Biomedical subjects

A E Washington

Publications and source records attributed to A E Washington.

At least 37 records · Page 2Linked to original sources

PubMed1994

Cost-effectiveness of a routine varicella vaccination program for US children.

OBJECTIVE: To evaluate the economic consequences of a routine varicella vaccination program that targets healthy children. METHODS: Decision analysis was used to compare the costs, outcomes, and cost-effectiveness of a routine vaccination program with no intervention. Clinical outcomes were based on a mathematical model of vaccine efficacy that relied on published and unpublished data and on expert opinion. Medical utilization rates and costs were collected from multiple sources, including the Kaiser Permanente Medical Care Program and the California Hospital Discharge Database. RESULTS: A routine varicella vaccination program for healthy children would prevent 94% of all potential cases of chickenpox, provided the vaccination coverage rate is 97% at school entry. It would cost approximately $162 million annually if one dose of vaccine per child were recommended at a cost of $35 per dose. From the societal perspective, which includes work-loss costs as well as medical costs, the program would save more than $5 for every dollar invested in vaccination. However, from the health care payer's perspective (medical costs only), the program would cost approximately $2 per chickenpox case prevented, or $2500 per life-year saved. The medical cost of disease prevention was sensitive to the vaccination coverage rate and vaccine price but was relatively insensitive to assumptions about vaccine efficacy within plausible ranges. An additional program for catch-up vaccination of 12-year-olds would have high incremental costs if the vaccination coverage rate of children of preschool age were 97%, but would result in net savings at a coverage rate of 50%. CONCLUSIONS: A routine varicella vaccination program for healthy children would result in net savings from the societal perspective, which includes work-loss costs as well as medical costs. Compared with other prevention programs, it would also be relatively cost-effective from the health care payer's perspective.

Acyclovir↗

PubMed1994

Prevalence, incidence, and correlates of syphilis seroreactivity in multiethnic San Francisco neighborhoods.

To examine the extent of infection with syphilis in an inner-city community, we determined the prevalence, incidence, and correlates of syphilis seroreactivity in a representative sample of unmarried whites, African Americans, and Hispanics living in San Francisco during 1988 to 1989 and again 1 year later in 1989 to 1990. One thousand seven hundred seventy single men and women aged 20 to 44 were surveyed in a random household sample drawn from three neighborhoods of varying geographic and cultural characteristics. Syphilitic infection was determined by testing specimens with the microhemagglutination assay for antibodies to Treponema pallidum (MHA-TP). Of blood samples available from 1262 participants from the initial survey, 32 (2.5%) were MHA-TP reactive. After adjustment for age, a reactive syphilis serology was significantly predicted (P < 0.05) by African American race, homosexual activity (men), and less education. In homosexually active men, lifetime number of male sex partners and the presence of antibody to the human immunodeficiency virus (HIV) significantly predicted syphilis seroreactivity (P < 0.01). One year later, of 841 specimens available for testing, an additional 13 (1.5%) had become MHA-TP reactive. Eleven (85%) of the new cases were in heterosexual men and women. Although San Francisco citywide incidence data indicate that syphilis may be decreasing for the city as a whole, incidence data on a community level suggests that syphilitic infection is increasing in high-risk heterosexual communities. Thus, syphilis prevention programs should rely on serologic testing at the community level to plan effective intervention strategies.

Adult↗

PubMed1994

Pelvic inflammatory disease. A brief overview.

Most pelvic inflammatory disease (PID) is caused by the ascent of sexually transmitted disease pathogens from the endocervix. In fact, PID remains the most common serious complication of infection from sexually transmitted bacterial pathogens. PID also may be caused by normal vaginal micro-organisms (such as those associated with bacterial vaginosis) that have overgrown in the vagina. PID has been linked to the occurrence of long-term sequelae, most commonly and most importantly infertility and ectopic pregnancy. In many patients PID may remain undiagnosed and asymptomatic, and may not become evident until such long-term consequences become manifest. We briefly review the epidemiology of PID including case definitions, the prevalence of the problem, and causal pathways and associated risk factors. Risk factors for both PID and its sequelae are discussed in relation to the mechanism of ascent of associated etiologic agents from the lower to the upper genital tract.

Female↗

PubMed1994

The cost-effectiveness of prenatal carrier screening for cystic fibrosis.

OBJECTIVE: To evaluate the economic consequences of routinely offering cystic fibrosis-carrier screening to pregnant white women under 35 years of age. METHODS: Decision analysis was used to evaluate the health outcomes and medical costs of a screening program from the health care payer's perspective. Probabilities were taken from the literature; cost data were based on consultations with laboratory and hospital administrators. Sensitivity analysis was performed for key assumptions. RESULTS: If the test acceptance rate were 78% and the screening test identified 85% of carriers, a prenatal cystic fibrosis-carrier screening program would identify slightly more than half of the high-risk pregnancies in the population. For a cohort of one million pregnant women, it would cost $83 million. If the proportion of couples choosing abortion were 30% and the lifetime cost of medical care for cystic fibrosis were $243,650, the program would save $12 million in averted costs of medical care for cystic fibrosis, for a net cost of $71 million. Even after accounting for the savings in averted medical care for cystic fibrosis, the cost per high-risk pregnancy identified would be $82,000; the cost per unwanted cystic fibrosis birth averted would be $1.4 million. Results were sensitive to the cost and sensitivity of the screening test, but relatively insensitive to the test acceptance rate and therapeutic abortion rates between 50-100% among pregnancies identified with cystic fibrosis. CONCLUSION: A prenatal cystic fibrosis-carrier screening program would not save the health care payer money under most assumptions, but may be justified if the benefit of the early information provided to expectant parents is judged worth the cost.

Abortion, Induced↗

PubMed1993

Cesarean delivery for women presenting with genital herpes lesions. Efficacy, risks, and costs.

OBJECTIVE: To assess the effect of cesarean delivery on neonatal and maternal morbidity and mortality and their associated costs for two populations of women presenting with genital herpes lesions at delivery: those with and those without a history of genital herpes. DATA SOURCES: MEDLINE (search for herpes simplex virus and neonatal, cesarean, and mortality) and recognized experts. DATA EXTRACTION: The quality of the overall data used for baseline values was graded using a predetermined scale. RESULTS: The practice of cesarean delivery for women with a history of genital herpes lesions that recur at delivery results in more than 1580 excess cesarean deliveries performed for every poor neonatal outcome prevented, a cost per neonatal herpes case averted of $2.5 million and a cost per quality-adjusted life-year gained of $203,000. For these women, lowering the efficacy of cesarean delivery or the herpes simplex virus vertical transmission rate could result in maternal deaths outnumbering neonatal deaths prevented. In contrast, cesarean delivery for women with no history of genital herpes simplex virus who have lesions at delivery has low maternal costs per neonatal benefit and saves money. CONCLUSIONS: Women who present with their first clinical episode of genital herpes at delivery should have a cesarean section performed. However, the current practice of cesarean delivery for women with a history of genital herpes lesions that recur at delivery results in high maternal morbidity and mortality at substantial financial expense, underscoring the urgency of examining alternative management strategies.

Cesarean Section↗

PubMed1993

Pelvic inflammatory disease: metaanalysis of antimicrobial regimen efficacy.

An extensive body of literature has investigated the efficacy of antimicrobial regimens used to treat pelvic inflammatory disease (PID), leaving many clinicians confused about how to choose among them. This study provides a formal appraisal of these reports. Thirty-four treatment studies published between 1966 and 1992 were identified, using Medline and bibliographies, and evaluated qualitatively and quantitatively in a metaanalysis. Twenty-one studies met the criteria for inclusion in this evaluation: appropriate system for making the diagnosis of PID, standardized assessment of clinical outcome, and entry and follow-up evaluation for lower genital tract infection with Neisseria gonorrhoeae and Chlamydia trachomatis. This metaanalysis identifies a considerable range of quality in study methods and research design and underscores the limitations inherent in comparing such data. Despite this, a number of antimicrobial regimens appear to have very good short-term clinical and microbiologic efficacy. Pooled clinical cure rates range from 75% to 94% and pooled microbiologic cure rates range from 71% to 100%. A cost comparison is provided, and future research priorities are suggested.

Adolescent↗

PubMed1993

Cost of ectopic pregnancy management: surgery versus methotrexate.

OBJECTIVE: To estimate the potential annual cost savings of methotrexate (MTX) therapy for ectopic pregnancy (EP) at our institution and nationally. DESIGN: Retrospective. SETTING: San Francisco General Hospital. PATIENTS: All patients treated for EP in 1991. INTERVENTIONS: Medical records and billing statements were reviewed. MAIN OUTCOME MEASURES: Direct costs were determined from billing statements, and indirect costs were estimated based on published data. Potential annual national cost savings from MTX treatment were then extrapolated using national statistics on the incidence of EP. RESULTS: Fifty EPs were treated with an average direct cost of $7,972 per case. Direct and indirect costs totaled > $500,000. Fifteen (30%) of the cases would have been eligible for MTX treatment with a resultant cost savings of > $160,000. The potential annual national cost savings would be in excess of $280 million. CONCLUSIONS: If preliminary findings suggesting the effectiveness of MTX as an alternative therapy for EP are confirmed, appropriate use of MTX will not only reduce morbidity but also the substantial cost.

Adolescent↗

PubMed1993

Ectopic pregnancy in the United States: economic consequences and payment source trends.

OBJECTIVE: To estimate the annual direct and indirect costs of ectopic pregnancy in the United States and to examine trends in payment source. METHODS: We analyzed hospital discharge data for 1982-1989 from a San Francisco hospital and California statewide data for 1983-1987 to estimate direct medical care costs and to determine payment sources. Examination of national labor data was used to compute indirect cost. RESULTS: The total cost of ectopic pregnancy in 1990 was estimated to be nearly $1.1 billion. Direct costs of hospitalization and other medical treatment contributed 77% of the total costs, with average hospital costs estimated to be $6079, hospitalization-related physician fees $3254, and average outpatient costs $149, for a total direct cost-per-case of $9482. Of the total indirect costs ($250.5 million), 67% was attributed to the value of lost wages and the remainder to the lost value of household management. Public payment sources covered the largest portion of ectopic pregnancy-related direct costs among women aged 19 and younger (35%), but private insurance covered the largest portion among women aged 20-29 (32%) and women aged 30 and older (43%). In general, the proportion of payments made by private insurance has decreased, while the proportion of payments made by public pay sources and health maintenance organizations and preferred provider organizations has increased. CONCLUSIONS: Ectopic pregnancy results in a substantial economic burden, with an increasing share of direct costs being borne by public pay sources. Appropriate use of cost-effective management approaches can reduce costs, while preventive measures that decrease the risk of ectopic pregnancy can both save resources and, more important, spare human suffering.

Adolescent↗

PubMed1992

Prevalence and correlates of herpes simplex infections. The population-based AIDS in Multiethnic Neighborhoods Study.

OBJECTIVE: To examine the extent and correlates of infection with herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) in an inner-city community, we studied the prevalence of antibodies to these viruses and their association with risk behaviors in a representative sample of unmarried white, black, and Hispanic adults living in San Francisco, Calif. DESIGN: Cross-sectional, community-based, random household survey. PARTICIPANTS: In 1988 and 1989, we surveyed 1770 unmarried men and women aged 20 to 44 years from three San Francisco neighborhoods of varying geographic and cultural characteristics. MAIN OUTCOME MEASURES: HSV-1 and HSV-2 antibodies based on an immunodot assay using type-specific glycoproteins gG-1 and gG-2. RESULTS: Of blood samples from 1212 participants available for testing, 750 (62%) had HSV-1 antibodies and 400 (33%) had HSV-2 antibodies. After controlling for other variables, HSV-1 antibody was significantly correlated (P less than .05) with older age (in heterosexual men, women, and homosexually active men), less education (in heterosexual men and women), and Hispanic (especially those not born in the United States) or black race. HSV-2 antibody was significantly correlated (P less than .05) with female gender, number of lifetime sexual partners and older age (in heterosexual men and women), and low levels of education and black or Hispanic race (in women). Among those with antibody to HSV-2, only 28 (19%) of 149 men and 32 (13%) of 251 women reported a history of genital herpes. However, most men (62%) and women (84%) who reported a history of genital herpes had HSV-2 antibodies. We observed a similar pattern (low sensitivity and moderate specificity) for a history of facial herpes and the presence of HSV-1 antibodies. After controlling for other variables, HSV-2 antibodies were associated with a lower frequency of HSV-1 antibodies among homosexual men infected with the human immunodeficiency virus. CONCLUSIONS: HSV-1 antibodies were found in nearly two thirds of single urban adults and were most common among Hispanics not born in the United States. HSV-2 antibodies were found in one third of this population and were associated with risk behaviors for sexually transmitted diseases. For both facial and genital herpes infections, self-reporting of infection was very insensitive and moderately specific.

Adult↗

PubMed1992

Estimation of the break-even point for smoking cessation programs in pregnancy.

BACKGROUND: Successful programs to help pregnant women quit smoking have been developed and evaluated, but formal smoking cessation programs are not a part of care at most prenatal sites. The cost of such programs may be an issue. Considering the costs of adverse maternal and infant outcomes resulting from smoking, we estimated there would be an amount of money a prenatal program could invest in smoking cessation and still "break even" economically. METHODS: A model was developed and published data, along with 1989 hospital charge data, were used to arrive at a break-even point for smoking cessation programs in pregnancy. RESULTS: Using overall United States data, we arrived at a break-even cost of $32 per pregnant woman. When these data were varied to fit specific US populations, the break-even costs varied from $10 to $237, with the incidence of preterm low birth weight having the most impact on the cost. CONCLUSIONS: It may be advisable to invest greater amounts of money in a prenatal smoking cessation program for some populations. However, for every population there is an amount that can be invested while still breaking even.

Cost-Benefit Analysis↗

PubMed1991

Diagnosing pelvic inflammatory disease. A comprehensive analysis and considerations for developing a new model.

OBJECTIVE: --To examine the accuracy of existing diagnostic indicators for pelvic inflammatory disease and to develop guidelines for a new diagnostic model. DATA SOURCES: --Studies were identified for the period 1969 through 1990. A Medline search of the English-language literature was conducted using the subject terms pelvic inflammatory disease or salpingitis and diagnosis. In addition, abstracts and bibliographies of articles and books were reviewed. STUDY SELECTION: --Studies were selected if pelvic inflammatory disease was diagnosed using laparoscopic findings or narrow clinical rules. Of the 15 reports identified, 12 were included in this analysis. The selected studies were grouped by a quality rating based on subject selection, definition of pelvic inflammatory disease, data analysis, and other measures. DATA EXTRACTION: --Diagnostic findings were divided into four categories: historical (symptoms), clinical examination (signs), laboratory, and combinations of the above. Sensitivity and specificity were extracted using raw data. Data were classified by quality rating. DATA SYNTHESIS: --Historical findings were usually not statistically significant predictors of pelvic inflammatory disease, and when they were they tended toward low sensitivity and high specificity, while clinical findings were somewhat more sensitive and about as specific. Several laboratory tests showed consistent value in pelvic inflammatory disease diagnosis, with high sensitivity and specificity. Combinations of indicators permitted high sensitivity or high specificity but not both simultaneously. CONCLUSIONS: --No single or combination diagnostic indicator was found to reliably predict pelvic inflammatory disease. Combining published evidence with practical clinical considerations, a diagnostic approach is proposed that emphasizes diagnostic sensitivity when clinical presentation is mild and more thorough evaluation when a woman is severely ill. Research is needed to evaluate the accuracy and acceptability of specific diagnostic models and to investigate new diagnostic indicators.

Female↗

PubMed1991

Pelvic inflammatory disease. Key treatment issues and options.

OBJECTIVE: --To examine available data regarding optimal antimicrobial therapy for pelvic inflammatory disease (PID) and to address selected treatment issues confronting clinicians caring for women with PID. DATA SOURCES: --Studies evaluated to help establish the Centers for Disease Control's 1989 Sexually Transmitted Diseases Treatment Guidelines and other reports published since 1985. A MEDLINE search of English-language literature was conducted using the indexing terms "pelvic inflammatory disease" or "pelvic infections" or "salpingitis" and "treatment". In addition, abstracts and bibliographies of articles and books were reviewed. STUDY SELECTION: --Studies were selected for detailed review if they evaluated the effectiveness of an antimicrobial regimen for treatment of PID. DATA EXTRACTION: --All studies were evaluated to determine the numbers of women treated and the percentage with clinical or microbiologic evidence of cure. DATA SYNTHESIS: --A variety of combination antimicrobial regimens are highly effective in providing clinical and microbiologic evidence of cure; few data are available to assess optimal therapy for prevention of late sequelae. Because PID is polymicrobial in cause, recommended antimicrobial regimens are broad-spectrum in coverage. CONCLUSIONS: --No single agent that provides sufficient coverage is currently available. Several combination regimens appear highly effective clinically even among women with tubo-ovarian abscess formation. Uncertainties regarding the effectiveness of antimicrobial therapy for prevention of late sequelae complicate decisions regarding the choice among regimens and the appropriateness of ambulatory treatment of women with PID. Pending better data, hospitalization should be strongly considered, where feasible, particularly for those women with PID desiring further childbearing. Sex partners of all women with PID should be treated.

Anti-Bacterial Agents↗

PubMed1991

Cost of and payment source for pelvic inflammatory disease. Trends and projections, 1983 through 2000.

Pelvic inflammatory disease (PID) and its sequelae affect millions of women in the United States at substantial costs. To estimate these total costs annually and to determine payment sources, we analyzed data from local, state, and national sources. Direct costs for PID and PID-associated ectopic pregnancy and infertility were estimated to be $2.7 billion, and indirect costs were estimated to be $1.5 billion, for a total cost of $4.2 billion in 1990. Overall, private insurance covered the largest portion of the direct costs of PID (41%), followed by public payment sources (30%). However, the proportion of payments made by private insurance appears to be decreasing, while that by public payment sources is increasing. In the year 2000, costs associated with PID are projected to approach $10 billion if the current PID incidence persists, with an increasing proportion of this expense burdening public institutions. Prevention of PID is needed both to reduce human suffering and to contain rising costs.

Adult↗

PubMed1991

Preventing pelvic inflammatory disease.

Effective strategies for preventing pelvic inflammatory disease (PID) are crucial to protect women from adverse reproductive consequences and to avoid substantial economic losses. To identify current PID prevention options and assess their efficacy, we conducted a literature search and examined relevant data in published reports. We organized our review by level of participation (ie, individuals, providers, and communities) and prevention (ie, primary, secondary, and tertiary). For individuals, several prevention strategies related to personal protection appear promising, but few have been appropriately evaluated. For providers of health care, five prevention measures are recommended, including such primary prevention activities as counseling and patient education in addition to the usual diagnosis and treatment. Specific evidence supporting the efficacy of these provider practices, however, is limited. For communities, maintaining comprehensive sexually transmitted disease control strategies to prevent lower genital tract chlamydial and gonococcal infection is most important in reducing both symptomatic and asymptomatic PID. We provide specific recommendations for preventing PID and outline research needs.

Contraceptive Devices, Female↗

PubMed1991

Assessing risk for pelvic inflammatory disease and its sequelae.

To assess the risk for pelvic inflammatory disease (PID), a practitioner must evaluate the likelihood that a woman has PID or will be exposed to a sexually transmitted disease causing PID. Successful risk assessment depends on accurate information about variables influencing risk of PID. To determine the current state of knowledge about PID risk variables, we examined data in published reports. Data on each risk variable were scrutinized to discern which link(s) in the PID risk chain it affects (acquisition of a sexually transmitted disease, development of PID, or development of PID sequelae) and whether it is a risk marker or a risk factor. Most PID risk variables, particularly sexual behaviors, are associated with acquisition of a sexually transmitted disease, rather than development of PID itself. With the exception of age, demographic and social indicators of risk appear to be risk markers, while contraceptive practices appear more often to be risk factors than risk markers. Additional data are needed for most PID risk variables confidently to categorize them as risk factors. Enough information is available, however, to begin assessing risk for PID, so that appropriate counseling can ensue and timely diagnosis can be made.

Age Factors↗

PubMed1990

Screening for Chlamydia trachomatis in adolescent males: a cost-based decision analysis.

To evaluate the cost and benefits of screening tests for Chlamydia trachomatis in adolescent males, we developed a decision analysis model and compared the leukocyte esterase urine dipstick test with culture, with direct-smear fluorescent antibody (DFA), and with the option of no screening (no treatment). The leukocyte esterase test has the lowest average cost-per-cure ($51) compared with direct-smear fluorescent antibody ($192) and culture ($414). Compared with the DFA, we estimate that the leukocyte esterase test saves over $9,727 per cohort of 1,000 sexually active adolescent males screened. Sensitivity analyses show the leukocyte esterase test results in a lower cost-per-cure and lower overall costs (per cohort) than culture and direct-smear fluorescent antibody at any prevalence of C. trachomatis infection, and lower overall costs (per cohort) than no screening at prevalences above 21 percent.

Adolescent↗

PubMed1989

Vaginal douching as a possible risk factor for pelvic inflammatory disease.

To prevent pelvic inflammatory disease (PID) and its consequences, risk factors must be identified. A review of the literature supports the possibility that vaginal douching may affect the risk factor of PID, and new data are presented on douching practices of women hospitalized with PID. Individual case reports and controlled studies support associations between vaginal douching and both PID and ectopic pregnancy. The prevalence and distribution of douching are also compatible with a possible association. The temporal pattern of PID symptoms may be linked to douching and menses. The nature of the douche solution and the douching technique may be important variables with regard to douching as a PID risk factor. A case-control epidemiologic study is recommended to clarify the relationships between PID and douching.

Female↗

PubMed1988

Cost-effectiveness of prenatal screening and immunization for hepatitis B virus.

Perinatal transmission of hepatitis B virus is associated with substantial morbidity and mortality, yet controversy still exists regarding the value of routine screening of pregnant women in the United States and subsequent immunization of their at-risk neonates. To evaluate the cost-effectiveness of such a screening and immunization program, we developed a decision analysis model and obtained data from published reports, chart review, and a Delphi survey to determine outcome probabilities and costs. When considering direct and indirect costs, routine screening and immunization would be cost-effective at a prevalence of 0.06%, significantly lower than the national prevalence of 0.2%. At an annual national birth rate of 3.5 million births, a national policy of routine screening of all pregnant women would result in an annual net savings of more than $105 million. In the high-risk groups, as many as 140 cases of acute neonatal hepatitis and as many as 1400 cases of chronic liver disease would be prevented yearly per 100,000 pregnant women screened, at a net annual savings of as much as $765 million.

Carrier State↗