Economic evaluation of Cardio inCode®, a clinical-genetic function for coronary heart disease risk assessment.

BACKGROUND: A clinical­genetic function (Cardio inCode®) was generated using genetic variants associated with coronary heart disease (CHD), but not with classical CHD risk factors, to achieve a more precise estimation of the CHD risk of individuals by incorporating genetics into risk equations [Framingham and REGICOR (Registre Gironí del Cor)]. OBJECTIVE: The objective of this study was to conduct an economic analysis of the CHD risk assessment with Cardio inCode®, which incorporates the patient's genetic risk into the functions of REGICOR and Framingham, compared with the standard method (using only the functions). METHODS: A Markov model was developed with seven states of health (low CHD risk, moderate CHD risk, high CHD risk, CHD event, recurrent CHD, chronic CHD, and death). The reclassification of CHD risk derived from genetic information and transition probabilities between states was obtained from a validation study conducted in cohorts of REGICOR (Spain) and Framingham (USA). It was assumed that patients classified as at moderate risk by the standard method were the best candidates to test the risk reclassification with Cardio inCode®. The utilities and costs (€; year 2011 values) of Markov states were obtained from the literature and Spanish sources. The analysis was performed from the perspective of the Spanish National Health System, for a life expectancy of 82 years in Spain. An annual discount rate of 3.5 % for costs and benefits was applied. RESULTS: For a Cardio inCode® price of €400, the cost per QALY gained compared with the standard method [incremental cost-effectiveness ratio (ICER)] would be €12,969 and €21,385 in REGICOR and Framingham cohorts, respectively. The threshold price of Cardio inCode® to reach the ICER threshold generally accepted in Spain (€30,000/QALY) would range between €668 and €836. The greatest benefit occurred in the subgroup of patients with moderate­high risk, with a high-risk reclassification of 22.8 % and 12 % of patients and an ICER of €1,652/QALY and €5,884/QALY in the REGICOR and Framingham cohorts, respectively. Sensitivity analyses confirmed the stability of the study results. CONCLUSIONS: Cardio inCode® is a cost-effective risk score option in CHD risk assessment compared with the standard method.

Death as a sentinel event: the mortality experience of Puerto Ricans in the United States.

The mortality data for 1996 and 1997 reveal that Puerto Ricans in the United States lag behind other Hispanics in terms of age-adjusted death rates. The better health status of Cubans in the United States can be explained by their immigration history and more favorable socio-economic conditions. The greater mortality risks of mainland Puerto Ricans compared to Mexican-Americans is more difficult to explain. While Puerto Ricans have more entitlements, higher incomes, and more education than their Mexican counterparts, the Mexicans have higher levels of employment and more stable families, indicators which apparently affect the relative risk of death. The data also show that, of all the Hispanic subgroups, the Puerto Ricans exhibit the most marked gender differentials, mainland Puerto Rican men being significantly more at risk than females. Finally, the data on infant mortality show that babies born to Puerto Rican women are less likely to survive their first year of life than infants born to women of other Hispanic origins. Each of these indicators suggests the greater vulnerability of mainland Puerto Ricans and confirms the disadvantaged status of this population vis-a-vis other groups.

[To the northernmost part of the airlift bridge: the Puerto Ricans in the United States]. / Al extremo norte del puente aéreo: las puertorriqueñas en los Estados Unidos.

This article examines the available data on the health status of Puerto Rican women in the United States. Statistics on reproductive health, cancer and AIDS indicate that the health status of these women is lower than that of both their U.S. and island counterparts. Usually, the health of immigrants lies somewhere between that of the population of the country of origin, and that of the 'host' country. Puerto Rican women, however, deviate from this pattern. The health lag which U.S. Puerto Rican women are experiencing suggests that the social dislocation which accompanies migration has not diminished over time. Puerto Rican women in the U.S., on the contrary, seem to have lost protective factors that shielded them from certain risks without acquiring the monetary, psycological, and information resources which would allow them to adopt preventive measures and make a more effective use of the existing health services.

The death divide: differentials in premature mortality by gender in Puerto Rico.

The use of the indicator "years of potential life lost" (YPLL) highlights the extent to which premature mortality in Puerto Rico is a predominantly male phenomenon. While men accounted for 58.6% of all deaths in 1987, they represented fully 71.8% of all YPLL attributed to the thirteen leading causes of death. The breakdown of YPLL by gender also underlines sex-specific differences in the causes of mortality. While accidents constitute the leading cause of premature death among men, malignant neoplasms take the lead among women. Similarly, homicides and cirrhosis are significant sources of years of life lost among males, while pneumonia/influenza and diabetes are higher priorities among females. These findings suggest that health promotion strategies need to be gender-specific in order to reach the right targets.

Education for public health in Puerto Rico: 1940-1942.

Formal training in public health in Puerto Rico began in 1940 when a degree-granting Division of Public Health was established within the existing School of Tropical Medicine. The division was sponsored by five institutions--the Puerto Rico Department of Health, the U.S. Public Health Service, the Children's Bureau, the University of Puerto Rico, and Columbia University--each which had a different concept of the aims, scope and character of the training. Conflicts relating to these issues were exacerbated by managerial and budgetary problems, and the program began fitfully and with great difficulties. As a result, the training which was planned in 1940 and launched in 1941 was scrapped or redesigned the following year.

["Pink collar" medicine: implications of the feminization of the profession]. / Medicina de "cuello rosado": implicaciones de la feminización de la profesión.

The rising number and proportion of women in medicine has implications for patient care as well as for the health care delivery system as a whole. Women physicians tend to establish more reciprocal relationships with patients, and are more likely to listen to psycho-social problems than their male colleagues. Other gender-based differences are evident in the practice settings and sites chosen by the two sexes. Women cluster in certain specialties, and are more likely to locate in urban areas and have salaried practices. They also work fewer hours and have lower incomes than their male counterparts. These differences have created heirarchical distinctions within the medical profession. This in turn suggests the possibility of the creation of a "pink collar" medicine.

[Lost years of potential capacity: mortality in Puerto Rico, 1986]. / Años de capacidad potencial perdidos: la mortalidad en Puerto Rico, 1986.

This article uses the indicator "Years of Potential Life Lost" (YPLL) to rank the major causes of premature death in Puerto Rico. This highlights the importance of accidents. When the YPLL computed for 1986 are compared to those for 1977, we can detect reductions in premature mortality due to cerebrovascular diseases and arteriosclerosis, and marked increases due to diabetes, homicides, and pneumonias and influenzas. The latter three causes are highly associated with lifestyles; the prevention of premature mortality in Puerto Rico therefore requires behavioral changes and environmental measures to reduce the risk factors linked with the etiology of these conditions.

A "class A" institution: the struggle for the University of Puerto Rico School of Medicine.

Although the possibility of developing a medical school in Puerto Rico surfaced periodically between 1900 and 1940, it was not until World War II, when the military draft uncovered the poor conditions of the Puerto Rican population and deprived the island of many physicians, that a doctor shortage was discovered and pressures for the creation of a medical school mounted. University authorities and the A.M.A. conducted separate studies to determine the viability of such a school; both concluded that Puerto Rico could support a medical college, but endorsed only a "Class A" school. There was less of a consensus concerning the benefits and objectives of the school, its location, and the relationship between the proposed institution and the existing School of Tropical Medicine. These issues embroiled a number of academic and political parties in a struggle which lasted five years.