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Background: Herpes zoster (HZ), or shingles, is caused by reactivation of latent varicella-zoster virus after a primary infection with either wild-type or vaccine-type varicella-zoster virus, the latter having been introduced in 1995 for children. Since then, few population-based data about the incidence of childhood HZ are available., Methods: We identified children aged < or = 12 years who were vaccinated with 1 dose of varicella vaccine between 2002 and 2008 in a prepaid health plan and followed them through their electronic health records for a diagnosis of HZ. The medical records of these children were reviewed. Persistent and chronic conditions for these children before HZ were identified., Results: There were 172,163 children vaccinated, with overall follow-up of 446,027 person-years (Incidence rate = 27.4 per 100,000 person-years, 95% confidence interval: 22.7-32.7). Children vaccinated after age 5 years had a higher but not statistically significant different rate than children vaccinated between 12 and 18 months (34.3 vs. 28.5 per 100,000 person-years). Among children vaccinated between 12 and 18 months, incidence rates gradually increased each year in the first 4 years after vaccination (P < 0.001). Among the HZ cases, there were 1 (0.7%) case of lymphoid leukemia, 1 (0.7%) case of drug abuse, 16 (11.1%) cases of asthma with 3 or more acute exacerbations, 12 (8.3%) cases of developmental disorders, and 3 (2.1%) cases of psychological or mental disorders., Conclusions: These data demonstrate that diagnosed HZ is rare among children following varicella vaccine. Despite the small numbers, the roles of delayed vaccination, severe asthma, and development disorders warrant further investigation. In the future, analyses of HZ isolates will be needed to identify the virus strains causing reactivation.

A number of different groups exist within those ages sixty-five and up. They have varying dental needs and resources with which to treat those needs. This program is targeted at those individuals who are moving toward age sixty-five, currently have dental insurance through their employer, and desire to prepay their dental insurance premiums for the remainder of their lives while preserving any unused portion of their prepaid amount for their heirs. It does so by creating a "dental annuity" instrument with minimal administrative burden.

Background: Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies., Objective: The objective of this study was to learn if variations exist in the treatment of nonmelanoma skin cancer in different practice settings., Research Design: Prospective cohort study., Subjects: Subjects consisted of consecutive patients with nonmelanoma skin cancer at a university-affiliated private dermatology practice and the dermatology clinic at the nearby affiliated Veterans Affairs (VA) medical center., Data: We studied data from medical records and patient surveys., Results: Overall, 1777 nonrecurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller and less likely to be on visible areas of the body. Treatments varied between the 2 sites (P <0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in multivariable models controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (odds ratio, 2.39; 95% confidence interval, 1.54-3.70)., Conclusions: Care for nonmelanoma skin cancer varied at 2 academic practice sites that are near each other and that share some clinician staff. These findings raise questions not only about overuse or underuse of procedures at the 2 sites, but also about systematic differences in patient preferences and/or physician incentives in prepaid and fee-for-service settings.

Objective: To better inform study design decisions when sampling patients within health plans and physician practices with multiple analysis goals., Study Setting: Chronic eye care patients within six health plans across the United States., Study Design: We developed a simulation-based approach for designing multistage samples. We created a range of candidate designs, evaluated them with respect to multiple sampling goals, investigated their tradeoffs, and identified the design that is the best compromise among all goals. This approach recognizes that most data collection efforts have multiple competing goals., Data Collection: We constructed a sample frame from all diabetic patients in six health plans with evidence of chronic eye disease (glaucoma and retinopathy)., Principal Findings: Simulations of different study designs can uncover efficiency gains as well as inform potential tradeoffs among study goals. Simulations enable us to quantify these efficiency gains and to draw tradeoff curves., Conclusions: When designing a complex multistage sample it is desirable to explore the tradeoffs between competing sampling goals via simulation. Simulations enable us to investigate a larger number of candidate designs and are therefore likely to identify more efficient designs.

The Balanced Budget Act of 1997 introduced the Medicare+Choice program, which expanded the types of organizations that could assume Medicare prepaid capitated risk. Among the many new options, the provider-sponsored organization (PSO) received the most attention, although there have been few PSO applications filed. Organizations considering the PSO opportunity can gauge their readiness by evaluating the ease with which they can adopt key aspects of successful HMOs.

Background and Design: Data from the 1985 and 1992 National Ambulatory Medical Care Survey and the 1992 National Health Interview Study were used to determine changes in total visit rates for patients with common skin disease and the proportion of all visits to dermatologists that were provided as part of managed care plans. The setting was a sample of office-based practitioners across the United States. The patients were from a sample of 106,200 office visits in 1985 and 1992 and 128,412 persons who provided data for a population-based interview study. The main outcome measure were number of visits per year and percentage increase from 1985 to 1992 by reason for visit, specialty of physician consulted, and type of insurance expected to pay for the visit and the percentage of persons with specific demographic characteristics who have managed care coverage. The changing source of payment for all office visits and visits for skins diseases as a result of managed care is assessed., Results: From 1985 to 1992, the percentage of office visits with managed care coverage more than doubled. The proportion of managed care patients with skin complaints cared for by dermatologists declined. The age-adjusted rates of visits for adults with managed care insurance to dermatologists are less than one third the rate for other adults without prepaid care., Conclusion: Managed care is rapidly growing as the source of payment for the office-based care of skin complaints. The role of dermatologists in providing this care is diminishing.

Objective: Although depression is one of the most common problems of medical and psychiatric outpatients, it has not been clear whether the extent of medical comorbidity among depressed patients varies across major types of clinical settings in which depressed patients receive care--especially by type of treating clinician (general medical versus mental health specialty) or type of payment for services (prepaid versus fee-for-service)., Methods: The authors examined these issues using data on 1,152 adult outpatients with current depressive symptoms and a lifetime history of unipolar depressive disorder who received care in one of three health care delivery systems in three U.S. sites., Results: Depressed patients had a similarly high prevalence (64.9%-71.0%) of any of eight common chronic medical conditions whether they were seen in the general medical or specialty mental health sector; however, those visiting medical clinicians had a significantly higher prevalence of the two most common chronic medical conditions, hypertension and arthritis. Among depressed patients with hypertension, those visiting the general medical sector were more likely to be taking antihypertensive medication than were those visiting the mental health specialty sector. Type of payment (prepaid versus fee-for-service) was unrelated to either prevalence or severity of comorbid medical conditions, suggesting that the typical depressed patient in all types of practices studied had medical comorbidity., Conclusions: These data suggest that clinicians in all health care settings must be prepared to encounter chronic medical conditions and complaints in the depressed patients who visit them.