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Biomedical subjects

D R Holtgrave

Publications and source records attributed to D R Holtgrave.

72 records · Page 4Linked to original sources
PubMed1993

Dimensions of risk perception for financial and health risks.

This study of 29 MBA students compares two models of risk perception for both financial and health risk stimuli. The first, inspired by Luce and Weber's Conjoint Expected Risk (CER) model, uses five dimensions: probability of gain, loss and status quo, and expected benefit and harm. The second, inspired by the Slovic et al. psychometric model, employs seven dimensions: voluntariness, dread, control, knowledge, catastrophic potential, novelty, and equity. The CER-type model provided a better fit for most subjects and stimuli. Adding the psychological risk dimensions from the Slovic et al. model explained only modestly more variance. Relationships between the dimensions of the two models are described and the construction of a hybrid model explored.

Accidents↗
PubMed1993

American adults' knowledge of HIV testing availability.

OBJECTIVES: Understanding client needs, knowledge, and preferences about services is necessary to ensure that human immunodeficiency virus (HIV) counseling and testing programs are accessible. This study addressed knowledge of HIV testing availability. METHODS: To study American adults' knowledge of HIV testing availability, we collected data during 1990 by random digit-dialing telephone surveys of adults residing in 44 states and the District of Columbia. RESULTS: Of the 81,557 persons who responded, almost two thirds identified medical doctors as a source of HIV testing. Fourteen percent identified public sites, and 12% said they didn't know where to go for HIV testing. Persons who were older, less educated, and had lower incomes were less likely to know where they could go for testing. Persons identifying public sites shared some characteristics with others who lacked adequate health care coverage. CONCLUSIONS: Physicians will be increasingly called upon to provide HIV counseling and testing to their patients. This may require additional training to provide effective, individualized, risk-reduction messages about sexual and drug use behaviors. Even when persons have adequate information about availability, sociodemographic characteristics are likely to influence preferences for HIV counseling and testing.

AIDS Serodiagnosis↗
PubMed1993

Transurethral prostatectomy versus transurethral dilatation of the prostatic urethra for benign prostatic hyperplasia: a cost-utility analysis.

Transurethral prostatectomy is the treatment currently preferred for benign prostatic hyperplasia. A new procedure, transurethral dilatation of the prostatic urethra, has lower costs and mortality and complication rates but may be less effective. These two strategies were evaluated by using cost-utility analysis, a form of cost-effectiveness analysis in which the benefit is defined in terms of individual preferences. Under the model assumptions, the cost of transurethral dilatation is less than the cost of transurethral prostatectomy for patients with benign prostatic hyperplasia ($7084 versus $8647) and slightly more effective: 11.787 quality adjusted life years versus 11.766. Thus, transurethral prostatectomy is said to be dominated. Results indicate that if patients are rigorously selected, and if balloon catheters of 30-35mm in size are utilized, transurethral dilatation could be the initial treatment of choice for eligible patients with benign prostatic hyperplasia.

Catheterization↗
PubMed1992

The evaluation and treatment of men with asymptomatic prostate nodules in primary care: a decision analysis.

BACKGROUND: Whether to perform periodic rectal examinations in asymptomatic men as a screening test for prostatic cancer remains controversial. A randomized clinical trial that tests the efficacy of further evaluation and treatment of men who have been found to have asymptomatic prostate nodules may never be carried out. Decision analysis was therefore used to further investigate this clinical issue. METHODS: A decision tree was developed to model the decision of whether to biopsy an asymptomatic prostate nodule found by digital rectal examination in a 65-year-old man by his primary care physician. Test operating characteristics, probabilities of disease at different stages, probabilities of side effects from various treatments, and average life expectancies were obtained from the medical literature. Utilities for the various possible health outcome states were obtained from ratings by two experienced primary care physicians using the Kaplan-Anderson Quality of Well-Being Scale. These were used to adjust the quality-of-life expectancies for each outcome state. Multiple sensitivity analyses were performed to assess the robustness of the conclusions. RESULTS: Disregarding patient utilities, the average survival benefit of evaluation and treatment is 1.1 months. When quality-of-life adjustments are included in the analysis, evaluation and treatment results in an average loss of 3.5 quality-adjusted months of life. Factors that shift the decision toward evaluation and treatment include a positive predictive value of a prostate nodule for cancer of 49% or greater, specificity of prostate biopsy of 98.3% or greater, and the availability of much more effective treatment for stage D cancers. Factors that do not substantially affect the decision are cancer-free life expectancy, the percentage of cancers that are stage B at time of discovery, the sensitivity of prostate biopsy, and more effective treatment for stage C cancer, assuming the same rate of adverse consequences from treatment. CONCLUSIONS: The evaluation and treatment of prostatic nodules found by digital rectal examination in asymptomatic men in the primary care setting does not lead to significant improvement in life expectancy and adversely affects quality of life. Digital rectal examination should not be performed by primary care physicians as a screening test for prostate cancer.

Aged↗
PubMed1991

Predicting EPA's forthcoming CO standards in light of new clinical evidence.

For the past several years, the EPA has been monitoring clinical studies on the adverse health effects of heart patients' exposure to carbon monoxide. This paper examines the impact of three such studies (including the multi-center CO study organized by the Health Effects Institute) on the forthcoming EPA standards for carbon monoxide. Eleven peer-nominated specialists with expertise in environmental science and public policy were interviewed according to a specific protocol. Overall, the experts felt that the HEI study would receive greater weight than the other two studies in the regulatory process for a variety of technical reasons. Weighting each expert opinion equally, we conclude that there is about a 0.69 probability that the CO standards will be retained at their present levels, a 0.28 probability that the standards will be tightened, and a 0.03 probability that the standards will be relaxed. When asked to imagine that the HEI data were never collected and then asked to reassess their probability judgments, the mean probability judgment that the standards will be relaxed rose to 0.11, while the mean probability judgment that the standards will be tightened fell to 0.20. A modest degree of variability in expert opinion is reported in the paper. While the HEI study may receive relatively great weight in the regulatory process, it increases only slightly the probability that EPA's CO standards will be changed.

Angina Pectoris↗
PubMed1991

Cost-effectiveness of hepatitis B screening in a mental health institution.

In 1982, the Ohio Department of Health Screening established guidelines for hepatitis B screening and vaccination for intermediate mental health care facilities. The present study was developed to evaluate the cost-effectiveness of these guidelines. Data from an intermediate mental health care institution in Champaign/Urbana, Illinois, were used. The analysis considered the direct costs and benefits accrued over a 3-year period and a range of transmission rates. At a 3-year transmission rate of 0.030, the screening and vaccination policy cost $7300 per case of hepatitis B avoided (or $345,800 per hepatitis B fatality avoided). At a more likely 3-year transmission rate of 0.271, the screening and vaccination policy cost $300 per case of hepatitis B avoided (or $12,100 per hepatitis B fatality avoided). Either way, the active prevention policy compares very well with the amounts of money spent by the US Government on other life-saving programs. A general cost-effectiveness model is given that can be adapted for institution-specific analyses at other mental health care facilities.

Cost-Benefit Analysis↗
PubMed1991

Colloids versus crystalloids in fluid resuscitation: an analysis of randomized controlled trials.

BACKGROUND: Controversy about fluid therapy in resuscitation has existed since the 1960s. The difficulty could be that fluid behavior at the lung capillary membrane level may vary depending on the patient's particular pathology. METHODS: Mortality rates taken from randomized controlled trials were analyzed to compare colloidal and crystalloidal fluid for resuscitation efforts. We controlled for the underlying pathological process by categorizing subjects into three groups: (1) surgical stress, (2) hypovolemia, and (3) severe pulmonary failure. A cost-effectiveness analysis also was performed. RESULTS: No statistically significant differences in mortality rates were found. The cost of each life saved using crystalloids is $45.13, and the cost of each life saved using colloidal solutions is $1493.60. CONCLUSIONS: Because there is no significant mortality-rate advantage to using colloids, and because the cost-effectiveness ratio for crystalloids is much lower than for colloids, it is concluded that crystalloids should always be used in resuscitation efforts.

Colloids↗
PubMed1989

Maternal health locus of control beliefs, utilization of childhood preventive health services, and infant health.

This study examined the relationships among mothers' health locus of control beliefs concerning their children's health, utilization of childhood preventive health services, and child health status. Mothers' health beliefs were measured with the Parental Health Belief (PHB) scales developed to explore three factors: (1) mothers' degree of perceived control or internality with respect to their children's health, (2) the extent to which they believe that "chance" or (3) "powerful others" affected their children's health. Eighty-eight low- and middle-socioeconomic status black and Caucasian mothers and infants participated. Results indicate relationships among maternal health locus of control beliefs, utilization of preventive health services, and child health outcome, suggesting targeted ways in which utilization of childhood preventive health services and child health levels might be improved.

Adolescent↗
PubMedDate not supplied

How HIV treatment advances affect the cost-effectiveness of prevention.

OBJECTIVE: The cost-effectiveness of an HIV prevention program depends, in part, on its potential to avert HIV-related medical care costs. Recent advances in antiretroviral therapy have made HIV/AIDS treatment both more effective and more costly, which might make HIV prevention either more or less cost-effective. The objective of the present study was to explicate the relationship between the effectiveness and costs of HIV treatment and the cost-effectiveness of HIV prevention programs. METHODS: A basic analytic framework was used to compare the cost-effectiveness of HIV prevention interventions with respect to different HIV/AIDS medical care scenarios. Algebra was used to calculate a cost-effectiveness threshold that distinguishes prevention programs that become more cost-effective when therapeutic advances simultaneously increase or decrease the cost and effectiveness of treatment from those that become less cost-effective. Recent estimates of the costs and consequences of combination antiretroviral therapy were used to illustrate the calculation method. RESULTS: The advent of combination antiretroviral therapies for HIV has increased the cost-effectiveness of some, but not all, HIV prevention interventions. CONCLUSIONS: Whether a particular prevention program becomes more or less cost-effective as a consequence of advancements in the medical treatment of HIV/AIDS depends upon the specific characteristics of both the program and the therapy.

Adult↗
PubMedDate not supplied

Physicians' risk attitudes, laboratory usage, and referral decisions: the case of an academic family practice center.

Individual differences in physicians' laboratory use and referral rates are important aspects of practice variation that have real financial and health consequences. A way to explain these differences is needed. In this empirical study, physicians' risk attitudes (measured on a multidimensional scale) are shown to be good predictors of use rates for certain specific laboratory procedures, but not good predictors of physicians' referral rates. A 15-item survey form that measured risk-taking attitudes in the financial, health, social, and ethical domains was administered to all clinical faculty at an academic family practice center (n = 14). Each physician's utilization rates for the 17 most frequently ordered laboratory procedures were calculated for all patient visits for one calendar year. Overall referral rates were calculated for the same period. Physicians' risk attitudes (12 completed the survey) accounted for over 50% of the variance for several of the laboratory procedures. For example, the rank-order correlation between the complete blood count utilization rate and a Likert-scale item measuring physicians' propensity to take physical risks was 0.91 (p less than 0.001). The details of these findings help to explain an important component of practice variation.

Academic Medical Centers↗
PubMedDate not supplied

Teaching clinical decision making in a family practice clerkship.

Limited health care resources and other social factors are making clinical decision making (CDM) a necessary subject of study for medical students. However, CDM material is technical and could be perceived by students as arcane. This study evaluated student attitudes toward a CDM module imbedded in a third-year medical student (MSIII) family medicine clerkship. A survey instrument was used for the evaluation and included a within-subject check for response consistency. The results show that MSIIIs feel that technical CDM material is within their grasp and that it is relevant to their day-to-day care of patients.

Attitude↗
PubMedDate not supplied

Threshold analysis and programs for prevention of HIV infection.

BACKGROUND: Measuring the economic effectiveness of HIV-infection prevention activities poses special challenges in terms of behavioral change and health outcomes assessment. METHODS: One way to address this difficulty is to employ threshold analysis to determine a level of cost per HIV infection averted above which society would seem unwilling to pay. The authors employ a cost-utility analytic framework to determine a monetary threshold for HIV prevention programs, subject base-case results to sensitivity analyses, and apply these results to the Centers for Disease Control and Prevention's fiscal year 1993 budget for extramural HIV prevention programs. RESULTS: The monetary threshold for cost per HIV infection averted was calculated to be $417,000 in 1993 dollars, and ranged from $185,000 to $648,000 depending upon the dollar amount society would be willing to pay per quality-adjusted life year gained. CONCLUSIONS: Economic evaluations of particular HIV-infection prevention activities at least can begin by determining whether their levels of effectiveness are above or below this derived monetary threshold, and refinements beyond this dichotomous evaluation can proceed as further data become available.

Adult↗
PubMedDate not supplied

Circumcision: a decision analysis of its medical value.

Routine neonatal circumcision has long been controversial. Presented here is a cost-effectiveness analysis of the consequences of the treatment choices (circumcision versus no circumcision) using a decision tree model. For a simulated 85-year life expectancy, routine neonatal circumcision had an expected lifetime cost of $164.61 per patient circumcised and a quality-adjusted survival of 84.999 years. Conversely, for the noncircumcision approach, the expected average lifetime cost was $139.26 per patient, and the quality-adjusted survival was 84.971 years. The net cost-effectiveness ($919.87 per quality-adjusted life year) is within the range usually considered worthwhile for public health policy. However, because of the minor differences in lifetime cost ($25) and benefit (10 days of life) for an individual and the tenuous values available for disease incidence and surgical risk, we conclude that there is no medical indication for or against circumcision. Additional analyses suggested that reported benefits in preventing penile cancer and infant urinary tract infections are insignificant compared to the surgical risks of post neonatal circumcision. The decision regarding circumcision may most reasonably be made on nonmedical factors such as parent preference or religious convictions.

Circumcision, Male↗
PubMedDate not supplied

An overview of the effectiveness and efficiency of HIV prevention programs.

Because of the enormity of the HIV-AIDS epidemic and the urgency for preventing transmission, HIV prevention programs are a high priority for careful and timely evaluations. Information on program effectiveness and efficiency is needed for decision-making about future HIV prevention priorities. General characteristics of successful HIV prevention programs, programs empirically evaluated and found to change (or not change) high-risk behaviors or in need of further empirical study, and economic evaluations of certain programs are described and summarized with attention limited to programs that have a behavioral basis. HIV prevention programs have an impact on averting or reducing risk behaviors, particularly when they are delivered with sufficient resources, intensity, and cultural competency and are based on a firm foundation of behavioral and social science theory and past research. Economic evaluations have found that some of these behaviorally based programs yield net economic benefits to society, and others are likely cost-effective (even if not cost-saving) relative to other health programs. Still, specific improvements should be made in certain HIV prevention programs.

Adolescent↗
PubMedDate not supplied

Estimating the value of preventing a human immunodeficiency virus infection.

We estimated the medical cost savings for a case of human immunodeficiency virus (HIV) infection prevented. Using medical care cost estimates, assumptions concerning knowledge of serostatus, time spent in various stages of HIV disease, and a discount factor, we estimated the present value of future cost savings for a case of HIV prevented, which ranged from $56,000 to $80,000. Since this method excludes both indirect costs and direct costs other than medical care, these figures underestimate the true cost savings for a case of HIV prevented. However, the method may prove useful in assigning a systematic economic value to an HIV infection averted that can be used in cost-benefit analyses of HIV prevention interventions.

Cost Savings↗
PubMedDate not supplied

Counseling and testing for HIV prevention: costs, effects, and cost-effectiveness of more rapid screening tests.

New rapid human immunodeficiency virus (HIV) antibody tests permit many individuals to receive test results and appropriate counseling at one clinic visit. Because currently used tests require significant time for processing, all individuals must return for a second visit for test results and counseling. Since return rates for the second visit are low, the more rapid tests present an opportunity to improve the efficiency of HIV counseling and testing. The authors compared the costs and effectiveness of the currently used counseling and testing procedure and a streamlined procedure made possible by the new, more rapid screening tests. When test-positive clients are given preliminary screening test results, the rapid procedure is more cost-effective than the current procedure. Since over 90% of the clients in most clinics will test negative, the rapid counseling and testing procedure allows the vast majority of clients to be counseled and tested and to receive their results and posttest counseling in one visit. However, in the case where the goal of HIV counseling and testing is to focus only on infected individuals, if information regarding a positive result from the rapid screening test is not given to clients at the initial visit before a confirmatory test is performed, then the rapid counseling and testing procedure is not more cost-effective than the current procedure.

AIDS Serodiagnosis↗
PubMedDate not supplied

Preventing perinatal transmission of HIV--costs and effectiveness of a recommended intervention.

OBJECTIVE: To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections. METHOD: The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost. RESULTS: Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million. CONCLUSION: Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.

AIDS Serodiagnosis↗