Health Policy

‘Big Push’ To Reduce Maternal Mortality In Uganda And Zambia Enhanced Health Systems But Lacked A Sustainability Plan

‘Big Push’ To Reduce Maternal Mortality In Uganda And Zambia Enhanced Health Systems But Lacked A Sustainability Plan
doi: 10.1377/hlthaff.2013.0637 Health Aff June 2014 vol. 33 no. 6 1058-1066

Margaret E. Kruk, Miriam Rabkin, Karen Ann Grépin, Katherine Austin-Evelyn, Dana Greeson, Tsitsi Beatrice Masvawure, Emma Rose Sacks, Daniel Vail and Sandro Galea
06/01/2014

In the past decade, “big push” global health initiatives financed by international donors have aimed to rapidly reach ambitious health targets in low-income countries. The health system impacts of these efforts are infrequently assessed. Saving Mothers, Giving Life is a global public-private partnership that aims to reduce maternal mortality dramatically in one year in eight districts in Uganda and Zambia. We evaluated the first six to twelve months of the program’s implementation, its ownership by national ministries of health, and its effects on health systems. The project’s impact on maternal mortality is not reported here. We found that the Saving Mothers, Giving Life initiative delivered a large “dose” of intervention quickly by capitalizing on existing US international health assistance platforms, such as the President’s Emergency Plan for AIDS Relief. Early benefits to the broader health system included greater policy attention to maternal and child health, new health care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership. Sustaining and scaling up early gains of similar big push initiatives requires longer-term commitments and a clear plan for transition to national control.

The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries

The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries
Journal of Epidemiology & Global Health, Vol 4, no. 2, pp. 115-124. DOI: 10.1016/j.jegh.2013.10.004

Batouli, A., P. Jahanshahi, C.P. Gross, D.V. Makarov, and J.B.Yu
06/01/2014

Background: Cancer continues to rise as a contributor to premature death in the developing world. Despite this, little is known about whether cancer outcomes are related to a country’s income level, and what aspects of national healthcare systems are associated with improved cancer outcomes.

Methods: The most recent estimates of cancer incidence and mortality were used to calculate mortality-to-incidence ratio (MIR) for the 85 countries with reliable data. Countries were categorized according to high-income (Gross Domestic Product (GDP) > $15,000) or middle/low-income (GDP < $15,000), and a multivariate linear regression model was used to determine the association between healthcare system indicators and cancer MIR. Indicators study included per capita GDP, overall total healthcare expenditure (THE), THE as a proportion of GDP, total external beam radiotherapy devices (TEBD) per capita, physician density, and the year 2000 WHO healthcare system rankings.

Results: Cancer MIR in high-income countries (0.47) was significantly lower than that of middle/low-income countries (0.64), with a p < 0.001. In high-income countries, GDP, health expenditure and TEBD showed significant inverse correlations with overall cancer MIR. A $3040 increase in GDP (p = 0.004), a $379 increase in THE (p < 0.001), or an increase of 0.59 TEBD per 100,000 population (p = 0.027) were all associated with a 0.01 decrease in cancer MIR. In middle/low-income countries, only WHO scores correlated with decreased cancer MIR (p = 0.022); 12 specific cancer types also showed similar significant correlations (p < 0.05) as overall cancer MIR.

Conclusions: The analysis of this study suggested that cancer MIR is greater in middle/low-income countries. Furthermore, the WHO healthcare score was associated with improved cancer outcomes in middle/low-income countries while absolute levels of financial resources and infrastructure played a more important role in high-income countries.

Association between Arsenic Exposure from Drinking Water and Hematuria: Results from the Health Effects of Arsenic Longitudinal Study

Association between Arsenic Exposure from Drinking Water and Hematuria: Results from the Health Effects of Arsenic Longitudinal Study
Toxicology & Applied Pharmacology, Vol. 276, no. 1, pp 21-27. DOI: 10.1016/j.taap.2014.01.015

McClintock, T.R., Y. Chen, F. Parvez, D.V. Makarov, W. Ge, T. Islam, A. Ahmed, M. Rakibuz-Zaman, R. Hasan, G. Sarwar, V. Slavkovich, M.A. Bjurlin, J.H. Graziano, and H. Ahsan
04/01/2014

Arsenic (As) exposure has been associated with both urologic malignancy and renal dysfunction; however, its association with hematuria is unknown. We evaluated the association between drinking water As exposure and hematuria in 7843 men enrolled in the Health Effects of Arsenic Longitudinal Study (HEALS). Cross-sectional analysis of baseline data was conducted with As exposure assessed in both well water and urinary As measurements, while hematuria was measured using urine dipstick. Prospective analyses with Cox proportional regression models were based on urinary As and dipstick measurements obtained biannually since baseline up to six years. At baseline, urinary As was significantly related to prevalence of hematuria (P-trend < 0.01), with increasing quintiles of exposure corresponding with respective prevalence odds ratios of 1.00 (reference), 1.29 (95% CI: 1.04–1.59), 1.41 (95% CI: 1.15–1.74), 1.46 (95% CI: 1.19–1.79), and 1.56 (95% CI: 1.27–1.91). Compared to those with relatively little absolute urinary As change during follow-up (− 10.40 to 41.17 μg/l), hazard ratios for hematuria were 0.99 (95% CI: 0.80–1.22) and 0.80 (95% CI: 0.65–0.99) for those whose urinary As decreased by > 47.49 μg/l and 10.87 to 47.49 μg/l since last visit, respectively, and 1.17 (95% CI: 0.94–1.45) and 1.36 (95% CI: 1.10–1.66) for those with between-visit increases of 10.40 to 41.17 μg/l and > 41.17 μg/l, respectively. These data indicate a positive association of As exposure with both prevalence and incidence of dipstick hematuria. This exposure effect appears modifiable by relatively short-term changes in drinking water As.

Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen

Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen
BJU International. DOI: 10.1111/bju.12748

Prabhu, V., T. Lee, S. Loeb, J.H. Holmes, H.T. Gold, H. Lepor, D.F. Penson, and D.V. Makarov
03/24/2014

Objective: To examine public and media response to the United States Preventive Services Task Force's (USPSTF) draft (October 2011) and finalized (May 2012) recommendations against prostate-specific antigen (PSA) testing using Twitter, a popular social network with over 200 million active users.

Materials and Methods: We used a mixed methods design to analyze posts on Twitter, called “tweets.” Using the search term “prostate cancer,” we archived tweets in the 24 hour periods following the release of the USPSTF draft and finalized recommendations. We recorded tweet rate per hour and developed a coding system to assess type of user and sentiment expressed in tweets and linked articles.

Results: After the draft and finalized recommendations, 2042 and 5357 tweets focused on the USPSTF report, respectively. Tweet rate nearly doubled within two hours of both announcements. Fewer than 10% of tweets expressed an opinion about screening, and the majority of these were pro-screening during both periods. In contrast, anti-screening articles were tweeted more frequently in both draft and finalized study periods. From the draft to the finalized recommendations, the proportion of anti-screening tweets and anti-screening article links increased (p= 0.03 and p<0.01, respectively).

Conclusions: There was increased Twitter activity surrounding the USPSTF draft and finalized recommendations. The percentage of anti-screening tweets and articles appeared to increase, perhaps due to the interval public comment period. Despite this, most tweets did not express an opinion, suggesting a missed opportunity in this important arena for advocacy.

Promotion of Healthy Eating through Public Policy: A Controlled Experiment

Promotion of Healthy Eating through Public Policy: A Controlled Experiment
American Journal of Preventative Medicine. 2013; 45(1): 49-55. http://dx.doi.org/10.1016/j.amepre.2013.02.023

Elbel B, Taksler G, Mijanovich T, Abrams C, Dixon LB
02/13/2014

Background
To induce consumers to purchase healthier foods and beverages, some policymakers have suggested special taxes or labels on unhealthy products. The potential of such policies is unknown.

Purpose
In a controlled field experiment, researchers tested whether consumers were more likely to purchase healthy products under such policies.

Methods
From October to December 2011, researchers opened a store at a large hospital that sold a variety of healthier and less-healthy foods and beverages. Purchases (N=3680) were analyzed under five conditions: a baseline with no special labeling or taxation, a 30% tax, highlighting the phrase “less healthy” on the price tag, and combinations of taxation and labeling. Purchases were analyzed in January–July 2012, at the single-item and transaction levels.

Results
There was no significant difference between the various taxation conditions. Consumers were 11 percentage points more likely to purchase a healthier item under a 30% tax (95% CI=7%, 16%, p<0.001) and 6 percentage points more likely under labeling (95% CI=0%, 12%, p=0.04). By product type, consumers switched away from the purchase of less-healthy food under taxation (9 percentage point decrease, p<0.001) and into healthier beverages (6 percentage point increase, p=0.001); there were no effects for labeling. Conditions were associated with the purchase of 11–14 fewer calories (9%–11% in relative terms) and 2 fewer grams of sugar. Results remained significant controlling for all items purchased in a single transaction.

Conclusions
Taxation may induce consumers to purchase healthier foods and beverages. However, it is unclear whether the 15%–20% tax rates proposed in public policy discussions would be more effective than labeling products as less healthy.

HIV testing in the nation’s opioid treatment programs, 2005-2011: The role of state regulations

HIV testing in the nation’s opioid treatment programs, 2005-2011: The role of state regulations
Health Services Research, 2014 (February), 49(1):230-48. DOI: 10.1111/1475-6773.12094

D’Aunno, T., Pollack, H.A., Jiang, L., Metsch, L.R. & Friedmann, P. D.
02/03/2014

Objective: To identify the extent to which clients in a national sample of opioid treatment programs (OTPs) received HIV testing in 2005 and 2011; to examine relationships between state laws for informed consent and pretest counseling and rates of HIV testing among OTP clients.

Data Source: Data were collected from a nationally representative sample of OTPs in 2005 (n = 171) and 2011 (n = 200).

Study Design: Random-effects logit and interval regression analyses were used to examine changes in HIV testing rates and the relationship of state laws to HIV testing among OTPs.

Data Collection: Data on OTP provision of HIV testing were collected in phone surveys from OTP managers; data also were collected on state laws for HIV testing.

Principal Findings: The percentage of OTPs offering HIV testing decreased significantly from 93 percent in 2005 to 64 percent in 2011. Similarly, the percentage of clients tested decreased from an average of 41 percent in 2005 to 17 percent in 2011. OTPs located in states whose laws do not require pretest counseling and that use opt-out consent were more likely to provide HIV testing and to test higher percentages of clients.

Conclusions: The results show the need to increase HIV testing among OTP clients; the results also underscore the beneficial possibilities of dropping pretest counseling as a requirement for HIV testing and of using the opt-out approach to informed consent for testing.

Radical Prostatectomy Improves and Prevents Age Dependent Progression of Lower Urinary Tract Symptoms

Radical Prostatectomy Improves and Prevents Age Dependent Progression of Lower Urinary Tract Symptoms
Journal of Urology. Vol. 191, no. 2, pp. 412-417. DOI: 10.1016/j.juro.2013.08.010

Prabhu, V., G.B. Taksler, G. Sivarajan, J. Laze, D.V. Makarov, and H. Lepor
02/01/2014

Purpose: The prevalence of lower urinary tract symptoms increases with age and impairs quality of life. Radical prostatectomy has been shown to relieve lower urinary tract symptoms at short-term followup but the long-term effect of radical prostatectomy on lower urinary tract symptoms is unclear.

Materials and Methods: We performed a prospective cohort study of 1,788 men undergoing radical prostatectomy. The progression of scores from the self-administered AUASS (American Urological Association symptom score) preoperatively, and at 3, 6, 12, 24, 48, 60, 84, 96 and 120 months was analyzed using models controlling for preoperative AUASS, age, prostate specific antigen, pathological Gleason score and stage, nerve sparing, race and marital status. This model was also applied to patients stratified by baseline clinically significant (AUASS greater than 7) and insignificant (AUASS 7 or less) lower urinary tract symptoms.

Results: Men exhibited an immediate worsening of lower urinary tract symptoms that improved between 3 months and 2 years after radical prostatectomy. Overall the difference between mean AUASS at baseline and at 10 years was not statistically or clinically significant. Men with baseline clinically significant lower urinary tract symptoms experienced immediate improvements in lower urinary tract symptoms that lasted until 10 years after radical prostatectomy (13.5 vs 8.81, p <0.001). Men with baseline clinically insignificant lower urinary tract symptoms experienced a statistically significant but clinically insignificant increase in mean AUASS after 10 years (3.09 to 4.94, p <0.001). The percentage of men with clinically significant lower urinary tract symptoms decreased from baseline to 10 years after radical prostatectomy (p = 0.02).

Conclusions​: Radical prostatectomy is the only treatment for prostate cancer shown to improve and prevent the development of lower urinary tract symptoms at long-term followup. This previously unrecognized long-term benefit argues in favor of the prostate as the primary contributor to male lower urinary tract symptoms.

The Contribution of Health Care and Other Interventions to Black-White Disparities in Life Expectancy, 1980-2007

The Contribution of Health Care and Other Interventions to Black-White Disparities in Life Expectancy, 1980-2007
Population Research and Policy Review, Vol. 33, no. 1 (Feb 2014), pp. 97-126. doi: 10.1007/s11113-013-9309-2

Elo, I.T., H. Beltran-Sanchez, and J. Macinko
02/01/2014

Black–white mortality disparities remain sizable in the United States. In this study, we use the concept of avoidable/amenable mortality to estimate cause-of-death contributions to the difference in life expectancy between whites and blacks by gender in the United States in 1980, 1993, and 2007. We begin with a review of the concept of “avoidable mortality” and results of prior studies using this cause-of-death classification. We then present the results of our empirical analyses. We classified causes of death as amenable to medical care, sensitive to public health policies and health behaviors, ischemic heart disease, suicide, HIV/AIDS, and all other causes combined. We used vital statistics data on deaths and Census Bureau population estimates and standard demographic decomposition techniques. In 2007, causes of death amenable to medical care continued to account for close to 2 years of the racial difference in life expectancy among men (2.08) and women (1.85). Causes amenable to public health interventions made a larger contribution to the racial difference in life expectancy among men (1.17 years) than women (0.08 years). The contribution of HIV/AIDS substantially widened the racial difference among both men (1.08 years) and women (0.42 years) in 1993, but its contribution declined over time. Despite progress observed over the time period studied, a substantial portion of black–white disparities in mortality could be reduced given more equitable access to medical care and health interventions.

The Cost Implications of Prostate Cancer Screening in the Medicare Population

The Cost Implications of Prostate Cancer Screening in the Medicare Population
Cancer, Vol. 120, no. 1, pp. 96-102. DOI: 10.1002/cncr.28373

Ma, X., R. Wang, J.B. Long, J.S. Ross, P.R. Soulos, J.B. Yu, D.V. Makarov, H.T. Gold, and C.P. Gross
01/01/2014

Background: Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening.

Methods: A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level.

Results: Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11).

Conclusions: Medicare prostate cancer screening–related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.

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