Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis

BACKGROUND

High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality.

OBJECTIVE

This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers.

METHODS

A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches.

RESULTS

For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t₁₆₈=23.2; P<.001), family costs (t₁₈₅=9.2; P<.001), and total costs (t₁₇₁=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars.

CONCLUSIONS

The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431.

Implementation of a Statewide Policy Mandating School-Based Fitness Assessment Screening, Georgia: 2018

Objectives. To evaluate the statewide implementation of childhood fitness assessment and reporting in Georgia.Methods. We collected survey data from 1683 (919 valid responses from a random-digit-dialed survey and 764 valid responses from a Qualtrics panel) parents of public school students in Georgia in 2018.Results. Most parents reported that their child participated in fitness assessments at school, yet only 31% reported receiving results. If a child was identified as needing improvement, parents were significantly more likely to change the diet and exercise of both the child and the family.Conclusions. A state-level mandatory fitness assessment for children may be successful in state-level surveillance of fitness levels; parental awareness of the policy, receipt of the fitness assessment information, and action on receiving the screening information require more efforts in implementation.

Cost-effectiveness of couples' voluntary HIV counselling and testing in six African countries: a modelling study guided by an HIV prevention cascade framework

INTRODUCTION

Couples' voluntary HIV counselling and testing (CVCT) is a high-impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost-per-HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost-effectiveness.

METHODS

We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling-up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs-per-couple tested were also estimated based on our previous studies. We used these parameters as well as country-specific inputs to model the impact of CVCT over a five-year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics (South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone). Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs-per-HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted.

RESULTS

We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs-per-HIV infection averted were lowest in Zimbabwe ($550) and highest in South Africa ($1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country's President's Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost-per-couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access.

CONCLUSIONS

Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries' five-year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low.

There's no such thing as a free TB diagnosis: Catastrophic TB costs in Urban Uganda

Identifying and reducing TB-related costs is necessary for achieving the End TB Strategy's goal that no family is burdened with catastrophic costs. This study explores costs during the pre-diagnosis period and assesses the potential for using coping costs as a proxy indicator for catastrophic costs when comprehensive surveys are not feasible. Detailed interviews about TB-related costs and productivity losses were conducted with 196 pulmonary TB patients in Kampala, Uganda. The threshold for catastrophic costs was defined as 20% of household income. Multivariable regression analyses were used to assess the influence of patient characteristics on economic burden, and the positive predictive value (PPV) of coping costs was estimated. Over 40% of patients experienced catastrophic costs, with average (median) pre-diagnosis costs making up 30.6% (14.1%) of household income. Low-income status (AOR = 2.91, 95% CI = 1.29, 6.72), hospitalisation (AOR = 8.66, 95% CI = 2.60; 39.54), and coping costs (AOR = 3.84, 95% CI = 1.81; 8.40) were significantly associated with the experience of catastrophic costs. The PPV of coping costs as an indicator for catastrophic costs was estimated to be 73% (95% CI = 58%, 84%). TB patients endure a substantial economic burden during the pre-diagnosis period, and identifying households that experience coping costs may be a useful proxy measure for identifying catastrophic costs.

The Protecting Strong African American Families Program: a Randomized Controlled Trial with Rural African American Couples

This study presents results from a randomized controlled trial of the Protecting Strong African American Families (ProSAAF) program, a family-centered intervention designed to promote strong couple, coparenting, and parent-child relationships in two-parent African American families. A total of 346 African American couples with an early adolescent child participated; all families lived in rural, low-income communities in the southern USA. Intent-to-treat growth curve analyses involving three waves and spanning 17 months indicated that ProSAAF participants, compared with control participants, reported greater improvements in relationship communication, confidence, satisfaction, partner support, coparenting, and parenting. More than 80% of the couples attended all six of the in-home, facilitator-led sessions; costs to implement the program averaged $1739 per family. The findings inform the ongoing debate surrounding prevention programs for low-income and ethnic minority couples.

Reach, Uptake, and Satisfaction of Three Delivery Modes of FUEL Your Life

Background. FUEL Your Life (FYL) is a worksite translation of the Diabetes Prevention Program (DPP). In a randomized controlled trial, participants in a phone coaching condition demonstrated greater weight loss compared to participants in a group coaching or self-study condition. The purpose of this article is to describe the differences in participant reach, intervention uptake, and participant satisfaction for each delivery mode. Method. Employees who were overweight, obese, or at high risk for diabetes were recruited from city-county governments. Process evaluation data were collected from health coach records, participant surveys, and research team records. Differences between groups were tested using Pearson chi-square test and one-way analysis of variance. Results. Employee reach of targeted enrollment was highest for the self-study condition. Overall, intervention uptake was highest in the phone coaching condition. Participants who received phone coaching had increased uptake of the participant manual and self-monitoring of food compared to participants who received group coaching or self-study. Discussion. FYL demonstrated that DPP could be effectively delivered in the worksite by three different modalities. When implemented in a self-study mode, reach is greater but intervention uptake is lower. Phone health coaching was associated with greater intervention exposure.

A Statewide Hospital-Based Safe Infant Sleep Initiative: Measurement of Parental Knowledge and Behavior

Sleep-related infant deaths are a leading cause of infant mortality in Georgia, and these deaths are largely associated with unsafe sleep practices among caregivers. In early 2016, the Georgia Department of Public Health launched the Georgia Safe to Sleep Hospital Initiative, providing hospitals with safe infant sleep information and educational materials to be distributed to families and newborns. This study examined the knowledge and behaviors of a sample of Georgia parents after the implementation of the Hospital Initiative and identified the family characteristics and intervention components most closely associated with the knowledge and practice of safe infant sleep. The primary caretakers of all infants born in Georgia from August to October 2016 were invited to complete a web-based survey 1 month after hospital discharge. The final sample size included 420 parents of newborns, and the primary outcomes assessed included two measures of knowledge and four measures of infant sleep behaviors regarding infant sleep position and location. Most respondents demonstrated knowledge of the correct recommended sleep position (90%) and location (85%). Logistic regression revealed that receipt of information in the hospital was significantly correlated with safe sleep behaviors, and infant sleep habits tended to influence safe sleep practices. Additionally, Medicaid parents receiving bassinets from the hospital were 74% less likely to bed share (OR 0.26; 95% CI 0.007). Implementation of a statewide hospital initiative was associated with high levels of parental knowledge and behavior and may have been successful in reducing the practice of bed sharing among Medicaid parents.

Cost Effectiveness of a Weight Management Program Implemented in the Worksite: Translation of Fuel Your Life

OBJECTIVE

Conduct a cost-effectiveness analysis of the Fuel Your Life (FYL) program dissemination.

METHODS

Employees were recruited from three workplaces randomly assigned to one of the conditions: telephone coaching, small group coaching, and self-study. Costs were collected prospectively during the efficacy trial. The main outcome measures of interest were weight loss and quality-adjusted life years (QALYs).

RESULTS

The phone condition was most costly ($601 to $589/employee) and the self-study condition was least costly ($145 to $143/employee). For weight loss, delivering FYL through the small group condition was no more effective, yet more expensive, than the self-study delivery. For QALYs, the group delivery of FYL was in an acceptable cost-effectiveness range ($22,400/QALY) relative to self-study (95% confidence interval [CI]: $10,600/QALY-dominated).

CONCLUSIONS

Prevention programs require adaptation at the local level and significantly affect the cost, effectiveness, and cost-effectiveness of the program.

Implementing a Statewide Safe to Sleep Hospital Initiative: Lessons Learned

Sleep-related infant deaths continue to be a major, largely preventable cause of infant mortality, especially in Georgia. The Georgia Department of Public Health (DPH), as part of a multi-pronged safe infant sleep campaign, implemented a hospital initiative to (1) provide accurate safe infant sleep information to hospital personnel; (2) support hospitals in implementing and modeling safe sleep practices; and (3) provide guidance on addressing caregiver safe sleep concerns. A process evaluation was conducted to determine progress toward four goals set out by DPH: (1) all birthing hospitals have a safe infant sleep policy; (2) all safe infant sleep policies reference the AAP 2011 recommendations; (3) all safe infant sleep policies specify the type and/or content of patient safe sleep education; and (4) all hospitals require regular staff training on safe sleep recommendations. Data were collected via structured interviews and document review of crib audit data and safe sleep policies. All 79 birthing hospitals in the state participated in the statewide campaign. Prior to the initiative, 44.3% of hospitals had a safe sleep policy in place; currently, 87.3% have a policy in place. The majority (91.4%) of hospitals have provided safe sleep training to their staff at this time. Important lessons include: (1) Engagement is vital to success; (2) A comprehensive implementation guide is critical; (3) Piloting the program provides opportunities for refinement; (4) Ongoing support addresses barriers; and (5) Senior leadership facilitates success.

Law Accommodating Nonmotorized Road Users and Pedestrian Fatalities in Florida, 1975 to 2013

OBJECTIVES

To examine the effect of Florida's adoption of Statute 335.065-a law requiring the routine accommodation of nonmotorized road users (i.e., a "Complete Streets" policy)-on pedestrian fatalities and to identify factors influencing its implementation.

METHODS

We used a multimethod design (interrupted time-series quasi-experiment and interviews) to calculate Florida's pedestrian fatality rates from 1975 to 2013-39 quarters before and 117 quarters after adoption of the law. Using statistical models, we compared Florida with regional and national comparison groups. Semistructured interviews were conducted with 10 current and former Florida transportation professionals in 2015.

RESULTS

Florida's pedestrian fatality rates decreased significantly-by at least 0.500% more each quarter-after Statute 335.065 was adopted, resulting in more than 3500 lives saved across 29 years. Interviewees described supports and challenges associated with implementing the law.

CONCLUSIONS

Florida Statute 335.065 is associated with a 3-decade decrease in pedestrian fatalities. The study also reveals factors that influenced the implementation and effectiveness of the law. Public Health Implications. Transportation policies-particularly Complete Streets policies-can have significant, quantifiable impacts on population health. Multimethod designs are valuable approaches to policy evaluations.

The impact of nursing students on the health-related quality of life and perceived social support of a rural population in Ecuador: effects of a service-based learning course

BACKGROUND

Students seeking degrees in healthcare in Ecuador participate in community improvement projects and provide free health services under the supervision of faculty health professionals. The aim of this study is to determine the impact of a community-based intervention delivered by nursing students on health-related quality of life (HRQoL) and perceived social support of a rural population in Ecuador.

METHODS

A quasi-experimental non-equivalent control group design study was conducted in two rural communities in Tumbaco, Ecuador. Families from one rural community were invited to participate in the intervention, receiving 8 weekly home visits from nursing students. Families from a neighboring community were similarly recruited as wait-list controls. One member of each family was consented into the study; the final sample included 43 intervention participants and 55 control participants. HRQoL and perceived social support were assessed before and after the intervention in both groups. The SF-12 was used to measure HRQoL, including eight domain scores and two composite scores, and the Interpersonal Support Evaluation List was used as an indicator of perceived social support. Difference-in-differences (DD) analyses were conducted to mitigate the effects of any baseline differences in the non- equivalent control group design.

RESULTS

When compared to the control group, the intervention group realized significant improvements in the physical component summary score of the SF-12 (4.20, p < 0.05) and the physical function domain of the SF-12 (4.92, p < 0.05). There were no statistically significant differences for any other components of the SF-12 or in the measure of perceived social support.

CONCLUSIONS

Nursing students completing their rural service rotation have the potential to improve the health-related quality of life of rural residents in Ecuador. Future research should continue to examine the impact of service-based learning on recipient populations.

Benefit-Cost Analysis of Undergraduate Education Programs: An Example Analysis of the Freshman Research Initiative

Institutions and administrators regularly have to make difficult choices about how best to invest resources to serve students. Yet economic evaluation, or the systematic analysis of the relationship between costs and outcomes of a program or policy, is relatively uncommon in higher education. This type of evaluation can be an important tool for decision makers considering questions of resource allocation. Our purpose with this essay is to describe methods for conducting one type of economic evaluation, a benefit-cost analysis (BCA), using an example of an existing undergraduate education program, the Freshman Research Initiative (FRI) at the University of Texas Austin. Our aim is twofold: to demonstrate how to apply BCA methodologies to evaluate an education program and to conduct an economic evaluation of FRI in particular. We explain the steps of BCA, including assessment of costs and benefits, estimation of the benefit-cost ratio, and analysis of uncertainty. We conclude that the university's investment in FRI generates a positive return for students in the form of increased future earning potential.

A Prospective Programmatic Cost Analysis of Fuel Your Life: A Worksite Translation of DPP

OBJECTIVE

An accounting of the resources necessary for implementation of efficacious programs is important for economic evaluations and dissemination.

METHODS

A programmatic costs analysis was conducted prospectively in conjunction with an efficacy trial of Fuel Your Life (FYL), a worksite translation of the Diabetes Prevention Program. FYL was implemented through three different modalities, Group, Phone, and Self-study, using a micro-costing approach from both the employer and societal perspectives.

RESULTS

The Phone modality was the most costly at $354.6 per participant, compared with $154.6 and $75.5 for the Group and Self-study modalities, respectively. With the inclusion of participant-related costs, the Phone modality was still more expensive than the Group modality but with a smaller incremental difference ($461.4 vs $368.1).

CONCLUSIONS

This level of cost-related detail for a preventive intervention is rare, and our analysis can aid in the transparency of future economic evaluations.

The burden of child maltreatment in the East Asia and Pacific region

This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. Systematic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child maltreatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region's per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US $151 billion, accounting for 1.88% of the region's GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child maltreatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally.

Cost-effectiveness analysis of community active case finding and household contact investigation for tuberculosis case detection in urban Africa

Introduction

Case detection by passive case finding (PCF) strategy alone is inadequate for detecting all tuberculosis (TB) cases in high burden settings especially Sub-Saharan Africa. Alternative case detection strategies such as community Active Case Finding (ACF) and Household Contact Investigations (HCI) are effective but empirical evidence of their cost-effectiveness is sparse. The objective of this study was to determine whether adding ACF or HCI compared with standard PCF alone represent cost-effective alternative TB case detection strategies in urban Africa.

Methods

A static decision modeling framework was used to examine the costs and effectiveness of three TB case detection strategies: PCF alone, PCF+ACF, and PCF+HCI. Probability and cost estimates were obtained from National TB program data, primary studies conducted in Uganda, published literature and expert opinions. The analysis was performed from the societal and provider perspectives over a 1.5 year time-frame. The main effectiveness measure was the number of true TB cases detected and the outcome was incremental cost-effectiveness ratios (ICERs) expressed as cost in 2013 US$ per additional true TB case detected.

Results

Compared to PCF alone, the PCF+HCI strategy was cost-effective at US$443.62 per additional TB case detected. However, PCF+ACF was not cost-effective at US$1492.95 per additional TB case detected. Sensitivity analyses showed that PCF+ACF would be cost-effective if the prevalence of chronic cough in the population screened by ACF increased 10-fold from 4% to 40% and if the program costs for ACF were reduced by 50%.

Conclusions

Under our baseline assumptions, the addition of HCI to an existing PCF program presented a more cost-effective strategy than the addition of ACF in the context of an African city. Therefore, implementation of household contact investigations as a part of the recommended TB control strategy should be prioritized.

Cost-effectiveness of Legacy for Children™ for Reducing Behavioral Problems and Risk for ADHD among Children Living in Poverty

This paper describes the programmatic costs required for implementation of the Legacy for Children™ (Legacy) program at two sites (Miami and Los Angeles) and enumerate the cost-effectiveness of the program. Legacy provided group-based parenting intervention for mothers and children living in poverty. This cost-effectiveness analysis included two behavioral outcomes, behavioral problems, and attention-deficit/hyperactivity disorder (ADHD), and programmatic costs collected prospectively (2008 US$). Incremental costs, effects, the incremental cost-effectiveness ratio (ICER), and cost-effectiveness acceptability curves were estimated for the intervention groups relative to a comparison group with a 5 year analytic horizon. The intervention costs per family for Miami and Los Angeles were $16,900 and $14,100, respectively. For behavioral problems, the incremental effects were marginally significant (p=0.11) for Miami with an ICER of $178,000 per child at high risk for severe behavioral problems avoided. For ADHD, the incremental effects were significant (p=0.03) for Los Angeles with an ICER of $91,100 per child at high risk for ADHD avoided. Legacy was related to improvements in behavioral outcomes within two community-drawn sites and the costs and effects are reasonable considering the associated economic costs.

Linking costs to health outcomes for allocating scarce public health resources

Introduction:

Resources for public health (PH) are scarce and policymakers face tough decisions in determining their funding priorities. The difficulty of making these decisions is compounded by current PH accounting systems, which are ill-equipped to link fiscal resources to PH outcomes. This paper examines the types of revenues and expenditures, health services, and health outcomes that are being tracked at the local and state PH levels. The authors provide recommendations for strengthening the ability of local and state governments to link expenditures to PH outcomes, both within and across jurisdictions.

Framework and Next Steps:

The source of revenue data for most local jurisdictions is the accounting systems used for the budgeting and auditing of fiscal activities, and these are primarily linked to specific PH programs. In contrast, expenditure data are mostly generic and typically span multiple PH programs with no link to specific PH activities. Many challenges exist to then link PH activities to health outcomes data, which are often collected through separate reporting systems at the local, state, and national levels. Policy change at the state level and implementation strategies that are standardized across local health departments are required to assess the costs and health outcomes of PH activities.

Conclusion:

Information linking PH expenditures to health outcomes of PH services could greatly inform the decision-making process. This information will allow investments in PH to be better understood and will provide a strong foundation for the PH services and systems research community to understand variation and drive improvement. Ultimately, these data could be used to improve accountability at the local and state PH department levels.

Yield of undetected tuberculosis and human immunodeficiency virus coinfection from active case finding in urban Uganda

OBJECTIVES

To determine the yield of undetected active tuberculosis (TB), TB and human immunodeficiency virus (HIV) coinfection and the number needed to screen (NNS) to detect a case using active case finding (ACF) in an urban community in Kampala, Uganda.

METHODS

In a door-to-door survey conducted in Rubaga community from January 2008 to June 2009, residents aged ≥15 years were screened for chronic cough (≥2 weeks) and tested for TB disease using smear microscopy and/or culture. Rapid testing was used to screen for HIV infection. The NNS to detect one case was calculated based on population screened and undetected cases found.

RESULTS

Of 5102 participants, 3868 (75.8%) were females; the median age was 24 years (IQR 20-30). Of 199 (4%) with chronic cough, 160 (80.4%) submitted sputum, of whom 39 (24.4%, 95%CI 17.4-31.5) had undetected active TB and 13 (8.1%, 95%CI 6.7-22.9) were TB-HIV co-infected. The NNS to detect one TB case was 131 in the whole study population, but only five among the subgroup with chronic cough.

CONCLUSION

ACF obtained a high yield of previously undetected active TB and TB-HIV cases. The NNS in the general population was 131, but the number needed to test in persons with chronic cough was five. These findings suggest that boosting the identification of persons with chronic cough may increase the overall efficiency of TB case detection at a community level.

Cost-effectiveness of the strong African American families-teen program: 1-year follow-up

INTRODUCTION

Alcohol use poses a major threat to the health and well being of rural African American adolescents by negatively impacting academic performance, health, and safety. However, rigorous economic evaluations of prevention programs targeting this population are scarce.

METHODS

Cost-effectiveness analyses were conducted of SAAF-T relative to an attention-control intervention (ACI), as part of a randomized prevention trial. Outcomes of interest were the number of alcohol use and binge drinking episodes prevented, one year following the intervention. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves (CEACs) were used to determine the cost-effectiveness of SAAF-T compared to the ACI intervention.

RESULTS

For the 473 participating youth completing baseline and follow-up assessments, the incremental per participant costs were $168, while the incremental per participant effects were 3.39 episodes of alcohol use prevented and 1.36 episodes of binge drinking prevented. Compared to the ACI intervention, the SAAF-T program cost $50 per reduction in an alcohol use episode and $123 per reduced episode of binge drinking. For the CEACs, at thresholds of $100 and $440, SAAF-T has at least a 90% probability of being cost-effective, relative to the ACI, for reductions in alcohol use and binge drinking episodes, respectively.

CONCLUSIONS

The SAAF-T intervention provides a potentially cost-effective means for reducing the African American youths' alcohol use and binge drinking episodes.

Integrating condom skills into family-centered prevention: efficacy of the Strong African American Families-Teen program

PURPOSE

The Strong African American Families-Teen (SAAF-T) program, a family-centered preventive intervention that included an optional condom skills unit, was evaluated to determine whether it prevented unprotected intercourse and increased condom efficacy among rural African American adolescents. Ancillary analyses were conducted to identify factors that predicted youth attendance of the condom skills unit.

METHODS

Sixteen-year-old African American youths (N = 502) and their primary caregivers were randomly assigned to SAAF-T (n = 252) or an attention control (n = 250) intervention. SAAF-T families participated in a 5-week family skills training program that included an optional condom skills unit. All families completed in-home pretest, posttest, and long-term follow-up interviews during which adolescents reported on their sexual behavior, condom use, and condom efficacy. Because condom use was addressed only in an optional unit that required caregiver consent, we analyzed efficacy using complier average causal effect analyses.

RESULTS

Attendance in both SAAF-T and the attention control intervention averaged 4 of 5 sessions; 70% of SAAF-T youth attended the condom skills unit. Complier average causal effect models indicated that SAAF-T was efficacious in reducing unprotected intercourse and increasing condom efficacy among rural African American high school students. Exploratory analyses indicated that religious caregivers were more likely than nonreligious caregivers to have their youth attend the condom skills unit.

CONCLUSIONS

Results suggest that brief condom skills educational modules in the context of a family-centered program are feasible and reduce risk for sexually transmitted infections and unplanned pregnancies.

National Institutes of Health State-of-the-Science Conference: role of active surveillance in the management of men with localized prostate cancer

National Institutes of Health (NIH) Consensus and State-of-the-Science Statements are prepared by independent panels of health professionals and public representatives on the basis of 1) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality, 2) presentations by investigators working in areas relevant to the conference questions during a 2-day public session, 3) questions and statements from conference attendees during open discussion periods that are part of the public session, and 4) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of NIH or the U.S. government. The statement reflects the panel’s assessment of medical knowledge available at the time the statement was written. Thus, it provides a “snapshot in time” of the state of knowledge on the conference topic. When reading the statement, keep in mind that new knowledge is inevitably accumulating through medical research. The following statement is an abridged version of the panel’s report, which is available in full at http://consensus.nih.gov/2011/prostatefinalstatement.htm

Benefits and costs of a free community-based primary care clinic

This study estimates the benefits and costs of a free clinic providing primary care services. Using matched data from a free clinic and its corresponding regional hospital on a sample of newly enrolled clinic patients, patients' non-urgent emergency department (ED) and inpatient hospital costs in the year prior to clinic enrollment were compared to those in the year following enrollment to obtain financial benefits. We compare these to annual estimates of the costs associated with the delivery of primary care to these patients. For our sample (n = 207), the annual non-urgent ED and inpatient costs at the hospital fell by $170 per patient after clinic enrollment. However, the cost associated with delivering primary care in the first year after clinic enrollment cost $505 per patient. The presence of a free primary care clinic reduces hospital costs associated with non-urgent ED use and inpatient care. These reductions in costs need to be sustained for at least 3 years to offset the costs associated with the initially high diagnostic and treatment costs involved in the delivery of primary care to an uninsured population.

NIH State-of-the-Science Conference Statement: Role of active surveillance in the management of men with localized prostate cancer

OBJECTIVE

To provide healthcare providers, patients, and the general public with a responsible assessment of currently available data on the use of active surveillance and other observational management strategies for low-grade, localized prostate cancer.

PARTICIPANTS

A non-U.S. Department of Health and Human Services, nonadvocate 14-member panel representing the fields of cancer prevention and control, urology, pathology, epidemiology, genetics, transplantation, bioethics, economics, health services research, shared decisionmaking, health communication, and community engagement. In addition, 22 experts from pertinent fields presented data to the panel and conference audience.

EVIDENCE

Presentations by experts and a systematic review of the literature prepared by the Tufts Evidence-based Practice Center, through the Agency for Healthcare Research and Quality (AHRQ). Scientific evidence was given precedence over anecdotal experience.

CONFERENCE PROCESS

The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

CONCLUSIONS

Prostate cancer screening with prostate-specific antigen (PSA) testing has identified many men with low-risk disease. Because of the very favorable prognosis of low-risk prostate cancer, strong consideration should be given to modifying the anxiety-provoking term "cancer" for this condition. Treatment of low-risk prostate cancer patients with radical prostatectomy or radiation therapy leads to side effects such as impotence and incontinence in a substantial number. Active surveillance has emerged as a viable option that should be offered to patients with low-risk prostate cancer. More than 100,000 men a year diagnosed with prostate cancer in the United States are candidates for this approach. However, there are many unanswered questions about active surveillance strategies and prostate cancer that require further research and clarification. These include: • Improvements in the accuracy and consistency of pathologic diagnosis of prostate cancer • Consensus on which men are the most appropriate candidates for active surveillance • The optimal protocol for active surveillance and the potential for individualizing the approach based on clinical and patient factors • Optimal ways to communicate the option of active surveillance to patients • Methods to assist patient decisionmaking • Reasons for acceptance or rejection of active surveillance as a treatment strategy • Short- and long-term outcomes of active surveillance. Well-designed studies to address these questions and others raised in this statement represent an important health research priority. Qualitative, observational, and interventional research designs are needed. Due to the paucity of evidence about this important public health problem, all patients being considered for active surveillance should be offered participation in multicenter research studies that incorporate community settings and partners.

Benefits of preventing a death associated with child maltreatment: evidence from willingness-to-pay survey data

Although assessing the costs of an intervention to prevent child maltreatment is straightforward, placing a monetary value on benefits is challenging. Respondents participating in a statewide random-digit-dialed survey were asked how much they would be willing to pay to prevent a death caused by child maltreatment. Our results suggested that society may value preventing a death from child maltreatment at $15 million. If a child maltreatment intervention is effective enough to save even 1 life, then in many cases, its benefits will outweigh its costs.

Propensity for intimate partner abuse and workplace productivity: why employers should care

It has been demonstrated that intimate partner violence (IPV) victimization is costly to employers, but little is known about the economic consequences associated with employing perpetrators. This study investigated propensity for partner abuse as a predictor of missed work time and on-the-job decreases in productivity among a small sample of male employees at a state agency (N=61). Results suggest that greater propensity for abusiveness is positively associated with missing work and experiencing worse productivity on the job, controlling for level of education, income, marital status, age, and part-time versus full-time employment status. Additional research could clarify whether IPV perpetration is a predictor of decreased productivity among larger samples and a wider variety of workplace settings. Employers and IPV advocates should consider responding to potential IPV perpetrators through the workplace in addition to developing victim-oriented policies and prevention initiatives.

Health-related quality of life among adults who experienced maltreatment during childhood

OBJECTIVES

We sought to assess the difference in a preference-based measure of health among adults reporting maltreatment as a child versus those reporting no maltreatment.

METHODS

Using data from a study of adults who reported adverse childhood experiences and current health status, we matched adults who reported childhood maltreatment (n = 2812) to those who reported no childhood maltreatment (n = 3356). Propensity score methods were used to compare the 2 groups. Health-related quality-of-life data (or "utilities") were imputed from the Medical Outcomes Study 36-Item Short Form Health Survey using the Short Form-6D preference-based scoring algorithm.

RESULTS

The combined strata-level effects of maltreatment on Short Form-6D utility was a reduction of 0.028 per year (95% confidence interval=0.022, 0.034; P<.001). All utility losses for the childhood-maltreatment versus no-childhood-maltreatment groups by age group were significantly different: 18-39 years, 0.042; 40-49 years, 0.038; 50-59 years, 0.023; 60-69 years, 0.016; 70 or more years, 0.025.

CONCLUSIONS

Persons who experienced childhood maltreatment had significant and sustained losses in health-related quality of life in adulthood relative to persons who did not experience maltreatment. These data are useful for assessing the cost-effectiveness of interventions designed to prevent child maltreatment in terms of cost per quality-adjusted life years saved.

Child maltreatment, youth violence, and intimate partner violence: developmental relationships

BACKGROUND

Understanding the cycle of violence, from victimization to perpetration across the life span, is critical for designing successful prevention interventions. This study uses a nationally representative sample to examine the developmental relationships among three forms of child maltreatment, youth violence perpetration or victimization, and young adult intimate partner violence (IPV) perpetration or victimization.

METHODS

Data describing self-reported youth violence perpetration (or victimization) from Wave I of the National Longitudinal Study of Adolescent Health (1994-1995) were matched with self-reported IPV perpetration (or victimization) in young adult sexual relationships and retrospective reports of child maltreatment collected during Wave III (2001-2002). Bivariate probit regression models were used to analyze the developmental relationships between child maltreatment, youth violence, and IPV. Analyses were completed in September 2006.

RESULTS

Compared to nonvictims of child maltreatment, victims of child maltreatment are more likely to perpetrate youth violence (a likelihood increase ranging from -1.2% to 6.6% for females and 3.7% to 11.9% for males) and young adult IPV (an increase from 8.7% to 10.4% for females and from 1.3% to 17.2% for males), although the direct and indirect effects vary by type of child maltreatment experienced. Gender differences exist in the links between child maltreatment, youth violence and IPV, and in the effects of socioeconomic factors on youth violence and IPV.

CONCLUSIONS

Results suggest that it may be important to account for gender differences when designing violence prevention programs, and an integrative approach is critical for stopping the developmental trajectory of violence.

The costs of fatal and non-fatal falls among older adults

OBJECTIVE

To estimate the incidence and direct medical costs for fatal and non-fatal fall injuries among US adults aged >or=65 years in 2000, for three treatment settings stratified by age, sex, body region, and type of injury.

METHODS

Incidence data came from the 2000 National Vital Statistics System, 2001 National Electronic Injury Surveillance System-All Injury Program, 2000 Health Care Utilization Program National Inpatient Sample, and 1999 Medical Expenditure Panel Survey. Costs for fatal falls came from Incidence and economic burden of injuries in the United States; costs for non-fatal falls were based on claims from the 1998 and 1999 Medicare fee-for-service 5% Standard Analytical Files. A case crossover approach was used to compare the monthly costs before and after the fall.

RESULTS

In 2000, there were almost 10 300 fatal and 2.6 million medically treated non-fatal fall related injuries. Direct medical costs totaled 0.2 billion dollars for fatal and 19 billion dollars for non-fatal injuries. Of the non-fatal injury costs, 63% (12 billion dollars ) were for hospitalizations, 21% (4 billion dollars) were for emergency department visits, and 16% (3 billion dollars) were for treatment in outpatient settings. Medical expenditures for women, who comprised 58% of the older adult population, were 2-3 times higher than for men for all medical treatment settings. Fractures accounted for just 35% of non-fatal injuries but 61% of costs.

CONCLUSIONS

Fall related injuries among older adults, especially among older women, are associated with substantial economic costs. Implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.

Measuring health-related quality of life for child maltreatment: a systematic literature review

Background

Child maltreatment causes substantial morbidity and mortality in the U.S. Morbidity associated with child maltreatment can reduce health-related quality of life. Accurately measuring the reduction in quality of life associated with child maltreatment is essential to the economic evaluation of educational programs and interventions to reduce the incidence of child maltreatment. The objective of this study was to review the literature for existing approaches and instruments for measuring quality-of-life for child maltreatment outcomes.

Methods

We reviewed the current literature to identify current approaches to valuing child maltreatment outcomes for economic evaluations. We also reviewed available preference-based generic QOL instruments (EQ-5D, HUI, QWB, SF-6D) for appropriateness in measuring change in quality of life due to child maltreatment.

Results

We did not identify any studies that directly evaluated quality-of-life in maltreated children. We identified 4 studies that evaluated quality of life for adult survivors of child maltreatment and 8 studies that measured quality-of-life for pediatric injury not related to child maltreatment. No study reported quality-of-life values for children younger than age 3.

Currently available preference-based QOL instruments (EQ-5D, HUI, QWB, SF-6D) have been developed primarily for adults with the exception of the Health Utilities Index. These instruments do not include many of the domains identified as being important in capturing changes in quality of life for child maltreatment, such as potential for growth and development or psychological sequelae specific to maltreatment.

Conclusion

Recommendations for valuing preference-based quality-of-life for child maltreatment will vary by developmental level and type of maltreatment. In the short-term, available multi-attribute utility instruments should be considered in the context of the type of child maltreatment being measured. However, if relevant domains are not included in existing instruments or if valuing health for children less than 6 years of age, direct valuation with a proxy respondent is recommended. The choice of a proxy respondent is not clear in the case of child maltreatment since the parent may not be a suitable proxy. Adult survivors should be considered as appropriate proxies. Longer-term research should focus on identifying the key domains for measuring child health and the development of preference-based quality-of-life instruments that are appropriate for valuing child maltreatment outcomes.

The relationship between obesity and injuries among U.S. adults

PURPOSE

To quantify the relationship between body mass index (BMI) and rates of medically attended injuries by mechanism (overall, fall, motor vehicle, and sport-related) and by nature (strain/sprain, lower extremity fracture, and dislocations), and between BMI and injury treatment costs.

DESIGN

Cross-sectional analysis. SETTING. The noninstitutionalized population of the United States.

SUBJECTS

The 1999-2000, 2000-2001, and 2001-2002 waves of the Medical Expenditure Panel Survey, a large, nationally representative dataset, were combined to create the analysis sample. The final sample included 42,304 adults. MEASURES. Medically attended injury rates by mechanism and nature of injury and related treatment costs.

ANALYSIS

Logistic regressions were used to separately estimate the odds of sustaining any injury by mechanism or by nature for overweight (25 < BMI : 29.9) and three categories of obese individuals compared with those who were normal weight. A second set of regressions tested whether, given that an injury occurred, obese individuals had greater injury treatment costs. RESULTS. Slightly more than one in five adults sustain an injury each year that requires medical treatment. The odds of sustaining an injury are 15% (overweight) to 48% (Class III obesity) greater among those with excess weight. Conditional on sustaining an injury, BMI did not have a significant impact on injury treatment costs.

CONCLUSION

Our findings show a clear association between BMI and the probability of sustaining an injury. If increasing BMI is causing the rise in injury rates, then the incidence of injuries, including those related to falls, sprains/strains, lower extremity fractures, and joint dislocations, are likely to increase as the prevalence of obesity increases.

Medical costs and productivity losses due to interpersonal and self-directed violence in the United States

BACKGROUND

Violence-related injuries, including suicide, adversely affect the health and welfare of all Americans through premature death, disability, medical costs, and lost productivity. Estimating the magnitude of the economic burden of violence is critical for understanding the potential amount of resources that can be saved if cost-effective violence prevention efforts can be broadly applied. From 2003 to 2005, the lifetime medical costs and productivity losses associated with medically treated injuries due to interpersonal and self-directed violence occurring in the United States in 2000 were assessed.

METHODS

Several nationally representative data sets were combined to estimate the incidence of fatal and nonfatal injuries due to violence. Unit medical and productivity costs were computed and then multiplied by corresponding incidence estimates to yield total lifetime costs of violence-related injuries occurring in 2000.

RESULTS

The total costs associated with nonfatal injuries and deaths due to violence in 2000 were more than $64.8 [corrected] billion. Most of this cost ($64.4 billion or 92%) was due to lost productivity. However, an estimated $5.6 billion was spent on medical care for the more than 2.5 million injuries due to interpersonal and self-directed violence.

CONCLUSIONS

The burden estimates reported here provide evidence of the large health and economic burden of violence-related injuries in the U.S. But the true burden is likely far greater and the need for more research on violence surveillance and prevention are discussed.

A cost analysis of a smoke alarm installation and fire safety education program

INTRODUCTION

While smoke alarm installation programs can help prevent residential fire injuries, the costs of running these programs are not well understood.

METHOD

We conducted a retrospective cost analysis of a smoke alarm installation program in 12 funded communities across four states. Costs included financial and economic resources needed for training, canvassing, installing, and following-up, within four cost categories: (a) personnel, (b) transportation, (c) facility, and (d) supplies.

RESULTS

Local cost per completed home visit averaged 214.54 dollars, with an average local cost per alarm installed of 115.02 dollars. Combined state and local cost per alarm installed across all four states averaged 132.15 dollars. For every 1% increase in alarm installation, costs per alarm decrease by 1.32 dollars.

CONCLUSIONS

As more smoke alarms are installed, the average installation cost per alarm decreases. By demonstrating effective economies of scale, this study suggests that smoke alarm programs can be implemented efficiently and receive positive economic returns on investment.

A Comparison of the Case???Control and Case???Crossover Designs for Estimating Medical Costs of Nonfatal Fall-Related Injuries Among Older Americans

OBJECTIVES

Although the case-crossover design has been used widely in epidemiological and cost-offset studies as an alternative to the case-control design, it is rarely applied to cost-of-illness studies. In this study, costs for a series of hospitalized and nonhospitalized fall-related injuries were computed using the 2 approaches to allow for a direct comparison of the results.

RESEARCH DESIGN

We used claims data from the Medicare fee-for-service 5% Standard Analytical Files. For the case-control design, those who sustained nonfatal fall-related injuries were tracked for 1 year after their first fall, and costs were compared, using regression analysis, to annual costs for a comparison sample of nonfallers. The case-crossover design used a modified regression approach that compared monthly costs of fallers before and after fall.

RESULTS

We present unit costs for falls requiring (1) a hospitalization resulting in a live discharge, (2) an emergency department visit not resulting in an admission, and (3) falls requiring office-based or hospital outpatient visits only. Using the case-control design, these costs were $22,260, $3890, and $5040 respectively. Using the case-crossover design, these estimates were reduced to $20,920, $3230, and $4200.

CONCLUSIONS

On average, estimates of the costs of fall injuries from the case-control design were between 6% and 17% greater than those from the case-crossover approach. These differences likely result from our inability to control for comorbidity differences between fallers and nonfallers in the case-control design. Under several scenarios, including unobserved heterogeneity between cases and controls, the case-crossover design, although computationally more intensive, produces more accurate results.

The acute medical care costs of fall-related injuries among the U.S. older adults

OBJECTIVES

Falls in the older adults are a major public health concern. The growing population of adults 65 years or older, advances in medical care and changes in the costs of care motivated our study of the acute health care costs of fall-related injuries among the older adults in the United States of America.

DESIGN AND SETTINGS

The Market Scan Medicare Supplemental database 1998 was used to estimate reimbursed costs for hospital, emergency department (ED), and outpatient clinic treatments for unintentional falls among older adults.

RESULTS

A fall on the same level due to slipping, tripping, or stumbling was the most common mechanism of injury (28%). Mean hospitalisation cost was 17,483 US dollars(S.D.: 22,426 US dollars) in 2004 US dollars. Femur fracture was the most expensive type of injury (18,638 US dollars, S.D.: 19,990 US dollars). The mean reimbursement cost of an ED visit was 236 US dollars and 412 US dollars for an outpatient clinic visit.

CONCLUSION

The magnitude of the economic and social costs of falls in older adults underscores the need for active research in the field of falls prevention.

Therapeutic foster care for the prevention of violence: a report on recommendations of the Task Force on Community Preventive Services

In therapeutic foster care programs, youths who cannot live at home are placed in homes with foster parents who have been trained to provide a structured environment that supports their learning social and emotional skills. To assess the effectiveness of such programs in preventing violent behavior among participating youths, the Task Force on Community Preventive Services conducted a systematic review of the scientific literature regarding these programs. Reported and observed violence, including violent crime, were direct measures. Proxy measures were externalizing behavior (i.e., behavior in which psychological problems are acted out), conduct disorder, and arrests, convictions, or delinquency, as ascertained from official records, for acts that might have included violence. Reviewed studies assessed two similar interventions, distinguished by the ages and underlying problems of the target populations. Therapeutic foster care for reduction of violence by children with severe emotional disturbance (hereafter referred to as cluster therapeutic foster care) involved programs (average duration: 18 months) in which clusters of foster-parent families cooperated in the care of children (aged 5-13 years) with severe emotional disturbance. The Task Force found insufficient evidence to determine the effectiveness of this intervention in preventing violence. Therapeutic foster care for the reduction of violence by chronically delinquent adolescents (hereafter referred to as program-intensive therapeutic foster care) involved short-term programs (average duration: 6-7 months) in which program personnel collaborated closely and daily with foster families caring for adolescents (aged 12-18 years) with a history of chronic delinquency. On the basis of sufficient evidence of effectiveness, the Task Force recommends this intervention for prevention of violence among adolescents with a history of chronic delinquency. This report briefly describes how the reviews were conducted, provides additional information about the findings, and provides information that might help communities in applying the intervention locally.

First reports evaluating the effectiveness of strategies for preventing violence: early childhood home visitation. Findings from the Task Force on Community Preventive Services

Early childhood home visitation programs are those in which parents and children are visited in their home during the child's first 2 years of life by trained personnel who provide some combination of the following: information, support, or training regarding child health, development, and care. Home visitation has been used for a wide range of objectives, including improvement of the home environment, family development, and prevention of child behavior problems. The Task Force on Community Preventive Services (the Task Force) conducted a systematic review of scientific evidence concerning the effectiveness of early childhood home visitation for preventing several forms of violence: violence by the visited child against self or others; violence against the child (i.e., maltreatment [abuse or neglect]); other violence by the visited parent; and intimate partner violence. On the basis of strong evidence of effectiveness, the Task Force recommends early childhood home visitation for the prevention of child abuse and neglect. The Task Force found insufficient evidence to determine the effectiveness of early childhood home visitation in preventing violence by visited children, violence by visited parents (other than child abuse and neglect), or intimate partner violence in visited families. (Note that insufficient evidence to determine effectiveness should not be interpreted as evidence of ineffectiveness.) No studies of home visitation evaluated suicide as an outcome. This report provides additional information regarding the findings, briefly describes how the reviews were conducted, and provides information that can help in applying the recommended intervention locally.

Cost of illness in the 1993 waterborne Cryptosporidium outbreak, Milwaukee, Wisconsin

To assess the total medical costs and productivity losses associated with the 1993 waterborne outbreak of cryptosporidiosis in Milwaukee, Wisconsin, including the average cost per person with mild, moderate, and severe illness, we conducted a retrospective cost-of-illness analysis using data from 11 hospitals in the greater Milwaukee area and epidemiologic data collected during the outbreak. The total cost of outbreak-associated illness was 96.2 million US dollars: 31.7 million US dollars in medical costs and 64.6 million US dollars in productivity losses. The average total costs for persons with mild, moderate, and severe illness were 116 US dollars, 47 US dollars, and 7,808 US dollars, respectively. The potentially high cost of waterborne disease outbreaks should be considered in economic decisions regarding the safety of public drinking water supplies.

Assessing preferences for prevention versus treatment using willingness to pay

BACKGROUND

Rising health care costs and limited resources necessitate trade-offs between resources allocated toward prevention and those toward treatment. Information from opinion polls suggests citizens favor spending a higher proportion of all health care dollars on prevention rather than treatment.

OBJECTIVES

To assess the policy implications of willingness to pay (WTP) for use in cost-benefit analysis (CBA) as a method for capturing individual preferences for prevention and treatment in the context of resource allocation decisions.

METHODS

The authors recruited a random sample of 1456 US residents age 18 years and greater by telephone using random-digit dialing. The survey was designed as a 3-stage (phone-mail-phone) process and was conducted between December 1998 and March 1999. For all persons completing the survey (N = 1104), the authors 1st collected respondents' opinions about the costs and effectiveness of prevention versus treatment programs in general. Half of respondents were then asked to state their WTP for a hypothetical prevention scenario and half were asked to state their WTP for a hypothetical treatment scenario. Both scenarios were specific to the same health context and included an identical reduction in mortality risk.

RESULTS

WTP for treatment was significantly greater than WTP for prevention, $665 and $223, respectively. Prior opinions on the relative effectiveness afforded by preventive and treatment interventions moderately influenced the WTP estimates for persons randomized to either scenario. Prior opinions on costs had no significant effect on WTP estimates for either scenario. WTP significantly increased with age and household income in the full sample but was not significantly affected by gender or educational attainment.

CONCLUSIONS

The aggregated WTP responses from the prevention and treatment scenarios presented in our study would imply that treatment is more strongly preferred by society than prevention when the health context is the same and benefits of each are held constant. A better understanding is needed of the discrepancy between citizens' stated preferences for prevention (e.g., through polling) and our findings that they were willing to pay substantially more for treatment than for prevention.

Rotavirus vaccine and intussusception: how much risk will parents in the United States accept to obtain vaccine benefits?

Postlicensure surveillance of a newly licensed rotavirus vaccine suggested an increased risk of intussusception. Little was known about the amount of risk parents would tolerate to obtain the vaccine's benefits or the extent to which risk would reduce the price parents would pay for the vaccine. Parents of infants aged 12 months or younger were asked to accept or reject two hypothetical vaccines associated with varying degrees of risk. Parents chose from a list the amount they would pay for two additional hypothetical vaccines, with and without a risk of intussuception. The authors conducted face-to-face surveys in September 1999 among a convenience sample of parents in three US cities. Of 405 eligible parents, 260 (64%) participated. To achieve a 90% acceptance rate, the vaccine could be associated with no more than 1,794 (95% confidence interval: 1,551, 2,025) cases of intussusception in a fully vaccinated, national cohort of infants. The median willingness to pay for three vaccine doses, when vaccination was associated with 1,400 cases of intussusception, was $36 (95% confidence interval: $28, $46) compared with $110 (95% confidence interval: $96, $126) for the risk-free vaccine. The most important aspect of this study may be the methodology to assess how parents balance the benefits and risks of childhood vaccines.

An ounce of prevention ... what are the returns? Second edition, 1999

CONTEXT

Because human and financial resources are limited, health efforts must focus on prevention strategies that yield the most benefit for the investment. Many current strategies identified in the literature offer opportunities to promote health at a reasonable cost.

OBJECTIVE

To present a literature-based review of evidence demonstrating that prevention can be an effective and wise use of resources through CDC's An Ounce of Prevention ... What Are the Returns? Second Edition.

DESIGN

Systematic review of cost-effectiveness literature for a selected group of prevention strategies.

SETTING

Prevention strategies relevant to the U.S. population.

RESULTS

Data indicate that the health conditions considered can be addressed through prevention strategies that are either cost effective or cost saving.

CONCLUSIONS

An Ounce of Prevention ... What Are the Returns? Second Edition can be used to conveniently access information on prevention strategies, the diseases and injuries they address, and their cost effectiveness. It also complements other comprehensive prevention guides. However, limitations of the available cost-effectiveness studies indicate that standardized procedures should be followed for studies of all recommended prevention strategies. Researchers must standardize review procedures to improve both the quality and comparability of studies.

Evaluating the cost-effectiveness of clinical and public health measures

Cost-effectiveness analysis, an analytic tool that expresses as a ratio the cost of obtaining an additional unit of health outcome, can help decision makers achieve more health protection for the same or less cost. We characterize the state of the cost-effectiveness analysis literature by reviewing how this technique is applied to various clinical and public health interventions. We describe the results of cost-effectiveness analyses for over 40 interventions to reduce cancer, heart disease, trauma, and infectious disease. The cost-effectiveness ratios for these interventions vary enormously, from interventions that save money to those that cost more than $1 million per year of life gained. The methods used to derive the cost-effectiveness ratios also vary considerably, and we summarize this variation within each health area. Greater uniformity of analytical practice will be necessary if cost-effectiveness analysis is to become a more influential tool in debates about resource allocation.