% for lead poisoning, 30% for asthma (range, 10-35%), 5% for cancer (range, 2-10%), and 10% for neurobehavioral disorders (range, 5-20%). Total annual costs are estimated to be $54.9 billion (range $48.8-64.8 billion): $43.4 billion for lead poisoning, $2.0 billion for asthma, $0.3 billion for childhood cancer, and $9.2 billion for neurobehavioral disorders. This sum amounts to 2.8 percent of total U.S. health care costs. This estimate is likely low because it considers only four categories of illness, incorporates conservative assumptions, ignores costs of pain and suffering, and does not include late complications for which etiologic associations are poorly quantified. The costs of pediatric environmental disease are high, in contrast with the limited resources directed to research, tracking, and prevention.

The objective of this study is to evaluate the clinical aspects of laparoscopic management of adnexal masses. The feasibility of this approach has been demonstrated, but the safe and effective use of laparoscopy for this indication requires training, technical skills and experience on the part of the laparoscopist. If used appropriately, many patients will benefit from minimally-invasive surgery. We compared clinical factors of patients having laparoscopy to those having laparotomy in a case-control study of 30 patients with adnexal masses. Oophorectomy or ovarian cystectomy was performed by laparoscopy for 20 women and by laparotomy for 10 women. Comparing the 2 groups, the most significant difference was the decrease in length of hospital stay in the laparoscopy group. There were no significant differences in operative time or intraoperative complications. Estimated blood loss was lower in the laparoscopy group, and no intraoperative complications occurred. No patient required conversion from laparoscopy to laparotomy. All patients had benign disease despite the inclusion of patients with risk factors for ovarian carcinoma. This study clearly demonstrates the clinical benefits of laparoscopic management of adnexal masses treated with oophorectomy or ovarian cystectomy.

To determine the difference in length of hospital stay for geriatric medical-surgical inpatients with or without psychiatric comorbidity, the authors prospectively interviewed 467 admissions by using the Structured Clinical Interview for DSM-III-R and the Mini-Mental State Exam. At admission, 208 (44.5%) inpatients had a current psychiatric comorbidity, 51 (10.9%) had an anxiety disorder, 88 (18.8%) had a depressive disorder, and 126 (27%) had cognitive impairment. The patients with cognitive impairment had a significantly prolonged hospital stay compared with those without cognitive impairment (14.6 vs. 10.6 days). No difference existed in length of stay for the patients with and without anxiety disorders (11.6 vs. 11.6 days) or depressive disorders (11.0 vs 11.8 days). In view of the limited resources available for screening elderly medical-surgical inpatients for psychiatric comorbidity, this study suggests the utility of identifying cognitive impairment and targeting it for interventions to reduce the clinical burden and to decrease hospital stays.

Objective: To evaluate an infant hearing screening program utilizing the high risk register (HRR) and auditory brainstem response (ABR)., Design: A cost-effectiveness analysis of the screening program employing a retrospective cohort identified by chart review. The analysis was performed on a hypothetical cohort of 100,000 births and the results compared with a base model derived from literature review., Setting: Mount Sinai Hospital, New York City, an urban, tertiary care institution., Patients: All infants born between November 1990 and October 1993, approximately 16,500. Cost-effectiveness analysis focused on test results of 420 infants failing the HRR and 381 who subsequently received ABR., Results: Analysis of the Mount Sinai Hospital (MSH) protocol showed it to be less cost-effective than other similar programs. The cost per hearing loss was far more at MSH than that found elsewhere. Further, the MSH program was ineffective in detecting infants with congenital hearing loss--identifying only one case between 1990 and 1993. Analysis of high risk criteria finds a low incidence of family history of hearing loss in the Mount Sinai cohort while other studies find a very high incidence., Conclusions: It appears that the poor performance of the MSH protocol is due to low specificity and sensitivity of the HRR. This generates a costly and ineffective program as follow-up exams focus on ruling-out false-positives rather than correctly identifying true hearing losses. Further evaluation is needed to determine whether changes in the application of the HRR or utilization of newer, low-cost tests such as otoacoustic emissions (OAE) may be effective in universal infant hearing screening.

Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of $14,500 to $16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.

Screening programmes for cervical cancer have been credited with reducing the incidence of and mortality from cervical cancer. The main components of these screening programmes are: (i) their level of organisation; (ii) the age at which women begin screening; (iii) the age at which women discontinue screening; (iv) the interval between repeat screens; (v) the frequency at which the programmes provide screening; and (vi) the response to an abnormal screening test. However, not all screening programmes are equally efficient and differences in programme components can result in big differences in their cost effectiveness. Studies that employ cost-effectiveness analysis (CEA) to examine the efficiency of different programme components can inform the development of cost-effective programmes. This article presents findings of an international review of cost-effectiveness studies of cervical cancer screening. These studies consistently find that certain types of programmes are more cost effective than others. Programmes that are centrally organised and implemented by the public sector are reported to be more cost effective than those that use public funds for screening at other medical visits (convenience screening), or those that provide guidelines for healthcare professionals and the public to promote spontaneous discretionary screening. There is also substantial agreement about the cost effectiveness of other programme components. When multiple screenings are possible, studies report that they should generally begin at age 25 to 35 years and end at age 65 to 70 years, although it is important that older women have 3 normal Papanicolaou (Pap) smears before the discontinuation of screening. The interval for repeat screens that is reported to provide the best balance between cost and life-years saved is between 3 and 5 years. However, when a choice must be made between screening more women fewer times, or screening fewer women more times, most studies indicate that it is more cost effective to prioritize resources to obtain at least one screening for each woman. The screening of previously unscreened and high-risk populations has been shown to be especially cost effective. Despite this agreement, many studies report that models of the cost effectiveness of screening for cervical cancer are sensitive to a number of parameters. Changes in the attendance rate of the programme, the quality of the Pap smear, and the cost of the Pap smear can markedly change the cost effectiveness of a screening programme. Finally, this review discusses different perspectives of social choice analysis (e.g. CEA and cost-benefit analysis), when the objective is to prevent cervical cancer and the options are to screen, detect and treat, to reduce behavioural risk factors, and/or to pursue promising biological research.

This study sought to identify the prevalence of unstable housing situations, and for whom they occurred, and to examine differences in health care utilization by housing status. Housing status and inpatient and outpatient health care utilization of 1,851 HIV-infected individuals was ascertained through interviews. Nine percent of respondents were in unstable housing situations. Unstable housing was associated with significantly lower functional status. The unstably housed were more likely to visit an emergency room (p < 0.05) and had fewer ambulatory visits than persons with stable housing (p < 0.03). They incurred nearly five more hospital days and their average hospitalization was approximately 1.5 days longer than the stably housed, although these differences were not significant. Utilization of ambulatory care is lower among unstably housed persons with HIV disease, which may have led to their increased reliance upon emergency rooms and hospitals. Helping HIV-infected individuals maintain adequate housing could reverse this pattern.

The Visiting Nurse Service of New York and Empire Blue Cross and Blue Shield implemented in 1990 the "At Home Options Program" (AHOP), an enhanced package of home care and other noninpatient services for HIV-positive clients. AHOP aims to reduce total treatment costs and hospital days. Clients (N = 52) completed mailed satisfaction surveys. Overall, clients were very satisfied with AHOP services. Clients expressed concerns, however, about the uneven quality of substitute paraprofessionals, and said they needed easier access to a knowledgeable healthcare professional. Operational concerns included inadequate information dissemination and administrative oversights. Findings will inform subsequent program activities.

Purpose: To determine the frequency with which stereotaxic core biopsy of the breast obviated diagnostic surgical biopsy and to estimate the savings in cost of diagnosis with this procedure., Materials and Methods: Stereotaxic core biopsy of 182 nonpalpable, mammographically evident lesions was performed, and data from clinical follow-up were obtained. Savings in cost were assessed by using national Medicare reimbursement data and a relative value system based on national physician reviews (Relative Values for Physicians [RVP])., Results: Stereotaxic core biopsy replaced a surgical procedure in 140 of 182 patients. The mean adjusted direct savings in cost per stereotaxic core biopsy were $893 (Medicare) or $1,491 (RVP). Use of stereotaxic core biopsy decreased the cost of diagnosis by 52% (RVP) or 55% (Medicare)., Conclusion: Stereotaxic core biopsy obviated surgical biopsy for most nonpalpable lesions sampled, resulting in a greater than 50% reduction in biopsy costs. If these results were generalizable to the national level, annual savings would approach $200 million.

Objective: This study describes demographic characteristics of pediatric AIDS patients, describes hospital and community-based service utilization patterns, and analyzes medical and social support service usage patterns with respect to patient demographic characteristics, clinical trial participation, functional/developmental status, and social environment., Data Sources and Study Setting: Data reported in this study are from the AIDS Costs and Service Utilization Survey (ACSUS) and cover the six-month period beginning March 1991 (N = 135). Pediatric patients who sought care for HIV-related problems were sampled at seven different hospitals in five metropolitan regions of the United States. All of the participating hospitals had clinics specifically serving pediatric patients infected with HIV. The sample consists of HIV-positive patients who had had at least one HIV-related symptom or condition., Study Design: A stratified probability sample design guided the sampling strategy, which included oversampling in two large hospitals from two of the five metropolitan areas. Survey data cover an 18-month time period of health care utilization, cost, and financing information from HIV-infected patients and their providers. Utilization measures are standardized to a six-month period. Per capita income, family structure, informal personal network, functional status, and clinical trial participation are tested for associations with patterns of utilization. In addition, a weighted ten-point social severity scale was developed to assess family/household stability., Data Collection: Data were collected through a screener instrument completed by the person accompanying the child to a hospital clinic visit (usually a a parent), and through two interviews conducted in person with the patients' primary caregivers. Data from the questionnaires were coded and assembled into computerized SAS analysis files by WESTAT:, Principal Findings: Children in this sample are 62 percent African American, 25 percent Hispanic, and 10 percent White. Medicaid is the primary payer for 92 percent. Mean per capita income is $3,440. Fewer than one-half (41 percent) of the families of the children receive Aid to Families with Dependent Children (AFDC). (AFDC). Within the six-month period, approximately one-third of the sample (29.6 percent) was hospitalized. Mean length of stay was 16.0 days. Clinical trial participation was positively related to mean number of hospital clinic visits and receipt of formal (paid) home care. There were no differences in use of community clinic, mental health, and inpatient facilities by clinical trial status. Participation in clinical trials was positively related to income and negatively related to social severity. In four cities, emergency room use was consistently lower for clinical trial participants than for nonparticipants., Conclusions: Data from the first six months of the ACSUS pediatric sample suggest that participation in clinical trials may bring about access to social services that appear to reduce emergency room use. However, the findings reported here are descriptive and exploratory. Further multivariate, nonparametric analyses of the full 18-month provider-patient merged data set are necessary to confirm the simple correlations found in this study.

Despite the growing number of HIV-related hospital admissions, reports of hospitalization experiences of persons with AIDS has been sparse. As part of a larger quantitative study to assess how arrangements of care of patients with AIDS are related to quality of care, the authors analyzed qualitative data collected during interviews with 50 patients hospitalized for HIV-related complications. The responses are suggestive of problematic hospital care issues and indicate psychosocial concerns. Overarching themes emerged of communication deficits and depersonalizing behavior. This research can help healthcare professionals develop increased sensitivity to patients' perspectives of their circumstances. More extensive research is needed to evaluate and improve the experiences of patients during hospitalization for HIV-related illness.

Objective: To analyze the costs and benefits of alternative cervical cancer screening schedules among elderly women., Setting: Population-based screening programs., Design: A Markov model predicts the outcomes of periodic screening, diagnosis, and treatment for cervical cancer among women from 65 to 109 years of age., Patients: A hypothetical cohort of one million 65-year-old women; representative of the U.S. population., Measurements: The costs and yields of screening., Results: Triennial screening reduced mortality from cervical cancer among the elderly by 74% at a cost of $2254 per year of life saved. Annual screening increased costs to $7345 per year of life saved; less frequent schedules yielded lower costs but decreased savings in life. These results were most sensitive to the quality of the Papanicolaou smear and the characteristics of the women using the benefit. If the sensitivity of the Papanicolaou smear was reduced from a baseline estimate of 75% to 50% and the specificity was decreased to 87% from 95%, the cost effectiveness ratio increased by nearly $7000 per year of life saved. If triennial screening is targeted to women who have not had regular screening, the program will save money as well as years of life; however, screening women who have been screened regularly is considerably less efficient, increasing costs to $33,572 per year of life saved., Conclusion: The success of the new Medicare benefit depends substantially on physicians assuring that their elderly patients, particularly women without regular prior screening, obtain high quality Papanicolaou smears. The data also show that after a woman 65 years of age or older has a history of regular negative smears, screening is inefficient and can cease.

An AIDS unit model ("cluster beds") and a general inpatient placement model ("scatter beds") in a major teaching hospital were compared to determine whether they differed on several dimensions of care. After controlling for severity of illness, (the major predictor of admission to the AIDS unit), length of stay, charges, and inpatient mortality rates did not differ between the two settings. Equal proportions of White, Hispanic, male, and privately insured patients were found in both settings. Nursing staff turnover rates were comparable to those of other sites. However, the data raise new issues regarding access to AIDS units for older, Black, and female patients.

The effect of cost sharing on health services utilization is analyzed from a new perspective, that is, its effects on physician response to cost sharing. A primary data set was constructed using medical records and billing files from a large multispecialty group practice during the three-year period surrounding the introduction of cost sharing to the United Mine Workers Health and Retirement Fund. This same group practice also served an equally large number of patients covered by United Steelworkers' health benefit plans, for which similar utilization data were available. The questions addressed in this interinsurer study are: (1) to what extent does a physician's treatment of medically similar cases vary, following a drop in patient visits as a result of cost sharing? and (2) what is the impact, if any, on costs of care for other patients in the practice (e.g., "spillover effects" such as cost shifting)? Answers to these kinds of questions are necessary to predict the effects of cost sharing on overall health care costs. A fixed-effects model of physician service use was applied to data on episodes of treatment for all patients in a private group practice. This shows that the introduction of cost sharing to some patients in a practice does, in fact, increase the treatment costs to other patients in the same practice who remain under stable insurance plans. The analysis demonstrates that when the economic effects of cost sharing on physician service use are analyzed for all patients within a physician practice, the findings are remarkably different from those of an analysis limited to those patients directly affected by cost sharing.

Providing efficacious, compassionate, and efficient medical care to persons with HIV infection is one of the greatest challenges that will face US hospitals this decade. Unfortunately, there have been almost no studies of how organizational arrangements are related to the quality of care. We developed an interview protocol and conducted a pilot study to evaluate the instrument's ability to detect differences in selected interpersonal aspects of care provided to persons with AIDS. We evaluated the care received in two different treatment models in a major teaching hospital: a designated AIDS unit and general medical beds. We assessed several areas of patient care that are clinically important and that patients can evaluate: communication between patients and providers, patient education, respect for patient preferences, emotional support, involvement of family and friends, trust and confidence, physical care, pain management, AIDS knowledge, perceived segregation, confidentiality, and financial information. Patients generally were very satisfied with their hospital care, but many reported problems with certain aspects of their care. The instrument used detected differences between the care reported by patients treated in general hospital beds and in a designated AIDS unit in several specific aspects of care.

Because there is no tuberculin screening schedule currently recommended for adults, we used a Markov process in a cost-effectiveness analysis to determine an optimal strategy. We simulated the prognosis of a cohort of black 20-year-olds to evaluate the effects of various screening schedules with intradermal tuberculin and administration of isoniazid prophylaxis to those with positive results. The schedule with the lowest cost-effectiveness ratio is a single screening at 50 years of age, which costs $41,672 per quality-adjusted life year (QALY) gained. The cost-effectiveness ratio is nearly the same for all schedules involving a single screening between 30 and 70 years of age. Repeated screening strategies are less cost effective. Sensitivity analysis shows that the range of acceptable screening strategies changes significantly under alternate assumptions about the mortality from isoniazid hepatitis. However, screening at 50 years of age remains nearly optimal under the alternatives considered. Altering the values of other parameters generally produced only small changes. Tuberculin screening at 50 years of age should be added to primary care preventive practices because the strategy is as cost effective as standard health interventions and is robust to alternative assumptions. If further research confirms the base case assumptions about isoniazid toxicity, consideration should be given to increasing screening to every 10 years, which would produce a larger health benefit, albeit at substantially higher cost.

Using explicit criteria, delirium was diagnosed in 15% of a cohort of 133 hospitalized patients. Following each patient's discharge or death, the length of stay was compared with the diagnosis related group-predicted length of hospitalization. An analysis of stay variations disclosed that delirious patients exceeded their predicted stay by an average of 13 days, while nondelirious patients exceeded theirs by 3.3 days. The mean (+/- SD) length of hospitalization for patients with delirium was significantly longer than for their nondelirious counterparts (21.6 +/- 23.7 days vs 10.6 +/- 10.1 days, respectively). Hospitals treating high proportions of patients with delirium as a comorbidity to a principal somatic diagnosis should institute measures for the early detection of and appropriate intervention in patients with this condition. These steps may help reduce prolonged hospitalizations and minimize financial risk under the current diagnosis related group reimbursement system.

A survey of six geriatric experts concerning the normative role content of physicians providing primary care for the elderly emphasizes the importance of distinguishing reversible and irreversible components of a patient's problems and of conducting multidimensional functional assessments. Appreciation of the role of the environment in maintaining functional capacity should be inculcated in practitioners treating the elderly. Medicare payment methods should recognize that the elderly require more professional time for adequate care, and should address transportation needs.

Occupational diseases and deaths are costly events. They are responsible for: 1) direct medical costs; 2) indirect costs, resulting from lost production, foregone opportunities, and diminished investment; and 3) non-economic costs, including pain and suffering, disrupted careers, and devastated families. To develop a partial estimate of the total costs of occupational disease in New York State, we have examined four categories of illness: occupational cancer, chronic respiratory disease and the pneumoconioses, cerebrovascular and cardiovascular disease, and end-stage renal failure. We base our partial estimate on the human capital approach to the costs of these illnesses. Using the best measures available, including both incidence and prevalence statistics, mortality records, and a variety of financial data, we employ two cost accounting techniques of the human capital approach, the incidence method, and the prevalence method. Our analysis shows that these four occupational illnesses are costing New York over $600 million per year. This figure is a pragmatic but conservative, lower-bound estimate of the relative magnitude of total economic costs of occupational disease in New York State. The largest proportion of these costs (80%) is due to occupational cancer. The failure of the health care system to recognize the costs of occupational disease precludes recognition of the economic benefits which would result from preventing these illnesses. This study, it is hoped, will stimulate advances in epidemiological and economic approaches to resolve this important measurement problem.

Evidence of the degree of fit between the special needs of the elderly and the service mix and payment level of ambulatory services offered under the Medicare program is presented in this second part of a two-part study of geriatric office care. Results from interviews with a focus group of 60 practicing clinicians, incorporating diversity of geography and practice setting, are described and compared with the view of geriatricians. Between 30 and 57% of the clinicians are aware of negative effects of Medicare's benefit structure on specific aspects of their practice.

Isoniazid chemoprophylaxis is not recommended for all persons infected with tubercle bacilli. Because of the small but significant risk of isoniazid hepatotoxicity, chemoprophylaxis is reserved for only those at the highest risk of tuberculosis activation. To evaluate this policy, we performed a cost-effectiveness analysis of isoniazid chemoprophylaxis for two populations with positive tuberculin skin tests: recent tuberculin converters, who are at high risk for activation, and older tuberculin reactors, who have a low risk for activation and for whom chemoprophylaxis is not now recommended. The cost-effectiveness ratios found were stable, despite wide variations in model assumptions and probability estimates. For high-risk tuberculin reactors, chemoprophylaxis resulted in net medical care monetary savings, extended life expectancy, and fewer fatal illnesses. For low-risk tuberculin reactors, chemoprophylaxis resulted in positive, but small, health effects. Because the cost to gain these positive effects were also small, the resulting cost-effectiveness ratios were reasonable and in the realm of accepted prevention strategies: $12,625 to gain one year of life and $35,011 to avert one death. These findings suggest that the current policy is too restrictive and that many in the large population of low-risk tuberculin reactors should be considered for isoniazid chemoprophylaxis.