The National Institute on Aging and the Alzheimer's Association charged a workgroup with the task of revising the 1984 criteria for Alzheimer's disease (AD) dementia. The workgroup sought to ensure that the revised criteria would be flexible enough to be used by both general healthcare providers without access to neuropsychological testing, advanced imaging, and cerebrospinal fluid measures, and specialized investigators involved in research or in clinical trial studies who would have these tools available. We present criteria for all-cause dementia and for AD dementia. We retained the general framework of probable AD dementia from the 1984 criteria. On the basis of the past 27 years of experience, we made several changes in the clinical criteria for the diagnosis. We also retained the term possible AD dementia, but redefined it in a manner more focused than before. Biomarker evidence was also integrated into the diagnostic formulations for probable and possible AD dementia for use in research settings. The core clinical criteria for AD dementia will continue to be the cornerstone of the diagnosis in clinical practice, but biomarker evidence is expected to enhance the pathophysiological specificity of the diagnosis of AD dementia. Much work lies ahead for validating the biomarker diagnosis of AD dementia.

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The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer's disease

Background Little is known about the general population prevalence or severity of DSM-IV mental disorders. Objective To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Participants Nine thousand two hundred eighty-two English-speaking respondents 18 years and older. Main Outcome Measures Twelve-month DSM-IV disorders. Results Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population. Conclusion Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.

/pdf/prevalence-severity-and-comorbidity-of-12-month-dsm-iv-54fahxwd1s.pdf

Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication

ContextUncertainties exist about prevalence and correlates of major depressive
disorder (MDD).ObjectiveTo present nationally representative data on prevalence and correlates
of MDD by Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) criteria, and on study
patterns and correlates of treatment and treatment adequacy from the recently
completed National Comorbidity Survey Replication (NCS-R).DesignFace-to-face household survey conducted from February 2001 to December
2002.SettingThe 48 contiguous United States.ParticipantsHousehold residents ages 18 years or older (N = 9090) who responded
to the NCS-R survey.Main Outcome MeasuresPrevalence and correlates of MDD using the World Health Organization's
(WHO) Composite International Diagnostic Interview (CIDI), 12-month severity
with the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR),
the Sheehan Disability Scale (SDS), and the WHO disability assessment scale
(WHO-DAS). Clinical reinterviews used the Structured Clinical Interview for DSM-IV.ResultsThe prevalence of CIDI MDD for lifetime was 16.2% (95% confidence interval
[CI], 15.1-17.3) (32.6-35.1 million US adults) and for 12-month was 6.6% (95%
CI, 5.9-7.3) (13.1-14.2 million US adults). Virtually all CIDI 12-month cases
were independently classified as clinically significant using the QIDS-SR,
with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9% very severe. Mean
episode duration was 16 weeks (95% CI, 15.1-17.3). Role impairment as measured
by SDS was substantial as indicated by 59.3% of 12-month cases with severe
or very severe role impairment. Most lifetime (72.1%) and 12-month (78.5%)
cases had comorbid CIDI/DSM-IV disorders, with MDD
only rarely primary. Although 51.6% (95% CI, 46.1-57.2) of 12-month cases
received health care treatment for MDD, treatment was adequate in only 41.9%
(95% CI, 35.9-47.9) of these cases, resulting in 21.7% (95% CI, 18.1-25.2)
of 12-month MDD being adequately treated. Sociodemographic correlates of treatment
were far less numerous than those of prevalence.ConclusionsMajor depressive disorder is a common disorder, widely distributed in
the population, and usually associated with substantial symptom severity and
role impairment. While the recent increase in treatment is encouraging, inadequate
treatment is a serious concern. Emphasis on screening and expansion of treatment
needs to be accompanied by a parallel emphasis on treatment quality improvement.

/pdf/the-epidemiology-of-major-depressive-disorder-results-from-2kfxdgis3p.pdf

The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R).

Background. A 10-question screening scale of psychological distress and a six-question short-form scale embedded within the 10-question scale were developed for the redesigned US National Health Interview Survey (NHIS). Methods. Initial pilot questions were administered in a US national mail survey (N fl 1401). A reduced set of questions was subsequently administered in a US national telephone survey (N fl 1574). The 10-question and six-question scales, which we refer to as the K10 and K6, were constructed from the reduced set of questions based on Item Response Theory models. The scales were subsequently validated in a two-stage clinical reappraisal survey (N fl 1000 telephone screening interviews in the first stage followed by N fl 153 face-to-face clinical interviews in the second stage that oversampled first-stage respondents who screened positive for emotional problems) in a local convenience sample. The second-stage sample was administered the screening scales along with the Structured Clinical Interview for DSM-IV (SCID). The K6 was subsequently included in the 1997 (N fl 36116) and 1998 (N fl 32440) US National Health Interview Survey, while the K10 was included in the 1997 (N fl 10641) Australian National Survey of Mental Health and Well-Being. Results. Both the K10 and K6 have good precision in the 90th‐99th percentile range of the population distribution (standard errors of standardized scores in the range 0‐20‐0‐25) as well as consistent psychometric properties across major sociodemographic subsamples. The scales strongly discriminate between community cases and non-cases of DSM-IV}SCID disorders, with areas under the Receiver Operating Characteristic (ROC) curve of 0‐87‐0‐88 for disorders having Global Assessment of Functioning (GAF) scores of 0‐70 and 0‐95‐0‐96 for disorders having GAF scores of 0‐50. Conclusions. The brevity, strong psychometric properties, and ability to discriminate DSM-IV cases from non-cases make the K10 and K6 attractive for use in general-purpose health surveys. The scales are already being used in annual government health surveys in the US and Canada as well as in the WHO World Mental Health Surveys. Routine inclusion of either the K10 or K6 in clinical studies would create an important, and heretofore missing, crosswalk between community and clinical epidemiology.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/F141675CCD0E08C0FB98E01C006B4E0D/S0033291702006074a.pdf/div-class-title-short-screening-scales-to-monitor-population-prevalences-and-trends-in-non-specific-psychological-distress-div.pdf

Short screening scales to monitor population prevalences and trends in non-specific psychological distress.

Offering a unifying theoretical perspective not readily available in any other text, this innovative guide to econometrics uses simple geometrical arguments to develop students' intuitive understanding of basic and advanced topics, emphasizing throughout the practical applications of modern theory and nonlinear techniques of estimation. One theme of the text is the use of artificial regressions for estimation, reference, and specification testing of nonlinear models, including diagnostic tests for parameter constancy, serial correlation, heteroscedasticity, and other types of mis-specification. Explaining how estimates can be obtained and tests can be carried out, the authors go beyond a mere algebraic description to one that can be easily translated into the commands of a standard econometric software package. Covering an unprecedented range of problems with a consistent emphasis on those that arise in applied work, this accessible and coherent guide to the most vital topics in econometrics today is indispensable for advanced students of econometrics and students of statistics interested in regression and related topics. It will also suit practising econometricians who want to update their skills. Flexibly designed to accommodate a variety of course levels, it offers both complete coverage of the basic material and separate chapters on areas of specialized interest.

Estimation and Inference in Econometrics

Price Indexes for Medical Care Goods and Services

Americans purchase health insurance in various ways. Some buy individual policies. For them, medical underwriting is common, and preexisting conditions can preclude, limit, or dramatically increase the cost of coverage. Many buy insurance through small employers, which typically offer little or no choice of plan. Their premiums tend to be higher than those of consumers purchasing through large employers, which can bargain effectively on prices. Large employers usually offer a modest selection of high-quality plans at competitive prices. Medicare recipients can join traditional Medicare and then choose drug coverage from any of dozens of stand-alone prescription-drug plans (PDPs) or join MedicareAdvantage and choose among numerous private health plans. Given that plan choices are difficult to make and that large purchasers can whittle down prices, a reformed health care system is likely to employ health insurance exchanges to stand between consumers and insurers. The Massachusetts Health Insurance Connector, in operation since 2007, runs the best-known such organization.

Health Insurance Exchanges â€” Making the Markets Work

Policy Points Much concern about generic drug markets has emerged in recent policy debates. Important changes in regulations, the structure of purchasing, and the length of the drug supply chain have affected generic drug markets. Effective price competition remains the rule in generic markets for large-selling drugs. Smaller markets and those for injectable products often have less price competition and are more susceptible to supply disruptions. Context The image of generic drugs as a commodity sold in competitive markets is an oversimplification, as evidenced by increasing accounts of price spikes, sustained high price-cost margins, and market disruptions. The mismatch between the canonical economic model of generic drug markets and reality motivated our empirical project. Methods To explore recent changes in those factors impacting the supply and demand for generic drugs, we studied, from a variety of sources, the data on price, competition, supply disruptions and recalls, changes to the supply chain, and buy-side concentration. We examined quarterly data through 2018 for a cohort of 77 molecules that lost patent protection during the so-called patent cliff between 2010 and 2013. Findings On the supply side, we found that for large-market oral solids, generic entry and price declines were consistent with past studies showing a significant number of market entrants and substantial reductions in the average price of a molecule. In smaller markets for oral solids and injectable products, we observed fewer entrants, higher rates of exit, smaller price reductions, and, in some cases, considerable price instability. The number of reported shortages increased across all generic market types over time, with the rate of shortage increases especially pronounced in markets for injectable products. The number of product recalls also rose over our study period. Although we did not estimate causal effects, we did find several changes in the market environment for generic drugs that may contribute to these phenomena. The demand side for generics has become more concentrated. Supply chains rely more on producers outside the United States (particularly from China and India). Contracting practices have undergone changes that may inhibit competition in product supply. FDA regulatory scruitiny has increased. Conclusions Competition in generic drug markets varies widely by market size and product form. Recent changes in demand-side market structure imply more downward pressure on prices stemming from buy-side concentration. The FDA's greater regulatory oversight puts upward pressure on costs, and the lengthening of the supply chain increases production uncertainty for producers. Demand and supply-side changes point to further market instabilities across all generic markets due to producers' changing economic position.

The Evolution of Supply and Demand in Markets for Generic Drugs.

The Affordable Care Act is altering the way healthcare is delivered, addressing new demonstrations that will make innovative care models 'business as usual.' Is our workforce ready for the changes? In their 2008 report, "Retooling for an Aging America: Building the Healthcare Workforce," the Institute of Medicine (IOM) articulated a vision for the future care of aging adults with a key feature being new models of care. They built this vision upon three quality principles that the IOM had articulated nearly a decade earlier: addressing the healthcare needs of the older population in a comprehensive manner; providing services efficiently; and enabling older individuals to be key partners in their own care. The report proposed new models of care to achieve this vision, and that activating these models would require meaningful changes in the workforce. Apparently, the U.S. Congress took note because the Affordable Care Act (ACA) includes a number of important provisions promoting promising service models, such as Accountable Care Organizations; establishing new demonstrations, such as Independence at Home; and making it easier for states and provider organizations to make proven models of care part of their business as usual. In this article, we describe the target population for many of the improved and new models of care-older adults with multiple chronic conditions and functional impairments. We highlight some of the new and evolving models included in the ACA as they relate to the target population, then focus on features of the new models that aim to improve quality of care and have important implications for the workforce. Next, we provide a snapshot of the current long-term services and supports (LTSS) direct-care workforce, and reconcile what we know about today's workforce with the workforce implications of selected ACA provisions- including training, new provider organizations, workplace design, delegations of authority, and restructuring of payment incentives. Finally, we offer some thoughts about implementation, evaluation, and the evolution of changing models of care and their workforce consequences. While we focus primarily on the direct-care workers who deliver LTSS, we recognize many new program models and demonstrations also have implications for other professionals, such as geriatricians, nurses, and social workers. The Population In recent years, policy makers have paid a great deal of attention to the financial and human costs of chronic medical conditions. Roughly half of the U.S. population has at least one chronic condition, and caring for them accounts for nearly 80 percent of healthcare spending in this country. Closer examination of the data reveals that within this population, spending is concentrated on a subset of people with a constellation of care needs. Less than a third of people with a chronic condition experience a functional limitation in one or more activities of daily living. People with a chronic condition who also receive assistance with a functional impairment represent only 14 percent of adult community residents, yet they account for 46 percent of healthcare spending. This group spends three-fold that spent by people with just a functional impairment (Alecxih et al., 2010). About 42 percent of this spending went for in-patient (largely hospital) care, primarily paid for by Medicare. The direct-care workforce is a critical cog in serving this population, which faces challenges in mobility, complications in access to healthcare, and communication problems. Ideas aimed at improving the quality and efficiency of the workforce caring for these individuals must recognize the complexities of serving people with health conditions and functional impairments. Further, innovative approaches to hiring, firing, training, promoting, organizing, and paying workers must recognize that most older individuals want to live independently for as long as possible, even when they need services and supports. …

A Vision for the Future: New Care Delivery Models Can Play a Vital Role in Building Tomorrow's Eldercare Workforce

A question that is of central importance to health policy overall and policy towards Aprescription drug markets specifically is, are the revenues of pharmaceutical manufacturers too high? Answering this question for prescription drugs is harder than it is for many other products because prescription drugs can be produced for pennies a pill but it takes many millions of dollars to bring a new drug to market. We judge the performance of the prescription drug market according to whether important new drugs are developed to treat disease and extend life and by how much we spend on pharmaceuticals. These 2 goals conflict in a basic way. Public policy reflects that conflict. On the one hand, we have established a patent system aimed at protecting intellectual property rights and creating economic incentives for pharmaceutical firms to bring new drugs to market. On the other hand, we continuously debate how to hold down the costs of prescription drugs. Patents establish periods during which a seller of prescription drugs is given market power (in some cases a monopoly) that permits them to sell at higher prices and earn higher profits than would result in a competitive market. It is this profit that is supposed to cover the costs of developing new drugs and provide prescription drug manufacturers with a return sufficient to justify the investment in Research and Development (R&D). The purpose of the patent system is to create temporary market power for the firm that innovates because a competitive market would drive prices down to something approximating the incremental costs of production (pennies a pill). Such prices would result in revenues that would not permit pharmaceutical companies to recover their investments in R&D. Efficient policy would be reflected by a market that results in just enough profit to pharmaceutical manufacturers to induce adequate innovation and not a penny more. How would we know such a market if we saw one? This would require calculating rates of return in the pharmaceutical industry that appropriately take account of the costs of R&D and compare it to the rates of return in other industries. This was the subject of a comprehensive study by the now defunct Congressional Office of Technology Assessment (OTA).1 Assessing pharmaceutical rates of return is a very difficult undertaking, and wide agreement on estimates is hard to reach. Much of the passion in the debate over the cost of bringing new drugs to market stems from the implications for pharmaceutical rates of return. The idea is that excess profits would be an indicator that we pay prescription drug manufacturers too much while rates of return below those in other industries would signal too little is being paid. The paper by Keyhani, Deiner-West, and Powe in this issue of Medical Care2 attempts to offer empirical evidence on whether Americans pay too much for pharmaceutical products by examining the relationship between indicators of development costs and prices. As discussed above, in a competitive market, prices are related to incremental production costs but not fixed or sunk costs (like R&D). In markets for brand name

Richard G. Frank

Papers

Price Indexes for Medical Care Goods and Services

Health Insurance Exchanges â€” Making the Markets Work

The Evolution of Supply and Demand in Markets for Generic Drugs.

A Vision for the Future: New Care Delivery Models Can Play a Vital Role in Building Tomorrow's Eldercare Workforce

Looking for truth in all the wrong places.