Health Affairs

BACKGROUND: The use of in vitro fertilization has engendered considerable debate about who should have the procedure, whether health insurance should cover the cost, and if so, to what extent. We investigated the cost of a successful delivery with in vitro fertilization. METHODS: We calculated the cost per successful delivery with in vitro fertilization (defined as at least one live birth) for a general population of couples undergoing in vitro fertilization and for two subgroups: couples with a diagnosis of tubal disease (who have a better chance of success), and couples in which the woman is over the age of 40 years and the man has a low sperm count (who have a lower chance of success). Information on charges per cycle of in vitro fertilization was obtained from six facilities across the country; delivery rates with this procedure were estimated from the literature. RESULTS: On average, the cost incurred per successful delivery with in vitro fertilization increases from $66,667 for the first cycle of in vitro fertilization to $114,286 by the sixth cycle. The cost increases because with each cycle in which fertilization fails, the probability that a subsequent effort will be successful declines. Sensitivity analyses indicated that the cost per delivery ranges from $44,000 to $211,940. For couples with a better chance of successful in vitro fertilization (i.e., those with a diagnosis of tubal disease), it costs $50,000 per delivery for the first cycle and $72,727 for the sixth. For couples in which the woman is older and there is a diagnosis of male-factor infertility, the cost rises from $160,000 for the first cycle to $800,000 for the sixth. CONCLUSIONS: The debate about insurance coverage for in vitro fertilization must take into account ethical judgments and social values. But analyses of costs and cost effectiveness help elucidate the economic implications of using in vitro fertilization and thus inform the policy discussion.

The use of in vitro fertilization (IVF) has increased rapidly in recent years and debate has focused on whether health insurance should cover the procedure. We developed and disseminated a contingent valuation survey to investigate how individuals value IVF treatment. Couples pursuing in vitro fertilization can be viewed as purchasing an increased probability of conceiving and bearing a child. In our survey, respondents were asked if they would pay stated amounts for IVF, under various assumptions about the probability of success. The survey explores the ex post perspective, (respondents' willingness to pay (WTP) for IVF in the event that they are infertile), the ex ante perspective, (WTP for IVF insurance, assuming respondents do not know their infertility status), WTP for a public IVF program, and how respondents value IVF relative to mortality risk reduction. Among 150 respondents who were potential childbearers, average WTP was $17,730 for a 10% chance at having a child through IVF in the event of infertility. Average WTP was $865 for a lifetime insurance benefit providing access to a 10% chance. Among 231 respondents of all ages, average WTP was $32 per year in taxes for a public program giving 1,200 couples per year in Massachusetts a 10% chance. The estimated implied ex post WTP per statistical baby was $177,730, while ex ante WTP per statistical baby was $1.8 million. The results of regression analyses were consistent with theoretical predictions, (e.g., increasing WTP with household income). The contingent valuation method is a potentially useful tool in understanding how people value the benefits of IVF. Further research is needed to test the validity of this methodology.

OBJECTIVES: Although the broad impacts of Alzheimer's disease (AD) are increasingly recognized, little work has focused on the overall health-related quality of life experienced by Alzheimer's disease patients and their caregivers. The study had two main objectives: (1) to test the feasibility of measuring health utilities in Alzheimer's disease with a generic preference-weighted instrument using proxy respondents and (2) to assess the utility scores of Alzheimer's disease patients (and their caregivers) in different disease stages and care setting. METHODS: A cross-sectional study of 679 Alzheimer's disease patient/caregiver pairs was conducted at 13 sites in the United States: four academic medical centers, four managed care plans, two assisted living facilities, and three nursing homes. The Health Utilities Index Mark II (HUI:2) questionnaire was administered to caregivers of patients who responded both as proxies for patients and for themselves. Responses to the questionnaire were converted into a global utility score, between 0 and 1, using the HUI:2 multi-attribute utility function. RESULTS: Global utility scores varied considerably across patients' Alzheimer's disease stage: for the six stages assessed (questionable, mild, moderate, severe, profound, and terminal), mean utility scores were 0.73, 0.69, 0.53, 0.38, 0.27, and 0.14, respectively. In multiple regression analyses, Alzheimer's disease stage was a negative and significant predictor of utility scores for patients; setting did not exert an independent effect. Utility scores for the caregivers were insensitive to patients' Alzheimer's disease stage and setting. CONCLUSIONS: Patients' Alzheimer's disease stage had a substantial influence on health utilities, as measured by the HUI:2. More research is needed to assess the validity of using proxy respondents.

This study informs policy makers and third-party payers of the prevalence and characteristics of the severely to profoundly hearing-impaired population in the United States. Nationally representative data were used for estimations in consultation with an expert advisory panel. The prevalence of severe to profound hearing impairment among the US population ranges from 464,000 to 738,000, with 54 percent of this population over age 65 years. Persons with hearing impairment are more likely to be publicly insured, less likely to have private insurance, have lower family incomes, are less educated, and are more likely to be unemployed than the general population. Approximately half a million Americans are severely to profoundly hearing impaired and appear to be more vulnerable, both financially and educationally, as compared to the US population. As a result, access to medical and technological interventions that may assist their hearing loss may be limited.

Whether they realize it or not, journalists reporting on health care developments deliver public health messages that can influence the behavior of clinicians and patients. Often these messages are delivered effectively by seasoned reporters who perform thoughtfully even in the face of breaking news and tight deadlines. But all too frequently, what is conveyed about health by many other journalists is wrong or misleading. Some distortion is attributable to ignorance or an inability to interpret and convey the nuanced results of clinical studies. And some is due to uncertainty about journalists' proper role: Is our job to describe the bigger . . .

The provision of high-quality, efficient care results from the coordinated, cooperative efforts of multiple technically competent health care providers working in concert over time, spanning disciplinary and professional boundaries. Accordingly, the role of medical education must include the development of providers who are both expert clinicians and expert team members. However, the competencies underlying effective teamwork are only just beginning to be integrated into medical school curricula and residency programs. Therefore, continuing education (CE) is a vital mechanism for practitioners already in the field to develop the attitudes, behaviors (skills), and cognitive knowledge necessary for highly reliable and effective team performance.The present article provides an overview of more than 30 years of evidence regarding team performance and team training in order to guide, shape, and build CE activities that focus on developing team competencies. Recognizing that even the most comprehensive and well-designed team-oriented CE programs will fail unless they are supported by an organizational and professional culture that values collaborative behavior, ten evidence-based lessons for practice are offered in order to facilitate the use of the science of team-training in efforts to foster continuous quality improvement and enhance patient safety.

Preterm pregnancies account for approximately 10% of the total pregnancies and are associated with low birth weight (LBW) babies. Recent studies have shown that LBW babies are at an increased risk of developing brain disorders such as cognitive dysfunction and psychiatric disorders. Maternal nutrition, particularly, micronutrients involved in one-carbon metabolism (folic acid, vitamin B(12), and docosahexaenoic acid (DHA)) have a major role during pregnancy for developing fetus and are important determinants of epigenesis. A series of our studies in pregnancy complications have well established the importance of omega 3 fatty acids especially DHA. DHA regulates levels of neurotrophins like brain-derived neurotrophic factor and nerve growth factor, which are required for normal neurological development. We have recently described that in one carbon metabolic pathway, membrane phospholipids are major methyl group acceptors and reduced DHA levels may result in diversion of methyl groups toward deoxyribonucleic acid (DNA) ultimately resulting in DNA methylation. In this review, we propose that altered maternal micronutrients (folic acid, vitamin B(12)), increased homocysteine, and oxidative stress levels that cause epigenetic modifications may be one of the mechanisms that contribute to preterm birth and poor fetal outcome, increasing risk for behavioural disorders in children.

Though HIV/AIDS has spread to rural areas, little empirical evidence is available on where patients living in these areas receive care. This article presents estimates of rural residents in care for HIV/AIDS, their demographic and health-related characteristics, information about whether they receive care in a rural or urban setting, and data on the drug therapies prescribed. The estimates come from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults receiving care in the contiguous United States. Regardless of the definition used--enrollment site, usual source of HIV care, or site of most recent hospitalization--almost three quarters of rural residents with HIV/AIDS obtained their health care in urban areas. The authors find that differences in the demographic characteristics of those using urban vs. rural care do not drive the decision on where to obtain care, with the primary difference being that people with a rural provider tend to be older. Rural residents with an urban usual source of HIV care incurred significant inconvenience in obtaining care--the majority said their care was not conveniently located, they had substantially longer mean travel times, and over 25% had put off obtaining care in the past 6 months because they did not have a way to get to their provider. Given the considerable burden this places on a chronically ill population,further research is needed to explore how provider supply and provider experience affect the decision to travel for care and how quality of care is affected.

The issue on "The Patient Experience in Ontario 2020: What is Possible?"taught us how Ontario is trying to shift to a consistent culture of patient engagement at all levels of their healthcare system, from clinical to organizational and political.We all know that our healthcare systems, built between 1940 and 1970, were structured around acute and highly specialized care provided by health facilities.Now, we see that needs have changed considerably over the last 30 years due to a significant increase in the prevalence of chronic diseases (Beaglehole et al. 2011), which is currently the leading cause of morbidity and mortality in Western countries ( Jeon et al. 2009).In particular, in Canada, 65% of the population aged 12 and above and 90% of Patient Engagement: The Quebec Path

After 30 years of supporting graduate medical education through open-ended payment policies that rewarded academic medical centers for producing more physicians, the federal government last year curtailed Medicare's generous commitment to subsidize the training of new doctors. At the same time, Congress reclaimed for teaching hospitals the educational funds that were embedded in Medicare's payments to managed-care organizations, most of which were not passed on to the institutions actually doing the training. These provisions and many more (some 300 in the case of Medicare alone) were contained in the Balanced Budget Act of 1997, a measure signed into law last . . .

BACKGROUND: Maternal fatty acid nutrition during pregnancy and lactation determines the transfer of long-chain polyunsaturated fatty acids via the placenta and through human milk. Neural maturation of breast-fed infants is known to be linked to breast-milk long-chain polyunsaturated fatty acid concentrations. In spite of this, the fatty acid composition of breast milk in pre-eclamptic mothers is poorly understood. OBJECTIVES: To compare the fatty acid composition of breast milk of pre-eclamptic (n = 45) with normotensive (n = 85) mothers and examine the association of breast-milk fatty acids with plasma fatty acids. METHODS: Milk and plasma fatty acid methyl esters were prepared and analyzed by the modified method of Manku and colleagues using gas chromatography. RESULTS: Docosahexaenoic acid (DHA) concentrations were significantly increased (p < 0.01) in breast milk in spite of lower maternal plasma DHA concentrations (p < 0.05) in pre-eclamptic women. However, there was no difference in arachidonic acid levels between groups in spite of reduced maternal plasma arachidonic acid levels. CONCLUSIONS: The data suggest that in pre-eclampsia, the relation between plasma and milk DHA is altered. The resulting higher milk DHA concentrations are beneficial for infants.

Few health care providers have the training to address depression, anxiety, and other conditions in their older patients.

BACKGROUND AND AIM: Maternal nutrition is an important determinant of the duration of pregnancy and fetal growth, and thereby influences pregnancy outcome. Folic acid and vitamin B(12) are involved in one-carbon metabolism and are reported to underlie intrauterine programming of adult diseases. METHODS: In the present study, the levels of folate, vitamin B(12) and homocysteine were measured in mothers delivering preterm (PT; gestation <37 weeks; n = 67), those delivering preterm due to preeclampsia (PT-PE; n = 49) and women delivering at term (control group; n = 76). RESULTS: Increased vitamin B(12) and homocysteine levels (p < 0.05 for both) were seen in the PT-PE and PT groups as compared to the controls. In addition, reduced folate levels (p < 0.05) were observed in the PT group. A negative association of maternal plasma homocysteine with birth weight was seen in the idiopathic preterm group. CONCLUSIONS: Altered maternal micronutrients and resultant increased homocysteine concentrations exist in women delivering preterm. These alterations may also be partly associated with other factors such as undiagnosed inflammatory conditions or inadequate placentation in some women. Since these micronutrients play an important role in epigenetic regulation of vital genes involved in the fetal programming of adult diseases, further studies need to be undertaken to understand their role in preterm deliveries.

Data from a 1996 cross-sectional study examining the costs of care for Alzheimer's Disease patients are used to estimate the potential cost savings that could result by substituting assisted living for nursing home care for AD residents with health profiles that appear to be manageable within assisted living facilities that specialize in dementia care. Results indicate that up to 13.9% of nursing home costs could be saved, making such a service substitution an attractive alternative in the provision of residential care for certain categories of AD patients.

BACKGROUND/AIMS: Our earlier study has shown that increased maternal oxidative stress and reduced antioxidants like vitamin E and C play an important role in fetal growth in preeclampsia. However, the role of antioxidants and their effects on gestation and birth outcome in normotensive pregnancies are not conclusive. The present study examined plasma malondialdehyde as a marker of oxidative stress and antioxidant concentrations (vitamins E and C) in maternal as well as in cord blood samples in normotensive women who delivered both preterm and at term. METHODS: 140 normotensive pregnant women were recruited at Bharati Medical Hospital, Pune, India, during the year 2007. Maternal and cord samples were examined for oxidative stress levels and vitamin C and E concentrations in women who delivered preterm (n=40) and at term (n=100). Mean values were compared with those of women delivering at term using the t test. RESULTS: Increased (p<0.05) oxidative stress was seen in preterm mothers as well as in cord samples. Preterm mothers had higher vitamin C concentrations (p<0.05), and these were positively associated with oxidative stress (p=0.02). Vitamin E levels were comparable between groups. CONCLUSIONS: Increased maternal circulating vitamin C concentrations and increased oxidative stress are associated with preterm delivery.

Allopathic medical schools in the United States enroll and graduate a total of about 16,000 students a year — a number that has been remarkably consistent for two decades.1 Interest in medical education has remained high throughout this period, with the result that more applications to medical schools have been rejected every year than have been accepted, despite the excellent qualifications of many of the candidates whose applications are rejected. At the same time, the number of entry-level residency positions in U.S. teaching hospitals has greatly exceeded the number of graduates of U.S. medical schools. As a result, teaching hospitals . . .

OBJECTIVES: The introduction of the Medicare Prospective Payment System and the more recent rise of managed care plans have greatly increased the importance of effective hospital financial management. Because physicians play a central role in directing hospital resource use, policies to influence physician behavior and to align physician and hospital interests more effectively are being advocated increasingly. This article evaluates the effect of nine strategies to facilitate physician involvement and integration into the hospital on hospital financial performance. METHODS: Data came primarily from the Prospective Payment Assessment Commission's hospital-physician relations survey of 1,485 hospitals and the Medicare Cost Reports. Both ordinary least squares and first differencing models were used to evaluate the effect of physician integration on hospital financial performance. RESULTS: Hospitals with lower margins and higher costs were more likely to have implemented strategies to integrate physicians and to modify physician behavior than their counterparts. Analysis using first differencing models indicated that making department heads responsible for the profits and losses had a significant positive effect on margins, whereas including medical staff on the hospital's board and offering physicians management services had a significant negative impact on average Medicare costs. In addition the number of strategies implemented was associated positively with financial performance. The paper also emphasizes the importance of model specification in evaluations of hospital-physician arrangements. CONCLUSIONS: Changes in hospital-physician relations may have been one reason why hospitals have been relatively successful at containing costs and retaining profitability in recent years. More research needs to be done on which specific arrangements affect hospital financial performance, as well as their effect on the quality of patient care.

Importance: Military and civilian trauma experts initiated a collaborative effort to develop an integrated learning trauma system to reduce preventable morbidity and mortality. Because the Department of Defense does not currently have recommended guidelines and standard operating procedures to perform military preventable death reviews in a consistent manner, these performance improvement processes must be developed. Objectives: To compare military and civilian preventable death determination methods to understand the existing best practices for evaluating preventable death. Evidence Review: This systematic review followed the PRISMA reporting guidelines. English-language articles were searched from inception to February 15, 2017, using the following databases: MEDLINE (Ovid), Evidence-Based Medicine Reviews (Ovid), PubMed, CINAHL, and Google Scholar. Articles were initially screened for eligibility and excluded based on predetermined criteria. Articles reviewing only prehospital deaths, only inhospital deaths, or both were eligible for inclusion. Information on study characteristics was independently abstracted by 2 investigators. Reported are methodological factors affecting the reliability of preventable death studies and the preventable death rate, defined as the number of potentially preventable deaths divided by the total number of deaths within a specific patient population. Findings: Fifty studies (8 military and 42 civilian) met the inclusion criteria. In total, 1598 of 6500 military deaths reviewed and 3346 of 19 108 civilian deaths reviewed were classified as potentially preventable. Among military studies, the preventable death rate ranged from 3.1% to 51.4%. Among civilian studies, the preventable death rate ranged from 2.5% to 85.3%. The high level of methodological heterogeneity regarding factors, such as preventable death definitions, review process, and determination criteria, hinders a meaningful quantitative comparison of preventable death rates. Conclusions and Relevance: The reliability of military and civilian preventable death studies is hindered by inconsistent definitions, incompatible criteria, and the overall heterogeneity in study methods. The complexity, inconsistency, and unpredictability of combat require unique considerations to perform a methodologically sound combat-related preventable death review. As the Department of Defense begins the process of developing recommended guidelines and standard operating procedures for performing military preventable death reviews, consideration must be given to the factors known to increase the risk of bias and poor reliability.

Obtaining high response rates on physician surveys provides a difficult challenge to health services researchers. Recent studies have indicated that the use of a prepaid incentive can dramatically increase response rates. The National Survey of Diagnostic Allergy Testing included a controlled experiment in which one group of respondents received a prepaid monetary incentive while a second group did not receive an incentive. Persons assigned to a third group received a prepaid incentive only if they did not respond to the first mailing. The study examined whether or not the decision to provide a monetary incentive can be postponed until the results of the initial mailing are available. This would enable researchers to restrict the use of monetary incentives to surveys where early results indicate response rates may be inadequate. The findings confirmed earlier studies which indicated that the use of a prepaid incentive leads to a large increase in response rate. The study indicated, however, that the value of a prepaid incentive is greatly diminished if the inventive is postponed until the second mailing. The study also indicated the great majority of nonresponders do not cash the incentive checks. The prepaid incentive is, therefore, an effective and relatively inexpensive way of reducing

Since the mid-19th century, when the first formal health departments were established in the United States, commissioners, directors, and secretaries of public health have functioned as senior members of the staffs of public executives, mayors, governors, and presidents. They have provided important political, managerial, and scientific leadership to agencies of government that have played increasingly important roles in national life, from the sanitary revolution of the 19th century to the prevention of HIV/AIDS and the control of tobacco use today. Although public health officials come from a variety of backgrounds and oversee agencies of varied size and composition, there are philosophical themes that describe and define the commonality of their work. These themes are captured metaphorically by 3 celebrated figures: Don Quixote, Machiavelli, and Robin Hood. By turns, the public health official functions as a determined idealist (Don Quixote), a cunning political strategist (Machiavelli), and an agent who redistributes resources from the wealthier sectors of society to the less well off (Robin Hood.) All 3 personae are important, but, it is argued, Robin Hood is the most endangered.