Impact of morbid obesity on medical expenditures in adults.

CONTEXT: Morbid obesity (body mass index (BMI) > or =40 kg/m2) is associated with substantially increased morbidity and mortality from chronic health conditions and with poorer health-related quality of life; however, less is known about the impact of morbid obesity on healthcare expenditures. OBJECTIVE: To examine the impact of morbid obesity on healthcare expenditures using a nationally representative sample of US adults. DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional analysis of 16 262 adults from the 2000 Medical Expenditure Panel Survey, a nationally representative survey of the noninstitutionalized civilian population of the United States. Per capita healthcare expenditures were calculated for National Institutes of Health BMI categories, based on self-reported height and weight, using a two-part, multivariable model adjusted for age, gender, race, income, education level, type of health insurance, marital status, and smoking status. MAIN OUTCOME MEASURES: Odds of incurring any healthcare expenditure and per capita healthcare expenditures associated with morbid obesity in 2000. RESULTS: When compared with normal-weight adults, the odds of incurring any healthcare expenditure in 2000 were two-fold greater among adults with morbid obesity. Per capita healthcare expenditures for morbidly obese adults were 81% (95% confidence interval (CI): 48-121%) greater than normal-weight adults, 65% (95% CI: 37-110%) greater than overweight adults, and 47% (95% CI: 11-96%) greater than adults with class I obesity. Excess costs among morbidly obese adults resulted from greater expenditures for office-based visits, outpatient hospital care, in-patient care, and prescription drugs. Aggregate US healthcare expenditures associated with excess body weight among morbidly obese US adults exceeded $11 billion in 2000. CONCLUSIONS: The economic burden of morbid obesity among US adults is substantial. Further research is needed to identify interventions to reduce the incidence and prevalence of morbid obesity and improve the health and economic outcomes of morbidly obese adults.

What should be reported in a methods section on utility assessment?

BACKGROUND: The measurement of utilities, or preferences, for health states may be affected by the technique used. Unfortunately, in papers reporting utilities, it is often difficult to infer how the utility measurement was carried out. PURPOSE: To present a list of components that, when described, provide sufficient detail of the utility assessment. METHODS: An initial list was prepared by one of the authors. A panel of 8 experts was formed to add additional components. The components were drawn from 6 clusters that focus on the design of the study, the administration procedure, the health state descriptions, the description of the utility assessment method, the description of the indifference procedure, and the use of visual aids or software programs. The list was updated and redistributed among a total of 14 experts, and the components were judged for their importance of being mentioned in a Methods section. RESULTS: More than 40 components were generated. Ten components were identified as necessary to include even in an article not focusing on utility measurement: how utility questions were administered, how health states were described, which utility assessment method(s) was used, the response and completion rates, specification of the duration of the health states, which software program (if any) was used, the description of the worst health state (lower anchor of the scale), whether a matching or choice indifference search procedure was used, when the assessment was conducted relative to treatment, and which (if any) visual aids were used. The interjudge reliability was satisfactory (Cronbach's alpha = 0.85). DISCUSSION: The list of components important for utility papers may be used in various ways, for instance, as a checklist while writing, reviewing, or reading a Methods section or while designing experiments. Guidelines are provided for a few components.

Are aggressive treatment strategies less cost-effective for older patients? The case of ventilator support and aggressive care for patients with acute respiratory failure.

OBJECTIVES: A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estimated the incremental cost-effectiveness of providing mechanical ventilation and intensive care for patients of various ages who had acute respiratory failure. DESIGN: Retrospective analysis of data on acute respiratory failure from Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Acute hospital. PARTICIPANTS: 1,005 with acute respiratory failure; 963 received ventilator support and 42 had ventilator support withheld. MEASUREMENTS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (SUPPORT) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or = 10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUPPORT patients and estimated utilities (quality-of-life weights) using time-tradeoff questions. We used hospital fiscal data and Medicare data to estimate healthcare costs. We divided patients into three age groups (< 65, 65-74, and > or = 75 years); for each age group, we performed separate analyses for patients with a < or = 50% probability of surviving at least 2 months (high-risk group) and those with a > 50% probability of surviving at least 2 months (low-risk group). RESULTS: Of the 963 patients who received ventilator support, 44% were female; 48% survived 6 months; and the median (25th, 75th percentile) age was 63 (46, 75) years. For the 42 patients for whom ventilator support was withheld, the median survival was 3 days. For low-risk patients (> 50% estimated 2-month survival), the incremental cost (1998 dollars) per quality-adjusted life-year (QALY) saved by providing ventilator support and aggressive care increased across the three age groups ($32,000 for patients age < 65, $44,000 for those age 65-74, and $46,000 for those age > or = 75). For high-risk patients, the incremental cost-effectiveness was much less favorable and was least favorable for younger patients ($130,000 for patients age < 65, $100,000 for those age 65-74, and $96,000 for those age > or = 75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensitive to the costs of the index hospitalization. CONCLUSIONS: For patients with relatively good short-term prognoses, we found that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor short-term prognoses, ventilator support and aggressive care were much less cost-effective for adults of all ages.

Time costs associated with cervical cancer screening.

OBJECTIVES: Time costs borne by women when undergoing cervical cancer screening have rarely been elucidated, although such costs may pose substantial barriers to care. The purpose of this project was to quantify the opportunity costs associated with cervical cancer screening in young women attending Planned Parenthood Clinics. METHODS: We conducted a self-report survey of 105 women from six clinics to measure travel, waiting, and exam times associated with cervical cancer screening. Respondents recorded their time of arrival and departure, length of time in the waiting room, age, income level, and hours per week they worked outside of the home. Time costs were valued three ways: through self-reported hourly wage, age- and gender-adjusted minimum earnings, and national age- and gender-adjusted hourly wages. RESULTS: Respondents were on average 24 years old, worked 29 hours per week outside the home, and earned less than $20,000 per year. Mean time for one-way travel was 18.7 minutes; waiting room time was 16.9 minutes; and exam time was 50.8 minutes. Time costs were estimated to be $14.08 per visit based upon the self-reported hourly wage; $16.46 per visit based upon age- and gender-adjusted minimum earnings; and $19.63 per visit based upon age- and gender-adjusted national wage rates. CONCLUSIONS: Time costs associated with cervical cancer screening represent an important opportunity cost and should be considered in studies attempting to identify barriers to screening adherence. Our results indicate that time costs accounted for up to 25% of cervical cancer screening costs. Time costs should be identified, measured, valued, and included in cost-effectiveness analyses of cervical cancer screening.

Cost-effectiveness of pravastatin therapy for survivors of myocardial infarction with average cholesterol levels.

BACKGROUND: The objective of this study was to assess the cost-effectiveness of pravastatin therapy in survivors of myocardial infarction with average cholesterol levels. METHODS: We performed a cost-effectiveness analysis based on actual clinical, cost, and health-related quality-of-life data from the Cholesterol and Recurrent Events (CARE) trial. Survival and recurrent coronary heart disease events were modeled from trial data in Markov models, with the use of different assumptions regarding the long-term benefit of therapy. RESULTS: Pravastatin therapy increased quality-adjusted life expectancy at an incremental cost of $16,000 to $32,000 per quality-adjusted life-year gained. In subgroup analyses, the cost-effectiveness of pravastatin therapy was more favorable for patients >60 years of age and for patients with pretreatment low-density lipoprotein cholesterol levels >125 mg/dL. Results were sensitive to the cost of pravastatin and to assumptions about long-term survival benefits from pravastatin therapy. CONCLUSIONS: The cost-effectiveness of pravastatin therapy in survivors of myocardial infarction with average cholesterol levels compares favorably with other interventions.

Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

PURPOSE: Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. SUBJECTS AND METHODS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support. We estimated life expectancy based on long-term follow-up of SUPPORT patients. Utilities were estimated using time-tradeoff questions. Costs (in 1998 dollars) were based on hospital fiscal data and Medicare data. RESULTS: Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 dependence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator support was withheld, the median survival was 3 days. Among patients whose estimated probability of surviving at least 2 months from the time of ventilator support ("prognostic estimate") was 70% or more, the incremental cost per quality-adjusted life-year (QALY) saved by providing rather than withholding ventilator support and aggressive care was $29,000. For medium-risk patients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate < or =50%), it was $110,000 per QALY. When assumptions were varied from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76, 000 for medium-risk patients, and from $67,000 to $200,000 for high-risk patients. CONCLUSIONS: Ventilator support and intensive care for acute respiratory failure due to pneumonia or acute respiratory distress syndrome are relatively cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival < or =50%, the cost per QALY is more than threefold greater at >$100,000.

Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. SISVistA Investigators. Scrutiny of ICU Severity Veterans Health Sysyems Technology Architecture.

OBJECTIVE: To evaluate the feasibility of an automated intensive care unit (ICU) risk adjustment tool (acronym: SISVistA) developed by selecting a subset of predictor variables from the Acute Physiology and Chronic Health Evaluation (APACHE) III available in the existing computerized database of the Department of Veterans Affairs (VA) healthcare system and modifying the APACHE diagnostic and comorbidity approach. DESIGN: Retrospective cohort study. SETTING: Six ICUs in three Ohio Veterans Affairs hospitals. PATIENT SELECTION: The first ICU admission of all patients from February 1996 through July 1997. OUTCOME MEASURE: Mortality at hospital discharge. METHODS: The predictor variables, including age, comorbidity, diagnosis, admission source (direct or transfer), and laboratory results (from the +/- 24-hr period surrounding admission), were extracted from computerized VA databases, and APACHE III weights were applied using customized software. The weights of all laboratory variables were added and treated as a single variable in the model. A logistic regression model was fitted to predict the outcome and the model was validated using a boot-strapping technique (1,000 repetitions). MAIN RESULTS: The analysis included all 4,651 eligible cases (442 deaths). The cohort was predominantly male (97.5%) and elderly (63.6 +/- 12.0 yrs). In multivariate analysis, significant predictors of hospital mortality included age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.04-1.09), comorbidity (OR, 1.11; 95% CI, 1.08-1.15), total laboratory score (OR, 1.07; 95% CI, 1.06-1.08), direct ICU admission (OR, 0.39; 95% CI, 0.31-0.49), and several broad ICU diagnostic categories. The SISVistA model had excellent discrimination and calibration (C statistic = 0.86, goodness-of-fit statistics; p > .20). The area under the receiver operating characteristic curve of the validated model was 0.86. CONCLUSIONS: Using common data elements often found in hospital computer systems, SISVistA predicts hospital mortality among patients in Ohio VA ICUs. This preliminary study supports the development of an automated ICU risk prediction system on a more diverse population.

Predicting functional status outcomes in hospitalized patients aged 80 years and older.

OBJECTIVE: To develop a model estimating the probability of a patient aged 80 years or older having functional limitations 2 months and 12 months after being hospitalized. DESIGN: A prospective cohort study. SETTING: Four teaching hospitals in the US. PARTICIPANTS: Enrolled patients were nonelective hospital admissions aged 80 years or older who stayed in hospital at least 48 hours. The 804 patients who survived and completed an interview at 2 months and the 450 who completed an interview at 12 months were from the 1266 patients in the Hospitalized Elderly Longitudinal Project (HELP) (76% and 47% of survivors, respectively). Median age of the 2-month survivors was 84.7 years. MEASUREMENTS AND MAIN OUTCOMES: Patient function 2 and 12 months after enrollment was defined by the number of dependencies in Activities of Daily Living (ADLs). Ordinal logistic regression models were constructed to predict functional status. Predictors included demographic characteristics, disease category, geriatric conditions, severity of physiologic imbalance, current quality of life, and exercise capacity and ADLs 2 weeks before study admission. RESULTS: Before admission, 39% of patients were functionally independent in ADLs. Of patients who survived and were interviewed at 2 months, 32% were functionally independent, and at 12 months, 36% were independent. Among patients with no baseline dependencies, 42% had developed one or more limitations 2 months later, and 41 % had limitations 12 months later. The patient's ability to perform activities of daily living at baseline was the most important predictor of functional status at both 2 and 12 months. In a multivariable predictive model, independent predictors of poorer functional status at 2 months included: worse baseline functional status and quality of life; depth of coma, if any; lower serum albumin level; presence of dementia, depression, or incontinence; being bedridden; medical record documentation of need for nursing home; and older age. Model performance, assessed using Somers' D, was 0.61 for 2 months and 0.57 for 12 months (Receiver Operating Characteristic (ROC) area = 0.81 and .79, respectively.) Bootstrap validation of the month 2 model also yielded a Somers' D = 0.60. The models were well calibrated over the entire risk range. The ROC area for prediction of the loss of independence was 0.76 for 2 months and 0.68 for 12 months. CONCLUSIONS: Many older patients are functionally impaired at the time of hospitalization, and many develop new functional limitations. A limited amount of readily available clinical information can yield satisfactory predictions of functional status 2 months after hospitalization. Models like this may prove to be useful in clinical care. This work illuminates a potential method for risk adjustment in research studies and for monitoring quality of care.

Ineffectiveness of the SUPPORT intervention: review of explanations.

BACKGROUND: The aim of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments -- SUPPORT -- was to improve the care of seriously ill patients by improving decision-making for patients with life-threatening illnesses. Several theories have been proposed to explain why the SUPPORT intervention was unsuccessful at improving outcomes. OBJECTIVE: To review and discuss explanations offered by others regarding why the SUPPORT intervention failed to have a discernible impact on its prespecified outcome measures. DESIGN: A descriptive review of published articles and book chapters, with synthesis of data-based and conceptual insights. METHODS: The Medline, Bioethicsline, and Ethx databases were searched for citations to SUPPORT articles between 1994 and the end of 1998. This search was supplemented by other published materials that had come to the authors' attention. RESULTS: The critiques and explanations regarding the reasons the SUPPORT intervention did not improve outcomes were catalogued and organized into 11 major categories, the first 10 of which are explored in the present study: (1) the inception cohort was biased against an effect of the intervention, (2) the intervention was not implemented as designed, (3) the intervention failed because nurses were too readily ignored, (4) the intervention was too polite, (5) the intervention presented information ineffectively, (6) the intervention did not focus on primary care physicians, (7) the intervention falsely dichotomized do not resuscitate (DNR) decisions, (8) the intervention needed more years on site or an earlier start with each patient, (9) the intervention required more appropriate outcome measures, (10) the intervention was irrelevant because usual care is not seriously flawed, (11) the conceptual model behind SUPPORT was fundamentally flawed in aiming to improve individual, patient-level decision-making as the way to improve seriously ill, hospitalized patients' experiences. CONCLUSIONS: Although some of the critiques were found to raise important concerns, we conclude in each case that the explanation offered is inadequate to explain the failure of the intervention. We urge further reflection on the fundamental assumptions that informed the design of that intervention and refer the reader to a more comprehensive treatment of that issue in the companion paper in this volume.

Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment.

BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects. OBJECTIVE: To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective. DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change. RESULTS: Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform. CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.

The cost-effectiveness of elective Cesarean delivery for HIV-infected women with detectable HIV RNA during pregnancy.

OBJECTIVES: To determine the net health consequences, costs, and cost-effectiveness of alternative delivery strategies for HIV-infected pregnant women with detectable HIV RNA in the USA. DESIGN: Cost-effectiveness analysis using a probabilistic decision model. METHODS: The model compared two strategies: elective Cesarean section and vaginal delivery. Data for HIV transmission rate, maternal death rate, health-related quality of life and costs were obtained from the literature, national databases, and a tertiary hospital's cost accounting system. Model outcomes included total lifetime costs, quality-adjusted life expectancy, maternal death rate, HIV transmission rate, and incremental cost-effectiveness ratios. RESULTS: Elective Cesarean section resulted in a vertical HIV transmission rate of 34.9 per 1000 births compared with 62.3 per 1000 births for vaginal delivery. Elective Cesarean section was more effective (38.7 quality adjusted life years per mother and child pair) and less costly ($10600 per delivery) than trial of labor (38.2 combined quality adjusted life years at a cost of $14500 per delivery). However, elective Cesarean section increased maternal mortality by 2.4 deaths per 100000 deliveries. The results were consistent over a wide range of the variables, but were sensitive to the risk of HIV transmission with vaginal delivery and the relative risk of HIV transmission with elective Cesarean section. CONCLUSIONS: In pregnant HIV-infected women with detectable HIV RNA, elective Cesarean section would reduce total costs and increase overall quality-adjusted life expectancy for the mother-child pair, albeit at a slight loss of quality adjusted life expectancy to the mother.

Health values of patients with bipolar disorder.

BACKGROUND: Despite a growing number of studies of patients' health values (utilities), little is known about health values of patients with mental illness, particularly bipolar (manic-depressive) disorder. METHODS: We administered a computerized rating scale, time tradeoff, and standard gamble to 53 patients. Patients were asked to rate or value their current state of health overall and then their current mental health. In addition, we administered the SF-36; Inventory of Depressive Symptoms (IDS-C); Positive and Negative Syndrome Scale (PANSS); Young Mania Rating Scale (YMRS); and Global Assessment of Functioning Scale. RESULTS: The patients' median (25th, 75th percentile) age was 43 (37, 50); 62% were female. Mean (+/- SD) health ratings for current overall health were 68.0 (+/- 20.3) vs. 61.0 (+/- 25.7) for current mental health (p-value for difference = 0.02). On the time tradeoff, scores for current overall health averaged 0.71 (+/- 0.37) vs. 0.61 (+/- 0.39) for current mental health (p = 0.02); on the standard gamble, mean scores were 0.77 (+/- 0.32) for current overall health vs. 0.70 (+/- 0.35) for current mental health (p = 0.11). In univariate analyses, rating scale, time-tradeoff, and standard gamble scores for both current overall health and for current mental health were correlated with the SF-36 and all psychiatric scale (magnitude of r = 0.22-0.76) except the YMRS (magnitude of r < or = 0.13). In multivariable analyses, health values for current overall health were related to factors different from those that were related to health values for current mental health (R2 = 0.38-0.65), and none of the health value measures was related to the YMRS. CONCLUSION: Health values of patients with bipolar disorder are higher for their current health overall than for their current state of mental health. Health values are related to certain health status attributes and to level of depression but perhaps not to level of mania.

Expert panel vs decision-analysis recommendations for postdischarge coronary angiography after myocardial infarction.

CONTEXT: Expert panels and decision-analytic techniques are increasingly used to determine the appropriateness of medical interventions, but these 2 approaches use different methods to process evidence. OBJECTIVE: To compare expert panel appropriateness ratings of coronary angiography after myocardial infarction (from the time of hospital discharge to 12 weeks after infarction) with the health gains and cost-effectiveness predicted by a decision-analytic model. DESIGN: Comparison of the degree of importance of the clinical variables considered in expert panel appropriateness ratings vs a previously published decision-analytic model. Identification of 36 clinical scenarios from the expert panel that could be simulated by the decision-analytic model. MAIN OUTCOME MEASURES: Appropriateness score and appropriateness classification (expert panel) vs gain in quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (decision-analytic model). RESULTS: The most important clinical variables were similar in the 2 approaches, with the exercise tolerance test result exerting the greatest leverage on strength of recommendation for angiography. Among the expert panel clinical scenarios considered to be appropriate for coronary angiography that could be simulated in the decision-analysis model, the median (interquartile range) health gain and incremental cost-effectiveness ratio were 0.59 (0.41-0.76) QALYs and $27000 ($23000-$35000) per QALY gained, respectively. Among the clinical scenarios that expert panels considered inappropriate, the corresponding medians (interquartile ranges) were 0.24 (0.19-0.34) QALYs and $54000 ($36000-$58000) per QALY gained. The Spearman rank correlation between appropriateness score and QALY gain was 0.58 (P<.001) and between appropriateness score and estimated incremental cost-effectiveness ratios was -0.66 (P<.001). CONCLUSIONS: For the 36 expert panel scenarios that could be simulated by the decision-analytic model, there was moderate to good agreement between the appropriateness score and both the health gain and the incremental cost-effectiveness ratio of coronary angiography compared with no angiography in the convalescent phase of acute myocardial infarction, but several scenarios judged as inappropriate by the expert panel approach had cost-effectiveness ratios comparable with many generally recommended medical interventions. Formal synthesis of expert judgment and decision modeling is warranted in future efforts at guideline development.

Use of chart reminders for physicians to promote discussion of advance directives in patients with AIDS.

To determine if use of a physician chart reminder improves the rate of physician-initiated discussion and subsequent completion of advance directives (ADs) in patients with AIDS, a controlled study was conducted with 74 patients with AIDS and ten physicians providing primary care at a university-based hospital clinic. Chart reminders were placed on medical records of intervention patients at each primary care clinic visit for six months. Twelve out of 39 (31%) reminder group patients, but only three out of 35 (9%, p = 0.02) control patients underwent AD discussion with physicians. Further, more subjects in the reminder group completed ADs (28% versus 9%, p = 0.03). Controlling for demographic and clinical factors, only assignment to reminder group was associated with discussion and completion of ADs. Physician-level analysis showed that the effect was physician-dependent. Physician chart reminders are an effective tool for promoting discussion and completion of ADs in patients with AIDS although the effect is physician-dependent.

The will to live among HIV-infected patients.

BACKGROUND: Patients infected with HIV value both longevity and health. OBJECTIVE: To understand how HIV-infected patients value their health. DESIGN: Interview study. SETTING: Regional treatment center for HIV. PATIENTS: 51 patients with HIV infection. MEASUREMENTS: Life-satisfaction, health rating, time-tradeoff, and standard-gamble scores. RESULTS: Of the 51 patients, 49% (95% CI, 35% to 63%) said that their life was better currently than it was before they contracted HIV infection; only 29% said that life was currently worse. The mean (+/- SD) time-tradeoff score was 0.95 +/- 0.10, indicating that, on average, patients would give up no more than 5% of their remaining life expectancy in their current state of health in exchange for a shorter but healthy life. The average health rating score was 71.0 +/- 18.7 on a scale of 0 to 100, and the average standard-gamble score was 0.80 +/- 0.27. Factors contributing to life satisfaction and time-tradeoff scores included spirituality and having children. CONCLUSION: Many patients with HIV have a strong will to live, and many feel that life with HIV is better than it was before they became infected.

Management of sore throats in children: a cost-effectiveness analysis.

OBJECTIVE: To perform a cost-effectiveness analysis of treatment management strategies for children older than 3 years who present with signs or symptoms of pharyngitis. DESIGN: Decision model with 7 strategies, including neither testing for streptococcus nor treating with antibiotics; treating empirically with penicillin V; basing treatment on results of a throat culture (Culture); and basing treatment on results of enzyme immunoassay or optical immunoassay rapid tests, performed alone or in combination with throat cultures. In these 7 strategies, all tests are performed in a local reference laboratory. In a sensitivity analysis, we examined the cost-effectiveness of 4 strategies involving office-based testing. We obtained data on event probabilities and test characteristics from our hospital's clinical laboratory and the literature; costs for the analysis were based on resource use. RESULTS: At a baseline prevalence of 20.8% for streptococcal pharyngitis, the Culture strategy was the least expensive and most effective, with an average cost of $6.85 per patient. The outcome was sensitive to the prevalence of streptococcal pharyngitis, the rheumatic fever attack rate, the cost of the enzyme immunoassay test, and the cost of culturing and reporting culture results. The Culture strategy was also preferred if amoxicillin was substituted for oral penicillin. For office-based testing, Culture was the least costly strategy, but treatment based on results of the optical immunoassay test alone had an incremental cost-effectiveness ratio of $1.6 million per additional life saved. CONCLUSION: In a setting with adherent patients, children with sore throats should generally get throat cultures in lieu of rapid streptococcus antigen tests.

Rewarding teaching faculty with a reimbursement plan.

OBJECTIVE: To develop a system for measuring the teaching effort of medical school faculty and to implement a payment system that is based on it. DESIGN: An interventional study with outcomes measured before and after the intervention. SETTING: A department of internal medicine with a university hospital and an affiliated Veterans Administration hospital. INTERVENTION: We assigned a value in teaching units to each teaching activity in proportion to the time expended by the faculty and the intensity of their effort. We then calculated total teaching units for each faculty member in the Division of General Internal Medicine and for combined faculty effort in each subspecialty division in the Department of Medicine. After determining the dollar value for a teaching unit, we distributed discretionary teaching dollars to each faculty member in the Division of General Internal Medicine and to each subspecialty division according to total teaching units. MEASUREMENTS AND MAIN RESULTS: The distribution of discretionary teaching dollars was determined. In the year after the intervention, there was a substantial redistribution of discretionary teaching dollars among divisions. Compared with an increase in total discretionary dollars of 11.4%, the change in allocation for individual divisions ranged from an increase of 78.2% to a decrease of -28.5%. Further changes in the second year after the intervention were modest. The distribution of teaching units among divisions was similar to the distribution of questions across subspecialties on the American College of Physicians In-Training Examination (r =.67) and the American Board of Internal Medicine Certifying Examination (r =.88). CONCLUSIONS: It is possible to measure the value of teaching effort by medical school faculty and to distribute discretionary teaching funds among divisions according to the value of teaching effort. When this intervention was used at our institution, there were substantial changes in the amounts received by some divisions. We believe that the new distribution more closely approximates the desired distribution because it reflects the desired emphasis on knowledge as measured by two of the most experienced professional groups in internal medicine. We also believe that our method is flexible and adaptable to the needs of most clinical teaching