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Biomedical subjects

David A Asch

Publications and source records attributed to David A Asch.

At least 19 recordsLinked to original sources
PubMed2003

Life insurance and breast cancer risk assessment: adverse selection, genetic testing decisions, and discrimination.

Life insurance industry access to genetic information is controversial. Consumer groups argue that access will increase discrimination in life insurance premiums and discourage individuals from undergoing genetic testing that may provide health benefits. Conversely, life insurers argue that without access to risk information available to individuals, they face substantial financial risk from adverse selection. Given this controversy, we conducted a retrospective cohort study to evaluate the impact of breast cancer risk information on life insurance purchasing, the impact of concerns about life insurance discrimination on use of BRCA1/2 testing, and the incidence of life insurance discrimination following participation in breast cancer risk assessment and BRCA1/2 testing. Study participants were 636 women who participated in genetic counseling and/or genetic testing at a University based clinic offering breast cancer risk assessment, genetic counseling, and BRCA1/2 testing between January 1995 and May 2000. Twenty-seven women (4%) had increased and six (1%) had decreased their life insurance since participation in breast cancer risk assessment. The decision to increase life insurance coverage was associated with predicted breast cancer risk (adjusted OR 1.03 for each 1% absolute increase in risk, 95% CI 1.01-1.10) and being found to carry a mutation in BRCA1/2 (OR 5.10, 95% CI 1.90-13.66). Concern about life insurance discrimination was inversely associated with the decision to undergo BRCA1/2 testing (RR 0.67, 95% CI 0.52-0.85). No respondent reported having life insurance denied or canceled. In this cohort of women, these results indicate that information about increased breast cancer risk is associated with increase in life insurance purchasing, raising the possibility of adverse selection. Although fear of insurance discrimination is associated with the decision not to undergo BRCA1/2 testing, there was no evidence of actual insurance discrimination from BRCA1/2 testing.

Breast Neoplasms↗
PubMed2003

Prior antimicrobial drug exposure: a risk factor for trimethoprim-sulfamethoxazole-resistant urinary tract infections.

OBJECTIVES: Antimicrobial drug use is believed to be an important risk factor for the emerging problem of antimicrobial drug resistance, yet strong evidence for the causal relationship in community settings has been limited. Detailed analysis of this risk factor at the level of the individual patient has been hampered by limited availability of drug exposure data among patients with outpatient infections. We used a novel data system to identify patterns of individual antimicrobial drug exposures associated with trimethoprim-sulfamethoxazole-resistant urinary tract infections (UTIs). MATERIALS AND METHODS: This was a retrospective case-control study. Subjects were veterans with Gram-negative UTIs seen at the Philadelphia VA Medical Center from 1 July 1996 to 31 December 1999. Subjects were linked to a national VA outpatient pharmacy database. Cases and controls were identified based on the results of trimethoprim-sulfamethoxazole susceptibility testing. RESULTS: Three hundred and ninety-three veterans with UTIs could be linked to electronic pharmacy records. The overall rate of trimethoprim-sulfamethoxazole drug resistance was 13%, without significant annual variation. Antimicrobial drug exposure within 6 months was strongly associated with the probability of a trimethoprim-sulfamethoxazole-resistant infection (OR = 4.1, 95% CI 2.2-7.5). This association extended to exposure to other antimicrobial drugs in addition to trimethoprim-sulfamethoxazole and the overall association displayed a dose-response relationship in terms of the number of prior drug exposures. CONCLUSIONS: Prior antimicrobial drug exposure is a strong risk factor for infection with trimethoprim-sulfamethoxazole-resistant Gram-negative bacteria among patients with UTIs.

Adolescent↗
PubMed2003

Hypertensive patients' willingness to participate in placebo-controlled trials: implications for recruitment efficiency.

BACKGROUND: Underenrollment and selective enrollment plague many clinical trials. Little is known about why hypertensive patients agree or refuse to participate in placebo-controlled trials (PCT) of antihypertensive drugs, whether the prospect of receiving placebo influences willingness to participate (WTP), or whether patients who participate differ from those who do not. METHODS: We described a hypothetical PCT of a new antihypertensive drug to 126 patients who would be eligible for ongoing phase III trials. We solicited patient motivations and concerns regarding trial participation by using open-ended questions, assessed the patients' stated WTP, and used logistic regression to determine patient characteristics associated with WTP. We reassessed WTP in 62 patients after revealing, in random order, that 10%, 30%, and 50% of patients would receive placebo. RESULTS: The most commonly cited motivations for participating included personal health benefits (40%), helping other patients (37%), and contributing to scientific knowledge (15%). The most common concerns were having to stop current medications (56%), inconvenience/annoyance (38%), fear of known side effects (35%), and the possibility of receiving placebo (24%). Overall, 47% of patients (95% confidence interval, 38% to 56%) were willing to participate. Younger patients (57% versus 37%; P =.01), nonsmokers (50% versus 24%; P =.04), and patients who had participated in research previously (77% versus 20%; P =.009) were all significantly more willing to participate. Fewer patients were willing to participate as the percentage who would receive placebo increased (P =.02), but randomly assigning fully half of patients to placebo still yielded maximal recruitment efficiency. CONCLUSIONS: Hypertensive patients participate in trials for altruistic and personal health reasons. Differences between patients who do or do not participate may influence trial outcomes. The proportion of patients receiving placebo influences some patients' enrollment decisions but is not a key determinant of recruitment efficiency.

Altruism↗
PubMed2003

The influence of cost-effectiveness information on physicians' cancer screening recommendations.

Physicians are increasingly faced with choices in which one screening strategy is both more effective and more expensive than another. One way to make such choices is to examine the cost-effectiveness of the more costly strategy over the less costly one. However, little is known about how cost-effectiveness information influences physicians' screening decisions. We surveyed 900 primary care US physicians, and presented each with a hypothetical cancer-screening scenario. We created three familiar screening scenarios, involving cervical, colon, and breast cancer. We also created three unfamiliar screening scenarios. Physicians were randomized to receive one of nine questionnaires, each containing one screening scenario. Three questionnaires posed one of the familiar screening scenarios without cost-effectiveness information, three posed one of the familiar scenarios with cost-effectiveness information, and three posed one of the unfamiliar scenarios with cost-effectiveness information. The cost-effectiveness information for familiar scenarios was drawn from the medical literature. The cost-effectiveness information for unfamiliar scenarios was fabricated to match that of a corresponding familiar scenario. In all questionnaires, physicians were asked what screening alternative they would recommend. A total of 560 physicians responded (65%). For familiar scenarios, providing cost-effectiveness information had at most a small influence on physicians' screening recommendations; it reduced the proportion of physicians recommending annual Pap smears (p=0.003), but did not significantly alter the aggressiveness of colon cancer and breast cancer screening (both p's<0.1). For all three unfamiliar scenarios, physicians were significantly less likely to recommend expensive screening strategies than in corresponding familiar scenarios (all p's<0.001). Physicians' written explanations revealed a number of factors that moderated the influence of cost-effectiveness information on their screening recommendations. Providing physicians with cost-effectiveness information had only a moderate influence on their screening recommendations for cervical, colon, and breast cancer. Significantly, fewer physicians recommended aggressive screening for unfamiliar cancers than for familiar ones, despite similar cost-effectiveness. Physicians are relatively reluctant to abandon common screening strategies, even when they learn that they are expensive, and are hesitant to adopt unfamiliar screening strategies, even when they learn that they are inexpensive.

Adult↗
PubMed2003

Why would caregivers not want to treat their relative's Alzheimer's disease?

OBJECTIVES: To determine family caregivers' willingness to use Alzheimer's disease (AD)-slowing medicines and to examine the relationships between this willingness, dementia severity, and caregiver characteristics. DESIGN: Cross-sectional survey. SETTING: In-home interviews of patients from the Memory Disorders Clinic of the University of Pennsylvania's Alzheimer's Disease Center. PARTICIPANTS: One hundred two caregivers of patients with mild to severe AD who were registered at an Alzheimer's disease center. MEASUREMENTS: Subjects participated in an in-home interview to assess their willingness to use a risk-free AD-slowing medicine and a medicine with 3% annual risk of gastrointestinal bleeding. RESULTS: Half of the patients had severe dementia (n=52). Seventeen (17%) of the caregivers did not want their relative to take a risk-free medicine that could slow AD. Half (n=52) did not want their relative to take an AD-slowing medicine that had a 3% annual risk of gastrointestinal bleeding. Caregivers who were more likely to forgo risk-free treatment of AD were older (odds ratio (OR)=1.7, P=.04), were depressed (OR=3.66, P=.03), had relatives living in a nursing home (OR=3.6, P=.02), had relatives with more-severe dementia according to the Mini-Mental State Examination (MMSE) (OR=2.29, P=.03) or Dementia Severity Rating Scale (DSRS) (OR=2.55, P=.002), and rated their relatives' quality of life (QOL) poorly on a single-item global rating (OR=0.25, P=.001) and the 13-item quality-of-life (QOL)-AD scale (OR=0.38, P=.002). Caregivers who were more likely to forgo a risky treatment were nonwhite (OR=6.53, P=.005), had financial burden (OR=2.93, P=.02), and rated their relative's QOL poorly on a single-item global rating (OR=0.61, P=.01) and the QOL-AD (OR=0.56, P=.01). CONCLUSION: These results suggest that caregivers are generally willing to slow the progression of their relative's dementia even into the severe stage of the disease, especially if it can be done without risk to the patient. Clinical trials and practice guidelines should recognize that a caregiver's assessment of patient QOL and the factors that influence it affect a caregiver's willingness to use AD-slowing treatments.

Alzheimer Disease↗
PubMed2003

Incremental and average cost-effectiveness ratios: will physicians make a distinction?

Physicians are increasingly asked to use cost-effectiveness information when evaluating alternative health care interventions. Little is known about how the way such information is presented can influence medical decision making. We presented physicians with hypothetical screening scenarios with multiple options, varying the type of cost-effectiveness ratios provided as well as whether the scenarios described cancer screening settings that were familiar or unfamiliar. Half the scenarios used average cost-effectiveness ratios, as commonly reported, calculating benefits and costs relative to a no-screening option. The other half used the preferred incremental cost-effectiveness ratios, with each option's benefits and costs calculated relative to the next best alternative. Relative to average cost-effectiveness ratios, incremental cost-effectiveness information significantly reduced preference for the most expensive screening strategies in two of three unfamiliar scenarios. No such difference was found for familiar scenarios, for which physicians likely have established practice patterns. These results suggest that, in unfamiliar settings, average cost-effectiveness ratios as reported in many analyses reported in the literature can hide the often high price for achieving incremental health care goals, potentially causing physicians to choose interventions with poor cost effectiveness.

Cost-Benefit Analysis↗
PubMed2003

Misperceptions about beta-blockers and diuretics: a national survey of primary care physicians.

BACKGROUND: Based on a series of clinical trials showing no difference in the effectiveness or tolerability of most major classes of antihypertensive medications, the Joint National Commission on High Blood Pressure Treatment recommends that physicians prescribe beta-blockers or diuretics as initial hypertensive therapy unless there are compelling indications for another type of medication. Nevertheless, many physicians continue to favor more expensive medications like angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers as first line agents. The persistent use of these agents raises questions as to whether physicians perceive ACE inhibitors and calcium channel blockers to be better than beta-blockers and diuretics. METHODS: We surveyed 1,200 primary care physicians in 1997, and another 500 primary care physicians in 2000, and asked them to estimate the relative effectiveness and side effects of 4 classes of medication in treating a hypothetical patient with uncomplicated hypertension: ACE inhibitors, beta-blockers, calcium channel blockers, and diuretics. In addition, we asked them to indicate whether they ever provided free samples of hypertension medications to their patients. RESULTS: Perceptions of the relative effectiveness and side effects of the 4 classes of hypertension medications did not significantly change over the 3 years, nor did prescription recommendations. Physicians perceive that diuretics are less effective at lowering blood pressure than the other 3 classes (P <.001). They also perceive that beta-blockers are less tolerated than the other 3 classes (P <.001). In a multivariate model, perceptions of effectiveness and tolerability displayed significant associations with prescription preference independent of background variables. The only other variable to contribute significantly to the model was provision of free medication samples to patients. CONCLUSIONS: Despite numerous clinical trials showing no difference in the effectiveness or side-effect profiles of these 4 classes of drugs, most physicians believed that diuretics were less effective and beta-blockers were less tolerated than other medications. Moreover, their prescription practices were associated with their provision of free samples provided by pharmaceutical representatives, even after adjusting for other demographic characteristics. Efforts to increase physicians' prescribing of beta-blockers and diuretics may need to be directed at overcoming misunderstandings about the effectiveness and tolerability of these medicines.

Adrenergic beta-Antagonists↗
PubMed2003

When money is saved by reducing healthcare costs, where do US primary care physicians think the money goes?

BACKGROUND: Physician willingness to reduce medical costs is mixed. Some physicians might be unwilling to reduce medical costs because they are concerned about where the savings would go. OBJECTIVE: To determine whether primary care physicians might be less willing to choose a less expensive, less effective cancer screening alternative if they believe that the money saved goes to insurance companies. DESIGN: Anonymous mailed survey. PARTICIPANTS: A total of 865 US primary care physicians. MAIN OUTCOME MEASURES: Responses to one of several clinical vignettes presenting a choice between a less expensive, less effective cancer screening option and a more expensive, more effective alternative and responses to where physicians thought the savings might go if they chose the cheaper alternative. RESULTS: Fifty-three percent of physicians chose the most expensive screening alternative. In aggregate, physicians responded that more of any money saved would go to the managers or owners of insurance companies than to increased clinical services or reduced insurance premiums. Physicians choosing the more expensive screening test were more likely to believe that money saved from choosing the less expensive test would go to insurance company profits and salaries rather than to increased clinical services or reduced premiums (P < .001). CONCLUSIONS: Although US primary care physicians vary in where they think money saved in healthcare goes, most believe that more of it goes to the salaries of insurance company executives and the profits of insurance company owners than to improved clinical services or reduced premiums. The more physicians believe that this is where the money goes, the less willing they are to reduce healthcare costs.

Attitude of Health Personnel↗
PubMed2003

How physicians react to cost-effectiveness information.

Since 1998, the growth of health care spending has accelerated to levels not seen since the 1980s. This growth has renewed pressures on physicians to practice "cost-effective" care, since physicians' decisions account for the vast majority of all health care spending. But little is known about what physicians think about cost containment, and how they incorporate cost-effectiveness information into their practice patterns. This Issue Brief summarizes three related studies that describe primary care physicians' attitudes toward considering costs in their clinical decisions, and the effects of providing cost-effectiveness information on physicians' recommendations.

Attitude of Health Personnel↗
PubMed2002

Obtaining informed consent for cancer pain research: do patients with advanced cancer and patients with chronic pain have different concerns?

To explore the factors that patients with malignant and nonmalignant pain consider when deciding whether to enroll in pain research studies, determine whether their views are different, and determine whether willingness to enroll in research is associated with pain severity, semi-structured interviews were conducted with 80 patients (cancer pain: n = 40; chronic nonmalignant pain: n = 40). The risks and potential benefits that were important to patients with cancer were the same as those that were important to patients with chronic pain. Willingness to enroll in research was associated with pain severity (Spearman rho = 0.33; P = 0.041) in patients with chronic pain, but not in patients with cancer pain. Patients with cancer pain do not have different concerns than chronic pain patients do. Although chronic pain patients' willingness to enroll in research was related to pain severity and a desire for better pain management, cancer patients' willingness to enroll was not.

Adult↗
PubMed2002

Tensions in antibiotic prescribing: pitting social concerns against the interests of individual patients.

BACKGROUND: To reduce the prevalence of antibiotic-resistant bacteria in the community, physicians must optimize their use of antibiotics. However, optimal use from the perspective of the community (reserving newer agents for future use) is not always consistent with optimal use from the perspective of the individual patient (prescribing newer, broader agents). OBJECTIVES: To identify preferred patterns of antibiotic prescribing for patients with community-acquired pneumonia (CAP), measure explicit attitudes toward antibiotics and antibiotic resistance, and determine the relationship between these prescribing patterns and attitudes. DESIGN: Cross-sectional anonymous mail survey. PARTICIPANTS: National random sample of 400 generalist physicians (general internal medicine and family practice) and 429 infectious diseases specialists. MEASUREMENTS: Rank ordering of antibiotic preferences for a hypothetical outpatient with CAP and reasons for antibiotic selection. Endorsement of attitudes regarding antibiotic prescribing decisions and resistance. RESULTS: Both generalists and infectious diseases specialists were more likely to prefer newer, broader drugs for the treatment of CAP compared to older agents still recommended by national guidelines. Physicians rated the issue of contributing to antibiotic resistance lowest among 7 determinants of their choices. CONCLUSIONS: Despite national guidelines and increasing public awareness, the public health concern of contributing to the problem of antibiotic resistance does not exert a strong impact on physician prescribing decisions for CAP. Future efforts to optimize antibiotic prescribing decisions will need to consider options for increasing the impact of public health issues on the patient-oriented decisions of individual physicians.

Adult↗
PubMed2002

Physicians' preferences for active-controlled versus placebo-controlled trials of new antihypertensive drugs.

OBJECTIVE: To evaluate physicians' preferences for referring patients to, and using information from, active-controlled trials (ACTs) versus placebo-controlled trials (PCTs) of new antihypertensive drugs. DESIGN AND SETTING: Nationwide mailed survey, with telephone contact of nonresponders to assess nonresponse bias. PARTICIPANTS: One thousand two hundred primary care physicians randomly selected from the American Medical Association's Master File. Of 1,154 physicians eligible to respond, 651 (56.4%) returned completed questionnaires. MEASUREMENTS AND MAIN RESULTS: We measured physicians' stated willingness to encourage hypertensive patients to enroll in ACTs and PCTs of new antihypertensive drugs, their views of the relative merits of ACTs versus PCTs, their stated willingness to prescribe new drugs tested in ACTs or PCTs, and their views regarding the overall justifiability of the 2 designs. Physicians were significantly more likely to indicate they would encourage their patients to enroll in ACTs than in PCTs (P <.0001). Physicians thought ACTs provided more valuable information for their practices, were more likely to lead to a public health benefit, offered enrolled patients greater opportunity for personal benefit, and were less likely to expose enrolled patients to unnecessary risks (all P <.0001). Physicians were more likely to prescribe new drugs that had been compared in ACTs (P <.0001), and viewed ACTs as a more justifiable method for testing new antihypertensive drugs (P <.0001). There was no evidence of nonresponse bias for these main results. CONCLUSIONS: Although PCTs remain the standard method for testing new antihypertensive drugs, physicians strongly prefer ACTs. Using ACTs to test new antihypertensive drugs may enhance the efficiency of patient recruitment and more strongly influence physicians' prescribing practices.

Antihypertensive Agents↗
PubMed2002

Paying hypertension research subjects.

CONTEXT: Cash payments are often used to compensate subjects who participate in research. However, ethicists have argued that these payments might constitute an undue inducement. OBJECTIVES: To determine whether potential subjects agree with theoretical arguments that a payment could be an undue inducement. DESIGN/SETTING/PARTICIPANTS: Survey of 350 prospective jurors. MAIN OUTCOME MEASURES: Belief that a 500 dollar payment for research participation would impair their own, and others' ability to think carefully about the risks and benefits of a clinical trial. RESULTS: Two hundred sixty-one jurors (74.6%) believed that a 500 dollar payment would impair subjects' ability to think carefully about the risks and benefits of research. Ninety-six of 120 (80%) expressed this concern about subjects with a low income (<20,000 dollars) compared to 92/117 (79%) of those with a middle income (20,000 dollars to 50,000 dollars), and 73/113 (65%) with a high income (>50,000 dollars). In contrast, only 69 (19.7%) of jurors believed that a 500 dollar payment would influence them. Jurors who believed that this payment would influence them reported lower incomes and less education. CONCLUSION: Members of the general public share ethical concerns about the influence of payments for research, although they believe that these concerns are more applicable to others than to themselves.

Adult↗
PubMed2002

Randomized trial of 5 dollars versus 10 dollars monetary incentives, envelope size, and candy to increase physician response rates to mailed questionnaires.

BACKGROUND: The validity of the results of mailed surveys is often threatened by nonresponse bias, which is made more likely when response rates are low. However, the effectiveness and cost-effectiveness of several strategies to increase response rates are uncertain. OBJECTIVES: To assess three strategies to increase response rates to mailed physician surveys: including a 10 dollars versus a 5 dollars cash incentive in the initial mailing, including a mint candy or not, and using a large versus small outgoing envelope. RESEARCH DESIGN AND SUBJECTS: Using a 2 x 2 x 2 factorial design, a randomized trial of these strategies was conducted in a survey of 1200 physicians randomly selected from the American Medical Association's Master File. RESULTS: Including a 10 dollars incentive yielded a significantly higher response rate (60.5% vs. 52.8%) (P = 0.009). The mailing and incentive costs per completed response were 12.24 dollars (95% CI, 11.75 dollars, 13.64 dollars) in the 5 dollars group and 18.48 dollars (95% CI, 17.77 dollars, 20.69 dollars) in the 10 dollars group. Each additional response obtained in the 10 dollars group came at an incremental cost of 61.26 dollars (95% CI, 36.98 dollars, 200.80 dollars). Neither inclusion of a mint nor use of a large envelope influenced the response rate. CONCLUSIONS: Investigators may increase response rates by including more money in the initial questionnaire packet, but there may be diminishing returns to serial increments in incentives greater than 5 dollars. Including smaller incentives in more questionnaires may maximize total responses.

Candy↗