Mixed methods assessment of the influence of demographics on medical advice of ChatGPT

OBJECTIVES

To evaluate demographic biases in diagnostic accuracy and health advice between generative artificial intelligence (AI) (ChatGPT GPT-4) and traditional symptom checkers like WebMD.

MATERIALS AND METHODS

Combination symptom and demographic vignettes were developed for 27 most common symptom complaints. Standardized prompts, written from a patient perspective, with varying demographic permutations of age, sex, and race/ethnicity were entered into ChatGPT (GPT-4) between July and August 2023. In total, 3 runs of 540 ChatGPT prompts were compared to the corresponding WebMD Symptom Checker output using a mixed-methods approach. In addition to diagnostic correctness, the associated text generated by ChatGPT was analyzed for readability (using Flesch-Kincaid Grade Level) and qualitative aspects like disclaimers and demographic tailoring.

RESULTS

ChatGPT matched WebMD in 91% of diagnoses, with a 24% top diagnosis match rate. Diagnostic accuracy was not significantly different across demographic groups, including age, race/ethnicity, and sex. ChatGPT's urgent care recommendations and demographic tailoring were presented significantly more to 75-year-olds versus 25-year-olds (P < .01) but were not statistically different among race/ethnicity and sex groups. The GPT text was suitable for college students, with no significant demographic variability.

DISCUSSION

The use of non-health-tailored generative AI, like ChatGPT, for simple symptom-checking functions provides comparable diagnostic accuracy to commercially available symptom checkers and does not demonstrate significant demographic bias in this setting. The text accompanying differential diagnoses, however, suggests demographic tailoring that could potentially introduce bias.

CONCLUSION

These results highlight the need for continued rigorous evaluation of AI-driven medical platforms, focusing on demographic biases to ensure equitable care.

Longitudinal association between e-cigarette use and respiratory symptoms among US adults: Findings from the Population Assessment of Tobacco and Health Study Waves 4-5

BACKGROUND

We assessed longitudinal effects of e-cigarette use on respiratory symptoms in a nationally representative sample of US adults by combustible tobacco smoking status.

METHODS

We analyzed Waves 4-5 public-use data from the Population Assessment of Tobacco and Health Study. Study sample included adult respondents who reported no diagnosis of respiratory diseases at Wave 4, and completed Waves 4-5 surveys with no missing data on analytic variables (N = 15,291). Outcome was a validated index of functionally important respiratory symptoms based on 7 wheezing/cough questions (range 0-9). An index score of ≥2 was defined as having important respiratory symptoms. Weighted lagged logistic regression models were performed to examine the association between e-cigarette use status at Wave 4 (former/current vs. never use) and important respiratory symptoms at Wave 5 by combustible tobacco smoking status (i.e., never/former/current smokers), adjusting for Wave 4 respiratory symptom index, sociodemographic characteristics, secondhand smoke exposure, body mass index, and chronic disease.

RESULTS

Among current combustible tobacco smokers, e-cigarette use was associated with increased odds of reporting important respiratory symptoms (former e-cigarette use: adjusted odds ratio [AOR] = 1.39, 95% confidence interval [CI]: 1.07-1.81; current e-cigarette use: AOR = 1.55, 95% CI: 1.17-2.06). Among former combustible tobacco smokers, former e-cigarette use (AOR = 1.51, 95% CI: 1.06-2.15)-but not current e-cigarette use (AOR = 1.59, 95% CI: 0.91-2.78)-was associated with increased odds of important respiratory symptoms. Among never combustible tobacco smokers, no significant association was detected between e-cigarette use and important respiratory symptoms (former e-cigarette use: AOR = 1.62, 95% CI: 0.76-3.46; current e-cigarette use: AOR = 0.82, 95% CI: 0.27-2.56).

CONCLUSIONS

The association between e-cigarette use and respiratory symptoms varied by combustible tobacco smoking status. Current combustible tobacco smokers who use e-cigarettes have an elevated risk of respiratory impairments.

Prevalence and factors associated with second hand smoke exposure among a sample of pregnant women in Cairo, Egypt

PURPOSE

This study estimated the prevalence of and factors associated with secondhand smoke (SHS) exposure, and assessed attitudes and knowledge about SHS among pregnant women in Cairo, Egypt.

METHODS

Pregnant women in the third trimester were recruited to participate in a survey assessing tobacco smoking and SHS exposure during their current pregnancy. Participants were recruited from three antenatal clinics in Cairo, Egypt, from June 2015 to May 2016. We examined differences in sociodemographic characteristics and SHS exposure, attitudes, and knowledge by smoking/SHS status. We used multivariable ordinary least squares regression to examine the association between husbands' smoking and pregnant women's mean daily hours of SHS exposure, adjusting for women's smoking status, age group, education, and urban (vs. suburban/rural) residence.

RESULTS

Of two hundred pregnant women aged 16-37 years, about two-thirds (69%) had a husband who smoked tobacco. During their current pregnancy, most women reported being non-smokers (71%), and 38% of non-smokers reported being SHS-exposed. Non-smokers exposed to SHS tended to live in more rural areas and have husbands who smoked in the home. In adjusted analyses, having a husband who smoked was significantly associated with a greater mean number of hours of SHS exposure per day exposed, and this difference was driven by husbands who smoked in the home (p < 0.001). Women in the SHS-exposed group were less likely than other groups to agree that SHS exposure was harmful to their own or their future child's health; however, all groups agreed that SHS was harmful to newborn health.

CONCLUSION

Among our sample of pregnant women in Cairo, Egypt, there was a high rate of SHS exposure as well as misconceptions about the safety of SHS exposure to a developing fetus. Our findings suggest a need for targeted education and gender-sensitive messaging about SHS exposure, along with improved enforcement of existing tobacco control policies.

Trial Participants' Perceptions of the Impact of Ecological Momentary Assessment on Smoking Behaviors: Qualitative Analysis

Background

Ecological momentary assessment (EMA) is an increasingly used tool for data collection in behavioral research, including smoking cessation studies. As previous addiction research suggests, EMA has the potential to elicit cue reactivity by triggering craving and increasing behavioral awareness. However, there has been limited evaluation of its potential influence on behavior.

Objective

By examining the perspectives of research participants enrolled in a tobacco treatment intervention trial, this qualitative analysis aims to understand the potential impact that EMA use may have had on smoking behaviors that may not have otherwise been captured through other study measures.

Methods

We performed a qualitative analysis of in-depth interviews with participants enrolled in a pilot randomized controlled trial of a tobacco treatment intervention that used SMS text messaging to collect EMA data on smoking behaviors. In the pilot randomized controlled trial, combustible cigarette and e-cigarette use and smoking-related cravings were measured as part of an EMA protocol, in which SMS text messaging served as a smoking diary. SMS text messaging was intended for data collection only and not designed to serve as part of the intervention. After a baseline assessment, participants were asked to record daily nicotine use for 12 weeks by responding to text message prompts that they received 4 times per day. Participants were prompted to share their experiences with the EMA text messaging component of the trial but were not directly asked about the influence of EMA on their behaviors. Transcripts were coded according to the principles of the framework for applied research. The codes were then examined, summarized, and grouped into themes based on the principles of grounded theory.

Results

Interviews were analyzed for 26 participants. The themes developed from the analysis suggested the potential for EMA, in the form of an SMS text messaging smoking diary, to influence participants' smoking behaviors. The perceived impacts of EMA text messaging on smoking behaviors were polarized; some participants emphasized the positive impacts of text messages on their efforts to reduce smoking, while others stressed the ways that text messaging negatively impacted their smoking reduction efforts. These contrasting experiences were captured by themes reflecting the positive impacts on smoking behaviors, including increased awareness of smoking behaviors and a sense of accountability, and the negative impacts on emotions and smoking behaviors, including provoking a sense of guilt and triggering smoking behaviors.

Conclusions

The collection of EMA smoking behavior data via SMS text messaging may influence the behaviors and perceptions of participants in tobacco treatment interventions. More research is needed to determine the magnitude of impact and mechanisms, to account for the potential effects of EMA. A broader discussion of the unintended effects introduced by EMA use is warranted among the research community.

Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial

BACKGROUND

Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model.

METHODS

Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout.

DISCUSSION

This study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303 .

Considerations for using predictive models that include race as an input variable: The case study of lung cancer screening

Indiscriminate use of predictive models incorporating race can reinforce biases present in source data and lead to an exacerbation of health disparities. In some countries, such as the United States, there is therefore a push to remove race from prediction models; however, there are still many prediction models that use race as an input. Biomedical informaticists who are given the responsibility of using these predictive models in healthcare environments are likely to be faced with questions like how to deal with race covariates in these models. Thus, there is a need for a pragmatic framework to help model users think through how to include race in their chosen model so as to avoid inadvertently exacerbating disparities. In this paper, we use the case study of lung cancer screening to propose a simple framework to guide how model users can approach the use (or non-use) of race inputs in the predictive models they are tasked with leveraging in electronic health records and clinical workflows.

Recognizing the value of meta-research and making it easier to find

Meta-research is a bourgeoning field studying topics with significant relevance to health sciences librarianship, such as research reproducibility, peer review, and open access. As a discipline that studies research itself and the practices of researchers, meta-research spans disciplines and encompasses a broad spectrum of topics and methods. The breadth of meta-research presents a significant challenge for identifying published meta-research studies. Introducing a subject heading for meta-research in the controlled vocabularies of literature databases has the potential to increase the visibility of meta-research, further advance the field, and expand its impact on research practices. Given the relatively recent designation of meta-research as a field and its expanding use as a term, now is the time to develop appropriate indexing vocabulary. We seek to call attention to the value of meta-research for health sciences librarianship, describe the challenges of identifying meta-research literature with currently available key terms, and highlight the need to establish controlled vocabulary specific to meta-research.

Using meta-research to foster diverse, equitable, and inclusive collaborative research networks

Fostering diverse, equitable, and inclusive collaborative research networks is important for advancing the field of aging research. Despite sizeable investment in research consortia and career development programs, there has been only moderate progress toward diversifying the research workforce studying aging. Without critically examining what works and what does not, continuing to place more resources into these same strategies may not result in a substantial improvement in diversity or the creation of collaborative networks. Using meta-research to rigorously evaluate potential strategies to promote diversity and collaboration may yield important insights that can be used to improve upon current efforts. For this reason, we sought to describe meta-research and highlight how its principles can be used to achieve the aging research community's collaboration and diversity goals.

Implementation of a relapse prevention program among smokers undergoing arthroplasty: lessons learned

BACKGROUND

Surgery is a potent motivator to help people quit smoking to reduce the risk of complications. Many patients who smoke receive tobacco cessation counseling prior to surgery and are able to quit, but do not receive the same resources after surgery and often resume smoking.

METHODS

We present a case study describing the recruitment process, study components, and lessons learned from StayQuit, a comprehensive relapse prevention program designed to prevent relapse after arthroplasty. Lessons learned were examined post hoc to determine challenges related to program implementation, using existing study procedures and information collected.

RESULTS

While a comprehensive postoperative relapse prevention program may be beneficial to patients, implementation of StayQuit is unlikely to be feasible under current circumstances. The primary challenges to successful implementation of StayQuit focused on themes of lack of engagement in the preoperative Orthopedic Surgery Quit Smoking Program (OSQSP) and an environment unfavorable to in-person enrollment on the day of surgery.

CONCLUSIONS

Postoperative relapse prevention programs may be beneficial for patients who quit smoking prior to elective surgery. To help guide implementation, it is important to consider surgeon behavior, the collaboration of clinical and non-clinical teams, and best practices for study enrollment in surgical settings.

Youth E-Cigarette Use and Functionally Important Respiratory Symptoms: The Population Assessment of Tobacco and Health (PATH) Study Waves 3 and 4

Respiratory effects of e-cigarette use among youth are not fully understood. This study investigated the longitudinal association between e-cigarette use and a validated index of functionally important respiratory symptoms among US youth. Data from Waves 3-4 of the Population Assessment of Tobacco and Health Study were analyzed. The sample included youth (aged 12-17) without asthma at baseline (Wave 3), who completed a follow-up survey (Wave 4), and were not missing data for analytic variables (n = 3899). Exposure was e-cigarette use status (never, former, or current) at baseline. The outcome was a respiratory symptom index based on responses for seven wheezing items at Wave 4. An index of ≥2 was defined as having functionally important respiratory symptoms. Lagged logistic regression models examined the association between baseline e-cigarette use and functionally important respiratory symptoms at follow-up by combustible tobacco use status (never or ever), and controlling for baseline covariates. At baseline, 13.7% of participants reported former e-cigarette use, and 4.3% reported current use. Baseline e-cigarette use did not increase the odds of having functionally important respiratory symptoms at follow-up regardless of combustible tobacco use status. Future research on larger populations of e-cigarette users with longer follow-up periods will improve our understanding of the respiratory risks associated with e-cigarette use among youth.

Behavioral Economics and Tobacco Control: Current Practices and Future Opportunities

Despite considerable progress, smoking remains the leading preventable cause of death in the United States. To address the considerable health and economic burden of tobacco use, the development of improved tobacco control and treatment interventions is critical. By combining elements of economics and psychology, behavioral economics provides a framework for novel solutions to treat smokers who have failed to quit with traditional smoking cessation interventions. The full range of behavioral economic principles, however, have not been widely utilized in the realm of tobacco control and treatment. Given the need for improved tobacco control and treatment, the limited use of other behavioral economic principles represents a substantial missed opportunity. For this reason, we sought to describe the principles of behavioral economics as they relate to tobacco control, highlight potential gaps in the behavioral economics tobacco research literature, and provide examples of potential interventions that use each principle.

A targeted approach to using e-cigarettes for harm reduction in adults

Smoking remains the leading preventable cause of death and disease in the US. While e-cigarettes (EC) are undeniably harmful when used by adolescents and nonsmokers, the perpetuation of the increasing negative perceptions of EC and widespread false belief that EC are equal or more harmful than combustible cigarettes (CC) represents a significant missed public health opportunity. EC have great potential to serve as a mechanism for smoking harm reduction among hard-to-treat populations of smokers who have failed to quit with currently available treatments. In this paper, we outline why we need to overcome the hostile EC research environment to explore the potential use of EC as a harm-reduction strategy in hard-to-treat populations.

Electronic cigarettes as a harm reduction strategy among patients with COPD: protocol for an open-label two arm randomized controlled pilot trial

Background

Smoking cessation is the most effective means of slowing the decline of lung function associated with chronic obstructive pulmonary disease (COPD). While effective smoking cessation treatments are available, they are underutilized and nearly half of people with COPD continue to smoke. By addressing both nicotine and behavioral dependence, electronic cigarettes (EC) could help people with COPD reduce the harm of combustible cigarettes (CC) through reductions in number of Cigarettes per Day (CPD) or quitting CC completely. The purpose of this pilot study is to identify barriers and facilitators to the use of and assess the preliminary effectiveness of EC as a harm reduction strategy among people with COPD.

Methods

In an open-label two-arm randomized controlled trial pilot study, 60 patients identified as smokers with a COPD diagnosis via electronic health records from a large urban health center are randomized in a 1:1 ratio to either standard care [counseling + nicotine replacement therapy (NRT)] or counseling + EC. The NRT arm will receive nicotine patches and nicotine lozenges for 12 weeks. The EC arm will receive EC for 12 weeks. Both cohorts will receive counseling from a licensed mental health counselor. Using ecological momentary assessment, participants will report their use of CC in both arms and EC use in the EC arm daily via text message. Primary outcomes will be feasibility and acceptability of intervention, and secondary outcomes will be reduction in CPD and change in COPD symptoms as measured by COPD Assessment Tool (CAT) score at 12-weeks. EC displacement of CC. To explore attitudes towards the use of EC as a harm-reduction strategy for patients with COPD, interviews will be performed with a sample of participants from both study arms.

Discussion

Despite decades of availability of smoking cessation medications, nearly half of people with COPD still smoke. This study aims to address the unmet need for feasible and effective strategies for reducing CC use among those with COPD, which has the potential to significantly improve the health of people with COPD who smoke.

Trial Registration ClinicalTrials.gov Identifier: NCT04465318.

Barriers to engagement in implementation science research: a national survey

Low levels of engagement in implementation science (IS) among health researchers is a multifaceted issue. With the aim of guiding efforts to increase engagement in IS research, we sought to identify barriers to engagement in IS within the health research community. We performed an online survey of health researchers in the United States in 2018. Basic science researchers were excluded from the sample. IS engagement was measured by self-reported conduct of or collaboration on an IS study in the past 5 years. Potential barriers tested were (a) knowledge and awareness of IS, (b) attitudes about IS research, (c) career benefits of IS, (d) research community support, and (e) research leadership support. We performed simple logistic regressions and tested multivariable logistic regression models of researcher characteristics and potential barriers as predictors of IS engagement. Of the 1,767 health researchers, 49.7% indicated they engaged in an implementation study. Being able to define IS (aOR 3.42, 95%CI 2.68-4.36, p < .001) and having attended IS training (aOR 3.77, 95%CI 2.96-4.81, p < .001) were associated with engaging in IS research. Among other potential barriers tested, perceptions that engaging in IS would not be good for their career (aOR 0.29, 95%CI 0.2-0.41, p < .001) was strongly associated with decreased engagement in IS research. Efforts to increase researcher familiarity with IS methods and foster support for IS within research communities, along with decreasing barriers to funding and publishing, are likely to be most effective for increasing engagement in IS research.

Cost-effectiveness of Direct Antiviral Agents for Hepatitis C Virus Infection and a Combined Intervention of Syringe Access and Medication-assisted Therapy for Opioid Use Disorders in an Injection Drug Use Population

BACKGROUND

There are too many plausible permutations and scale-up scenarios of combination hepatitis C virus (HCV) interventions for exhaustive testing in experimental trials. Therefore, we used a computer simulation to project the health and economic impacts of alternative combination intervention scenarios for people who inject drugs (PWID), focusing on direct antiviral agents (DAA) and medication-assisted treatment combined with syringe access programs (MAT+).

METHODS

We performed an allocative efficiency study, using a mathematical model to simulate the progression of HCV in PWID and its related consequences. We combined 2 previously validated simulations to estimate the cost-effectiveness of intervention strategies that included a range of coverage levels. Analyses were performed from a health-sector and societal perspective, with a 15-year time horizon and a discount rate of 3%.

RESULTS

From a health-sector perspective (excluding criminal justice system-related costs), 4 potential strategies fell on the cost-efficiency frontier. At 20% coverage, DAAs had an incremental cost-effectiveness ratio (ICER) of $27 251/quality-adjusted life-year (QALY). Combinations of DAA at 20% with MAT+ at 20%, 40%, and 80% coverage had ICERs of $165 985/QALY, $325 860/QALY, and $399 189/QALY, respectively. When analyzed from a societal perspective (including criminal justice system-related costs), DAA at 20% with MAT+ at 80% was the most effective intervention and was cost saving. While DAA at 20% with MAT+ at 80% was more expensive (eg, less cost saving) than MAT+ at 80% alone without DAA, it offered a favorable value compared to MAT+ at 80% alone ($23 932/QALY).

CONCLUSIONS

When considering health-sector costs alone, DAA alone was the most cost-effective intervention. However, with criminal justice system-related costs, DAA and MAT+ implemented together became the most cost-effective intervention.

Does Reducing Drinking in Patients with Unhealthy Alcohol Use Improve Pain Interference, Use of Other Substances, and Psychiatric Symptoms?

BACKGROUND

We aimed to investigate the impact of reducing drinking in patients with unhealthy alcohol use on improvement of chronic pain interference, substance use, and psychiatric symptoms.

METHODS

We analyzed longitudinal data from 2003 to 2015 in the Veterans Aging Cohort Study, a prospective, multisite observational study of US veterans, by emulating a hypothetical randomized trial (a target trial). Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and outcome conditions were assessed via validated survey items. Individuals were followed from the first time their AUDIT score was ≥ 8 (baseline), a threshold consistent with unhealthy alcohol use. We compared individuals who reduced drinking (AUDIT < 8) at the next follow-up visit with individuals who did not (AUDIT ≥ 8). We fit separate logistic regression models to estimate odds ratios for improvement of each condition 2 years postbaseline among individuals who had that condition at baseline: moderate or severe pain interference symptoms, tobacco smoking, cannabis use, cocaine use, depressive symptoms, and anxiety symptoms. Inverse probability weighting was used to account for potential selection bias and confounding.

RESULTS

Adjusted 2-year odds ratios (95% confidence intervals) for associations between reducing drinking and improvement or resolution of each condition were as follows: 1.49 (0.91, 2.42) for pain interference symptoms, 1.57 (0.93, 2.63) for tobacco smoking, 1.65 (0.92, 2.95) for cannabis use, 1.83 (1.03, 3.27) for cocaine use, 1.11 (0.64, 1.92) for depressive symptoms, and 1.33 (0.80, 2.22) for anxiety symptoms.

CONCLUSIONS

We found some evidence for improvement of pain interference symptoms and substance use after reducing drinking among US veterans with unhealthy alcohol use, but confidence intervals were wide.

Unrecognized implementation science engagement among health researchers in the USA: a national survey

Background

Implementation science (IS) has the potential to serve an important role in encouraging the successful uptake of evidence-based interventions. The current state of IS awareness and engagement among health researchers, however, is relatively unknown.

Methods

To determine IS awareness and engagement among health researchers, we performed an online survey of health researchers in the USA in 2018. Basic science researchers were excluded from the sample. Engagement in and awareness of IS were measured with multiple questionnaire items that both directly and indirectly ask about IS methods used. Unrecognized IS engagement was defined as participating in research using IS elements and not indicating IS as a research method used. We performed simple logistic regressions and tested multivariable logistic regression models of researcher characteristics as predictors of IS engagement.

Results

Of the 1767 health researchers who completed the survey, 68% stated they would be able to describe IS. Only 12.7% of the population self-identified as using IS methods. Of the researchers not self-identifying as using IS methods, 86.4% reported using the IS elements “at least some of the time.” Nearly half (47.9%) reported using process/implementation evaluation, 89.2% use IS measures, 27.3% use IS frameworks, and 75.6% investigate or examine ways to integrate interventions into routine health settings. IS awareness significantly reduced the likelihood of all measures of unrecognized IS engagement (aOR 0.13, 95% CI 0.07 to 0.27, p < 0.001).

Conclusion

Overall, awareness of IS is high among health researchers, yet there is also a high prevalence of unrecognized IS engagement. Efforts are needed to further disseminate what constitutes IS research and increase IS awareness among health researchers.

Insights Provided by Depression Screening Regarding Pain, Anxiety, and Substance use in a Veteran Population

Objective:

We sought to quantify the extent to which a depression screening instrument commonly used in primary care settings provides additional information regarding pain interference symptoms, anxiety, and substance use.

Methods:

Veterans Aging Cohort Study (VACS) data collected from 2003 through 2015 was used to calculate odds ratios (OR) for associations between positive depression screening result cutoffs and clustering conditions. We assessed the test performance characteristics (likelihood ratio value, positive predictive value, and the percentage of individuals correctly classified) of a positive Patient Health Questionnaire (PHQ-9 & PHQ-2) depression screen for the identification of pain interference symptoms, anxiety, and substance use.

Results:

A total 7731 participants were included in the analyses. The median age was 50 years. The PHQ-9 threshold of ≥20 was strongly associated with pain interference symptoms (OR 21.6, 95% CI 17.5-26.7) and anxiety (OR 72.1, 95% CI 52.8-99.0) and yielded likelihood ratio values of 7.5 for pain interference symptoms and 21.8 for anxiety and positive predictive values (PPV) of 84% and 95%, respectively. A PHQ-9 score of ≥10 still showed significant associations with pain interference symptoms (OR 6.1, 95% CI 5.4-6.9) and symptoms of anxiety (OR 11.3, 95% CI 9.7-13.1) and yet yielded lower likelihood ratio values (4.36 & 8.24, respectively). The PHQ-9 was less strongly associated with various forms of substance use.

Conclusion:

Depression screening provides substantial additional information regarding the likelihood of pain interference symptoms and anxiety and should trigger diagnostic assessments for these other conditions.

Perceptions of barriers and facilitators to engaging in implementation science: a qualitative study

OBJECTIVE

Understanding barriers and facilitators to engaging with implementation science (IS) research can provide insight into how to improve efforts to encourage more researchers to participate in IS research.

STUDY DESIGN

The study design used is a grounded theory qualitative study.

METHODS

We conducted semistructured telephone interviews with 20 health researchers familiar with IS that both report engaging in IS research and those that do not. We explored perceptions of barriers and facilitators to engaging in IS research. Themes surrounding difficulties defining IS, lack of training availability, and obstacles to forming research partnerships were discussed as barriers to engaging IS research. Interview topics were informed by the result of an online survey of health researchers in the US.

RESULTS

Themes surrounding difficulties defining IS, lack of training availability, and obstacles to forming research partnerships were discussed as barriers to engaging IS research. While accessible mentorship, exposure to formative experiences that develop interest in IS research and an increasing IS visibility were described as motivators for engaging in IS research.

CONCLUSIONS

These results highlight the importance of mentorship and exposure to IS ideas in motivating engagement in IS research and the presence of training and methodological barriers to engagement. Future research should expand this line of inquiry to include the perspectives of more junior researchers and students to better reflect the current IS environment.

Correction to: Unrecognized implementation science engagement among health researchers in the USA: a national survey

[This corrects the article DOI: 10.1186/s43058-020-00027-3.].

Association of Alcohol Screening Scores With Adverse Mental Health Conditions and Substance Use Among US Adults

IMPORTANCE

Alcohol screening may be associated with health outcomes that cluster with alcohol use (ie, alcohol-clustering conditions), including depression, anxiety, and use of tobacco, marijuana, and illicit drugs.

OBJECTIVE

To quantify the extent to which alcohol screening provides additional information regarding alcohol-clustering conditions and to compare 2 alcohol use screening tools commonly used for this purpose.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study used data from the Veterans Aging Cohort Study. Data were collected at 8 Veterans Health Administration facilities from 2003 through 2012. A total of 7510 participants were enrolled, completed a baseline survey, and were followed up. Veterans with HIV were matched with controls without HIV by age, race, sex, and site of care. Data were analyzed from January 2019 to December 2019.

EXPOSURES

The Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were used to assess alcohol use, with 4 risk groups delineated for each test: score 0 to 7 (reference), score 8 to 15, score 16 to 19, and score 20 to 40 (maximum score) for the full AUDIT and score 0 to 3 (reference), score 4 to 5, score 6 to 7, and score 8 to 12 (maximum score) for the AUDIT-C.

MAIN OUTCOMES AND MEASURES

Alcohol-clustering conditions, including self-reported symptoms of depression and anxiety and use of tobacco, marijuana, cocaine, other stimulants, opioids, and injection drugs.

RESULTS

A total of 6431 US patients (6104 [95%] men; median age during survey years 2003-2004, 50 years [range, 28-86 years; interquartile range, 44-55 years]) receiving care in the Veterans Health Administration completed 1 or more follow-up surveys when the AUDIT was administered and were included in the present analyses. Of the male participants, 4271 (66%) were African American, 1498 (24%) were white, and 590 (9%) were Hispanic. The AUDIT and AUDIT-C scores were associated with each alcohol-clustering condition. In particular, an AUDIT score of 20 or higher (vs <8, the reference) was associated with symptoms of depression (odds ratio [OR], 8.37; 95% CI, 6.20-11.29) and anxiety (OR, 8.98; 95% CI, 6.39-12.60) and with self-reported use of tobacco (OR, 14.64; 95% CI, 8.94-23.98), marijuana (OR, 12.41; 95% CI, 8.61-17.90), crack or cocaine (OR, 39.47; 95% CI, 27.38-56.90), other stimulants (OR, 21.31; 95% CI, 12.73-35.67), and injection drugs (OR, 8.67; 95% CI, 5.32-14.13). An AUDIT score of 20 or higher yielded likelihood ratio (sensitivity / 1 - specificity) values greater than 3.5 for depression, anxiety, crack or cocaine use, and other stimulant use. Associations between AUDIT-C scores and alcohol-clustering conditions were more modest.

CONCLUSIONS AND RELEVANCE

Alcohol screening can inform decisions about further screening and diagnostic assessment for alcohol-clustering conditions, particularly for depression, anxiety, crack or cocaine use, and other stimulant use. Future studies using clinical diagnoses rather than screening tools to assess alcohol-clustering conditions may be warranted.

Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention

BACKGROUND

Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window.

OBJECTIVE

We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times.

METHODS

Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%.

RESULTS

The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY.

CONCLUSION

II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.

Setting ambitious targets for surveillance and treatment rates among patients with hepatitis C related cirrhosis impacts the cost-effectiveness of hepatocellular cancer surveillance and substantially increases life expectancy: A modeling study

BACKGROUND

Hepatocelluar cancer (HCC) is the leading cause of death among people with hepatitis C virus (HCV)-related cirrhosis. Our aim was to determine the optimal surveillance frequency for patients with HCV-related compensated cirrhosis.

METHODS

We developed a decision analytic Markov model and validated it against data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) study group and published epidemiologic studies. Four strategies of different surveillance intervals were compared: no surveillance and ultrasound surveillance every 12, 6, and 3 months. We estimated lifetime survival, life expectancy, quality adjusted life years (QALY), total costs associated with each strategy, and incremental cost effectiveness ratios. We applied a willingness to pay threshold of $100,000. Analysis was conducted for two scenarios: a scenario reflecting current HCV and HCC surveillance compliance rates and treatment use and an aspirational scenario.

RESULTS

In the current scenario the preferred strategy was 3-month surveillance with an incremental cost-effectiveness ratio (ICER) of $7,159/QALY. In the aspirational scenario, 6-month surveillance was preferred with an ICER of $82,807/QALY because treating more people with HCV led to a lower incidence of HCC. Sensitivity analyses suggested that surveillance every 12 months would suffice in the particular circumstance when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available. Compared with the current scenario, the aspirational scenario resulted in a 1.87 year gain in life expectancy for the cohort because of large reductions in decompensated cirrhosis and HCC incidence.

CONCLUSIONS

HCC surveillance has good value for money for patients with HCV-related compensated cirrhosis. Investments to improve adherence to surveillance should be made when rates are suboptimal. Surveillance every 12 months will suffice when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available.

Cost-effectiveness of HIV care coordination scale-up among persons at high risk for sub-optimal HIV care outcomes

BACKGROUND

A study of a comprehensive HIV Care Coordination Program (CCP) showed effectiveness in increasing viral load suppression (VLS) among PLWH in New York City (NYC). We evaluated the cost-effectiveness of a scale-up of the CCP in NYC.

METHODS

We incorporated observed effects and costs of the CCP into a computer simulation of HIV in NYC, comparing strategy scale-up with no implementation. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression, and was calibrated to NYC HIV epidemiological data from 1997 to 2009. We assessed incremental cost-effectiveness from a health sector perspective using 2017 $US, a 20-year time horizon, and a 3% annual discount rate. We explored two scenarios: (1) two-year average enrollment and (2) continuous enrollment.

RESULTS

In scenario 1, scale-up resulted in a cost-per-infection-averted of $898,104 and a cost-per-QALY-gained of $423,721. In sensitivity analyses, scale-up achieved cost-effectiveness if effectiveness increased from RR1.11 to RR1.37 or costs decreased by 41.7%. Limiting the intervention to persons with unsuppressed viral load prior to enrollment (RR1.32) attenuated the cost reduction necessary to 11.5%. In scenario 2, scale-up resulted in a cost-per-infection-averted of $705,171 and cost-per-QALY-gained of $720,970. In sensitivity analyses, scale-up achieved cost-effectiveness if effectiveness increased from RR1.11 to RR1.46 or program costs decreased by 71.3%. Limiting the intervention to persons with unsuppressed viral load attenuated the cost reduction necessary to 38.7%.

CONCLUSION

Cost-effective CCP scale-up would require reduced costs and/or focused enrollment within NYC, but may be more readily achieved in cities with lower background VLS levels.

An Alternative Mathematical Modeling Approach to Estimating a Reference Life Expectancy

Background. Reference life expectancies inform frequently used health metrics, which play an integral role in determining resource allocation and health policy decision making. Existing reference life expectancies are not able to account for variation in geographies, populations, and disease states. Using a computer simulation, we developed a reference life expectancy estimation that considers competing causes of mortality, and is tailored to population characteristics. Methods. We developed a Monte Carlo microsimulation model that explicitly represented the top causes of US mortality in 2014 and the risk factors associated with their onset. The microsimulation follows a birth cohort of hypothetical individuals resembling the population of the United States. To estimate a reference life expectancy, we compared current circumstances with an idealized scenario in which all modifiable risk factors were eliminated and adherence to evidence-based therapies was perfect. We compared estimations of years of potential years life lost with alternative approaches. Results. In the idealized scenario, we estimated that overall life expectancy in the United States would increase by 5.9 years to 84.7 years. Life expectancy for men would increase from 76.4 years to 82.5 years, and life expectancy for women would increase from 81.3 years to 86.8 years. Using age-75 truncation to estimate potential years life lost compared to using the idealized life expectancy underestimated potential health gains overall (38%), disproportionately underestimated potential health gains for women (by 70%) compared to men (by 40%), and disproportionately underestimated the importance of heart disease for white women and black men. Conclusion. Mathematical simulations can be used to estimate an idealized reference life expectancy among a population to better inform and assess progress toward targets to improve population health.

Measuring Population Health in a Large Integrated Health System to Guide Goal Setting and Resource Allocation: A Proof of Concept

In integrated health care systems, techniques that identify successes and opportunities for targeted improvement are needed. The authors propose a new method for estimating population health that provides a more accurate and dynamic assessment of performance and priority setting. Member data from a large integrated health system (n = 96,246, 73.8% female, mean age = 44 ± 0.01 years) were used to develop a mechanistic mathematical simulation, representing the top causes of US mortality in 2014 and their associated risk factors. An age- and sex-matched US cohort served as comparator group. The simulation was recalibrated and retested for validity employing the outcome measure of 5-year mortality. The authors sought to estimate potential population health that could be gained by improving health risk factors in the study population. Potential gains were assessed using both average life years (LY) gained and average quality-adjusted life years (QALYs) gained. The simulation validated well compared to integrated health system data, producing an AUC (area under the curve) of 0.88 for 5-year mortality. Current population health was estimated as a life expectancy of 84.7 years or 69.2 QALYs. Comparing potential health gain in the US cohort to the Kaiser Permanente cohort, eliminating physical inactivity, unhealthy diet, smoking, and uncontrolled diabetes resulted in an increase of 1.5 vs. 1.3 LY, 1.1 vs. 0.8 LY, 0.5 vs. 0.2 LY, and 0.5 vs. 0.5 LY on average per person, respectively. Using mathematical simulations may inform efforts by integrated health systems to target resources most effectively, and may facilitate goal setting.

Quality of health economic evaluations for the ACC/AHA stable ischemic heart disease practice guideline: A systematic review

BACKGROUND

The American College of Cardiology/American Heart Association (ACC/AHA) recently published a rigorous framework to guide integration of economic data into clinical guidelines. We assessed the quality of economic evaluations in a major ACC/AHA clinical guidance report.

METHODS

We systematically identified cost-effectiveness analyses (CEAs) of RCTs cited in the ACC/AHA 2012 Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. We extracted: (1) study identifiers; (2) parent RCT information; (3) economic analysis characteristics; and (4) study quality using the Quality of Health Economic Studies instrument (QHES).

RESULTS

Quality scores were categorized as high (≥75 points) or low (<75 points). Of 1,266 citations in the guideline, 219 were RCTs associated with 77 CEAs. Mean quality score was 81 (out of 100) and improved over time, though 29.9% of studies were low-quality. Cost-per-QALY was the most commonly reported primary outcome (39.0%). Low-quality studies were less likely to report study perspective, use appropriate time horizons, or address statistical and clinical uncertainty. Funding was overwhelmingly private (83%). A detailed methodological assessment of high-quality studies revealed domains of additional methodological issues not identified by the QHES.

CONCLUSIONS

Economic evaluations of RCTs in the 2012 ACC/AHA ischemic heart disease guideline largely had high QHES scores but methodological issues existed among "high-quality" studies. Because the ACC/AHA has generally been more systematic in its integration of scientific evidence compared to other professional societies, it is likely that most societies will need to proceed more cautiously in their integration of economic evidence.

Cost-effectiveness of a combination strategy to enhance the HIV care continuum in Swaziland: Link4Health

INTRODUCTION

Link4Health, a cluster-RCT, demonstrated the effectiveness of a combination strategy targeting barriers at various HIV continuum steps on linkage to and retention in care; showing effectiveness in achieving linkage to HIV care within 1 month plus retention in care at 12 months after HIV testing for people living with HIV (RR 1.48, 95% CI 1.19-1.96, p = 0.002). In addition to standard of care, Link4Health included: 1) Point-of-care CD4+ count testing; 2) Accelerated ART initiation; 3) Mobile phone appointment reminders; 4) Care and prevention package including commodities and informational materials; and 5) Non-cash financial incentive. Our objective was to evaluate the cost-effectiveness of a scale-up of the Link4Health strategy in Swaziland.

METHODS AND FINDINGS

We incorporated the effects and costs of the Link4Health strategy into a computer simulation of the HIV epidemic in Swaziland, comparing a scenario where the strategy was scaled up to a scenario with no implementation. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression calibrated to Swaziland epidemiological data. It incorporated downstream health costs potentially saved and infections potentially prevented by improved linkage and treatment adherence. We assessed the incremental cost-effectiveness ratio of Link4Health compared to standard care from a health sector perspective reported in US$2015, a time horizon of 20 years, and a discount rate of 3% in accordance with WHO guidelines.[1] Our results suggest that scale-up of the Link4Health strategy would reduce new HIV infections over 20 years by 11,059 infections, a 7% reduction from the projected 169,019 cases and prevent 5,313 deaths, an 11% reduction from the projected 49,582 deaths. Link4Health resulted in an incremental cost per infection prevented of $13,310 and an incremental cost per QALY gained of $3,560/QALY from the health sector perspective.

CONCLUSIONS

Using a threshold of <3 x per capita GDP, the Link4Health strategy is likely to be a cost-effective strategy for responding to the HIV epidemic in Swaziland.

Using value of information methods to determine the optimal sample size for effectiveness trials of alcohol interventions for HIV-infected patients in East Africa

Background

Unhealthy alcohol consumption exacerbates the HIV epidemic in East Africa. Potential benefits of new trials that test the effectiveness of alcohol interventions could not be evaluated by traditional sampling methods. Given the competition for health care resources in East Africa, this study aims to determine the optimal sample size given the opportunity cost of potentially re-allocating trial funds towards cost-effective alcohol treatments.

Methods

We used value of information methods to determine the optimal sample size by maximizing the expected net benefit of sampling for a hypothetical 2-arm intervention vs. control randomized trial, across ranges of policymaker’s willingness-to-pay for the health benefit of an intervention. Probability distributions describing the relative likelihood of alternative trial results were imputed based on prior studies. In the base case, policymaker’s willingness-to-pay was based on a simultaneously resource-constrained priority (routine HIV virological testing). Sensitivity analysis was performed for various willingness-to-pay thresholds and intervention durations.

Results

A new effectiveness trial accounting for the benefit of more precise decision-making on alcohol intervention implementation would benefit East Africa $67,000 with the optimal sample size of 100 persons per arm under the base case willingness-to-pay threshold and intervention duration of 20 years. At both a conservative willingness-to-pay of 1 x GDP/capita and a high willingness-to-pay of 3 x GDP/capita for an additional health gain added by an alcohol intervention, a new trial was not recommended due to limited decision uncertainty. When intervention duration was 10 or 5 years, there was no return on investment across suggested willingness-to-pay thresholds.

Conclusions

Value of information methods could be used as an alternative approach to assist the efficient design of alcohol trials. If reducing unhealthy alcohol use is a long-term goal for HIV programs in East Africa, additional new trials with optimal sample sizes ranging from 100 to 250 persons per arm could save the opportunity cost of implementing less cost-effective alcohol strategies in HIV prevention. Otherwise, conducting a new trial is not recommended.

Cost-Effectiveness of Peer- Versus Venue-Based Approaches for Detecting Undiagnosed HIV Among Heterosexuals in High-Risk New York City Neighborhoods

INTRODUCTION

We used a computer simulation of HIV progression and transmission to evaluate the cost-effectiveness of a scale-up of 3 strategies to seek out and test individuals with undiagnosed HIV in New York City (NYC).

SETTING

Hypothetical NYC population.

METHODS

We incorporated the observed effects and costs of the 3 "seek and test" strategies in a computer simulation of HIV in NYC, comparing a scenario in which the strategies were scaled up with a 1-year implementation or a long-term implementation with a counterfactual scenario with no scale-up. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression, calibrated to NYC epidemiological data from 2003 to 2015. The 3 approaches were respondent-driven sampling (RDS) with anonymous HIV testing ("RDS-A"), RDS with a 2-session confidential HIV testing approach ("RDS-C"), and venue-based sampling ("VBS").

RESULTS

RDS-A was the most cost-effective strategy tested. When implemented for only 1 year and then stopped thereafter, using a societal perspective, the cost per quality-adjusted life-year (QALY) gained versus no intervention was $812/QALY, $18,110/QALY, and $20,362/QALY for RDS-A, RDS-C, and VBS, respectively. When interventions were implemented long term, the cost per QALY gained versus no intervention was cost-saving, $31,773/QALY, and $35,148/QALY for RDS-A, RDS-C, and VBS, respectively. When compared with RDS-A, the incremental cost-effectiveness ratios for both VBS and RDS-C were dominated.

CONCLUSIONS

The expansion of the RDS-A strategy would substantially reduce HIV-related deaths and new HIV infections in NYC, and would be either cost-saving or have favorable cost-effectiveness.

Potential return on investment of a family-centered early childhood intervention: a cost-effectiveness analysis

Background

ParentCorps is a family-centered enhancement to pre-kindergarten programming in elementary schools and early education centers. When implemented in high-poverty, urban elementary schools serving primarily Black and Latino children, it has been found to yield benefits in childhood across domains of academic achievement, behavior problems, and obesity. However, its long-term cost-effectiveness is unknown.

Methods

We determined the cost-effectiveness of ParentCorps in high-poverty, urban schools using a Markov Model projecting the long-term impact of ParentCorps compared to standard pre-kindergarten programming. We measured costs and quality adjusted life years (QALYs) resulting from the development of three disease states (i.e., drug abuse, obesity, and diabetes); from the health sequelae of these disease states; from graduation from high school; from interaction with the judiciary system; and opportunity costs of unemployment with a lifetime time horizon. The model was built, and analyses were performed in 2015–2016.

Results

ParentCorps was estimated to save $4387 per individual and increase each individual’s quality adjusted life expectancy by 0.27 QALYs. These benefits were primarily due to the impact of ParentCorps on childhood obesity and the subsequent predicted prevention of diabetes, and ParentCorps’ impact on childhood behavior problems and the subsequent predicted prevention of interaction with the judiciary system and unemployment. Results were robust on sensitivity analyses, with ParentCorps remaining cost saving and health generating under nearly all assumptions, except when schools had very small pre-kindergarten programs.

Conclusions

Effective family-centered interventions early in life such as ParentCorps that impact academic, behavioral and health outcomes among children attending high-poverty, urban schools have the potential to result in longer-term health benefits and substantial cost savings.

Is risk stratification ever the same as 'profiling'?

Physicians engage in risk stratification as a normative part of their professional duties. Risk stratification has the potential to be beneficial in many ways, and implicit recognition of this potential benefit underlies its acceptance as a cornerstone of the medical profession. However, risk stratification also has the potential to be harmful. We argue that 'profiling' is a term that corresponds to risk stratification strategies in which there is concern that ethical harms exceed likely or proven benefits. In the case of risk stratification for health goals, this would occur most frequently if benefits were obtained by threats to justice, autonomy or privacy. We discuss implications of the potential overlap between risk stratification and profiling for researchers and for clinicians, and we consider whether there are salient characteristics that make a particular risk stratification algorithm more or less likely to overlap with profiling, such as whether the risk stratification algorithm is based on voluntary versus non-voluntary characteristics, based on causal versus non-causal characteristics, or based on signifiers of historical disadvantage. We also discuss the ethical challenges created when a risk stratification scheme helps all subgroups but some more than others, or when risk stratification harms some subgroups but benefits the aggregate group.

Cost and Cost-Effectiveness of Students for Nutrition and eXercise (SNaX)

OBJECTIVE

To examine the cost and cost-effectiveness of implementing Students for Nutrition and eXercise (SNaX), a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education.

METHODS

Five intervention and 5 control middle schools (mean enrollment, 1520 students) from the Los Angeles Unified School District participated in a randomized controlled trial of SNaX. Acquisition costs for materials and time and wage data for employees involved in implementing the program were used to estimate fixed and variable costs. Cost-effectiveness was determined using the ratio of variable costs to program efficacy outcomes.

RESULTS

The costs of implementing the program over 5 weeks were $5433.26 per school in fixed costs and $2.11 per student in variable costs, equaling a total cost of $8637.17 per school, or $0.23 per student per day. This investment yielded significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks. The cost-effectiveness of the program, per student over 5 weeks, was $1.20 per additional fruit served during meals, $8.43 per additional full-priced lunch served, $2.11 per additional reduced-price/free lunch served, and $1.69 per reduction in snacks sold.

CONCLUSIONS

SNaX demonstrated the feasibility and cost-effectiveness of a middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. Its cost is modest and unlikely to be a significant barrier to adoption for many schools considering its implementation.

Use of Preoperative Testing and Physicians' Response to Professional Society Guidance

IMPORTANCE

The value of routine preoperative testing before most surgical procedures is widely considered to be low. To improve the quality of preoperative care and reduce waste, 2 professional societies released guidance on use of routine preoperative testing in 2002, but researchers and policymakers remain concerned about the health and cost burden of low-value care in the preoperative setting.

OBJECTIVE

To examine the long-term national effect of the 2002 professional guidance from the American College of Cardiology/American Heart Association and the American Society of Anesthesiologists on physicians' use of routine preoperative testing.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of nationally representative data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to examine adults in the United States who were evaluated during preoperative visits from January 1, 1997, through December 31, 2010. A quasiexperimental, difference-in-difference (DID) approach evaluated whether the publication of professional guidance in 2002 was associated with changes in preoperative testing patterns, adjusting for temporal trends in routine testing, as captured by testing patterns in general medical examinations.

MAIN OUTCOMES AND MEASURES

Physician orders for outpatient plain radiography, hematocrit, urinalysis, electrocardiogram, and cardiac stress testing.

RESULTS

During the 14-year period, the average annual number of preoperative visits in the United States increased from 6.8 million in 1997-1999 to 9.8 million in 2002-2004 and 14.3 million in 2008-2010. After accounting for temporal trends in routine testing, we found no statistically significant overall changes in the use of plain radiography (11.3% in 1997-2002 to 9.9% in 2003-2010; DID, -1.0 per 100 visits; 95% CI, -4.1 to 2.2), hematocrit (9.4% in 1997-2002 to 4.1% in 2003-2010; DID, 1.2 per 100 visits; 95% CI, -2.2 to 4.7), urinalysis (12.2% in 1997-2002 to 8.9% in 2003-2010; DID, 2.7 per 100 visits; 95% CI, -1.7 to 7.1), or cardiac stress testing (1.0% in 1997-2002 to 2.0% in 2003-2010; DID, 0.7 per 100 visits; 95% CI, -0.1 to 1.5) after the publication of professional guidance. However, the rate of electrocardiogram testing fell (19.4% in 1997-2002 to 14.3% in 2003-2010; DID, -6.7 per 100 visits; 95% CI, -10.6 to -2.7) in the period after the publication of guidance.

CONCLUSIONS AND RELEVANCE

The release of the 2002 guidance on routine preoperative testing was associated with a reduced incidence of routine electrocardiogram testing but not of plain radiography, hematocrit, urinalysis, or cardiac stress testing. Because routine preoperative testing is generally considered to provide low incremental value, more concerted efforts to understand physician behavior and remove barriers to guideline adherence may improve health care quality and reduce costs.

Evaluation of the 2011 long-lasting, insecticide-treated net distribution for universal coverage in Togo

BACKGROUND

Malaria remains a substantial public health problem in Togo. An integrated child health campaign was conducted in Togo in October 2011. This campaign included a component of free distribution of 2,799,800 long-lasting, insecticide-treated nets (LLINs) to households throughout Togo. This distribution marked the first effort in Togo at universal LLIN coverage and was not targeted specifically to children under five years and pregnant women, but to all household members. This study reports the results of the LLIN distribution campaign in terms of bed net possession and utilization.

METHODS

A representative household survey was implemented during the rainy season nine months after the LLIN distribution component of the campaign. Some 6,015 households selected through two stages of probability proportion to size stratified random sampling were interviewed using a brief questionnaire that included a demographic section with questions on the number of household members and sleeping spaces, and a campaign participation section with questions used to evaluate non-LLIN aspects of the campaign. A net roster listed all nets and their characteristics, and a household roster listed all members and visitors with information about bed net use. The questions addressed different aspects of bed net and LLIN possession and utilization. Crude weighted frequencies, percentages, and t- tests of association were calculated using the Stata 12.0 Survey features.

RESULTS

Possession of at least one bed net and/or LLIN increased from 41.3% to 96.7% (P <0.001). Household possession of at least one campaign LLIN was 93.3%. Report LLIN among pregnant women was 77.5% and 79.3% for children under five. For the general population LLIN use was 68.3%.

CONCLUSIONS

Due to the gap in LLIN possession and use and the significant number of individuals reporting a lack of nets as a reason for non-use, additional national LLIN distribution campaigns with a stronger educational component need to be implemented in order increase the use of available LLINs and to reach and maintain universal coverage of LLINs in Togo. The LLIN distribution campaign focusing on universal coverage of the general population in Togo was more successful at increasing LLIN possession and use of children under five years and pregnant women than other campaigns focusing only on these target groups.

Potential exposure to diazinon during yard applications

Applicators applying diazinon to yards were monitored to determine potential exposures received while using this commonly available pesticide around the home. Diazinon was applied to lawns and shrubs using compressed air or hose-end sprayers. Even with minimal clothing, the largest mean exposure received during any of the applications was estimated to be less than 0.2% of a lethal dose per hour. Exposure to the hands accounted for 85% or more of the total exposure, so simply protecting the hands would have essentially eliminated exposure.