Showing papers by "RAND Corporation published in 2008"
TL;DR: A systematic review was performed to synthesize the evidence for using publicly reported performance data to stimulate quality improvement activity, affect selection of providers, and improve clinical outcomes (effectiveness, patient safety, and patient-centeredness), and to assess theEvidence for unintended consequences.
Abstract: Public reporting of health care system performance might cause patients to migrate to high-performing systems, creating a business case for quality improvement programs. The authors synthesized the...
847 citations
TL;DR: This report focused on cancer, chronic heart failure, and dementia to illustrate differences in patient and caregiver experiences in the 3 characteristic trajectories of clinical and functional decline as they approach the end of life.
Abstract: This systematic evidence review supports the American College of Physicians guideline on palliative care at the end of life. Strong to moderate evidence supports use of various treatments for cance...
568 citations
TL;DR: A systematic review of 76 randomized trials and 24 meta-analyses found good evidence that several agents, including alendronate, zoledronic acid, and estrogen, reduced the risk for vertebral and...
Abstract: This systematic review of 76 randomized trials and 24 meta-analyses found good evidence that several agents, including alendronate, zoledronic acid, and estrogen, reduced the risk for vertebral and...
477 citations
TL;DR: The National Institutes of Health-sponsored Centers for Population Health and Health Disparities are the first federal initiative to support transdisciplinary multilevel research on the determinants of health disparities.
Abstract: Addressing health disparities has been a national challenge for decades. The National Institutes of Health-sponsored Centers for Population Health and Health Disparities are the first federal initiative to support transdisciplinary multilevel research on the determinants of health disparities. Their novel research approach combines population, clinical, and basic science to elucidate the complex determinants of health disparities. The centers are partnering with community-based, public, and quasi-public organizations to disseminate scientific findings and guide clinical practice in communities. In turn, communities and public health agents are shaping the research. The relationships forged through these complex collaborations increase the likelihood that the centers' scientific findings will be relevant to communities and contribute to reductions in health disparities.
445 citations
TL;DR: The positive association of neighborhood SES with fruit and vegetable intake is one important pathway through which the social environment of neighborhoods affects population health and nutrition for whites, blacks, and Hispanics in the United States.
415 citations
01 Jan 2008
TL;DR: This chapter uses examples of three software engineering surveys to illustrate the advantages and pitfalls of using surveys and discusses the six most important stages in survey-based research.
Abstract: Although surveys are an extremely common research method, surveybased research is not an easy option. In this chapter, we use examples of three software engineering surveys to illustrate the advantages and pitfalls of using surveys. We discuss the six most important stages in survey-based research: setting the survey’s objectives; selecting the most appropriate survey design; constructing the survey instrument (concentrating on self-administered questionnaires); assessing the reliability and validity of the survey instrument; administering the instrument; and, finally, analysing the collected data. This chapter provides only an introduction to survey-based research; readers should consult the referenced literature for more detailed advice.
386 citations
TL;DR: Rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese; however, further data are needed from rigorously designed studies.
Abstract: Context Use of bariatric surgery has increased dramatically during the past 10 years, particularly among women of reproductive age. Objectives To estimate bariatric surgery rates among women aged 18 to 45 years and to assess the published literature on pregnancy outcomes and fertility after surgery. Evidence Acquisition Search of the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases (Medline, EMBASE, Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness) to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Search terms included bariatric procedures, fertility, contraception, pregnancy, and nutritional deficiencies. Information was abstracted about study design, fertility, and nutritional, neonatal, and pregnancy outcomes after surgery. Evidence Synthesis Of 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50 000 cases annually for the 3 most recent years). Three matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. In 1 matched cohort study that compared maternal complication rates in women after laparoscopic adjustable gastric band surgery with obese women without surgery, rates of gestational diabetes (0% vs 22.1%, P Conclusion Rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese; however, further data are needed from rigorously designed studies.
378 citations
TL;DR: The current framework developed by the UCLA/RAND NIMH Center is presented to address this research-to-practice gap by providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings.
Abstract: The effective dissemination and implementation of evidence-based health interventions within community settings is an important cornerstone to expanding the availability of quality health and mental health services. Yet it has proven a challenging task for both research and community stakeholders. This paper presents the current framework developed by the UCLA/RAND NIMH Center to address this research-to-practice gap by: (1) providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings; (2) distinguishing among key components of the diffusion process—including contextual factors, adoption, implementation, and sustainment of interventions—showing how evaluation of each is necessary to explain the course of dissemination and outcomes for individual and organizational stakeholders; (3) facilitating the identification of new strategies for adapting, disseminating, and implementing relatively complex, evidence-based healthcare and improvement interventions, particularly using a community-based, participatory approach; and (4) enhancing the ability to meaningfully generalize findings across varied interventions and settings to build an evidence base on successful dissemination and implementation strategies.
365 citations
TL;DR: Certain environmental features may set the stage for neighborhood social interactions, thus serving as a foundation for underlying health and well-being, and have greater than expected impact on health.
323 citations
TL;DR: In this article, the authors used the Survey of Health, Ageing and Retirement in Europe (SHARE) dataset to address the question of what are the health impacts of retirement, and found significant evidence that retirement has a health-preserving effect on overall general health.
314 citations
TL;DR: In this sample, lifetime waterpipe use was as common as lifetime cigarette use, and perception of harm, perception of addictiveness, social acceptability, and popularity were all strongly related to waterpipe smoking.
Abstract: Background
Although waterpipe tobacco smoking seems to be increasing on U.S. university campuses, these data have come from convenience samples.
TL;DR: In this paper, the authors synthesize current information on genetic health services for common chronic adult-onset conditions by examining studies that have addressed the outcomes, consumer information needs, delivery, and challenges in integrating these services.
Abstract: Context The greatest public health benefit of advances in understanding the human genome may be realized for common chronic diseases such as cardiovascular disease, diabetes mellitus, and cancer. Attempts to integrate such knowledge into clinical practice are still in the early stages, and as a result, many questions surround the current state of this translation. Objective To synthesize current information on genetic health services for common adult-onset conditions by examining studies that have addressed the outcomes, consumer information needs, delivery, and challenges in integrating these services. Data Sources MEDLINE articles published between January 2000 and February 2008. Study Selection Original research articles and systematic reviews dealing with common chronic adult-onset conditions were reviewed. A total of 3371 citations were reviewed, 170 articles retrieved, and 68 articles included in the analysis. Data Extraction Data were independently extracted by one reviewer and checked by another with disagreement resolved by consensus. Variables assessed included study design and 4 key areas: outcomes of genomic medicine, consumer information needs, delivery of genomic medicine, and challenges and barriers to integration of genomic medicine. Data Synthesis Sixty-eight articles contributed data to the synthesis: 5 systematic reviews, 8 experimental studies, 35 surveys, 7 pre/post studies, 3 observational studies, and 10 qualitative reports. Three systematic reviews, 4 experimental studies, and 9 additional studies reported on outcomes of genetic services. Generally there were modest positive effects on psychological outcomes such as worry and anxiety, behavioral outcomes have shown mixed results, and clinical outcomes were less well studied. One systematic review, 1 randomized controlled trial, and 14 other studies assessed consumer information needs and found in general that genetics knowledge was reported to be low but that attitudes were generally positive. Three randomized controlled trials and 13 other studies assessed how genomic medicine is delivered and newer models of delivery. One systematic review and 19 other studies assessed barriers; the most consistent finding was the self-assessed inadequacy of the primary care workforce to deliver genetic services. Additional identified barriers included lack of oversight of genetic testing and concerns about privacy and discrimination. Conclusion Many gaps in knowledge about organization, clinician, and patient needs must be filled to translate basic and clinical science advances in genomics of common chronic diseases into practice.
TL;DR: This study examines both objective and subjective assessments of neighborhood conditions, exploring the overlap between different sources of information on neighborhoods and the relative strength of their association with adult self-rated health.
TL;DR: This article found that the occurrence of a terror attack in a given locality within three months of the elections causes an increase of 1.35 percentage points on that locality's support for the right bloc of political parties out of the two blocs vote.
Abstract: This article relies on the variation of terror attacks across time and space as an instrument to identify the causal effects of terrorism on the preferences of the Israeli electorate. We find that the occurrence of a terror attack in a given locality within three months of the elections causes an increase of 1.35 percentage points on that locality's support for the right bloc of political parties out of the two blocs vote. This effect is of a significant political magnitude because of the high level of terrorism in Israel and the fact that its electorate is closely split between the right and left blocs. Moreover, a terror fatality has important electoral effects beyond the locality where the attack is perpetrated, and its electoral impact is stronger the closer to the elections it occurs. Interestingly, in left-leaning localities, local terror fatalities cause an increase in the support for the right bloc, whereas terror fatalities outside the locality increase the support for the left bloc of parties. Given that a relatively small number of localities suffer terror attacks, we demonstrate that terrorism does cause the ideological polarization of the electorate. Overall, our analysis provides strong empirical support for the hypothesis that the electorate shows a highly sensitive reaction to terrorism.
TL;DR: This article found that the occurrence of a terror attack within three months of the elections is associated with a 1.35 percentage points increase on the local support for the right bloc of political parties out of the two blocs vote.
Abstract: This paper relies on the variation of terror attacks across time and space as an instrument to identify the causal effects of terrorism on the preferences of the Israeli electorate. We find that the occurrence of a terror attack within three months of the elections is associated with a 1.35 percentage points increase on the local support for the right bloc of political parties out of the two blocs vote. This effect is of a significant political magnitude given the level of terrorism in Israel and the fact that its electorate is closely split between the right and left blocs. Moreover, a terror fatality has important electoral effects beyond the locality where the attack is perpetrated, and their electoral impact is stronger the closer to the elections they occur. Interestingly, the observed political effects are not affected by the identity of the party holding office. These results provide empirical support for the hypothesis that the electorate shows a highly sensitive reaction to terrorism, and substantiate the claim that terror organizations especially target democratic regimes because these regimes are more prone to make territorial concessions.
TL;DR: To clarify the benefits of nephron‐sparing surgery among patients with early‐stage kidney cancer, the authors compared the frequency of renal and cardiovascular morbidity after partial or radical nephrectomy.
Abstract: BACKGROUND.
To clarify the benefits of nephron-sparing surgery among patients with early-stage kidney cancer, the authors compared the frequency of renal and cardiovascular morbidity after partial or radical nephrectomy.
METHODS.
This retrospective cohort study was based on linked Surveillance, Epidemiology, and End Results-Medicare data. The authors identified 10,886 patients who underwent partial or radical nephrectomy between 1991 and 2002. Medical claims were examined for the occurrence of adverse renal and/or cardiovascular outcomes, and multivariate survival models were fit to estimate the association between type of surgery and each clinical outcome, using propensity scores to balance the treatment cohorts with respect to measured patient and disease characteristics. To control for secular trends in the indications for partial nephrectomy, separate analyses were performed based on treatment era (1991–1999 or 2000–2002).
RESULTS.
During the study interval, 10,123 patients (93%) and 763 patients (7%) underwent radical or partial nephrectomy, respectively. During 2000 to 2002, patients who underwent partial nephrectomy experienced fewer adverse renal outcomes (16.4% vs 21.8%; adjusted hazard ratio, 0.74; 95% confidence interval, 0.58-0.94), including a trend toward less frequent receipt of dialysis services, dialysis access surgery, or renal transplantation. The likelihood of adverse cardiovascular outcomes did not differ by treatment.
CONCLUSIONS.
Among contemporary patients, partial nephrectomy was associated with less clinically apparent renal morbidity than radical nephrectomy. This finding motivates expanded use of partial nephrectomy among patients with early-stage kidney cancer. Given the potential for selection bias and residual confounding in this observational cohort, additional prospective studies will be necessary to validate the current findings. Cancer 2008. © 2007 American Cancer Society.
TL;DR: There is a need for interventions to reduce HIV stigma in the general public and to help families cope with stigma, from the perspective of multiple family members.
Abstract: We examined the interconnectedness of stigma experiences in families living with HIV, from the perspective of multiple family members. Semi-structured interviews were conducted with 33 families (33 parents with HIV, 27 children under age 18, 19 adult children, and 15 caregivers). Parents were drawn from the HIV Cost and Services Utilization Study, a representative sample of people in care for HIV in US. All of the families recounted experiences with stigma, including 100% of mothers, 88% of fathers, 52% of children, 79% of adult children, and 60% of caregivers. About 97% of families described discrimination fears, 79% of families experienced actual discrimination, and 10% of uninfected family members experienced stigma from association with the parent with HIV. Interpersonal discrimination seemed to stem from fears of contagion. Findings indicate a need for interventions to reduce HIV stigma in the general public and to help families cope with stigma.
TL;DR: Among a large Medicare cohort of fee-for-service beneficiaries with diabetes, comorbid depression was associated with an increase in all-cause mortality over a two-year period.
Abstract: Objective
To assess whether Medicare fee-for-service beneficiaries with depression and diabetes had a higher mortality rate over a 2-year period compared with beneficiaries with diabetes alone.
Journal Article•
TL;DR: A revised view of eating as an automatic behavior, as opposed to one that humans can self-regulate, has profound implications for the response to the obesity epidemic, suggesting that the focus should be less on nutrition education and more on shaping the food environment.
Abstract: The continued growth of the obesity epidemic at a time when obesity is highly stigmatizing should make us question the assumption that, given the right information and motivation, people can successfully reduce their food intake over the long term. An alternative view is that eating is an automatic behavior over which the environment has more control than do individuals. Automatic behaviors are those that occur without awareness, are initiated without intention, tend to continue without control, and operate efficiently or with little effort. The concept that eating is an automatic behavior is supported by studies that demonstrate the impact of the environmental context and food presentation on eating. The amount of food eaten is strongly influenced by factors such as portion size, food visibility and salience, and the ease of obtaining food. Moreover, people are often unaware of the amount of food they have eaten or of the environmental influences on their eating. A revised view of eating as an automatic behavior, as opposed to one that humans can self-regulate, has profound implications for our response to the obesity epidemic, suggesting that the focus should be less on nutrition education and more on shaping the food environment.
TL;DR: Providing this type of brief intervention is a viable approach to working with high-risk teens to decrease substance use and it is found that Project CHAT teens reported less marijuana use, lower perceived prevalence ofarijuana use, fewer friends who used marijuana, and lower intentions to use marijuana in the next 6 months.
TL;DR: Ass associations between symptoms of pain and symptoms and diagnoses of anxiety and depression in primary care patients are examined, revealing an association between reports of pain symptoms and not only depression, but also anxiety.
Abstract: Pain, anxiety, and depression are commonly seen in primary care patients and there is considerable evidence that these experiences are related. This study examined associations between symptoms of pain and symptoms and diagnoses of anxiety and depression in primary care patients. Results indicate that primary care patients who endorse symptoms of muscle pain, headache, or stomach pain are approximately 2.5-10 times more likely to screen positively for panic disorder, generalized anxiety disorder, or major depressive disorder. Endorsement of pain symptoms was also significantly associated with confirmed diagnoses of several of the anxiety disorders and/or major depression, with odds ratios ranging from approximately 3 to 9 for the diagnoses. Patients with an anxiety or depressive disorder also reported greater interference from pain. Similarly, patients endorsing pain symptoms reported lower mental health functioning and higher scores on severity measures of depression, social anxiety, and posttraumatic stress disorder. Mediation analyses indicated that depression mediated some, but not all of the relationships between anxiety and pain. Overall, these results reveal an association between reports of pain symptoms and not only depression, but also anxiety. An awareness of these relationships may be particularly important in primary care settings where a patient who presents with reports of pain may have an undiagnosed anxiety or depressive disorder.
TL;DR: For instance, the authors found that adolescents who were exposed to high levels of television sexual content were twice as likely to experience a pregnancy in the subsequent 3 years, compared with those with lower levels of exposure (10th percentile).
Abstract: OBJECTIVE.There is increasing evidence that youth exposure to sexual content on television shapes sexual attitudes and behavior in a manner that may influence reproductive health outcomes. To our knowledge, no previous work has empirically examined associations between exposure to television sexual content and adolescent pregnancy. METHODS.Data from a national longitudinal survey of teens (12‐17 years of age, monitored to 15‐20 years of age) were used to assess whether exposure to televised sexual content predicted subsequent pregnancy for girls or responsibility for pregnancy for boys. Multivariate logistic regression models controlled for other known correlates of exposure to sexual content and pregnancy. We measured experience of a teen pregnancy during a 3-year period. RESULTS.Exposure to sexual content on television predicted teen pregnancy, with adjustment for all covariates. Teens who were exposed to high levels of television sexual content (90th percentile) were twice as likely to experience a pregnancy in the subsequent 3 years, compared with those with lower levels of exposure (10th percentile). CONCLUSIONS.This is the first study to demonstrate a prospective link between exposure to sexual content on television and the experience of a pregnancy before the age of 20. Limiting adolescent exposure to the sexual content on television and balancing portrayals of sex in the media with information about possible negative consequences might reduce the risk of teen pregnancy. Parents may be able to mitigate the influence of this sexual content by viewing with their children and discussing these depictions of sex. Pediatrics 2008;122:1047‐1054
TL;DR: Understanding the causal pathway for overconsumption will be necessary to interrupt the mechanisms that lead to obesity.
Abstract: The past 30 years have seen dramatic changes in the food and physical activity environments, both of which contribute to the changes in human behavior that could explain obesity. This paper reviews documented changes in the food environment, changes in the physical activity environment and the mechanisms through which people respond to these environments, often without conscious awareness or control. The most important environmental changes have been increases in food accessibility, food salience and decreases in the cost of food. The increases in food marketing and advertising create food cues that artificially stimulate people to feel hungry. The existence of a metabolic pathway that allows excess energy to be stored as fat suggests that people were designed to overeat. Many internal mechanisms favor neurophysiologic responses to food cues that result in overconsumption. External cues, such as food abundance, food variety and food novelty, cause people to override internal signals of satiety. Other factors, such as conditioning and priming, tie food to other desirable outcomes, and thus increase the frequency that hunger is stimulated by environmental cues. People's natural response to the environmental cues are colored by framing, and judgments are flawed and biased depending on how information is presented. People lack insight into how the food environment affects them, and subsequently are unable to change the factors that are responsible for excessive energy consumption. Understanding the causal pathway for overconsumption will be necessary to interrupt the mechanisms that lead to obesity.
TL;DR: The proposed pooled kappa estimator efficiently summarizes interrater agreement by domain and makes better use of scarce subjects than simply averaging item-level kappas.
Abstract: We propose the pooled estimator of kappa, an efficient estimator when summarizing the interrater agreement for qualitative data with many items but few subjects. We evaluate this estimator through a simulation of proposed and alternative (average kappa) estimators and subsequently apply our method to calculate pooled and average kappas over 2,176 rated items from six semistructured interviews with sponsors of the CAHPS. The proposed pooled kappa estimator efficiently summarizes interrater agreement by domain. It is more widely applicable and makes better use of scarce subjects than simply averaging item-level kappas.
TL;DR: A 28-item measure of internalized HIV stigma composed of four scales based on previous qualitative work that captures stigma related to treatment and other aspects of the disease among sociodemographically diverse PLHA is developed.
Abstract: There is a need for a psychometrically sound measure of the stigma experienced by diverse persons living with HIV/AIDS (PLHA). The goal of this study was to develop and evaluate a multidimentional measure of internalized HIV stigma that captures stigma related to treatment and other aspects of the disease among sociodemographically diverse PLHA. We developed a 28-item measure of internalized HIV stigma composed of four scales based on previous qualitative work. Internal consistency reliability estimates in a sample of 202 PLHA was 0.93 for the overall measure, and exceeded 0.85 for three of the four stigma scales. Items discriminated well across scales, and correlations of the scales with shame, social support, and mental health supported construct validity. This measure should prove useful to investigators examining in the role of stigma in HIV treatment and health outcomes, and evaluating interventions designed to mitigate the impacts of stigma on PLHA.
TL;DR: The Bayesian Surname and Geocoding (BSG) method presented here efficiently integrates administrative data, substantially improving upon what is possible with a single source or from other hybrid methods; it offers a powerful tool that can help health care organizations address disparities until self-reported race/ethnicity data are available.
Abstract: Efforts to measure, monitor, and address racial/ethnic disparities in health care have been limited by the paucity of data regarding the race/ethnicity of users of the health care system. Indeed, until recently, many viewed the collection of such data as illegal (Fremont and Lurie 2004). One result is that the preponderance of studies on racial/ethnic differences in quality of care and patient outcomes has been limited to patients enrolled in Medicare or Medicaid. Several reports from the Institute of Medicine and the National Academy of Sciences recommend universal collection of self-reported data regarding race, ethnicity, and socioeconomic status as a first step toward addressing disparities (Institute of Medicine 2002; National Research Council 2004). While self-reported data are widely considered to be the gold standard, absent a mandate to do so, collection of such data will be slow and inconsistent.
Several efforts to collect and use such data are underway. For example, the Health Research and Educational Trust, an independent research affiliate of the American Hospital Association, has developed a toolkit for and is assisting a growing number of hospitals with collection of racial, ethnic, and language data. Similarly, a group of hospitals funded by the Robert Wood Johnson Foundation to address disparities in cardiovascular care have committed to collecting race/ethnicity data and monitoring quality of care for different racial/ethnic groups. State policy has also moved toward collecting racial/ethnic data. For example, as part of the Massachusetts health care reform legislation, collection of race/ethnicity data from all hospitalized patients is required by law (Boston Public Health Commission 2006). In California, SB 853 and related regulations require HMO plans to collect race, ethnicity, and language information (California State Senate 2007). Finally, several of the plans participating in the National Health Plan Collaborative to Improve Quality and Eliminate Disparities have begun voluntary collection of self-reported data on the race/ethnicity of their enrollees (National Health Plan Collaborative 2006). Aetna has the most experience in doing so, but even with a mandate from their CEO and significant investment of resources over the past 4 years, the plan has been able to obtain data on only one-third of their enrollees thus far. Although a few smaller regional plans that followed Aetna's lead have obtained a similar proportion of self-reported data in less time, completing the process will likely take several more years.
TL;DR: Examining gender wage disparities for four groups of college-educated women—black, Hispanic, Asian, and non-Hispanic white—using the National Survey of College Graduates finds that inferences from familiar regression-based decompositions can be quite misleading.
Abstract: In the U.S. college-educated women earn approximately 30 percent less than their non-Hispanic white male counterparts. We conduct an empirical examination of this wage disparity for four groups of women-non-Hispanic white, black, Hispanic, and Asian-using the National Survey of College Graduates, a large data set that provides unusually detailed information on higher-level education. Nonparametric matching analysis indicates that among men and women who speak English at home, between 44 and 73 percent of the gender wage gaps are accounted for by such pre-market factors as highest degree and major. When we restrict attention further to women who have "high labor force attachment" (i.e., work experience that is similar to male comparables) we account for 54 to 99 percent of gender wage gaps. Our nonparametric approach differs from familiar regression-based decompositions, so for the sake of comparison we conduct parametric analyses as well. Inferences drawn from these latter decompositions can be quite misleading.
TL;DR: In this paper, the information needs of adult cancer survivors, identifying sociodemographic, health, and healthcare-related factors associated with information needs, and examines the relationship between information needs and survivors' perceived mental and physical health.
Abstract: Background
This study describes the information needs of adult cancer survivors, identifies sociodemographic, health, and healthcare-related factors associated with information needs, and examines the relationship between information needs and survivors’ perceived mental and physical health.
TL;DR: Examination of the ability of recombinant human BMP-2 coated onto a titanium porous oxide implant surface to stimulate local bone formation including osseointegration and vertical augmentation of the alveolar ridge showed robust bone formation reaching or exceeding the implant platform.
Abstract: Background: Studies using ectopic rodent, orthotopic canine, and non-human primate models show that bone morphogenetic proteins (BMPs) coated onto titanium surfaces induce local bone formation. The objective of this study was to examine the ability of recombinant human BMP-2 (rhBMP-2) coated onto a titanium porous oxide implant surface to stimulate local bone formation including osseointegration and vertical augmentation of the alveolar ridge. Material and Methods: Bilateral, critical-size, 5 mm, supra-alveolar, peri-implant defects were created in 12 young adult Hound Labrador mongrel dogs. Six animals received implants coated with rhBMP-2 at 0.75 or 1.5 mg/ml, and six animals received implants coated with rhBMP-2 at 3.0 mg/ml or uncoated control. Treatments were randomized between jaw quadrants. The mucoperiosteal flaps were advanced, adapted and sutured to submerge the implants for primary intention healing. The animals received fluorescent bone markers at weeks 3, 4, 7 and 8 post-surgery when they were euthanized for histologic evaluation. Results: Jaw quadrants receiving implants coated with rhBMP-2 exhibited gradually regressing swelling that became hard to palpate disguising the contours of the implants. The histologic evaluation showed robust bone formation reaching or exceeding the implant platform. The newly formed bone exhibited characteristics of the adjoining resident Type II bone including cortex formation for sites receiving implants coated with rhBMP-2 at 0.75 or 1.5 mg/ml. Sites receiving implants coated with rhBMP-2 at 3.0 mg/ml exhibited more immature trabecular bone formation, seroma formation and peri-implant bone remodelling resulting in undesirable implant displacement. Control implants exhibited minimal, if any, bone formation. Thus, implants coated with rhBMP-2 at 0.75, 1.5 and 3.0 mg/ml exhibited significant bone formation (height and area) compared with the sham-surgery control averaging (± SD) 4.4 ± 0.4, 4.2 ± 0.7 and 4.2 ± 1.2 versus 0.8 ± 0.3 mm; and 5.0 ± 2.2, 5.6 ± 2.2 and 7.4 ± 3.5 versus 0.7 ± 0.3mm 2 , respectively (p<0.01). All the treatment groups exhibited clinically relevant osseointegration. Conclusions: rhBMP-2 coated onto titanium porous oxide implant surfaces induced clinically relevant local bone formation including vertical augmentation of the alveolar ridge and osseointegration. Higher concentrations/doses were associated with untoward effects.
TL;DR: A conceptual framework is proposed to guide researchers and policymakers in evaluating waste, implementing waste-reduction strategies, and reducing the burden of unnecessary health care spending to decrease waste in the U.S. health care system.
Abstract: Health care costs in the United States now account for 16 percent of the country's gross domestic product, and per capita health care spending is approximately twice that of other major industrialized countries (OECD 2008). Given that the U.S. system's performance is no better than that of other countries, much of the money must be spent unnecessarily or wastefully (Commonwealth Fund 2008). Our immense spending makes health care and health insurance increasingly unaffordable, and furthermore, 45.7 million Americans have no health insurance (DeNavas-Walt et al. 2008). It also threatens the nation's ability to pay for new treatments and technologies, which often are expensive, and to make other discretionary expenditures. Current and looming health care–spending obligations prevent the federal government from achieving universal insurance coverage or other national goals outside the health care system while maintaining national fiscal health (Orszag and Ellis 2007a, 2007b).
Inefficiencies persist within the health care system because—in contrast to other economic sectors in which competition and other economic incentives act to reduce the level of waste—none of the health care system's players have strong incentives to economize. Although it is necessary for protection against the potentially catastrophic costs of treatment, generous health insurance coverage insulates patients from the true cost of medical care (Pauly 1969). Fee-for-service providers are paid for all services, whether or not they are necessary. Furthermore, because physicians advise patients on what care they need and also provide that care, they lack incentives to ration. Insurance and medical uncertainties muffle price competition and, in our litigious climate, promote overscreening and overtreatment. Health insurers, chastened by the backlash against managed care, act passively in reimbursing health care spending and, as expenditures increase, merely pass costs along to purchasers in the form of higher premiums. The impact of these higher premiums on the insured is limited, however, owing to Medicare and other public insurance entitlements, as well as the tax subsidization of employer-sponsored health insurance. Together, all these factors allow inefficiency to thrive in the U.S. health care system.