Biomedical subjects

T A Lieu

Publications and source records attributed to T A Lieu.

53 records · Page 3Linked to original sources

PubMed1994

Cost-effectiveness of a routine varicella vaccination program for US children.

OBJECTIVE: To evaluate the economic consequences of a routine varicella vaccination program that targets healthy children. METHODS: Decision analysis was used to compare the costs, outcomes, and cost-effectiveness of a routine vaccination program with no intervention. Clinical outcomes were based on a mathematical model of vaccine efficacy that relied on published and unpublished data and on expert opinion. Medical utilization rates and costs were collected from multiple sources, including the Kaiser Permanente Medical Care Program and the California Hospital Discharge Database. RESULTS: A routine varicella vaccination program for healthy children would prevent 94% of all potential cases of chickenpox, provided the vaccination coverage rate is 97% at school entry. It would cost approximately $162 million annually if one dose of vaccine per child were recommended at a cost of $35 per dose. From the societal perspective, which includes work-loss costs as well as medical costs, the program would save more than $5 for every dollar invested in vaccination. However, from the health care payer's perspective (medical costs only), the program would cost approximately $2 per chickenpox case prevented, or $2500 per life-year saved. The medical cost of disease prevention was sensitive to the vaccination coverage rate and vaccine price but was relatively insensitive to assumptions about vaccine efficacy within plausible ranges. An additional program for catch-up vaccination of 12-year-olds would have high incremental costs if the vaccination coverage rate of children of preschool age were 97%, but would result in net savings at a coverage rate of 50%. CONCLUSIONS: A routine varicella vaccination program for healthy children would result in net savings from the societal perspective, which includes work-loss costs as well as medical costs. Compared with other prevention programs, it would also be relatively cost-effective from the health care payer's perspective.

Acyclovir↗

PubMed1994

Effects of vaccine information pamphlets on parents' attitudes.

OBJECTIVES: To describe how parents actually use federally mandated vaccine information pamphlets and to evaluate the pamphlets' effects on parents' opinions about vaccination. DESIGN: A controlled trial of vaccine information pamphlets based on a survey mailed to parents who either received (n = 140) or did not receive (n = 167) the pamphlets. STUDY POPULATION: Parents of infants aged 2 to 8 months in a suburban, mainly upper-middle class private group practice in northern California. RESULTS: More than 90% of parents believed that they had enough information to decide whether their child should be vaccinated, even among those who did not receive the pamphlets. Among parents who received the pamphlets, fewer than half (38%) read them thoroughly, and most (63%) said that they should be distributed only on the first visit for vaccinations. Parents who received the pamphlets did not differ from those who did not in terms of the proportions who would have liked more time to be spent discussing vaccines (34% vs 34%) or who were anxious about how the diphtheria and tetanus toxoids and pertussis vaccine would affect their child (60% vs 52%). CONCLUSIONS: Vaccine information pamphlets, when used as an adjunct to discussions with physicians and nurses, have little effect on the opinions of well-educated parents. Future research and policy changes might focus on how to make the contents of the pamphlets less frightening and on allowing greater flexibility in how they are distributed.

Adult↗

PubMed1994

The cost of childhood chickenpox: parents' perspective.

The development of a varicella vaccine has raised questions about the cost effectiveness of vaccination, but little information on the costs of chickenpox exists. The purpose of this study was to evaluate medical costs and the value of work loss among families whose children had chickenpox. Interviews were conducted with 179 families who made advice nurse calls or urgent care clinic visits to three clinics in the Northern California Kaiser Permanente Medical Care Plan. Two-thirds of working mothers and one-third of working fathers missed work to care for children with chickenpox. The mean value of the work lost because of chickenpox was $293/family or $183/chickenpox case. The estimated costs of nonprescription medications were $20/family or $12.50/chickenpox case. Children were sick enough to need to stay home for only one-third as many days as chicken actually stayed home because of school exclusion policies. These empiric results differ from previous estimates of the medical and work loss costs of varicella and should be included in analyses of the cost effectiveness of proposed vaccination programs.

Absenteeism↗

PubMed1994

Risk factors for delayed immunization among children in an HMO.

OBJECTIVES: Improving the timely delivery of childhood immunizations has become a national imperative. This study aimed to identify nonfinancial predictors of delayed immunization among patients with good financial access to preventive care. METHODS: This prospective cohort study used telephone interviews and a computerized immunization tracking system to evaluate 13-month-old children (n = 530) in a regional group-model health maintenance organization. RESULTS: More than one third of parents interviewed did not know when the next immunization was due. Thirteen percent were late for the measles-mumps-rubella immunization, recommended at 15 months of age, by 90 days or more. Independent predictors of delayed immunization included having a larger number of children (odds ratio [OR] = 1.4, P < .01), not having a regular doctor (OR = 2.9, P < .05), not knowing when the shot was due (OR = 2.0, P < .01), and not worrying about the risks of shots (OR = 1.4, P < .05). CONCLUSIONS: Financial access alone does not guarantee timely childhood immunization. In managed care settings, which may cover increasing numbers of children under health care reform, interventions are needed to better inform parents of when immunizations are due.

California↗

PubMed1994

The cost-effectiveness of prenatal carrier screening for cystic fibrosis.

OBJECTIVE: To evaluate the economic consequences of routinely offering cystic fibrosis-carrier screening to pregnant white women under 35 years of age. METHODS: Decision analysis was used to evaluate the health outcomes and medical costs of a screening program from the health care payer's perspective. Probabilities were taken from the literature; cost data were based on consultations with laboratory and hospital administrators. Sensitivity analysis was performed for key assumptions. RESULTS: If the test acceptance rate were 78% and the screening test identified 85% of carriers, a prenatal cystic fibrosis-carrier screening program would identify slightly more than half of the high-risk pregnancies in the population. For a cohort of one million pregnant women, it would cost $83 million. If the proportion of couples choosing abortion were 30% and the lifetime cost of medical care for cystic fibrosis were $243,650, the program would save $12 million in averted costs of medical care for cystic fibrosis, for a net cost of $71 million. Even after accounting for the savings in averted medical care for cystic fibrosis, the cost per high-risk pregnancy identified would be $82,000; the cost per unwanted cystic fibrosis birth averted would be $1.4 million. Results were sensitive to the cost and sensitivity of the screening test, but relatively insensitive to the test acceptance rate and therapeutic abortion rates between 50-100% among pregnancies identified with cystic fibrosis. CONCLUSION: A prenatal cystic fibrosis-carrier screening program would not save the health care payer money under most assumptions, but may be justified if the benefit of the early information provided to expectant parents is judged worth the cost.

Abortion, Induced↗

PubMed1994

Health insurance and preventive care sources of children at public immunization clinics.

BACKGROUND: Recent proposals to reform immunization financing aim to help more children receive vaccines at their sources of primary care. Under the current system, referrals of children from the private sector may strain public immunization clinics, but scant information exists on what proportions of public clinic patients actually have insurance or primary care sources. OBJECTIVE: To describe the health insurance, usual sources of health care, and referral patterns of children at low-cost public immunization clinics. DESIGN: Cross-sectional study based on face-to-face, structured interviews. SETTING: Public immunization clinics at three sites in Contra Costa County. PARTICIPANTS: Five hundred thirty-eight parents of children awaiting immunizations. RESULTS: Thirty-four percent of families at these public immunization clinics had Medicaid alone, whereas 24% had private insurance. Of those with private insurance, almost one third had at least partial coverage for vaccines. Sixty-two percent of families had sources of preventive care other than the immunization clinic, and most would have preferred to receive their vaccines at these sources. Most in this group named cost as the main barrier to immunizations at primary care sources; but one third of this group, including almost all the families insured by health maintenance organizations, named the wait for appointments at their usual source of care as the main barrier to receiving vaccines there. Two thirds of Medicaid patients and at least one third of privately insured patients were either uninformed or mistaken about whether their insurance covered vaccines. CONCLUSIONS: Financing reform may improve immunization delivery and reduce the load on public clinics. However, legislation to improve immunization financing will not achieve optimal results unless parent education is improved and organizational barriers are also removed.

California↗

PubMed1993

Race, ethnicity, and access to ambulatory care among US adolescents.

OBJECTIVES: Improving the health of minority adolescents will require a better understanding of factors that influence their access to and use of health care. This study describes the differences in health care access and use among White, Black and Hispanic adolescents and evaluates how such differences are influenced by insurance. METHODS: We used data on 7465 10- to 17-year-olds included in the child health supplement to the 1988 National Health Interview Survey. RESULTS: Much higher proportions of Blacks (16%) and Hispanics (28%) than of Whites (11%) were uninsured. Despite having worse reported health status, Black and Hispanic adolescents made notably fewer doctor visits in the past year than their White peers, and were more apt to lack usual sources of routine and acute care as well as continuity between sources of care. Having health insurance was associated with greater increase in access and usage measures for minority youth than for White youth. However, racial differences persisted even after adjusting for health insurance, family income, need, and other factors. CONCLUSIONS: Minority adolescents are particularly vulnerable to the problems of health care access that affect all youth. While health insurance is especially important for increasing appropriate health care use among minority youth, nonfinancial methods of enabling more equitable use also deserve further study.

Adolescent↗

PubMed1992

Effects of a night-float system on resident activities and parent satisfaction.

Night-float systems have recently been proposed as a way to reduce resident stress resulting from irregular sleep patterns. We prospectively evaluated the effects of a night-float system in which designated residents relieved on-call senior residents and interns of routine admissions of patients in medically stable condition during the late-night period (11 PM to 7 AM). Senior residents (3.7 vs 2.4 hours) and interns (3.7 vs 3.2 hours) reported sleeping more under the night-float system than under the traditional system. The night-float system did not affect residents' overall ratings of call nights. Educators who reviewed medical records agreed with residents' decisions about patients' appropriateness for admission using the night-float system in 95 (81%) of 117 cases. When educators disagreed with residents, the most common reasons were the patient's potential educational value or medical instability. The night-float system did not affect interns' ratings of the educational value of late-night admissions or parents' ratings of satisfaction with medical care. We conclude that the night-float system can increase resident sleep with little cost to parent satisfaction, but standards for selective use may be needed to avoid compromising patient care and resident education.

Consumer Behavior↗

PubMed1992

Interrupted care. The effects of paging on pediatric resident activities.

OBJECTIVE: To determine the content and urgency of pages and their effect on the activities of pediatric residents. DESIGN: Prospective survey. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Seventeen pediatric residents on regular pediatric services. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: On daily logs, interns recorded the activity interrupted by a page and rated the urgency and importance of the page. Almost half of all pages interrupted patient care activities, and 24% interrupted scheduled work rounds or teaching conferences. Interns reported that 34% of pages resulted in a change in patient treatment, but they rated 25% of all pages as unimportant. CONCLUSIONS: "Beepers" frequently interrupt pediatric residents involved in patient care activities and scheduled educational conferences. Studies of interventions aimed at decreasing unnecessary interruptions by pages are needed.

Burnout, Professional↗

PubMed1992

Clinical and cost-effectiveness of outpatient strategies for management of febrile infants.

Young infants with fever are at risk for serious bacterial infection, but no consensus exists on the optimal approach to diagnosis and treatment. Although the traditional recommendation is always to perform all sepsis tests, including lumbar puncture, and administer intravenous (IV) antibiotics until culture results are negative, recent studies suggest administering intramuscular (IM) ceftriaxone with outpatient follow-up or using laboratory and clinical data to exclude low-risk patients from hospitalization, further testing, and antibiotic treatment. A decision analysis model was used to evaluate six strategies for the diagnosis and treatment of infants aged 28 to 90 days with temperature greater than or equal to 38.0 degrees C. Data from the literature, data from a 1991 study of 503 febrile infants, and direct, short-term costs from the Children's Hospital of Philadelphia were used as model inputs. The model was run for a hypothetical cohort of 100,000 febrile infants who did not require admission for focal infection or for other reasons that clearly necessitated admission. The model included six strategies: (1) no intervention; (2) all sepsis tests (lumbar puncture, blood culture, urine culture, white blood cell count, and urinalysis) followed by hospitalization and IV antibiotics for all infants; (3) all sepsis tests followed by IM ceftriaxone and outpatient management for most infants; (4) blood and urine cultures with white blood cell count and urinalysis followed by either lumbar puncture and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants; (5) white blood cell count and urinalysis followed by either lumbar puncture, blood and urine cultures, and IV antibiotics for high-risk infants or outpatient management without antibiotics for low risk infants; and (6) clinical judgment followed by either all sepsis tests and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants. The two "all sepsis tests" strategies prevented the most cases of death or neurologic impairment, 78% (when IV antibiotics were used) and 76% (when IM ceftriaxone was used) of all potential cases. The most cost-effective strategy was to use all sepsis tests followed by IM ceftriaxone for all patients without meningitis, at an incremental cost of only $3900 per sequela prevented relative to no intervention. Strategies under which only those patients selected as high-risk by laboratory criteria received antibiotic treatment were less effective but incurred lower rates of antibiotic complications. Clinical judgment alone was the least clinically effective and the second least cost-effective strategy.(ABSTRACT TRUNCATED AT 400 WORDS)

Ambulatory Care↗

PubMed1991

Strategies for diagnosis and treatment of children at risk for occult bacteremia: clinical effectiveness and cost-effectiveness.

Decision analysis was used to evaluate the probable health benefits, complications, and costs of six management strategies for febrile children at risk for occult bacteremia. The strategy that combined blood culture with empiric oral antibiotic treatment for all patients was predicted to prevent the highest number of major infections and to have the lowest cost per major infection prevented. The strategy that combined a leukocyte count and blood culture for all patients, followed by empiric antibiotic treatment for those with leukocyte count greater than or equal to 10,000/mm3, had almost equal cost and clinical effectiveness and avoided many antibiotic complications. Culture of blood specimens from all patients and no empiric treatment constituted the third most clinically effective intervention but was the least cost-effective in this model. Giving a 2-day oral course of amoxicillin without testing had the lowest average cost per febrile patient but was the least clinically effective intervention. However, the low degree of effectiveness of empiric treatment alone was based on the assumption that oral amoxicillin therapy was only 20% effective in preventing major infections after bacteremia. At higher estimates of effectiveness, treatment alone became a more viable strategy. We conclude that approaches which combine blood culture with empiric antibiotic treatment are the most clinically effective and the most cost-effective strategies for children at risk for occult bacteremia.

Amoxicillin↗

PubMed1991

An approach to the evaluation and treatment of microscopic hematuria.

Persistent microscopic hematuria in children is most often benign or untreatable. The evaluation of microscopic hematuria in an otherwise healthy child need not require invasive and costly laboratory studies. The initial evaluation must look for signs of life-threatening causes of hematuria, i.e., hypertension, edema, oliguria, or significant proteinuria. If these are absent, a stepwise evaluation is suggested, which includes microscopic examination of the urine for red blood cell casts, a test for proteinuria, serum creatinine, and serial follow-up. Renal biopsy may establish a diagnosis but rarely changes the treatment in a child with asymptomatic isolated microscopic hematuria.

Child↗

PubMed1990

Cost-effectiveness of rapid latex agglutination testing and throat culture for streptococcal pharyngitis.

Decision analysis was used to evaluate the cost-effectiveness of four alternative strategies for management of pharyngitis in children ("treat all," "antigen test alone," "culture alone," "antigen test + culture"). In the model, estimates of test sensitivity and specificity, disease prevalence, treatment rates after positive test results, rates of complications for treated and untreated patient-cases, rates of antibiotic-induced complications, treatment effectiveness, and direct dollar costs of diagnosis and therapy were used. Results were expressed in terms of severe penicillin reactions per disease case prevented and dollars per complication prevented. Sensitivity analysis was performed to assess the impact of changes in parameter estimates on model outcomes. With treat all, 90% of streptococcal complications were prevented and there were low short-term direct dollar costs. However, treat all is associated with a high rate of penicillin allergy (70% of which occurs in uninfected children) and is the least cost-effective strategy when the costs of treating complications are included. The marginal cost of antigen test + culture is less than the cost of either one-test strategy. Antigen test + culture is the most cost-effective strategy when the costs of managing the complications of streptococcal infection are considered. Antigen test + culture is the most clinically effective strategy, and its benefits are obtained at a modest marginal cost relative to the one-test strategy.

Child↗

PubMed1989

Specialty choices at one medical school: recent trends and analysis of predictive factors.

Recent reports have raised the concern that personal care specialties, especially primary care specialties, are attracting fewer medical school graduates. In the present study, the authors evaluated the proportions of University of California, San Francisco (UCSF), medical school graduates entering personal care specialties and technology-oriented specialties from 1982 through 1988 and found no significant trend away from personal care specialties such as internal medicine, family practice, pediatrics, and psychiatry during these years. For the graduating class of 1988, admissions and questionnaire data were used to evaluate the importance of pre-admission, medical school, and postgraduate factors as determinants of specialty choice. The group entering personal care specialties (66% of all 1988 graduates) was significantly older and included more women and fewer minority students than the group entering technology-oriented specialties. Students rated income and lifestyle factors as being less important determinants of specialty choice than are medical school experiences and intrinsic qualities of the chosen specialties. However, compared with the students who entered personal care specialties, those who chose technology-oriented specialties over an alternate choice in personal care rated as significantly more important the opportunity to do procedures (p less than .001), income (p less than .005), the lesser degree of diagnostic uncertainty (p less than .005), and the rejected specialty's allowing less time for family (p less than .005) and for other interests (p less than .008). Exposure to acquired immunodeficiency syndrome and loan indebtedness were rated the least significant influences on specialty choice.(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired Immunodeficiency Syndrome↗

PubMed1988

Clinical evaluation of a latex agglutination test for streptococcal pharyngitis: performance and impact on treatment rates.

The accuracy and clinical utility of a latex agglutination test were compared with anaerobic throat culture on selective media for detection of Group A streptococcal pharyngitis in an urban pediatric emergency department. Among 255 symptomatic cases prevalence of positive culture was 29% and antigen test sensitivity was 55%. Among 100 asymptomatic controls prevalence of positive culture was 20% and antigen test sensitivity was 20%. Controls with positive cultures and cases with false negative antigen tests had significantly fewer colonies on culture than cases with true positive antigen tests (P less than 0.01). Symptoms and clinical findings were not associated with antigen test result or number of colonies on culture. Eighty percent of patients with positive cultures received treatment when the antigen test was used as an adjunct to culture, compared with a 57% treatment rate among the subgroup in whom follow-up treatment was attempted based on positive culture results alone (P less than 0.05). We conclude that: (1) the antigen test had lower sensitivity in routine clinical use than previously reported; (2) the high rate of false negative tests may result, in part, from a high proportion of specimens with low colony counts; and (3) the availability of the antigen test as an adjunct to culture significantly increased treatment rates.

Adolescent↗

PubMed1988

Hematuria and clinical findings as indications for intravenous pyelography in pediatric blunt renal trauma.

The essential aids in the evaluation of suspected blunt urinary tract injury are urinalysis and IVP. In 78 consecutive children who had IVPs because of trauma from January 1982 to March 1986, the following were evaluated: (1) the yield of IVP; (2) the correlations between IVP and hematuria, mechanism of injury, and associated clinical findings; and (3) the effect of IVP on patient management. Of the 26 children (33%) with abnormal IVP findings, 13 had congenital urinary tract anomalies only and 13 had urinary tract injuries (eight renal contusions, four renal lacerations with extravasation, and one bladder rupture). The number of RBCs per high-power field correlated with IVP evidence of injury (P less than .05). If only those patients with greater than or equal to 20 RBCs per high-power field had received IVPs, 42% of IVPs would have been avoided and no injuries or surgically correctable anomalies would have been overlooked. Urinary tract injury occurred significantly more often in patients with extremity fractures (P less than .05) and pelvic fractures (P less than .05). Mechanism of injury, admission to the hospital, and flank tenderness or hematoma were not associated with IVP evidence of trauma (P greater than .05), however. In four patients with trauma, results of IVP led to lengthened hospitalization or further diagnostic studies but did not result in surgery. Two patients in whom ureteropelvic junction obstruction was discovered incidentally had delayed corrective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMedDate not supplied

Clinical performance and effect on treatment rates of latex agglutination testing for streptococcal pharyngitis in an emergency department.

Of 556 children with symptoms of streptococcal pharyngitis in a pediatric hospital emergency department, 38.8% had positive results on either a rapid latex agglutination test or throat culture for Group A Streptococcus. Twenty-six percent of patients with negative latex agglutination test results had growth on culture of a paired specimen. Under the best assumption rapid test sensitivity was 44.9%. The treatment rate (84%) for cases detected by the rapid test was markedly higher than the rate (44%) for cases detected only by culture (P less than 0.001), presumably because the rapid test result is available sooner. We conclude that: the rapid test had a lower sensitivity in routine use in our pediatric emergency department population than in previous reports from research settings; and using the rapid test in addition to culture can significantly increase treatment rates.

Adolescent↗