Top line mentality.
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Financing, Personal↗
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Orthodontic treatment timing: a survey of orthodontists.
There has been much debate with respect to the ideal time to initiate orthodontic treatment. Recent clinical trials have tested the effects of early orthodontic treatment. The purpose of this study was to understand orthodontists' perspectives on the best time to initiate treatment, factors that preclude early treatment, and experiences with compliance or adherence problems among their younger patients. Questionnaires were distributed to 335 practicing orthodontists throughout the United States. Respondents were first asked to indicate the best stage to initiate orthodontic treatment for 41 different types of occlusal deviations. They were then asked what conditions might preclude early orthodontic treatment. After one reminder, 137 questionnaires (41%) were returned. The sample consisted of practitioners with 3 to 52 years of experience and represented 46 different orthodontic training programs; 19% were female. The majority (92%) were in private practice. Among the 41 conditions listed, orthodontists would most likely treat 21 in the early mixed dentition, especially anterior crossbites (> 76%); 13 in the late mixed dentition, especially deepbite (> 60%) and mandibular inadequacy (> 59%); and 4 in either stage. Only two conditions would be treated in later stages (maxillary midline diastema, 43%; and congenitally missing teeth,39%). One third would postpone treating mandibular prognathism until adulthood. Patient variables that precluded treatment were behavior (98%) and compliance (96%) problems. Finances (76%) and family disruptions (57%) were less important deterrents to treatment. Orthodontists' experience with Phase I treatment influenced their decisions (p < 0.01). Orthodontists who have been in practice longer were more likely to treat temporomandibular joint sounds (p < 0.003) and deviations in opening (p < 0.002) than less experienced orthodontists; the latter were more likely to refer such patients to temporomandibular disorder specialists. These findings suggest that early orthodontic intervention is the norm, but practice characteristics affect treatment timing.
Adult↗
How much are patients willing to pay to avoid intraoperative awareness?
STUDY OBJECTIVE: To determine how much patients are willing to pay to avoid intraoperative awareness? DESIGN: Observational study SETTING: University-affiliated metropolitan hospital. PATIENTS: 60 patients who completed a questionnaire (39 F, 21 M). The mean age was 43 years and the median household income range of 45,000-60,000 US dollars. INTERVENTIONS: Patients completed an interactive computer-generated questionnaire on the value of preventing intraoperative awareness and their willingness to pay for a "depth of anesthesia" monitor. Their willingness to pay for the prevention of postoperative pain, nausea and vomiting, postoperative grogginess, and sleepiness was also determined as a means of comparison. MEASUREMENTS AND MAIN RESULTS: Patients were willing to pay (WTP) 34 US dollars, 10 US dollars to 42 US dollars (median, interquartile range) for a monitor that would assist an anesthesia care provider assess the depth of anesthesia in an effort to avoid awareness. This increased to 43 US dollars, 20 US dollars to 77 US dollars (p < 0.0,001) (median, interquartile range), if the insurance company was making the payment and the WTP value only decreased minimally to 33 US dollars if the incidence of awareness was reduced 10-fold. CONCLUSION: The incidence of intraoperative awareness and WTP value for monitoring awareness have a nonlinear relationship (a risk averse utility function), which suggests that patients assign an intrinsic base value for a rare or very rare possibility of an event. Other healthcare economic analyses (such as cost effectiveness) do not take this factor into account and assume a linear value relationship (i.e., if something occurs ten times less frequently, it has ten times less value). IMPLICATION: The median value for patients' WTP for a monitor that might prevent awareness under anesthesia was 34 US dollars given an incidence of 5/1,000 cases. The incidence of awareness and WTP value have a nonlinear relationship suggesting that patients assign an intrinsic base value for the possibility of awareness.
Adult↗
Willingness-to-pay for colorectal cancer screening.
Willingness-to-pay (WTP) techniques are increasingly being used in economic evaluation, as a means of assessing the value of new health care technologies. This paper presents the results of a WTP investigation of two types of screening for colorectal cancer. A questionnaire was issued to a general population via general practitioners (GPs), yielding a sample of approximately 2000 cases for analysis. Regression models demonstrated that WTP was significantly influenced by factors such as gender, income, age, risk perceptions, illness experiences and health beliefs. The median WTP for screening emerged as being pound30 or pound50, depending on the method used to elicit WTP, but independent of the screening protocol. Combining the results with those from related research, it emerged, first, that WTP subjects offered higher values for flexible sigmoidoscopy screening than the costs actually incurred by revealed preference studies and, second, they offered WTP values similar to the likely resource costs of the screening procedures.
Adult↗
The political economy of abortion in India: cost and expenditure patterns.
Access to abortion services is not difficult in India, even in remote areas. Providers of abortion range from traditional birth attendants to auxiliary nurse midwives and pharmacists, unqualified and qualified private doctors, to gynaecologists. Despite a well-defined law, there is a lack of regulation of abortion services or providers, and the cost to women is determined by supply side economics. The state is not a leading provider of abortions; services remain predominantly in the private sector. Abortions in the public sector are free only if the woman accepts some form of contraception; other fees may also be charged. The cost of abortion varies considerably, depending on the number of weeks of pregnancy, the woman's marital status, the method used, type of anaesthesia, whether it is a sex-selective abortion, whether diagnostic tests are carried out, whether the provider is registered and whether hospitalisation is required. A review of existing studies indicates that abortions cost a substantial amount--first trimester abortion averages Rs.500- 1000 and second trimester abortion Rs.2000-3000. Given the number of unqualified providers and with 15-20% of maternal deaths due to unsafe abortions, the costs of unsafe abortions must also be counted. It is imperative for the state to regulate the abortion economy in India, both to rationalise costs and assure safe abortions for women.
Abortion, Induced↗
The tremendous cost of seeking hospital obstetric care in Bangladesh.
In Bangladesh, maternal mortality is estimated to be 320 per 100,000 live births, among the highest in the world, and most deliveries in rural areas occur at home. Women with obstetric complications fear to seek hospital care for various reasons; one of which is the tremendous cost. This paper shows how cost impedes rural, poor women's access to emergency obstetric care. The data are from a larger ethnographic study of childbirth practices in 2000--01 in Apurbabari village, the adjacent sub-district health complex and more distant tertiary hospitals at district level. Families had to spend what for them added up to a fortune for a caesarean section and other surgery, medicines, laboratory investigations, blood transfusion, food, travel and other expenses. Corruption in the form of demands for under-the-table payments to obtain these aspects of essential care is rife. Adequate resources should be allocated to the different health facilities, including for emergency obstetric treatment. Thana health complexes (sub-district hospitals) should be upgraded to provide comprehensive obstetric care. The system for prescribing drugs should be reformed and the causes of corruption investigated and addressed. Hospital care should not be allowed to further impoverish the poor. Addressing these issues will help to encourage rural, poor women to seek skilled delivery and post-partum care, particularly in emergency situations.
Bangladesh↗
Less affluent area of residence and lesser-insured status predict an increased risk of death or myocardial infarction after angiographic diagnosis of coronary disease.
PURPOSE: Low socioeconomic status (SES) predicts coronary artery disease (CAD) onset, but its value among patients with CAD is uncertain. Geographic measures (e.g., residential neighborhood) may predict risk, but this requires further evaluation. METHODS: A cohort of 3410 patients with significant, angiographically-defined CAD (> or =1 lesion of > or =70% stenosis) joined a registry during the period between 1993 and 2000 and was followed for 6.7 years (median 3.7 years). A geographic SES measure-residential economic status (RES)-and insurance type were examined for association with mortality or myocardial infarction (MI). RESULTS: In Cox regression adjusting for 17 covariates, lower RES quartile was associated with increased death/MI (p-trend<0.001), death (p-trend=0.001), and MI (p-trend=0.07). First RES quartile (vs. fourth) predicted death/MI (hazard ratio [HR]=1.32, 95% confidence interval [CI]=1.07-1.62, p=0.01) and death (HR=1.46, CI=1.12-1.91, p=0.006), but not MI (HR=1.18, p=0.31). Compared with private insurance, self-pay (HR=1.88, p=0.053), charity care (HR=1.71, p<0.001), and Medicaid (HR=1.43, p=0.24), but not Medicare (HR=0.95, p=0.68), were associated with death/MI. CONCLUSIONS: Both geographic (RES) and economic (insurance) measures of SES independently predicted risk of death/MI in a large population with angiographically-defined CAD. This suggests that SES remains a significant predictor of health outcomes after CAD has developed, and that geographic measures of SES deserve further evaluation.
Adult↗
Access to preventive health care: is method of payment a barrier for immigrant Hispanic women?
This study describes the payment category of 397 low-income Hispanic women and the relationship to compliance with family planning visits the first year postbirth. Only one-fourth of the women returned for the one-year family planning visit, when they would have received well-woman care. Pay category was not a factor in identifying those who returned. Health system barriers, patient cultural beliefs, and life circumstance may explain why women enter and then leave apparently seamless systems of care. To increase preventive care, more study is needed of interventions that build on women's existing cultural prescriptions for health behavior by health professionals who portray postbirth checks as wellness checks.
Adolescent↗
The effect of managed care on primary care services for women.
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Capitation Fee↗
Medicare and drug coverage: a women's health issue.
The lack of prescription drug coverage under the Medicare program translates into high out-of-pocket drug costs for seniors. This nationwide study of older Americans with hypertension ("high blood pressure") demonstrates that women bear the disproportionate burden of this gap in Medicare coverage. Women form the majority of older people with hypertension, and are less likely to have supplemental policies to cover the cost of the prescription drugs that are needed to treat the disease. Moreover, women have substantially lower incomes. Despite their economic vulnerability, older women with hypertension spend substantially more on prescription drugs than men.
Aged↗
Adolescent health care expenditures: a descriptive profile.
PURPOSE: To examine health care spending patterns for U.S. adolescents aged 10 to 18 years using nationally representative household survey data. METHODS: We analyzed data from the 1997 Medical Expenditure Panel Survey on total expenditures and out-of-pocket expenditures for health care based on a sample of 4882 adolescents. RESULTS: Compared with that for adults, health care expenditures for adolescents were low, averaging $799 US dollars per adolescent in 1997. Disabled and functionally impaired adolescents had disproportionately high expenditures ($1960 US dollars per capita). Blacks and adolescents living in poor families had disproportionately low expenditures ($358 and $609 US dollars per capita, respectively). Professional services provided by physicians and dentists accounted for more than one-half of all health care spending for adolescents. Only 2% of adolescents were hospitalized in 1997, but they accounted for about one-fifth of all health care expenditures. The share of health expenditures paid out of pocket varied by type of service, ranging from 3% for inpatient hospital care to 51% for dental care. When covered, insurance provided substantial financial protection for families of adolescents: those with public coverage paid 8%, those with private coverage paid 32%, and those without coverage paid 61% of their health care bills out of pocket. The share of health care bills paid out of pocket would be much lower if dental care was excluded. CONCLUSIONS: On the basis of our findings that health care expenditures for adolescents are low and that insurance coverage provides critically needed financial protection, we conclude that further expansions of public and private health insurance coverage for this population would provide significant benefits at modest additional cost. Additional efforts to improve coverage of services that are not now well-covered, such as dental care, would also be valuable.
Adolescent↗
MR and conventional angiography: work in progress toward assessing utility in radiology.
RATIONALE AND OBJECTIVES: The authors assessed health-related quality of life changes associated with peripheral x-ray angiography and magnetic resonance (MR) angiography. MATERIALS AND METHODS: Utility (the desirability or preference that individuals exhibit for a particular health state) was assessed in 30 patients with peripheral vascular disease referred for angiography by using a rating scale, additional categoric scaling questions to separate preference from experience, a willingness-to-pay technique, functional and cognitive status questions, and a time trade-off technique. All patients underwent both MR angiography and x-ray angiography. RESULTS: Patients reported significantly (P < .05) less anxiety after the test, less pain after the test, fewer new physical limitations, and less effect on performance of daily activities with MR angiography. Findings from the overall rating scale and categoric scaling questions also significantly (P < .05) favored MR angiography. Patients were willing to pay a mean of 2.12% of annual income to avoid MR angiography and a mean of 7.41% to avoid x-ray angiography. The median quality-adjusted life gain required by patients to undergo the procedures was 52.5-60 days for x-ray angiography and 10.5 days for MR angiography, without discounting. CONCLUSION: X-ray angiography has more profound short-term adverse effects on life than does MR angiography. Preference-based measures can be adapted to elicit patient values for short-term health states as seen in radiology.
Angiography↗
Relationship between quality of life instruments, health state utilities, and willingness to pay in patients with asthma.
BACKGROUND: In asthma, a substantial impact of disease is on quality of life rather than survival. To date, the quality of life effects of asthma have not been quantitated. OBJECTIVE: The purpose of this study was to quantitate the quality of life effects of asthma via measurement of the health utility of asthmatic patients, and the willingness to pay for an asthma cure. A second goal was to analyze how these measures are related to the different dimensions of quality of life as measured by general and disease specific quality of life instruments. METHODS: Health utilities were measured on a scale between 0 and 1 using the rating scale, time trade off, and standard gamble methods. Willingness to pay was elicited using both the dichotomous choice and the bidding game approach. Quality of life was assessed using both a generic instrument (the SF-36) and a disease-specific instrument (the Asthma TyPE). RESULTS: Sixty-nine patients with asthma were surveyed. The mean health utility was 0.68 with the rating scale method, 0.89 with the time trade off, and 0.91 with the standard gamble. On average, patients were willing to pay between $200 to $350 dollars more per month for an asthma cure. Nearly all correlations between dimensions of quality of life, health state utilities, and willingness to pay were in the expected direction. CONCLUSION: The two quality of life instruments performed about equally well in terms of being correlated with and being able to explain the responses to the health state utility questions and the willingness to pay questions. Correlations between the dimensions of the Asthma TyPE and the SF-36 were also fairly high. Further work should focus on validating and refining the different methods of quantitating quality of life for asthma patients.
Adult↗
Showdown for Medicare reforms.
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Financing, Personal↗
A comparison of the availability and affordability of a market basket in two communities in the Chicago area.
OBJECTIVE: The purpose of the present study was to characterise the food landscape of an inner city African American neighbourhood and its mixed-race suburban neighbour. Detailed analysis focuses on the relationship between community store mix and price, availability and produce quality. DESIGN: A market basket study was completed by members of the Chicago Food Systems Collaborative. The US Department of Agriculture's standard market basket survey and methodology were used. Additional items and analyses were added in consultation with community members. SETTING: Austin is a lower-middle-class African American community of 117,500 on the western edge of Chicago. Oak Park, which borders Austin, is an upper-middle-income suburb of 52,500 with a mixed racial profile. SUBJECTS: A market basket survey of every retail food store in Austin and Oak Park was completed. A total of 134 were included. RESULTS: Results indicate that Austin has many grocery stores and few supermarkets. Many Austin groceries stores carry produce that is usually competitively priced, but often of unacceptable quality. Supermarkets had the best selection. Prices were lowest at discount supermarkets. Prices of packaged items were higher at independent stores than at chain supermarkets, but fresh items were cheaper. CONCLUSIONS: Food access is related more to store type than number. In this study, item availability and produce quality varied greatly between store types. Price differences were complicated and varied by store type and food category. This has consequences in terms of food purchasing decisions and dietary quality that public health professionals should acknowledge.
Chicago↗
Raising twin babies and problems in the family.
Out of 296 mothers of twins interviewed about difficulties encountered while rearing twins, 49% mentioned inadequate sleep, 18% financial strain, 39% emotional disturbance, 22% disturbance in the marital relationship, and 43% lack of time to take care of other children. With the growth of twins, the problems gradually decreased, except for emotional disturbance, the most difficult period being the first year. Only 15% reported leaving the babies in the care of relatives during the day time. Overall, 68.2% felt the support from the father, but 39% of them felt the support was useless; 49% felt support from the mother-in-law, but 43% of them regarded the mother-in-law to be of no help; 36% were supported by their own mothers, but 54% mentioned that they had received little help. One must conclude that social support from relatives was inadequate. Public policy should take this fact into account and provide public health nurses and social workers to help the mothers of twins, especially during the first year.
Affective Symptoms↗
The use of hearing aids in the Northern Region.
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Adolescent↗
The construction, development and testing of a self-report questionnaire to identify social problems.
The construction and testing of a short self-report questionnaire identifying social problems, difficulties and dissatisfactions is described. The questionnaire covers housing, occupation, finance, social and leisure activities, child/parent and martial relationships, relationships with relatives, friends, neighbours and workmates, and legal problems. The results of the administration of the questionnaire in a number of settings are provided and discussed, and a final version is included in the Appendix.
Employment↗