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Introduction: Medical education topics might be locally prioritized using public health data on health outcomes and risk factors unrelated to quality of care. Methods: The Missouri Information for Community Assessment (MICA) supplied preventable hospitalization rates (PHRs) for asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart failure, and hypertension in 114 counties from 1998 to 2002. For each disease, a linear regression model predicted PHR from behavior, access, and disease prevalence data from MICA and other public data sources. For each disease in each county, the residual, unexplained PHR should include effects of local medical practices. Variation in relative priority of diseases between counties was estimated from raw PHR and unexplained PHR. Results: The raw values of the five PHRs varied geographically in different patterns. Regression models explained between 46% and 83% of the variability. The medical education priorities implied by unexplained PHR values differ from priorities inferred from unadjusted PHR or disease prevalence. Discussion: Patient behavior and poor health care access contribute to PHR but do not fully explain variation in PHR. If county-level unexplained PHR values identify high priority medical education topics, then other measures of importance, notably disease prevalence and PHR, are poor identifiers of high value topics. Although available predictor and outcome variables constrain the current analysis, unexplained variation in health outcome measures might identify educational opportunities. These observations suggest strategies for balancing and evaluating controlled trials of knowledge dissemination efforts and eventually for deploying educational activities. (Contains 2 tables and 1 figure.)

Abstract Background Tort law has legitimate social purposes of deterrence, punishment and compensation, but medical tort law does none of these well. Tort law could be counterproductive in medicine, encouraging costly defensive practices that harm some patients, restricting access to care in some settings and discouraging innovation. Discussion Patients might be better served by purchasing combined health and life insurance policies and waiving their right to pursue malpractice claims. The combined policy should encourage the insurer to profit by inexpensively delaying policyholders' deaths. A health and life insurer would attempt to minimize mortal risks to policyholders from any cause, including medical mistakes and could therefore pursue systematic quality improvement efforts. If policyholders trust the insurer to seek, develop and reward genuinely effective care; identify, deter and remediate poor care; and compensate survivors through the no-fault process of paying life insurance benefits, then tort law is largely redundant and the right to sue may be waived. If expensive defensive medicine can be avoided, that savings alone could pay for fairly large life insurance policies. Summary Insurers are maligned largely because of their logical response to incentives that are misaligned with the interests of patients and physicians in the United States. Patient, provider and insurer incentives could be realigned by combining health and life insurance, allowing the insurer to use its considerable information access and analytic power to improve patient care. This arrangement would address the social goals of malpractice torts, so that policyholders could rationally waive their right to sue.

Abstract Background Cigarette smoking takes a staggering toll on human health and attracts considerable public health attention, yet real solutions seem distant. The 2004 Family Smoking Prevention and Tobacco Control Act (US Senate bill S2461) would have given the US Food and Drug Administration limited authority to regulate cigarettes to "protect the public health." However, such legislation is unlikely to substantially reduce smoking or related deaths. Discussion The past 500 years of tobacco control efforts demonstrate that nicotine prohibition is a practical impossibility for numerous reasons, state revenue being one of the most ominous. The FDA already has regulatory authority over pharmaceutical grade nicotine products, and requires pharmacists to dispense the most addictive of these only with prescriptions. Meanwhile, every corner store can sell far more addictive and dangerous cigarettes to any adult. The FDA could immediately increase competition between cigarettes and clean nicotine products by approving available nicotine products for over-the-counter sales to adults. Similarly permissive regulation of cigarettes and addictive nicotine products will reduce tobacco use and improve smokers' health, but increase nicotine use in the population. Fortunately, restricted youth access and accurate labeling of nicotine's absolute risks will dissuade many non-smokers from experimenting with it, while accurate depiction of its risks relative to cigarette smoking will encourage many smokers to switch. The FDA could take a series of small steps that might ultimately replace a large proportion of cigarette smoking with equally addictive nicotine products, without risking serious public health setbacks. Vaccine, methadone, and injury prevention policies establish relevant public health precedents. Summary Cigarettes, or an equally addictive alternative, will be a permanent and common product in most societies. Regulations restricting only the safest addictive nicotine products are hard to justify. Addictive nicotine compliments other tobacco control strategies. Modern tobacco control policies are applicable to addictive nicotine. Controlled trials and test market studies are urgently needed to evaluate addictive nicotine as an alternative to smoking. Meanwhile, legislators should preserve the Food and Drug Administration's option to permit non-prescription sales of addictive nicotine.

Background: Telephone quitlines can help employees quit smoking. Quitlines typically use directive coaching, but nondirective, flexible coaching is an alternative. Call-2-Quit used a worksite-sponsored quitline to compare directive and nondirective coaching modes, and evaluated employee race and income as potential moderators.Methods: An unblinded randomized controlled trial compared directive and nondirective telephone coaching by trained laypersons. Participants were smoking employees and spouses recruited through workplace smoking cessation campaigns in a hospital system and affiliated medical school. Coaches were four non-medical women trained to use both coaching modes. Participants were randomized by family to coaching mode. Participants received up to 7 calls from coaches who used computer assisted telephone interview software to track topics and time. Outcomes were reported smoking abstinence for 7 days at last contact, 6 or 12 months after coaching began. Both worksites implemented new tobacco control policies during the study.Results: Most participants responded to an insurance incentive introduced at the hospital. Call-2-Quit coached 518 participants: 22 % were African-American; 45 % had incomes below $30,000. Income, race, and intervention did not affect coaching completion rates. Cessation rates were comparable with directive and nondirective coaching (26 % versus 30 % quit, NS). A full factorial logistic regression model identified above median income (odds ratio = 1.8, p = 0.02), especially among African Americans (p = 0.04), and recent quit attempts (OR = 1.6, p = 0.03) as predictors of cessation. Nondirective coaching was associated with high cessation rates among subgroups of smokers reporting income above the median, recent quit attempts, or use of alternative therapies. Waiting up to 4 weeks to start coaching did not affect cessation. Of 41 highly addicted or depressed smokers who had never quit more than 30 days, none quit.Conclusion: Nondirective coaching improved cessation rates for selected smoking employees, but less expensive directive coaching helped most smokers equally well, regardless of enrollment incentives and delays in receiving coaching. Some subgroups had very low cessation rates with either mode of quitline support.Trial Registration: ClinicalTrials.gov NCT02730260 , Registered March 31, 2016. [ABSTRACT FROM AUTHOR]

Objectives: To examine beliefs, prior use, and interest in using pharmacother­apy among people living with HIV/AIDS (PLWHA). Methods: Cross-sectional survey of smokers in a midwestern HIV clinic. Results: The sample (N = 146) included 69% men, 82% African Americans, 45% were in precontemplation for quitting, and 46% were interested in using pharmacotherapy. Primary reasons for non-use included cost and a belief that they would be able to quit on their own. Physician assistance was the strongest correlate of prior use. Perceived benefits and self-efficacy were the strongest correlates of willingness to use pharmaco­therapy. Conclusions: Future interventions should address misconceptions, perceived benefits, and self-efficacy for using cessation aids. Physicians should offer pharmacotherapy to all smokers. [ABSTRACT FROM AUTHOR]

Background. Health outcome utility assessments generally assume procedural invariance. Preference reversals violating procedural invariance occur in economic scenarios when the assessment process shifts from a choiceto a fill-in-the-blanktask. Purpose. To determine if similar reversals occur in utility assessments. Methods. One hundred thirty-six volunteer subjects completed 6 preference assessments of 4 personal health scenarios. Patients responded to otherwise identical tasks using either choice or fill-in-the-blank processes in a randomized crossover design. The authors determined the percentage of subjects preferring, or inferred to prefer, a given choice. Results. Preference reversals occurred in all assessment scenarios. Conclusions. These preference reversals are a potential source of confusion for utility assessment and informed consent. They could be manipulated to achieve ends other than the best interest of patients. Anchoring or the prominence hypothesis may explain these findings. [ABSTRACT FROM PUBLISHER]

Objective. The objective of this study was to determine rheumatoid arthritis (RA) patients’ preferences for validated health state scenarios depicting glucocorticoid adverse events, predictors of these preferences, and psychometric properties of different preference techniques in this population. Methods. Preferences were elicited by rating scale and time trade-off methods. Time trade-offs included trading current health for either time spent alive in an adverse health state for chronic conditions (time trade-off) or time spent in a sleeplike state for acute conditions (sleep trade-off). Results. A total of 107 subjects with long-standing RA participated in the preference interviews. Mean preference values (rating scale/trade-off) were lowest for serious fracture adverse events, including hip fracture requiring a nursing home stay (0.55 ± 0.22/0.76 ± 0.36) and vertebral fracture with chronic pain (0.59 ± 0.23/0.67 ± 0.35), and highest for cataracts (0.84 ± 0.17/0.96 ± 0.09) and wrist fracture (0.82 ± 0.18/0.81 ± 0.29). Rating scales had a stronger correlation (r= 0.88) with physician ranking of scenarios than trade-off methods (r = 0.31). All methods were feasible and demonstrated good reliability, while rating scale method showed better construct validity than trade-off techniques. Conclusion. Relative to their current health, RA patients assigned low preference values to many glucocorticoid adverse events, particularly those associated with chronic fracture outcomes. Results varied with the preference measure used, indicating that methodological attributes of preference determinations must be considered in clinical decision making. [ABSTRACT FROM PUBLISHER]

Context. Time preference (how preference for an outcome changes depending on when the outcome occurs) affects clinical decisions, but little is known about determinants of time preferences in clinical settings. Objectives. To determine whether information about mean population time preferences for specific health states can be easily assessed, whether mean time preferences are constant across different diseases, and whether under certain circumstances substantial fractions of the patient population make choices that are consistent with a negative time preference. Design. Self-administered survey. Setting. Family physician waiting rooms in four states. Patients. A convenience sample of 169 adults. Intervention. Subjects were presented five clinical vignettes. For each vignette the subject chose between interventions maximizing a present and a future health outcome. The options for individual vignettes varied among the patients so that a distribution of responses was obtained across the population of patients. Main outcome measure. Logistic regression was used to estimate the mean preference for each vignette, which was translated into an implicit discount rate for this group of patients. Results. There were marked differences in time preferences for future health outcomes based on the five vignettes, ranging from a negative to a high positive (116%) discount rate. Conclusions. The study provides empirical evidence that time preferences for future health outcomes may vary substantially among disease conditions. This is likely because the vignettes evoked different rationales for time preferences. Time preference is a critical element in patient decision making and cost-effectiveness research, and more work is necessary to improve our understanding of patient preferences for future health outcomes. Key words: time factors ; models, psychological; attitude to health; outcome assessment (health care). (Med Decis Making 2000;20:263-270) [ABSTRACT FROM PUBLISHER]

: PurposeTo determine utilities (patient preferences) for dry eye disease.: DesignSurvey study.: ParticipantsFifty-six patients with mild, moderate, or severe dry eye treated by ophthalmologists in the Eye Care Services department of Henry Ford Health Care System.: TestingPatients completed interactive software utility assessment questionnaires by the time trade-off (TTO) method. Utility scores were scaled such that a score of 1.0 = perfect health and 0 = death. Dry eye severity was independently classified using clinical parameters and physician/patient assessments. Global health status, visual functioning, and ocular symptoms were assessed by the Short Form-36 Health Survey, 25-Item National Eye Institute Visual Function Questionnaire (NEI VFQ-25), and Ocular Surface Disease Index survey instruments.: Main outcome measuresUtility scores for a range of dry eye severity states. These utilities were compared with utilities reported for other disease states. Correlations with the general and vision-related health status measures were conducted.: ResultsFifty-six patients completed the utility assessments with acceptable reliability. Mean utilities for moderate (0.78) and severe dry eye (0.72) by TTO were similar to historical reports for moderate (0.75) and more severe (class III/IV) angina (0.71), respectively. Utility scores correlated with the NEI VFQ-25 composite score (ρ = 0.32; P = 0.037) and with components of other health measures.: ConclusionsUtilities for the more severe forms of dry eye are in the range of conditions like class III/IV angina (0.71) that are widely recognized as lowering health utilities. Our results underscore how significantly dry eye impacts patients compared with other medical conditions. [Copyright &y& Elsevier]