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For more than a decade, reports have indicated that the supply of child neurologists is inadequate to provide care for the growing number of children with acquired and genetic neurological conditions. It is critical to understand how the shortages affect the practice of child neurology, the attitudes of child neurologists, and ability of the field to attract new members. This Issue Brief examines these workforce issues, and profiles the attitudes and practice characteristics of child neurologists and trainees.

Background This study examines the risk of development of significant depressive symptoms after a new diagnosis of cancer, diabetes, hypertension, heart disease, arthritis, chronic lung disease, or stroke. Methods The study used 5 biennial waves (1992-2000) of the Health and Retirement Study to follow a sample of 8387 adults (aged 51 to 61 years and without significant depressive symptoms in 1992) from 1994 to 2000. Time-dependent Cox regression models estimated adjusted hazard ratios (HRs) for an episode of significant depressive symptoms after a new diagnosis for each of the 7 medical conditions. Results Within 2 years of initial diagnosis, subjects with cancer had the highest hazard of depressive symptoms (HR, 3.55; 95% confidence interval [CI], 2.79-4.52), followed by subjects with chronic lung disease (HR, 2.21; 95% CI, 1.64-2.79) and heart disease (HR, 1.45; 95% CI, 1.09-1.93). The hazard for depressive symptoms for most of these diseases decreased over time; however, subjects with heart disease continued to have a higher risk for depressive symptoms even 2 to 4 years and 4 to 8 years after diagnosis, and a significantly higher hazard for depressive symptoms developed for persons with arthritis 2 to 4 years after diagnosis (HR, 1.46; 95% CI, 1.11-1.92). Conclusion The findings identify several high-risk patient groups who might benefit from depression screening and monitoring to improve health outcomes in this vulnerable population facing new medical illnesses.

Background— Although public release of quality information through report cards is intended to improve health care, there may be unintended consequences of report cards, such as physicians avoiding high-risk patients to improve their ratings. If physicians believe that racial and ethnic minorities are at higher risk for poor outcomes, report cards could worsen existing racial and ethnic disparities in health care. Methods and Results— To investigate the impact of New York’s CABG report card on racial and ethnic disparities in cardiac care, we estimated differences in the use of CABG, PTCA, and cardiac catheterization between white versus black and Hispanic patients hospitalized for acute myocardial infarction in New York before and after New York’s first CABG report card was released, adjusting for patient and hospital characteristics and national changes in racial and ethnic disparities in cardiac care. The racial and ethnic disparity in CABG use significantly increased in New York immediately after New York’s CABG report card was released, whereas disparities did not change significantly in the comparison states. There was no differential change in racial and ethnic disparities between New York and the comparison states in the use of cardiac catheterization or PTCA after the CABG report card was released. Over time, this increase in racial and ethnic disparities decreased to levels similar to those before the release of report cards. Conclusions— The release of CABG report cards in New York was associated with a widening of the disparity in CABG use between white versus black and Hispanic patients.

Managed care health plans currently cover about 90 percent of the people who receive employer-sponsored health insurance. The extent to which managed care plans disproportionately enroll low-risk relative to high-risk individuals has been a major concern from a policy perspective. Managed care plans may either be inherently more attractive to low- than high-risk enrollees or they may be more likely to design their plans to attract low-risk and repel high-risk enrollees. A number of studies have shown that Medicare HMOs attract a disproportionate share of the healthy elderly population (Eggers 1980; Eggers and Prihoda 1982; Brown et al. 1993; Cox and Hogan 1997; Call et al. 1999). Unlike the Medicare risk selection studies that are national in scope, most studies of risk selection in the employer-sponsored health insurance market examine single employers or employer coalitions, and the available evidence is mixed. Cutler and Zeckhauser (1998) found substantial favorable risk selection among state government employees in Massachusetts for the HMO plan relative to the fee-for-service plan. Altman, Cutler, and Zeckhauser (2003), examining the same dataset, find that almost half of the expenditure difference between indemnity and HMO plans for eight medical conditions is due to a lower incidence rate among HMO patients (favorable risk selection), with the remaining difference due to lower provider reimbursement. In contrast, the RAND Health Insurance Experiment did not find that a Seattle HMO experienced a favorable selection of patients (Manning, Newhouse, and Duan 1987), and Polsky and Nicholson (2004) conclude that HMOs in 60 metropolitan areas were not experiencing favorable selection with respect to non-HMOs in 1996 and 1997. Risk selection occurs when a certain type of health plan attracts a disproportionate share of enrollees with relatively low (or high) expected medical costs. Risk selection between managed care and nonmanaged care plans may reflect differences between low- and high-risk individuals in their preferences for a style of health care. In this case, risk selection is not necessarily inefficient. However, if premiums are not risk-adjusted to reflect the expected utilization of enrollees, health plans will have incentives to attract and retain relatively low-risk enrollees. In this case, risk selection may be inefficient with too few people in nonmanaged care plans (Cutler and Zeckhauser 1998). Eighty percent of the non-elderly who had health insurance in 1999 received it from their employer or from a family member's employer.1 In the employer-sponsored market, inefficient risk selection may occur because only 1 percent of U.S. employers adjust the premium payment to a health plan based on an employee's risk, or expected medical expenditures (Keenan et al. 2001).2 As a result, most health insurance companies receive the same revenue for enrolling a young healthy worker as an old sick worker, although the expected medical costs of the two workers could differ substantially. If health insurers design their plans to attract the relatively profitable, low-risk enrollees, an inefficient allocation of individuals to plans may result. A plan that attracts low-risk enrollees can charge a lower premium than a plan attracting high-risk enrollees. As a result, some people who would enroll in a relatively expensive plan (usually a non-HMO) if premiums were risk-adjusted to reflect their unique expected costs, will enroll instead in a less expensive plan (often an HMO) once the premium difference becomes sufficiently large (Cutler and Zeckhauser 1998). Even though few firms formally risk-adjust premium payments to health plans, risk selection may not be creating substantial inefficiencies. An estimated 20 percent of the employer-sponsored market is enrolled in self-insured plans where health insurance companies usually receive a fixed payment per employee to administer the plans and do not bear the financial risk of uncertain medical expenditures (McDonnell and Fronstin 1999; InterStudy 2000). Furthermore, about 50 percent of the people insured in the employer-sponsored market were offered a plan or a choice of plans from a single insurance carrier (Keenan et al. 2001). In these two situations health insurers have no incentive to design plans to attract low-risk employees. Some firms may also be implementing implicit (to the analyst) risk adjustment by setting the employer's contribution for plans experiencing adverse selection higher than the employer's contribution for plans experiencing favorable risk selection. Such behavior would encourage employees to enroll in the plan experiencing unfavorable selection. With the exception of Polsky and Nicholson (2004), all of the studies cited above that examine risk selection of HMOs in the non-elderly, employer-sponsored market are case studies of a single employer or employer coalition in a single market. Since many employers have instituted measures to mitigate incentives for health plans to target low-risk enrollees, the results from the case studies mentioned above may not be representative of national conditions. In this paper we examine whether HMO plans experience favorable risk selection in the employer-sponsored market by applying a “switcher” methodology to the Community Tracking Study Household Survey (CTSHS), a recently released national, panel dataset of enrollees in employer-sponsored health plans. The switcher methodology compares medical expenditures in the initial year for people who chose to switch from a non-HMO (a fee-for-service indemnity plan or a preferred provider organization) to an HMO plan versus the expenditures in the initial year for the people who remained in the non-HMO plan both years (and likewise for people who initially were enrolled in an HMO). By applying this methodology to a household survey rather than an employer-based survey, we are able to include switches that occur when people change employers. Finally, to provide a practical test of whether a simple risk-adjustment system can equate premiums with the associated costs of an enrollee, we further decompose risk selection into a component based on enrollee characteristics that health plans and employers clearly observe (e.g., gender and age) and a component based on enrollee characteristics that are more difficult to observe (e.g., preferences for medical care or health status). This decomposition will help determine whether risk-adjusting individual enrollee premiums based on easily observed characteristics is likely to minimize or eliminate the inefficiency associated with risk selection. We find that HMOs are experiencing favorable selection and that this selection would probably persist even if employers adjusted premiums based on an enrollee's gender and age. People who switched from a non-HMO to an HMO plan used 11 percent fewer medical services in the period prior to switching than people who remained in non-HMO plans, and this relatively low use persists once they enroll in an HMO, relative to those already enrolled in an HMO. We also find that people who switched from an HMO to a non-HMO plan used 18 percent more medical services in the period prior to switching than people who remained in the HMO plan. This relatively high use rate does persist once they enroll in the non-HMO, but the differential is not statistically significant. Ten percent of HMO enrollees switched to a non-HMO between the first and second round of the CTSHS survey, and their departure is predicted to reduce an HMO's aggregate medical expenditures by 2.0 percent per year. Favorable risk selection by HMOs would most likely persist even if employers adjusted health plan payments based on enrollees' gender and age, because the selection appears to occur based on enrollee characteristics that are difficult to observe, such as preferences for medical care and health status.

Self-medication is a common practice in many developing countries but little is known about its determinants. This study analyzes the factors that are associated with the use of self-medication in Mexico using the Mexican Health and Aging Study, a new nationally representative survey on adults aged 50 and over. We find that self-medication is related to socioeconomic status and the lack of access to professional healthcare. Our empirical results suggest that lack of government-sponsored health insurance coverage increases the propensity to self-medicate. A 10% increase in the proportion of adults with health insurance coverage could decrease the use of pharmacy consultations by .8% for public sector workers and by 1.7% for private sector workers. Increasing health insurance coverage could reduce the demand for self-medication by making healthcare more affordable and by changing the population perceptions about the benefits of modern medicine.

The purpose of this study was to measure the effects of social and economic variables, disease-related variables, and child gender on the decisions of parents in Kerala, India, to seek care for their children and on their choice of providers in the allopathic vs. the alternative system. A case-control analysis was done using data from the Kerala section of the 1996 Indian National Family Health Survey, a cross-sectional survey of a probability sample of households conducted by trained interviewers with a close-ended questionnaire. Of the 469 children who were eligible for this study because they had at least one common symptom suggestive of acute respiratory illness or diarrhea during the 2 weeks before the interview, 78 (17%) did not receive medical care, while the remaining 391 (83%) received medical care. Of the 391 children who received medical care, 342 (88%) received allopathic medical care, and 48 (12%) received alternative medical care. In multivariable analyses, parents chose not to seek medical care for their children significantly more often when the illness was mild, the child had a specific diagnosis, the mother had previously made fewer antenatal visits, and the family had a higher economic status. When parents sought medical care for their children, care was sought significantly more often in the alternative provider system when the child was a boy, the family lived in a rural area, and the family had a lower social class. We conclude that, in Kerala, disease severity and economic status predict whether children with acute respiratory infection or diarrhea are taken to medical providers. In contrast, most studies of this issue carried out in other populations have identified economic status as the primary predictor of medical system utilization. Also in Kerala, the gender of the child did not influence whether or not the child was taken for treatment but did influence whether care was sought in the alternative or the allopathic system.

Purpose: To use 5 years of primary data to compare the incremental cost-effectiveness of breast conservation and radiation versus mastectomy with the restriction of choice to a single therapy versus providing a choice of either therapy. Patients and Methods: We evaluated a random retrospective cohort of 2,517 Medicare beneficiaries treated for newly diagnosed stage I or II breast cancer from 1992 through 1994. The outcome measures were quality-adjusted life-years (QALYs) and 5-year medical costs. Risk and propensity score adjustments were used in the analysis. Results: A breast conservation and radiation regimen has significantly higher costs than mastectomy in the first year after surgery; the adjusted 5-year costs are $14,054 (95% confidence interval, $9,791 to $18,312) greater than those of mastectomy. The adjusted incremental cost-effectiveness ratio comparing breast conservation and radiation to mastectomy was $219,594 per QALY for the comparison of the two strategies. If the possibility of patient choice from maintaining the availability of multiple treatments versus restricting choice to mastectomy alone provides a quality-of-life gain of 0.031 QALYs, then the cost-effectiveness ratio of this choice option is $80,440 per QALY. Conclusion: The current system of providing a choice between mastectomy and breast conservation surgery is economically attractive when the economic analysis includes the benefit of patient choice of treatment.

Alcohol treatment services are increasingly combined with other health and social services to address the needs of multiple-problem clients. Hence, it has been of growing policy interest to find the most effective and the most cost-effective ways of linking these services. This symposium presents some recent studies in this area. The small but growing body of studies in this area has great potential to inform public policy debates.

Multiple treatment options exist for many medical conditions. The extent to which physicians should involve the patient in the choice the treatment to be delivered is not well understood.To test the impact of breast cancer treatment choice on patients' health state preferences.A cohort from 29 hospitals (primarily referral centers) in Massachusetts, Texas, Washington DC, and New York. Subjects were surveyed at 5 months, 1 year, and 2 years following surgery and asked whether they had a choice in the type of treatment received.Women age 67 or older treated in 1996 to 1997 for localized breast cancer (n = 683).Patient preferences for current health state, assessed with patient valuations using the visual analogue scale (VAS) from the EuroQol instrument and with general public valuations using the Health Utilities Index (HUI), and 1-year medical costs.For the adjusted analysis at 5 months, the adjusted mean VAS score was 78.7 for women who reported a choice and 75.3 for women who reported no choice, a difference of 3.4 (P = 0.03). The difference in the HUI score was 3.6 (P= 0.10) and the difference in the 1-year medical costs was -4363 dollars (P = 0.01). There were no statistically significant differences at the 1-year and 2-year interviews.A woman's perception of choice of surgical treatment for breast cancer is associated with a short-term benefit on her preference of health state, suggesting choice helps with recovery, but does not provide long-term benefits.

Most studies on the indirect costs of an illness and the cost effectiveness of a medical intervention or employer-sponsored wellness program assume that the value of reducing the number of days employees miss from work due to illness is the wage rate. This paper presents a general model to examine the magnitude and incidence of costs associated with absenteeism under alternative assumptions regarding the size of the firm, the production function, the nature of the firm's product, and the competitiveness of the labor market. We conclude that the cost of lost work time can be substantially higher than the wage when perfect substitutes are not available to replace absent workers and there is team production or a penalty associated with not meeting an output target. In the long run, workers are likely to bear much of the incidence of the costs associated with absenteeism, and therefore be the likely beneficiaries of any reduction in absenteeism.

This study uses a simulated patient approach to assess appointment availability and wait times for new primary care appointments in late 2012/early 2013 by insurance status and state. Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Outreach programs are needed, not only to help patients enroll but also to identify practices accepting new patients within each plan's network. Tracking new patient appointment availability over time can inform policies designed to strengthen primary care capacity and enhance the effectiveness of the coverage expansions with the Patient Protection and Affordable Care Act.

Background Immunosuppressive therapy with cyclosporin A has substantially improved clinical outcomes for renal transplantation. Whether basiliximab (a chimeric monoclonal antibody) demonstrates economic and quality-of-life advantages over other induction therapies has not yet been shown. Methods A multi-centre open-label clinical trial was conducted among renal transplant recipients in the US, in which patients were randomized into two induction therapy regimens: basiliximab and antithymocyte globulin (ATG) as part of a quadruple immunosuppressive regimen. Medical resources used and a EuroQol visual analogue scale (VAS) rating of quality of life were collected prospectively for the 135 dosed subjects for a period of 1 year post-treatment. We analysed the differences between treatment groups in 1-year costs and 1-year quality-adjusted survival. We also conducted a post hoc analysis of outcomes among the subgroup of patients identified as high risk. Results A significant difference was observed in first-year post-treatment costs (basiliximab, $45857; ATG, $54729; difference, $8872 (95% CI, $1169 to $16573). The savings from basiliximab can be attributed to the less expensive induction therapy (basiliximab, $2378; ATG, $8670; difference, $6292 (95% CI, $5165 to $7419)) and other savings during the initial hospitalization totalling $2609. One-year quality-adjusted survival was the same in both groups (basiliximab, 81.5; ATG, 81.1; difference, 0.45 (95% CI, -5.9 to 6.8)). The results of the post hoc analysis of the 48 high-risk patients were comparable to the analysis of all patients. Conclusions These results demonstrate lower first-year post-treatment costs in renal-transplant recipients receiving basiliximab compared to ATG with no differences in quality-adjusted survival. The results also suggest similar differences among high-risk subjects.

In this study, we assessed the influence of changes in health maintenance organization (HMO) penetration on the probability that established patient care physicians relocated their practices or left patient care altogether. For physicians who relocated their practices, we also assessed the impact of HMO penetration on their destination choices. We found that larger increases in HMO penetration decreased the probability that medical/surgical specialists in early career stayed in patient care in the same market, but had no impact on generalists, hospital-based specialists, or mid career medical/surgical specialists. We also found that physicians who relocated their practices were much more likely to choose destination markets with the same level of HMO penetration or lower HMO penetration compared with their origin markets than they were to choose destination markets with higher HMO penetration. The largely negligible impact of changes in HMO penetration on established physicians' decisions to relocate their practices or leave patient care is consistent with high relocation and switching costs. Relocating physicians' attraction to destination markets with the same level of HMO penetration as their origin markets suggests that, while physicians' styles of medical practice may adapt to changes in market conditions, learning new practice styles is costly.

The current health reform debate has laid bare the challenge with determining appropriate care in an environment of uncertain medical effectiveness and rising health care costs. Comparative and cost-effectiveness studies are policy tools that permit decision-makers, theoretically, to allocate limited resources toward the greatest health benefit. Without these tools, opportunity to improve health may be missed. For example, would investing in early childhood screening miss an opportunity for greater health benefits from an investment in improving adherence to treatments for asthma? The article in this issue by Gerald et al fills an import information gap and highlights much of the controversy that exists in recommendations for screening and cost-effectiveness analysis. The article finds that a school-based screening program in a highrisk population is highly unlikely to be cost-effective. In particular, they find the most cost-effective intervention would cost $151,000 per quality-adjusted life-year versus the alternative of no screening. These results are driven by 4 main inputs: how much having uncontrolled asthma reduces a person’s quality of life, how likely a parent is to follow up with a physician after receiving a positive screening result, the adequacy of asthma control in patients, and the treatment effects on symptoms. We suspect the results represent a lower bound estimate because benefits are more diffuse in lower-risk populations, and therefore the cost per quality-adjusted life-year would likely be higher in a population-based screening program. The main limitation of their study, as acknowledged by the authors, is a reliance on secondary data. Future research should consider conducting economic evaluation alongside an ongoing randomized clinical trial evaluating the effectiveness of asthma screening. Beyond the obvious result that childhood asthma screening is highly unlikely to be cost-effective, the investigation by Gerard et al provides a number of useful insights. Ideally, increased childhood screening would lead to better health outcomes because positive screening results would lead to confirmation of the initial diagnosis, access and receipt of early and appropriate treatment, adherence to treatment, and ultimately better health outcomes. However, for asthma screening, this is not the case because the follow-up to positive screening results, access to appropriate treatment, and

Objectives. To compare preference assessments that were made by using the EuroQol EQ-5D and the Health Utilities Index Mark II. Subjects. 561 patients in a randomized trial of tirilazad mesylate for aneurysmal subarachnoid hemorrhage. Measures . Three preference assessments (a value score for the EuroQol instrument and value and utility scores for the Health Utilities Index) made three months after randomization. The av erages for each of the three scores, stratified by clinical outcomes and attributes of the Health Utilities Index health status classification system, were compared. To eval uate potential sources of difference between the instruments, the authors estimated two alternative Health Utilities Index sconng rules that were based on patient re sponses to the EuroQol instrument. Results . Patients' ratings of their current health made by using the 100-point visual analog scale from the EuroQol instrument were more similar to the utility scores for the Health Utilities Index than they were to the value scores for the Health Utilities Index. The biggest differences between the visual analog scores for the EuroQol instrument and the utility scores for the Health Utilities index were seen at higher levels of functioning. Conclusion. For states representing higher levels of functioning, differences were seen between patients' self-ratings ob tained by using the EuroQol instrument and the patients' utility scores on the Health Utilities Index; for states representing lower levels of functioning, substantial agreement was observed between these two scores. Differences observed at the higher levels of functioning suggest that further research is needed to determine whether the Health Utility Index's assignment of a score of 1.0 to the reference state representing being healthy is appropriate. Key words: preference assessment; health utilities index; EuroQol; clinical trials; subarachnoid hemorrhage. (Med Decis Making 1999; 19:265- 275)

OBJECTIVES The rapid growth of health maintenance organizations is reshaping the practice opportunities available to physicians. The practice location decisions of new physicians provide a sensitive bellwether of these changes. This study assessed the effect of health maintenance organization penetration on practice location for physicians completing graduate medical education (GME). METHODS Conditional logit regression analysis was used to determine the effect of health maintenance organization penetration on practice location, controlling for other market characteristics. Subjects were physicians who finished GME between 1989 and 1994 and who located in one of the 98 US metropolitan areas with more than 500,000 population. The outcome measure was the particular metropolitan area chosen by each new physician. RESULTS Early in the study period, new generalists were significantly more likely to locate in metropolitan areas with high health maintenance organization penetration than in low penetration areas, whereas new specialists' practice location choices were not associated with health maintenance organization penetration. The likelihood of choosing a high penetration relative to a low penetration area declined with time, however, for both generalists and specialists. Consequently, by the end of the study period, health maintenance organization penetration had a weak but significant negative effect on practice location for generalists and a strong negative influence on practice location for specialists. CONCLUSIONS New generalists who completed graduate medical education between 1989 and 1994 were more likely than new specialists to locate in market areas with high health maintenance organization penetration; however, the proportions of both generalists and specialists who chose high penetration areas decreased during the study period. This finding may reflect reduced practice opportunities in high penetration areas relative to low penetration areas as health maintenance organizations' systems for controlling utilization began to yield results. Alternatively, new physicians may have become more hesitant to accept available positions in high penetration areas.

This study used data from a multinational phase III randomized, double-blind, vehicle-controlled trial to evaluate the cost-effectiveness of tirilazad mesylate (Freedox®) in the treatment of aneurysmal subarachnoid hemorrhage. In men, therapy with 6 mg/kg per day of tirilazad mesylate was associated with significantly increased survival, increased cost of care, and ratios of cost per death averted that compare favorably with the ratios of other life and death interventions. In women, it appeared to have no effects on costs or survival. Further clinical studies may provide additional information about the cost-effectiveness of this intervention.

Importance As many surgical procedures have undergone a transition from a standard, open surgical approach to a minimally invasive one in the past 2 decades, the diffusion of minimally invasive surgery may have had sizeable but overlooked effects on medical expenditures and worker productivity. Objective To examine the impact of standard vs minimally invasive surgery on health plan spending and workplace absenteeism for 6 types of surgery. Design Cross-sectional regression analysis. Setting National health insurance claims data and matched workplace absenteeism data from January 1, 2000, to December 31, 2009. Participants A convenience sample of adults with employer-sponsored health insurance who underwent either standard or minimally invasive surgery for coronary revascularization, uterine fibroid resection, prostatectomy, peripheral revascularization, carotid revascularization, or aortic aneurysm repair. Main Outcomes and Measure Health plan spending and workplace absenteeism from 14 days before through 352 days after the index surgery. Results There were 321 956 patients who underwent surgery; 23 814 were employees with workplace absenteeism data. After multivariable adjustment, mean health plan spending was lower for minimally invasive surgery for coronary revascularization (−$30 850; 95% CI, −$31 629 to −$30 091), uterine fibroid resection (−$1509; 95% CI, −$1754 to −$1280), and peripheral revascularization (−$12 031; 95% CI, −$15 552 to −$8717) and higher for prostatectomy ($1350; 95% CI, $611 to $2212) and carotid revascularization ($4900; 95% CI, $1772 to $8370). Undergoing minimally invasive surgery was associated with missing significantly fewer days of work for coronary revascularization (mean difference, −37.7 days; 95% CI, −41.1 to −34.3), uterine fibroid resection (mean difference, −11.7 days; 95% CI, −14.0 to −9.4), prostatectomy (mean difference, −9.0 days; 95% CI, −14.2 to −3.7), and peripheral revascularization (mean difference, −16.6 days; 95% CI, −28.0 to −5.2). Conclusions and Relevance For 3 of 6 types of surgery studied, minimally invasive procedures were associated with significantly lower health plan spending than standard surgery. For 4 types of surgery, minimally invasive procedures were consistently associated with significantly fewer days of absence from work.

Background Improving inhaled corticosteroid (ICS) adherence should improve asthma outcomes. Objective In a randomized controlled trial we tested whether an individualized problem-solving (PS) intervention improves ICS adherence and asthma outcomes. Methods Adults with moderate or severe asthma from clinics serving urban neighborhoods were randomized to PS (ie, defining specific barriers to adherence, proposing/weighing solutions, trying the best, assessing, and revising) or standard asthma education (AE) for 3 months and then observed for 3 months. Adherence was monitored electronically. Outcomes included the following: asthma control, FEV 1 , asthma-related quality of life, emergency department (ED) visits, and hospitalizations. In an intention-to-treat-analysis longitudinal models using random effects and regression were used. Results Three hundred thirty-three adults were randomized: 49 ± 14 years of age, 72% female, 68% African American, 7% Latino, mean FEV 1 of 66% ± 19%, and 103 (31%) with hospitalizations and 172 (52%) with ED visits for asthma in the prior year. There was no difference between groups in overall change in any outcome ( P > .20). Mean adherence (61% ± 27%) decreased significantly ( P = .0004) over time by 14% and 10% in the AE and PS groups, respectively. Asthma control improved overall by 15% ( P = .002). In both groups FEV 1 and quality of life improved by 6% ( P = .01) and 18% ( P 1 only occurred during monitoring but not subsequently after randomization. Rates of ED visits and hospitalizations did not significantly decrease over the study period. Conclusion PS was not better than AE in improving adherence or asthma outcomes. However, monitoring ICS use with provision of medications and attention, which was imposed on both groups, was associated with improvement in FEV 1 and asthma control.

Coronary revascularization is among the most common hospital-based major interventional procedures performed in the United States. It is uncertain how new revascularization technologies, new clinical evidence from trials, and updated clinical guidelines have influenced the volume and distribution of coronary revascularizations over the past decade.To examine national time trends in the rates and types of coronary revascularizations.A serial cross-sectional study with time trends of patients undergoing coronary artery bypass graft (CABG) surgery or percutaneous coronary interventions (PCIs) between 2001 and 2008 at US hospitals in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, which reports inpatient coronary revascularizations. These data were supplemented by Medicare outpatient hospital claims.Annual procedure rates of coronary revascularizations, CABG surgery, and PCI.A 15% decrease (P.001) in the annual rate of coronary revascularizations was observed from 2001-2002 to 2007-2008. The annual CABG surgery rate decreased steadily from 1742 (95% confidence interval [CI], 1663-1825) CABG surgeries per million adults per year in 2001-2002 to 1081 (95% CI, 1032-1133) CABG surgeries per million adults per year in 2007-2008 (P.001), but PCI rates did not significantly change (3827 [95% CI, 3578-4092] PCI per million adults per year in 2001-2002 vs 3667 [95% CI, 3429-3922] PCI per million adults per year in 2007-2008, P = .74). Between 2001 and 2008, the number of hospitals in the Nationwide Inpatient Sample providing CABG surgery increased by 12% (212 in 2001 vs 241 in 2008, P = .03), and the number of PCI hospitals increased by 26% (246 in 2001 vs 331 in 2008, P.001). The median CABG surgery caseload per hospital decreased by 28% (median [interquartile range], 253 [161-458] in 2001 vs 183 [98-292] in 2008; P.001) and the number of CABG surgery hospitals providing fewer than 100 CABG surgeries per year increased from 23 (11%) in 2001 to 62 (26%) in 2008 (P.001).In US hospitals between 2001 and 2008, a substantial decrease in CABG surgery utilization rates was observed, but PCI utilization rates remained unchanged.

Background: The erythropoiesis-stimulating agents (ESAs) epoetin alfa (EA) and darbepoetin alfa (DA) are treatments for chemotherapy-induced anemia. Therapy choice depends on many factors, including cost. Previous analyses have demonstrated differences in the characteristics of patients receiving EA vs. DA. We estimated cost differences between DA and EA in patients with cancer receiving chemotherapy using a propensity score matched analysis of baseline patient characteristics with and without hemoglobin (Hb) values. Methods: Data were extracted from electronic medical records in two US databases between January 2004 and December 2006. The study sample included 6743 patients receiving chemotherapy, with ≥ 1 visit during the study period, who received an ESA during a chemotherapy episode. Episodes of chemotherapy care were constructed using a 90 day gap in administration to identify the start and end. Patients receiving both, or neither, DA and EA during their initial chemotherapy episode, or with missing descriptive data were excluded. Drug costs were calculated from cumulative dose multiplied by 106% of the average sales price (ASP) for DA or EA. Two propensity score matches were conducted: first using variables available in administrative billing claims systems, then adding the baseline Hb test result. Regression-adjusted cost differences were estimated with and without baseline Hb, using generalized linear models. Results: Using baseline Hb as a variable resulted in a better match of the baseline characteristics for the EA and DA treatment groups compared to the original sample or the matched sample without baseline Hb. Mean ESA costs for the original sample were $4171 for EA and $3811 for DA (mean difference: $360; P Conclusions: Addition of baseline Hb as a variable in propensity score and ESA cost models affects ESA treatment cost estimates in patients with cancer receiving chemotherapy. Cost comparisons based on observational data should use analytical methods that account for differences in clinical variables between treatment groups.

We appreciate both Dr Harrington's response to our study and his concern regarding medicating children with autism. We agree that much of this prescribing behavior occurs in the absence of empirical evidence and is most likely exacerbated by 2 factors: (1) the short duration of and poor reimbursement for visits during which physicians must …

We appreciate the letter from Betlehem et al. and the information on the growth of educational opportunities for Hungarian nurses and the consequences of those efforts. The experience in Hungary confirms our analysis of nurses working in the United States: the skill level among nurses educated abroad is comparable to that of nurses educated in the United States. As the demand for university-trained nurses grows globally, countries like Hungary that undertake these educational reforms may see a greater percentage of their nursing work-force emigrate. If this migration encourages other countries to raise their standards for nursing education, we can only hope that this will spell better care for all patients of nurses.

6546 Background: Measuring surgical quality has recently focused on isolated processes (such as P4P measures) and intermediate outcomes (such as infection rates). Some have argued that such isolated measures are inherently flawed since they may have only minor influence on more important primary outcomes such as survival. Hence, referral decisions based on such isolated processes or intermediate outcomes may lead to less than optimal care. We asked whether surgeon type influenced isolated process measures (longer operative time, thought to be a function of increased node sampling), intermediate outcomes (deep wound infection, often found to be a function of operative time) and the primary outcome of survival. Methods: We obtained SEER-Medicare claims for the years 1991–2001 for ovarian cancer. We identified the first definitive cancer surgery and the surgical provider type for that procedure: General Surgeon (GS) N=545 and GYN Oncologist (GO) N=1,554. We determined operative time from the anesthesia claims, number of nodes sampled from the SEER record, deep wound infection from the ICD9CM secondary diagnoses and survival from Medicare vital status files. Models were adjusted for 30 patient characteristics and comorbidities. To account for potential reclassification bias due to variations in the pattern of node dissection across GO and GS surgical types, which can potentially influence stage identification, we report survival results both with and without stage adjustments. Results: Definitive surgery by GOs was associated with more extensive node dissection and longer operative time. GO patients also displayed a trend for increased deep wound infection as compared to cases operated on by GS. However, 5-year survival was significantly longer in the GO group, with or without stage adjustment. Conclusions: GO cases took longer, tended to have higher infection rates, yet had better overall 5-year survival. Isolated intermediate outcome measures, such as deep wound infection, may not be good quality indicators. No significant financial relationships to disclose. [Table: see text]

As treatment costs are increasingly determined from individual level cost data, the number of proposed multivariable methods for use in this analysis has multiplied. These methods involve estimation of multivariable cost functions that yield predictions at the individual level, coditional on interventions, patient characteristics, and other factors. What are these methods, how are they used properly, and what are the circumstances when one method is preferred over others? The purpose of this workshop will be to develop skills in conducting multivariable analysis of cost data from randomized trials. We will instruct participants in the use of ordinary least squares regression techniques and survival analysis techniques. We will discuss how non-normal cost data and censored cost data are properly and improperly handled in these methods. Participants will learn when it is appropriate to use log transformation of costs in their analysis and how to estimate unbiased treatment costs using smearing techniques. Participants will also learn how to apply the Cox proportional hazard model to analysis of costs. How does one determine which model is best given the circumstances? We will develop concepts important for evaluating the superior model: predictive validity and adherence to assumptions for unbiased estimators. We will present results from a simulation designed to evaluate how well the various methods perform under different circumstances. Those who want to learn the techniques of multivariable cost analysis and develop criteria for choosing the best technique will benefit from this workshop. Participants who would benefit include analysts of cost data and those who want to increase their understanding of the literature of economic evaluation.

6110 Background: Medical Oncologists (MOs) specialize in administering chemotherapy while Gynecologic Oncologists (GOs) specialize in the surgical management of gynecologic cancers as well as providing chemotherapy. We asked whether survival differed according to the type of specialist providing the chemotherapy after ovarian cancer surgery. Methods: Using merged SEER-Medicare clinical and administrative data from the years 1991 through 2001 we identified all patients who were diagnosed with ovarian cancer after the age of 65 and who received chemotherapy from a GO after surgery performed by any type of surgeon. Using optimal matching and a propensity score based on 35 prognostic characteristics, we identified similar patients who were operated on, and staged, by nearly identical types of surgeons but who received chemotherapy from an MO. Results: We identified 344 patients who were given chemotherapy for ovarian cancer by GOs after having undergone surgery by either GOs (76%), Gynecologists (16%), or general surgeons or other surgical specialties (8%). Patients given chemotherapy by MOs were matched to these patients. Both groups had nearly identical surgical specialists, age, year of treatment, stage, tumor grade, race and 32 other prognostic factors. There was no difference in overall survival between the GO or MO groups (P = 0.45, paired Prentice-Wilcoxon test). The 5 year survival was 35% (± 2.6%) for the GO group and 34% (± 2.6%) for the MO group. However, MOs administered chemotherapy over more weeks than did the GOs (patient mean = 16.5 Vs 12.1 weeks, P < 0.0023, Wilcoxon rank sum test) and MO patients had more weeks that included at least one of the following chemotherapy associated adverse events (neutropenia, anemia, thrombocytopenia, diarrhea, dehydration or mucositis) than did the GO group (patient mean = 16.2 Vs 8.9 weeks, P < 0.0001, Wilcoxon rank sum test). Conclusions: Despite differences in training, specialty emphasis, and practice style concerning the use of chemotherapy (MO patients had more weeks of chemotherapy and more weeks with chemotherapy associated adverse events than GO patients), we found no difference in survival between patients who received chemotherapy administered by gynecologic oncologists and medical oncologists. No significant financial relationships to disclose.

This comprehensive collection brings together more than 50 contributions from some of the most influential researchers in health economics. It authoritatively covers theoretical and empirical issues in health economics, with a balanced range of material on equity and efficiency in health care systems, health technology assessment and issues of concern for developing countries. This thoroughly revised second edition is expanded to include four new chapters, while all existing chapters have been extensively updated.

Objective: To provide a current profile of the practice of child neurology, report the attitudes of child neurologists toward practice, and analyze the supply of child neurologists. Methods: In March 2002, a questionnaire was sent to all active members of the Child Neurology Society (n = 1,051) and to nonmember physicians under age 70 who listed child neurology as a primary or secondary specialty on the American Medical Association Masterfile (n = 433). The response rate was 65%. Eligibility criteria were then applied to arrive at the sample of main specialty in child neurology working at least 20 hours per week in patient care. The final population was 604. Differences in practice characteristics were tested by practice type, and the number of full-time patient care child neurologists was projected by extrapolating to nonrespondents. Results: There are 904 full-time patient care child neurologists in the United States and 1.27 per 100,000 children. Career satisfaction is 90%, yet no growth in the supply is projected over the next 20 years. Wait times for an appointment average 53 and 44 days for a new and return visit, with longer wait times in university settings. Average annual income is $151,000. Conclusion: The practice characteristics of child neurologists suggest that the specialty will be challenged to meet patient demands.

OBJECTIVES: Selection bias in observational studies is described. Instrumental variable estimation is presented in detail as a method of identification of treatment effects. Practical issues related to the proper implementation of this technique are stressed. Propensity score methods are also discussed. PARTICIPANTS WHO WOULD BENEFIT: Researchers who use, evaluate, or conduct observational studies. While estimates of treatment outcomes and costs from randomized clinical trials are still considered the gold standard, the use of observational data for these estimates is common. Observational data are less costly to obtain, readily available, and represent actual practice. However, there is always a danger of selection bias when these data are used to identify the costs or outcomes of one particular treatment versus another. This is true even when quality risk adjustment methods and propensity score methods are employed. Instrumental variable estimation and propensity score methods have both been proposed to overcome the selection bias problem in observational studies. We describe selection bias and how instrumental variables analysis and propensity score methods overcome the problem. We then explain how one would apply these techniques correctly to common research problems emphasizing the importance of choosing when propensity score methods are sufficient or when instrumental variables analysis should be used.