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Steven M Teutsch

Publications and source records attributed to Steven M Teutsch.

At least 19 recordsLinked to original sources
PubMed2007

Lessons from cost-effectiveness research for United States public health policy.

The application of cost-effectiveness analysis to health care has been the subject of previous reviews. We address the use of economic evaluation methods in public health, including case studies of population-level policies, e.g., environmental regulations, injury prevention, tobacco control, folic acid fortification, and blood product safety, and the public health promotion of clinical preventive services, e.g., newborn screening, cancer screening, and childhood immunizations. We review the methods used in cost-effectiveness analysis, the implications for cost-effectiveness findings, and the extent to which economic studies have influenced policy and program decisions. We discuss reasons for the relatively limited impact to date of economic evaluation in public health. Finally, we address the vexing question of how to decide which interventions are cost effective and worthy of funding. Policy makers have funded certain interventions with rather high cost-effectiveness ratios, notably nucleic acid testing for blood product safety. Cost-effectiveness estimates are a decision aid, not a decision rule.

Cost-Benefit Analysis↗
PubMed2005

Cholesterol levels and statin use in patients with coronary heart disease treated in primary care settings.

INTRODUCTION: Therapy with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, has proven to be effective in the treatment of lipid disorders. However, statin therapy continues to be underused, even though statins are a relatively safe and well-tolerated class of agents. In this study, we assessed trends in lipid control in patients with heart disease who receive most of their health care in primary care clinics. The objective was to determine whether systems of care implemented within a large medical group are associated with improved treatment and control of dyslipidemia in a high-risk group of coronary heart disease patients. METHODS: All adults with heart disease in a Minnesota medical group (N = 2947) were identified using diagnosis and procedure codes related to coronary heart disease (sensitivity = 0.85; positive predictive value = 0.89) in 1996. Study subjects were observed from 1995 to 1998. Subjects had a baseline and follow-up test for low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. Changes between baseline and follow-up measurements and trends in the use of statins and other lipid-active agents among the study subjects were analyzed. RESULTS: Among 1388 subjects with two or more eligible lipid measurements, mean low-density lipoprotein cholesterol improved from 137.6 mg/dL to 111.0 mg/dL (P < .001), and mean high-density lipoprotein cholesterol improved from 42.3 mg/dL to 46.3 mg/dL (P < .001). The percentage of patients with low-density lipoprotein cholesterol < or = 100 mg/dL rose from 12.5% to 39.8% (P < .001), and the percentage with high-density lipoprotein cholesterol > or = 40 mg/dL rose from 52.5% to 67.6% (P < .001). In multivariate models, statin use was identified as the main factor that contributed to the improvement in low-density lipoprotein cholesterol (P < .001). Men had greater decreases in low-density lipoprotein cholesterol than women after adjusting for other variables (P < .001). Statin use rose from 24.3% at baseline to 69.6% at follow-up. The statin discontinuation rate was 8.3% for baseline statin users and 12.2% for subjects who used statins at any time during the study period. CONCLUSION: Investment in better heart disease care for patients in primary care clinics led to major improvement in lipid control over 30 months, primarily due to increased statin use. Improvements in low-density lipoprotein cholesterol and high-density lipoprotein cholesterol were sufficient to substantially reduce risk of subsequent major cardiovascular events.

Aged↗
PubMed2005

A quantitative analysis of fish consumption and coronary heart disease mortality.

Although a rich source of n-3 polyunsaturated fatty acids (PUFAs) that may confer multiple health benefits, some fish contain methyl mercury (MeHg), which may harm the developing fetus. U.S. government recommendations for women of childbearing age are to modify consumption of high-MeHg fish to reduce MeHg exposure, while recommendations encourage fish consumption among the general population because of the nutritional benefits. The Harvard Center for Risk Analysis convened an expert panel (see acknowledgements) to quantify the net impact of resulting hypothetical changes in fish consumption across the population. This paper estimates the impact of fish consumption on coronary heart disease (CHD) mortality and nonfatal myocardial infarction (MI). Other papers quantify stroke risk and the impacts of both prenatal MeHg exposure and maternal intake of n-3 PUFAs on cognitive development. This analysis identified articles in a recent qualitative review appropriate for the development of a dose-response relationship. Studies had to satisfy quality criteria, quantify fish intake, and report the precision of the relative risk estimates. Relative risk results were averaged, weighted proportionately by precision. CHD risks associated with MeHg exposure were reviewed qualitatively because the available literature was judged inadequate for quantitative analysis. Eight studies were identified (29 exposure groups). Our analysis estimated that consuming small quantities of fish is associated with a 17% reduction in CHD mortality risk, with each additional serving per week associated with a further reduction in this risk of 3.9%. Small quantities of fish consumption were associated with risk reductions in nonfatal MI risk by 27%, but additional fish consumption conferred no incremental benefits.

Adult↗
PubMed2005

A quantitative analysis of fish consumption and stroke risk.

Although a rich source of n-3 polyunsaturated fatty acids (PUFAs) that may confer multiple health benefits, some fish contain methyl mercury (MeHg), which may harm the developing fetus. U.S. government recommendations for women of childbearing age are to modify consumption of high-MeHg fish to reduce MeHg exposure, while recommendations encourage fish consumption among the general population because of the nutritional benefits. The Harvard Center for Risk Analysis convened an expert panel (see acknowledgements) to quantify the net impact of resulting hypothetical changes in fish consumption across the population. This paper estimates the impact of fish consumption on stroke risk. Other papers quantify coronary heart disease mortality risk and the impacts of both prenatal MeHg exposure and maternal intake of n-3 PUFAs on cognitive development. This analysis identified articles in a recent qualitative literature review that are appropriate for the development of a dose-response relationship between fish consumption and stroke risk. Studies had to satisfy quality criteria, quantify fish intake, and report the precision of the relative risk estimates. The analysis combined the relative risk results, weighting each proportionately to its precision. Six studies were identified as appropriate for inclusion in this analysis, including five prospective cohort studies and one case-control study (total of 24 exposure groups). Our analysis indicates that any fish consumption confers substantial relative risk reduction compared to no fish consumption (12% for the linear model), with the possibility that additional consumption confers incremental benefits (central estimate of 2.0% per serving per week).

Adult↗
PubMed2005

A quantitative risk-benefit analysis of changes in population fish consumption.

Although a rich source of n-3 polyunsaturated fatty acids (PUFAs) that may confer multiple health benefits, some fish contain methyl mercury (MeHg), which may harm the developing fetus. U.S. government recommendations for women of childbearing age are to modify consumption of high-MeHg fish, while recommendations encourage fish consumption among the general population because of nutritional benefits. To investigate the aggregate impacts of hypothetical shifts in fish consumption, the Harvard Center for Risk Analysis convened an expert panel (see acknowledgements). Effects investigated include prenatal cognitive development, coronary heart disease mortality, and stroke. Substitution of fish with high MeHg concentrations with fish containing less MeHg among women of childbearing age yields substantial developmental benefits and few negative impacts. However, if women instead decrease fish consumption, countervailing risks substantially reduce net benefits. If other adults (mistakenly and inappropriately) also reduce their fish consumption, the net public health impact is negative. Although high compliance with recommended fish consumption patterns can improve public health, unintended shifts in consumption can lead to public health losses. Risk managers should investigate and carefully consider how populations will respond to interventions, how those responses will influence nutrient intake and contaminant exposure, and how these changes will affect aggregate public health.

Adolescent↗
PubMed2005

Excess mortality, hospital stay, and cost due to candidemia: a case-control study using data from population-based candidemia surveillance.

OBJECTIVE: To determine the mortality, hospital stay, and total hospital charges and cost of hospitalization attributable to candidemia by comparing patients with candidemia with control-patients who have otherwise similar illnesses. Prior studies lack broad patient and hospital representation or cost-related information that accurately reflects current medical practices. DESIGN: Our case-control study included case-patients with candidemia and their cost-related data, ascertained from laboratory-based candidemia surveillance conducted among all residents of Connecticut and Baltimore and Baltimore County, Maryland, during 1998 to 2000. Control-patients were matched on age, hospital type, admission year, discharge diagnoses, and duration of hospitalization prior to candidemia onset. RESULTS: We identified 214 and 529 sets of matched case-patients and control-patients from the two locations, respectively. Mortality attributable to candidemia ranged between 19% and 24%. On multivariable analysis, candidemia was associated with mortality (OR, 5.3 for Connecticut and 8.5 for Baltimore and Baltimore County; P < .05), whereas receiving adequate treatment was protective (OR, 0.5 and 0.4 for the two locations, respectively; P < .05). Candidemia itself did not increase the total hospital charges and cost of hospitalization; when treatment status was accounted for, having received adequate treatment for candidemia significantly increased the total hospital charges and cost of hospitalization ($6,000 to $29,000 and $3,000 to $22,000, respectively) and the length of stay (3 to 13 days). CONCLUSION: Our findings underscore the burden of candidemia, particularly regarding the risk of death, length of hospitalization, and cost associated with treatment.

Adolescent↗
PubMed2005

Impact of 3-tier pharmacy benefit design and increased consumer cost-sharing on drug utilization.

OBJECTIVE: To estimate responsiveness of prescription demand within 9 therapeutic classes to increased cost-sharing compared with constant cost-sharing. STUDY DESIGN: Retrospective prescription claims analysis. METHODS: Between 1999 and 2001, 3 benefit plans changed from a 2-tier to a 3-tier design (cases); 1 plan kept a 2-tier design (controls). Study subjects needed 24 months of continuous coverage and a prescription filled < OR = 3 months before the benefit change for a nonsteroidal anti-inflammatory agent (NSAID), a cyclooxygenase (COX-2) inhibitor, a selective serotonin reuptake inhibitor (SSRI), a tricyclic antidepressant (TCA), an angiotensin-converting enzyme (ACE) inhibitor, a calcium-channel blocker (CCB), an angiotensin-receptor blocker (ARB), a statin, or a triptan. Changes in use were compared with the Wilcoxon signed rank test. Elasticity of demand among cases was calculated. RESULTS: Generally, medication possession ratios decreased for cases and increased for controls between 1999 and 2000. Switch rates increased for cases and decreased for controls for all classes but CCBs. Switches to lower copayments for ACE inhibitors, statins, and triptans occurred more often for cases. Discontinuation-rate changes for cases were 2 to 8 times those for controls. Generic-substitution rates depended on availability and initial generic utilization. Elasticity of demand for drugs was generally low, -0.16 to -0.10, for asymptomatic conditions (ACE inhibitors, ARBs, CCBs, statins), and moderate, -0.60 to -0.24, for symptomatic conditions (COX-2 inhibitors, NSAIDs, triptans, SSRIs). CONCLUSION: Use of retail prescription medications within 9 specific therapeutic classes decreased as copayment increased. Demand for pharmaceuticals was relatively inelastic with these copayment increases.

Cost Sharing↗
PubMed2004

A randomized controlled open trial of population-based disease and case management in a Medicare Plus Choice health maintenance organization.

INTRODUCTION: The object of this study was to examine the effect of population-based disease management and case management on resource use, self-reported health status, and member satisfaction with and retention in a Medicare Plus Choice health maintenance organization (HMO). METHODS: Study design consisted of a prospective, randomized controlled open trial of 18 months' duration. Participants were 8504 Medicare beneficiaries aged 65 and older who had been continuously enrolled for at least 12 months in a network model Medicare Plus Choice HMO serving a contiguous nine-county metropolitan area. Members were care managed with an expert clinical information system and frequent telephone contact. Main outcomes included self-reported health status measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), resource use measured by admission rates and bed-days per thousand per year, member satisfaction, and costs measured by paid claims. RESULTS: More favorable outcomes occurred in the intervention group for satisfaction with the health plan (P < .01) and the social function domain as measured by SF-36 (P = .04). There was no difference in member retention or mortality between groups. Use of skilled nursing home services was significantly lower in the intervention group than in the control (616 vs 747 days per thousand members per year, P = .02). This reduction, however, did not lead to lower mean total expenditures in the intervention group compared with the control (6828 dollars per member for 18 months vs 7001 dollars, P = .61). CONCLUSION: Population-based disease management and case management led to improved self-reported satisfaction and social function but not to a global net decrease in resource use or improved member retention.

Aged↗
PubMed2004

Pharmacy benefits and the use of drugs by the chronically ill.

CONTEXT: Many health plans have instituted more cost sharing to discourage use of more expensive pharmaceuticals and to reduce drug spending. OBJECTIVE: To determine how changes in cost sharing affect use of the most commonly used drug classes among the privately insured and the chronically ill. DESIGN, SETTING, AND PARTICIPANTS: Retrospective US study conducted from 1997 to 2000, examining linked pharmacy claims data with health plan benefit designs from 30 employers and 52 health plans. Participants were 528,969 privately insured beneficiaries aged 18 to 64 years and enrolled from 1 to 4 years (960,791 person-years). MAIN OUTCOME MEASURE: Relative change in drug days supplied (per member, per year) when co-payments doubled in a prototypical drug benefit plan. RESULTS: Doubling co-payments was associated with reductions in use of 8 therapeutic classes. The largest decreases occurred for nonsteroidal anti-inflammatory drugs (NSAIDs) (45%) and antihistamines (44%). Reductions in overall days supplied of antihyperlipidemics (34%), antiulcerants (33%), antiasthmatics (32%), antihypertensives (26%), antidepressants (26%), and antidiabetics (25%) were also observed. Among patients diagnosed as having a chronic illness and receiving ongoing care, use was less responsive to co-payment changes. Use of antidepressants by depressed patients declined by 8%; use of antihypertensives by hypertensive patients decreased by 10%. Larger reductions were observed for arthritis patients taking NSAIDs (27%) and allergy patients taking antihistamines (31%). Patients with diabetes reduced their use of antidiabetes drugs by 23%. CONCLUSIONS: The use of medications such as antihistamines and NSAIDs, which are taken intermittently to treat symptoms, was sensitive to co-payment changes. Other medications--antihypertensive, antiasthmatic, antidepressant, antihyperlipidemic, antiulcerant, and antidiabetic agents--also demonstrated significant price responsiveness. The reduction in use of medications for individuals in ongoing care was more modest. Still, significant increases in co-payments raise concern about adverse health consequences because of the large price effects, especially among diabetic patients.

Adult↗
PubMed2004

Promoting informed decisions about cancer screening in communities and healthcare systems.

Individuals are increasingly involved in decisions about their health care. Shared decision making (SDM), an intervention in the clinical setting in which patients and providers collaborate in decision making, is an important approach for informing patients and involving them in their health care. However, SDM cannot bear the entire burden for informing and involving individuals. Population-oriented interventions to promote informed decision making (IDM) should also be explored. This review provides a conceptual background for population-oriented interventions to promote informed decisions (IDM interventions), followed by a systematic review of studies of IDM interventions to promote cancer screening. This review specifically asked whether IDM interventions (1) promote understanding of cancer screening, (2) facilitate participation in decision making about cancer screening at a level that is comfortable for individuals; or (3) encourage individuals to make cancer-screening decisions that are consistent with their preferences and values.Fifteen intervention arms met the intervention definition. They used small media, counseling, small-group education, provider-oriented strategies, or combinations of these to promote IDM. The interventions were generally consistent in improving individuals' knowledge about the disease, accuracy of risk perceptions, or knowledge and beliefs about the pros and cons of screening and treatment options. However, few studies evaluated whether these interventions resulted in individuals participating in decision making at a desirable level, or whether they led to decisions that were consistent with individuals' values and preferences. More research is needed on how best to promote and facilitate individuals' participation in health care. Work is especially needed on how to facilitate participation at a level desired by individuals, how to promote decisions by patients that are consistent with their preferences and values, how to perform effective and cost-effective IDM interventions for healthcare systems and providers and in community settings (outside of clinical settings), and how to implement these interventions in diverse populations (such as populations that are older, nonwhite, or disadvantaged). Finally, work is needed on the presence and magnitude of barriers to and harms of IDM interventions and how they might be avoided.

Community Health Services↗
PubMed2003

Aligning quality for populations and patients: do we know which way to go?

Both the medical care and public health systems have invested considerable resources to define, measure, and improve quality and health outcomes. A movement toward accountability has generated performance indicators from the medical arena and "leading health indicators" from the public health arena. The focus on specific conditions by the medical care system has been at odds with public health's emphasis on improving population health and has perpetuated a bifurcated system. Aligning the goals of medical care with those of public health will require reformulation of performance measurement and accountability into a common language that is valued by both systems. Such a creation would amount to a whole that is stronger than the sum of the component parts.

Cooperative Behavior↗
PubMed2003

NCEP-defined metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years and older.

Although the individual components of the metabolic syndrome are clearly associated with increased risk for coronary heart disease (CHD), we wanted to quantify the increased prevalence of CHD among people with metabolic syndrome. The Third National Health and Nutrition Examination Survey (NHANES III) was used to categorize adults over 50 years of age by presence of metabolic syndrome (National Cholesterol Education Program [NCEP] definition) with or without diabetes. Demographic and risk factor information was determined for each group, as well as the proportion of each group meeting specific criteria for metabolic syndrome. The prevalence of CHD for each group was then determined. Metabolic syndrome is very common, with approximately 44% of the U.S. population over 50 years of age meeting the NCEP criteria. In contrast, diabetes without metabolic syndrome is uncommon (13% of those with diabetes). Older Americans over 50 years of age without metabolic syndrome regardless of diabetes status had the lowest CHD prevalence (8.7% without diabetes, 7.5% with diabetes). Compared with those with metabolic syndrome, people with diabetes without metabolic syndrome did not have an increase in CHD prevalence. Those with metabolic syndrome without diabetes had higher CHD prevalence (13.9%), and those with both metabolic syndrome and diabetes had the highest prevalence of CHD (19.2%) compared with those with neither. Metabolic syndrome was a significant univariate predictor of prevalent CHD (OR 2.07, 95% CI 1.66-2.59). However, blood pressure, HDL cholesterol, and diabetes, but not presence of metabolic syndrome, were significant multivariate predictors of prevalent CHD. The prevalence of CHD markedly increased with the presence of metabolic syndrome. Among people with diabetes, the prevalence of metabolic syndrome was very high, and those with diabetes and metabolic syndrome had the highest prevalence of CHD. Among all individuals with diabetes, prevalence of CHD was increased compared with those with metabolic syndrome without diabetes. However, individuals with diabetes without metabolic syndrome had no greater prevalence of CHD compared with those with neither.

Age Factors↗
PubMed2002

Postmenopausal hormone replacement therapy: scientific review.

CONTEXT: Although postmenopausal hormone replacement therapy (HRT) is widely used in the United States, new evidence about its benefits and harms requires reconsideration of its use for the primary prevention of chronic conditions. OBJECTIVE: To assess the benefits and harms of HRT for the primary prevention of cardiovascular disease, thromboembolism, osteoporosis, cancer, dementia, and cholecystitis by reviewing the literature, conducting meta-analyses, and calculating outcome rates. DATA SOURCES: All relevant English-language studies were identified in MEDLINE (1966-2001), HealthSTAR (1975-2001), Cochrane Library databases, and reference lists of key articles. Recent results of the Women's Health Initiative (WHI) and the Heart and Estrogen/progestin Replacement Study (HERS) are included for reported outcomes. STUDY SELECTION AND DATA EXTRACTION: We used all published studies of HRT if they contained a comparison group of HRT nonusers and reported data relating to HRT use and clinical outcomes of interest. Studies were excluded if the population was selected according to prior events or presence of conditions associated with higher risks for targeted outcomes. DATA SYNTHESIS: Meta-analyses of observational studies indicated summary relative risks (RRs) for coronary heart disease (CHD) incidence and mortality that were significantly reduced among current HRT users only, although risk for incidence was not reduced when only studies that controlled for socioeconomic status were included. The WHI reported increased CHD events (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.02-1.63). Stroke incidence but not mortality was significantly increased among HRT users in the meta-analysis and the WHI. The meta-analysis indicated that risk was significantly elevated for thromboembolic stroke (RR, 1.20; 95% CI, 1.01-1.40) but not subarachnoid or intracerebral stroke. Risk of venous thromboembolism among current HRT users was increased overall (RR, 2.14; 95% CI, 1.64-2.81) and was highest during the first year of use (RR, 3.49; 95% CI, 2.33-5.59) according to a meta-analysis of 12 studies. Protection against osteoporotic fractures is supported by a meta-analysis of 22 estrogen trials, cohort studies, results of the WHI, and trials with bone density outcomes. Current estrogen users have an increased risk of breast cancer that increases with duration of use. Endometrial cancer incidence, but not mortality, is increased with unopposed estrogen use but not with estrogen with progestin. A meta-analysis of 18 observational studies showed a 20% reduction in colon cancer incidence among women who had ever used HRT (RR, 0.80; 95% CI, 0.74-0.86), a finding supported by the WHI. Women symptomatic from menopause had improvement in certain aspects of cognition. Current studies of estrogen and dementia are not definitive. In a cohort study, current HRT users had an age-adjusted RR for cholecystitis of 1.8 (95% CI, 1.6-2.0), increasing to 2.5 (95% CI, 2.0-2.9) after 5 years of use. CONCLUSIONS: Benefits of HRT include prevention of osteoporotic fractures and colorectal cancer, while prevention of dementia is uncertain. Harms include CHD, stroke, thromboembolic events, breast cancer with 5 or more years of use, and cholecystitis.

Breast Neoplasms↗
PubMed2002

Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force.

PURPOSE: To determine whether counseling adults in primary care settings improves and maintains physical activity levels. DATA SOURCES: The Cochrane Database of Systematic Reviews and Registry of Controlled Trials and the MEDLINE, HealthStar, and Best Evidence databases were searched for papers published from 1994 to March 2002. STUDY SELECTION: Controlled trials, case-control studies, and observational studies that examined counseling interventions aimed at increasing physical activity in general primary care populations were reviewed. The researchers included trials in which 1) a patient's primary care clinician performed some of the counseling intervention; 2) behavioral outcomes (physical activity) were reported; and 3) the study was of "good" or "fair" quality, according to criteria developed by the U.S. Preventive Services Task Force. DATA EXTRACTION: Data were abstracted on design and execution, quality, providers, patients, setting, counseling intervention, and self-reported physical activity at follow-up. DATA SYNTHESIS: Eight trials involving 9054 adults met the inclusion criteria. Among six controlled trials with a usual care control group, the effects of counseling on physical activity were mixed. Because most studies had at least one methodologic limitation, it was difficult to rigorously assess the efficacy of the interventions. More research is needed to clarify the effect, benefits, and potential harms of counseling patients in primary care settings to increase physical activity. CONCLUSION: Evidence is inconclusive that counseling adults in the primary care setting to increase physical activity is effective.

Adult↗