Cost-effectiveness of combined outreach for the pneumococcal and influenza vaccines.

BACKGROUND: We conducted a cost-effectiveness analysis as part of a randomized, controlled trial of a community-based outreach initiative to promote the pneumococcal and influenza vaccines for people aged 65 years or older. METHODS: The analysis was based on primary data from the trial on the increase in vaccination rates and cost of the intervention, and published estimates of the effectiveness of the vaccines and cost of treatment. We performed partial stochastic analyses based on the confidence intervals (CIs) of the effectiveness of the intervention and of the vaccines. RESULTS: The cost-effectiveness ratio of the combined-outreach initiative as implemented was $35 486 per quality-adjusted life-year (QALY), whereas it was $53 547 per QALY for the pneumococcal vaccine and $130 908 per QALY for the influenza vaccine. In partial stochastic analyses, the quasi-CI of the combined-outreach initiative ranged from $15 145 to $152 311 per QALY. The cost-effectiveness ratio of the intervention targeted to people who had never received the pneumococcal vaccine or who had not received the influenza vaccine in the previous year was $11 771 per QALY, with a quasi-CI of $3330 to $46 095 per QALY. With the use of the projected cost of replicating the intervention, the cost-effectiveness ratio was $26 512 per QALY for the initiative as implemented and $7843 per QALY for a targeted initiative. CONCLUSIONS: The community-based outreach initiative to promote the pneumococcal and influenza vaccines was reasonably cost-effective. Further improvements in cost-effectiveness could be made by targeting the initiative or through lessons learned during the first year that would reduce the cost of the initiative in subsequent years.

Increasing influenza and pneumococcal immunization rates: a randomized controlled study of a senior center-based intervention.

BACKGROUND: Immunizations decrease morbidity from influenza and pneumococcal infections. Immunization levels remain below desired levels despite clinic-based and public education efforts. This paper describes a randomized, controlled trial of a senior center-based program, which used peer-to-peer outreach to increase pneumococcal and influenza immunization rates among an urban senior population. METHODS: Seniors were randomized to intervention or control groups. The intervention group received educational brochures mailed with reply cards to report immunization status, telephone calls from senior volunteers to unimmunized participants, and computerized immunization tracking. Immunization rates were obtained before and after the intervention by self-report. RESULTS: Among participants without prior pneumococcal immunization, the pneumococcal immunization rate among the intervention group (52.0%; 95% CI = 46.6%-57.4%) was significantly higher than that of the control group (30.9%; 95% CI = 26.6%-35.2%) (rate ratio = 1.68; 95% CI = 1.40-2.03). Among those without influenza immunization in the prior year, significantly more (50.0%; 95% CI = 40.0%-60.0%) were immunized against influenza in the intervention group than in the control group (23.0%; 95% CI = 15.2%-33.3%) (rate ratio = 2.17; 95% CI = 1.42-3.31). Among those with influenza immunization in the prior year, the rate ratio was 1.04 (95% CI = 1.01-1.07). CONCLUSIONS: The intervention increased both influenza and pneumococcal immunization rates to high levels, suggesting that further progress in increasing adult immunization coverage is possible.

Community occupational structure, basic services, and coronary mortality in Washington state, 1980-1994.

OBJECTIVE: Examine the association between county occupational structure, public expenditures, services availability, prevalence of risk factors, and coronary mortality rates, for 1980-1994, in Washington state. DESIGN: Washington's 39 counties were classified into three occupational structure categories: counties with the lowest percentages of the labor force in managerial, professional, and technical occupations were classified in category I; counties with the highest percentages were in category III. Directly age-adjusted coronary heart disease (CHD) mortality rates, aged 35-64 years, (from vital statistics and Census data), per capita expenditures (Washington Department of Revenue data), per capita services (U.S. Statistical Abstracts data), and the prevalence of CHD risk factors (BRFSS data) were calculated for each occupational structure category. RESULTS: CHD mortality rates and the prevalence of risk factors were inversely associated with occupational structure. Per capita expenditures for health, social, and employment services were 2.2 times, and for schools and recreation were 1.4 times higher in category III vs. I counties. Per capita numbers of child care, job training, employment services, exercise facilities, schools, and medical services were 1.5-6.4 times greater in category III vs. I counties. CONCLUSIONS: Strategies to improve community living conditions and decrease economic disparities between counties may be important to decrease geographic differences in premature CHD mortality.

Improving American Indian Cancer Data in the Washington State Cancer Registry using linkages with the Indian Health Service and Tribal Records.

BACKGROUND: Previous reports have suggested that American Indians are sometimes classified as other races on cancer registries. Also, cancer registries typically do not include data on tribal affiliation. This study determined the extent of racial misclassification of American Indians in the Washington State Cancer Registry (WSCR) and obtained tribal-specific cancer data for Washington State. METHODS: A computer file including persons registered for services with the Portland Area Indian Health Service (IHS) or who were enrolled members of 19 tribes in Washington, Oregon, and Idaho (n = 127,375) was linked with WSCR records of incident cases for 1992 and 1993 (n = 49,420). Linkage was conducted with probabilistic methods using the AutoMatch software package. RESULTS: Of 180 persons recorded as American Indian in the WSCR, 130 (72.2%) were identified in the IHS/tribal roll file. Of 259 American Indians included in the IHS/tribal file who were identified in the WSCR, 130 (50.2%) were classified as American Indian. The estimated age-adjusted cancer incidence among American Indians in Washington State increased from 153.5 per 100,000 population before record linkage to 267.5 per 100,000 after linkage. Of the 259 persons who were linked to the WSCR, 17 were not registered with IHS and appeared solely in the tribal rolls. Only two tribes had more than five identified cancer cases during the 2-year study period. CONCLUSIONS: The number of IHS-enrolled American Indians or tribal members included in the WSCR would be underestimated by one third in the absence of record linkages, and the estimated cancer incidence of 43.6% would be lower before linkage. It is feasible to obtain tribal-specific cancer rates by linking tribal rolls to cancer registries, although the small number of cases in most tribes is a significant limitation. Further efforts to improve racial classification of American Indians in cancer registries should be undertaken.

Carpal tunnel syndrome among grocery store workers.

The California Department of Health Services evaluated carpal tunnel syndrome (CTS), a median nerve entrapment condition associated with forceful and repetitive wrist motion, among grocery store workers at a large California supermarket where a CTS cluster had been reported. Forceful and repetitive wrist motion was measured, in three exposure levels, through a job classification scheme based upon type of work tasks and average time per week spent performing these tasks. A medical questionnaire and measurements of median sensory nerve conduction were used to measure CTS. CTS prevalence was 23% based upon a sample of 56 participants drawn from a workforce of 69 employees. A relative risk of 8.3 (95% confidence interval 2.6-26.4) for a history of CTS-like symptoms between the high and low exposure level groups held up after adjustment for the potential confounders of age, sex, alcohol consumption, and high-risk medical history. It was concluded that the basic principles of good ergonomic design should be used to prevent or diminish the risk of musculoskeletal injury in the workplace.

The 10-year experience of an academically affiliated occupational and environmental medicine clinic.

Occupational and environmental diseases are underrecognized. Among the barriers to the successful diagnosis, treatment, and prevention of these conditions are inadequate consultative and information resources. We describe the 10-year clinical and training experiences of an academically affiliated referral center that has as its primary goal the identification of work-related and other environmental diseases. The University of Washington Occupational and Environmental Medicine Program has evaluated 6,048 patients in its diagnostic and screening clinics. Among the 2,841 seen in the diagnostic clinics, 1,553 (55%) had a work-related condition. The most prevalent diagnoses included asbestos-related lung disease (n = 603), toxic encephalopathy (n = 160), asthma (n = 119), other specific respiratory conditions (n = 197), carpal tunnel syndrome (n = 86), and dermatitis (n = 82). The clinics serve as a training site for fellows in the specialty training program, primary care internal medicine residents, residents from other medical specialties, and students in industrial hygiene, toxicology, and occupational health nursing. The program serves two additional important functions: providing consultative services to community physicians and training specialists and other physicians in this underserved area of medicine.

Physician shortage in occupational and environmental medicine.

OBJECTIVE: To determine future training needs for physicians in occupational and environmental medicine based on goals established by the Institute of Medicine (IOM) for clinical practice in the field. DESIGN: A critical review of previously published estimates of the need and supply of physicians with clinical training in occupational and environmental medicine with the application of currently available data to produce revised estimates. MEASUREMENTS AND MAIN RESULTS: Need estimates reviewed from the National Institute for Occupational Safety and Health, the Graduate Medical Education National Advisory Committee (GMENAC), and the Bureau of Health Professions. Supply figures reviewed from GMENAC, the American Medical Association, the American College of Occupational Medicine, and the American Board of Preventive Medicine. Revised need figures are based on the estimated number of occupational and environmental physicians needed to provide adequate nationwide coverage as full-time academic faculty, community-based specialists, and public health physicians in state and local agencies. Revised supply estimates are based on review of available data. Need is estimated at 4600 to 6700 physicians (board-certified or eligible or with special competence in occupational and environmental medicine). Supply is estimated at 1200 to 1500. CONCLUSIONS: This review identified a deficit of 3100 to 5500 physicians in this newly evolving specialty. In order to address this shortfall in the next decade, graduate specialty training would need to be increased to about 3 to 5 times the current maximum capacity.

Comentarios sobre la investigacion clinica en Freud y Piaget. / Clinical research in Freud and Piaget

En este trabajo los autores reflexionan la forma en que Freud y Piaget abordaron sus respectivos objetos de estudio y hacen consideraciones sobre las teorias y metodos de dichos pensadores. Examinan, ademas las diferencias entre ambas tecnicas, la diferente posicion del individuo ante la entrevista (psicoanalitica en un caso, de investigacion en epistemologia genetica en el otro), y la estructuracion dispar que reciben los vinculos por parte de cada profesional en uno y otro caso; delimitan los objetivos en cada tipo de investigacion; y analizan el procedimiento de reconstruccion que les cabe, tanto al psiconalisis cuanto al investigador piagetiano a partir de los datos recogidos en la entrevista

Comentarios sobre la investigacion clinica en Freud y Piaget. / Clinical research in Freud and Piaget

En este trabajo los autores reflexionan la forma en que Freud y Piaget abordaron sus respectivos objetos de estudio y hacen consideraciones sobre las teorias y metodos de dichos pensadores. Examinan, ademas las diferencias entre ambas tecnicas, la diferente posicion del individuo ante la entrevista (psicoanalitica en un caso, de investigacion en epistemologia genetica en el otro), y la estructuracion dispar que reciben los vinculos por parte de cada profesional en uno y otro caso; delimitan los objetivos en cada tipo de investigacion; y analizan el procedimiento de reconstruccion que les cabe, tanto al psiconalisis cuanto al investigador piagetiano a partir de los datos recogidos en la entrevista