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Biomedical subjects

W J Kassler

Publications and source records attributed to W J Kassler.

At least 19 recordsLinked to original sources
PubMed2000

Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial.

OBJECTIVE: To estimate direct medical costs and average lifetime cost per case of pelvic inflammatory disease (PID). METHODS: We estimated the direct medical expenditures for PID and its three major sequelae (chronic pelvic pain, ectopic pregnancy, and infertility) and determined the average lifetime cost of a case of PID and its sequelae. We analyzed 3 years of claims data of privately insured individuals to determine costs, and 3 years of national survey data to determine number of cases of PID, chronic pelvic pain, and ectopic pregnancy. We developed a probability model to determine the average lifetime cost of a case of PID. RESULTS: Direct medical expenditures for PID and its sequelae were estimated at $1.88 billion in 1998: $1.06 billion for PID, $166 million for chronic pelvic pain, $295 million for ectopic pregnancy, and $360 million for infertility associated with PID. The expected lifetime cost of a case of PID was $1167 in 1998 dollars. The majority of those costs ($843 per case) represent care for acute PID rather than diagnosis and treatment of sequelae. Approximately 73% of cases will not accrue costs beyond the treatment of acute PID. CONCLUSION: The direct medical cost of PID is still substantial. The majority of PID related costs are incurred in the treatment of acute PID. Because most PID-related costs arise in the first year from treatment of acute PID infection, strategies that prevent PID are likely to be cost-effective within a single year.

Cost of Illness↗
PubMed2000

Missed opportunities to assess sexually transmitted diseases in U.S. adults during routine medical checkups.

OBJECTIVES: Although sexually transmitted diseases (STDs) cause tremendous health and economic burdens in our society, awareness and knowledge regarding STDs remain poor among health care providers. To examine missed opportunities for STD-related counseling, diagnosis and treatment, we investigated how frequently U.S. adults reported being asked about STDs by their health care providers during routine checkups. METHODS: We analyzed the responses of 3390 adults aged 18-64 who reported having a routine checkup during the past year in the 1994 U.S. National Health Interview Survey (NHIS), a nationally representative survey. We used a logistic model to determine factors that were independently associated with the likelihood of being asked about STDs during the checkup. RESULTS: Only 28% (+/-0.9%) of respondents reported being asked about STDs during their last routine checkup. Persons were significantly more likely (p<0.05) to be asked about STDs if they were aged under 45, male, single, had a household income under the federal poverty level, or were insured by a health maintenance organization, public coverage or by no plan rather than by a fee-for-service arrangement. CONCLUSIONS: Only about one quarter of U.S. adults reported being asked about STDs during routine checkups. Routine checkups in which these issues are not discussed may represent missed opportunities for STD prevention. Persons presenting for routine care can be counseled, screened and, if infected, can be treated. Interventions are needed at the patient, provider, and community levels to increase the opportunities to assess STD risk, to counsel, to diagnose, and to treat infections during routine checkups.

Adult↗
PubMed2000

Medical care expenditures for genital herpes in the United States.

BACKGROUND: Approximately 45 million Americans have serologic evidence of HSV-2 infection and HSV-2 seroprevalence in the United States has increased 30% over the past two decades. Despite rapid increases in HSV-2 prevalence, the last estimate of the U.S. national direct medical cost for genital herpes (GH) was completed in 1985. The objective of this study is to assess the U.S. direct medical expenditures for GH and its complications to assist policy makers in allocating limited STD resources efficiently. METHODS: We estimated the number of GH-related clinical visits and pharmacy claims from several national and state sources, estimated the average direct medical cost per visit from two administrative claims databases, and calculated the U.S. national direct medical costs for GH by applying the average direct medical cost per visit to the number of clinical visits and pharmacy claims. RESULTS: The U.S. national number of GH-related clinical visits was estimated to be 499,655 and there were approximately 2,056,1180 pharmacy claims annually. Of those clinical visits, private office-based physician and public STD clinic visits alone accounted for 89%. The U.S. national direct medical costs were estimated at $166 million annually for 1992-1994, which represents $207 million in 1999 dollars. Of the total cost, medical care accounted for 36% and drug treatment for 64%. CONCLUSIONS: The medical costs of pharmacy claims and office-based physician visits account for the majority of the medical expenditures for GH. Our estimates, based on the best available data on medical expenditure, indicate that GH is a major public health problem with a substantial economic burden.

Adolescent↗
PubMed1999

Rates of receiving HIV test results: data from the U.S. National Health Interview Survey for 1994 and 1995.

OBJECTIVE: To determine the frequency and predictors of receipt of HIV test results. METHODS: Analysis of responses from 19,127 adults in 1994 and 16,848 in 1995 surveyed for the U.S. National Health Interview Survey, using logit models to determine factors independently associated with decreased likelihood of receiving HIV test results. RESULTS: Overall, 12.5% (+/-1.0%) of persons tested in 1994 and 13.3% (+/-0.9%) in 1995 had not received their test results. Those whose test was not self-initiated were significantly less likely (p<.05) to receive their test results. The proportion who did not receive results was lowest among persons who had sought testing (6.1% in 1994 and 4.3% in 1995) and highest among persons whose tests were required for hospitalization or surgery (24.2% in 1994 and 22.9% in 1995). CONCLUSIONS: An estimated 2.3 million of the 17.5 million people tested annually for HIV infection did not receive their test results. Alternative measures to increase the number of persons who receive their results need to be evaluated. These may include enhancing prevention counseling about the importance of receiving test results, telephone notification, or using rapid HIV-screening tests that provide results at the time of testing.

AIDS Serodiagnosis↗
PubMed1999

New HIV cases attributable to syphilis in the USA: estimates from a simplified transmission model.

OBJECTIVE: Because syphilis can raise the likelihood of HIV transmission and acquisition, syphilis prevention in the USA has the potential benefit of reducing the number of new cases of HIV. We developed a simplified transmission model to estimate the annual number and cost of new, heterosexually-acquired HIV cases in the USA attributable to syphilis. DESIGN: We estimated the number of heterosexual, HIV serodiscordant partnerships in which syphilis was present in 1996. The model included the probability of transmission of HIV (with and without the presence of syphilis) and other parameters based on data from recent literature. Published direct costs (HIV treatment costs including antiretroviral therapy) and indirect costs (e.g., lost productivity) per case of HIV were used to estimate the annual cost of HIV cases attributable to syphilis. The potential savings in averted HIV costs related to syphilis were used to estimate the potential benefits of a syphilis elimination program. RESULTS: In 1996, an estimated 1082 new heterosexual cases of HIV in the USA could be attributed to syphilis. These cases represented direct costs of US$ 211 million and indirect costs of US$ 541 million; yielding US$ 752 million in total costs. Over 15 years, a syphilis elimination program could save over US$ 833 million (discounted at 3% annually) in averted direct medical costs of syphilis-related HIV infections. CONCLUSIONS: If the only benefit of syphilis elimination were to prevent new HIV cases attributable to syphilis, a national syphilis elimination program costing less than US$ 833 million would probably pay for itself.

Cost of Illness↗
PubMed1999

The rapid test paradox: when fewer cases detected lead to more cases treated: a decision analysis of tests for Chlamydia trachomatis.

BACKGROUND AND OBJECTIVES: Screening tests for detection of Chlamydia trachomatis include those processed in laboratories and those designed to be processed at the point of care. The latter tests can yield results at the time of the initial patient visit, but most available lab-processed tests have greater sensitivity. In settings where a proportion of patients do not return for treatment after positive test results, the less sensitive rapid tests could lead to the treatment of more patients and be more cost-effective. GOAL OF THIS STUDY: To determine the situations, if any, in which a rapid test might be more cost-effective and treat more infections than lab-based tests. STUDY DESIGN: A decision analysis framework was used to compare one point-of-care test (the BioStar Chlamydia OIA) with two lab-based tests (cell culture and the polymerase chain reaction [PCR] assay). It was assumed that all women in the model would be screened. Variables included in the analysis were the prevalence, test sensitivity and specificity, the probability of developing pelvic inflammatory disease after treated and untreated chlamydial infections, and the likelihood that patients would wait for rapid test results or return to the facility for treatment. RESULTS: The rapid test treated more cases of infection than the PCR alone if the return rate was less than 65%. A two-test algorithm of the rapid test followed by a PCR test on those initially testing negative identified and treated the greatest number of chlamydial infections and was the most cost-effective at all prevalences above 9%, but this finding was sensitive to the cost estimate for pelvic inflammatory disease. CONCLUSION: In settings where patient return for treatment is a problem, point-of-care tests contribute significantly to the detection and treatment of chlamydial infections among women.

Chlamydia Infections↗
PubMed1999

Privatization of STD services in Tacoma, Washington: a quality review.

BACKGROUND AND OBJECTIVES: This study describes key features of the privatized model of sexually transmitted disease (STD) service provision in Tacoma, Washington. GOALS: To assess the operational characteristics and the quality of care provided in the privatized STD clinics. STUDY DESIGN: Key informant interviews and surveys were conducted. Medical records were reviewed and compared to a standardized STD clinic medical record. Client treatment was compared to the Centers for Disease Control and Prevention (CDC) 1993 STD Treatment Guidelines. RESULTS: In 1997, the contract clinics provided 3,275 publicly sponsored STD visits. The goals of multiple access sites, STD screening, appropriate therapy for laboratory-diagnosed, bacterial STD were achieved. However, medical records were frequently incomplete and Gram stains were not done. Significant deviations from CDC STD Treatment Guidelines were documented in the medical management of pelvic inflammatory disease (PID). CONCLUSIONS: Privatized STD services would be improved by use of a standardized medical record. Availability of a Gram stain and management of PID as recommended by the CDC would augment quality of care.

Adolescent↗
PubMed1998

Rapid HIV testing with same-day results: a field trial in Uganda.

Rapid, on-site HIV testing with same-day results may improve services and increase the number of clients who learn their serostatus in developing countries. To validate test performance under field conditions and assess the change in the proportion of clients who learn their serostatus, we conducted a field trial using the Capillus HIV-1/HIV-2 assay (Cambridge Diagnostics) at the AIDS Information Centre counselling and testing sites in Uganda. Compared to the standard 2-EIA testing algorithm, the sensitivity of Capillus was 99.6% (95% CI; 98.5%, 99.9%), the specificity was 98.8% (95% CI; 98.1%, 99.3%), the positive predictive value was 96.5% (95% CI; 94.5%, 97.8%), and the negative predictive value was 99.9% (95% CI; 99.5%, 100%). It took less than 5 min to perform a single test, and results were returned to clients in less than an hour, during which time clients were counselled. This resulted in a 27% increase in the proportion of clients who learned their serostatus and received counselling. We conclude that simple, rapid HIV tests can be performed accurately on-site within the time frame of a clinic visit, increasing the number of clients who learn their serostatus and receive post-test counselling.

HIV Infections↗
PubMed1997

Home collection kits for HIV testing: evaluation of three strategies for dealing with insufficient dried blood specimens.

Home collection kits allow individuals to obtain a blood specimen at home and send it to a laboratory for HIV testing. In preliminary studies, 15% of kit users submitted specimens considered to be insufficient for analysis. The current Public Health Service policy requires the laboratory to reject all such specimens entirely and request a second specimen, even though some specimens are sufficient to perform an enzyme immunoassay (EIA) but not a Western blot (WB) test. Using decision analysis, we evaluated three strategies to handle specimens sufficient to perform an EIA but insufficient to perform a WB analysis: current recommendation, or baseline, for which no test is preformed and "quantity not sufficient" is reported; alternative 1 , for which an EIA is done and reported as "negative" or "quantity not sufficient" (if initially reactive); and alternative 2, for which an EIA is done and reported as "negative" or "a reactive screening test" (if initially reactive). Baseline strategy requires all consumers with an initial specimen sufficient for EIA only to submit a second specimen, but either alternative requires fewer than 3% to submit a second specimen. Although 80% of consumers with an initial specimen sufficient for EIA learn their test results only with the baseline strategy, more than 99% learn their test results with either alternative. With the scenario of high (2%) HIV prevalence, 91% of consumers who would be told "reactive screening test" are truly infected. At a low (0.1%) HIV prevalence, 33% of consumers who would be told "reactive screening test" are truly infected. When a specimen is sufficient for EIA only, it is preferable to perform the EIA instead of rejecting the specimen, because many persons can get results from the initial specimen and because many fewer are required to submit a second specimen. Current policy should be reexamined in light of these findings.

Blood Specimen Collection↗
PubMed1997

Eliminating access to anonymous HIV antibody testing in North Carolina: effects on HIV testing and partner notification.

Anonymous HIV testing may attract persons who might otherwise not be tested but may hinder partner notification. We evaluated the effects on North Carolina's HIV testing and partner notification programs of policy changes that eliminated and later restored anonymous testing in 82 counties. We used an interrupted time-series design to compare counties eliminating with counties retaining anonymous testing. We analyzed HIV testing and partner notification data from before, during, and after elimination of anonymous testing. After elimination of anonymous testing in 82 counties, the mean monthly level of testing (+/- SE) increased by 45%, or 548 (+/- 123) tests per month, while in 18 counties that retained anonymous testing, there was a 63% increase, or 802 (+/- 162) tests per month (p > .05). Among men of all races, testing increased by 16%, or 155 (+/- 35) tests per month, in counties that eliminated anonymous testing; and by 51%, or 305 (+/- 42) tests per month (p < .05), in counties that retained anonymous testing. After elimination of anonymous testing, both county types experienced similar increases in the rate of partners notified. However, partner notification was more successful if the index patient was tested confidentially; 2.7 times as many partners per index patient were notified and counseled. There was no effect on testing or on partner notification rates following restoration of anonymous testing. Substantial community opposition to eliminating anonymous testing was encountered. The policy change appeared to result in a slight decrease in testing among men and a slight increase in partners notified. Programs considering the elimination of anonymous testing should weigh these potential gains and losses, as well as the impact on relationships between the public health and advocacy communities

Confidentiality↗
PubMed1997

On-site, rapid HIV testing with same-day results and counseling.

BACKGROUND: New rapid HIV antibody tests have allowed provision of results and result-specific counseling on the day on initial visit, and have the potential to increase the efficiency of HIV counseling and testing. METHODS: To evaluate the use of rapid testing with same-day results in public clinics, the Single Use Diagnostic System HIV-1 rapid assay was used for a 3-month period at an anonymous testing clinic and a sexually transmitted disease (STD) clinic in Dallas, Texas. Non-reactive rapid test results were reported as HIV-negative. Reactive results were reported as 'preliminary positive'. These procedures were compared with standard testing during a baseline period, with respect to number of clients receiving results and post-test counseling, client satisfaction, counselor acceptance, cost and effectiveness at reducing HIV risk. RESULTS: Rapid testing resulted in an increase in the number of persons learning their serostatus: a 4% increase for uninfected and a 16% increase for infected clients at the Anonymous Testing Clinic; a 210% increase for uninfected patients and a 23% increase for infected patients at the STD clinic. Rapid testing resulted in a cost saving of US$ 11 per test in both the anonymous and STD clinics. Of those previously tested, 88% responded that they preferred the rapid test. In the year following initial HIV test, clients tested with rapid and standard procedures were equally likely to return to the clinic with a new STD (odds ratio, 0.97; 95% confidence interval, 0.7-1.4). CONCLUSIONS: Rapid, on-site HIV testing was feasible, preferred by clients, and, resulted in significant improvement in the number of persons learning their serostatus, without increasing the costs or decreasing the effectiveness of counseling and testing.

Counseling↗
PubMed1997

Partner notification to prevent pelvic inflammatory disease in women. Cost-effectiveness of two strategies.

BACKGROUND AND OBJECTIVES: Partner notification is an important strategy for prevention of Chlamydia trachomatis infection and pelvic inflammatory disease (PID). PID can be prevented by early diagnosis and treatment of the female sex partners of men infected with C. trachomatis (strategy 1) and by preventing reinfection in women through diagnosis and treatment of their male sex partners (strategy 2). STUDY DESIGN: Using a decision model, the cost-effectiveness of strategies 1 and 2 was compared to no partner notification. Outcomes were measured by cases of PID prevented and net costs expended from a health care system perspective. RESULTS: In a hypothetical cohort of 1,000 male and 1,000 female index patients, strategy 1 prevented 64 and strategy 2 prevented 20 cases of PID. Strategy 1 saved $247,000 and strategy 2 saved $33,000 over no partner notification. Sensitivity analysis showed that strategy 1 was cost-effective across a wide range of assumptions. Strategy 2 was cost-effective at baseline, but its cost-saving ability was subject to changes in the model. CONCLUSION: Partner notification of both male and female index patients is a cost-effective public health strategy for prevention of PID. In most settings, both strategies can and should be implemented.

Chlamydia Infections↗
PubMed1997

Advances in HIV testing technology and their potential impact on prevention.

Recent advances in HIV testing technology are increasing options for HIV testing which may lead to more persons at risk for HIV infection learning their serostatus. These advances include the development of simple rapid assays with visual reading, several of which can be used with whole blood (including finger stick) or with non-invasive alternative specimens like oral fluids or urine. Many of these new tests are simple enough to be used in nonclinical settings by public health workers or by consumers in the home. For some of these developments, such as rapid testing, enough is now known to recommend their use within specific clinical contexts. For other developments, such as home sample collection, understanding their true impact must wait for postmarketing evaluation. For technologies currently in development, such as true home testing, we are only beginning to understand and address the issues. We, as clinicians and public health practitioners who are interested in prevention, must begin to deal with the issues. We must identify important policy questions, develop a research agenda to begin to answer these questions, and devise strategies to maximize the opportunities for HIV prevention and minimize the potential for harm.

AIDS Serodiagnosis↗
PubMed1995

Impact of increased legal access to needles and syringes on community pharmacies' needle and syringe sales--Connecticut, 1992-1993.

In May 1992, the Connecticut legislature passed new laws aimed at increasing injecting drug users' (IDUs) access to sterile needles and syringes (syringes); as of July 1992, pharmacists were permitted to sell and individuals were permitted to possess up to 10 syringes without medical prescriptions (nonprescription syringes). We evaluated the impact of the new laws by conducting (1) prospective surveillance of syringe sales and policies at selected community pharmacies (pharmacies) and (2) a telephone survey of pharmacy managers' reports of syringe sales and policies at a statewide stratified random sample of pharmacies. Our data provide direct evidence that most, but not all, Connecticut pharmacies sold nonprescription syringes when permitted to do so by the new laws. For example, using the telephone survey data, we estimate that during November, 1993, 83% [95% CI: 77-89%] of all Connecticut pharmacies sold nonprescription syringes and 56,000 [95% CI: 44,000-68,000] nonprescription syringes were sold, during November 1993. Our data provide indirect evidence that IDUs were purchasing nonprescription syringes at pharmacies. For example, in five Hartford pharmacies located in neighborhoods where injection drug use was prevalent, the total number of nonprescription syringes sold per month increased significantly from 460 in July 1992 to 2,482 in June 1993 (p = 0.0001). The data suggest that the new laws increased IDUs' access to sterile syringes in Connecticut.

Centers for Disease Control and Prevention, U.S.↗
PubMed1995

Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers--Connecticut, 1992-1993.

To determine whether the simultaneous, partial repeal of needle prescription and drug paraphernalia laws in Connecticut affected purchasing and usage of needles and syringes (syringes) by injecting-drug users (IDUs) and risk of needlestick injuries to police officers, we conducted two serial cross-sectional surveys with IDUs recruited in drug treatment centers, correctional facilities, and health department settings. Reports of needlestick injuries among Hartford police officers were reviewed before and after the new laws. Among IDUs who reported ever sharing a syringe, syringe-sharing decreased after the new laws (52% before vs. 31% after; p = 0.02). Fewer IDUs reported purchasing syringes on the street after the new laws (74% before vs. 28% after; p < 0.0001). More IDUs reported purchasing syringes from a pharmacy after the new laws (19% before vs. 78% after; p < 0.0001). Eight to eleven months after the new laws were enacted, over two thirds (91 of 134) of active IDUs interviewed were aware of both new laws. Needlestick injury rates among Hartford police officers were lower after the new laws (six injuries in 1,007 drug-related arrests for 6-month period before new laws vs. two in 1,032 arrests for 6-month period after new laws). The changes in Connecticut laws were associated with decreases in self-reported syringe-sharing and increases in purchasing by IDUs of sterile syringes from reliable sources, suggesting that the simultaneous repeal of both prescription and paraphernalia laws is an important HIV prevention strategy.

Adolescent↗
PubMed1995

Performance of a rapid, on-site human immunodeficiency virus antibody assay in a public health setting.

Rapid, on-site human immunodeficiency virus (HIV) testing has the potential to improve the delivery of prevention services in publicly funded counseling and testing sites. The Single Use Diagnostic System (SUDS) HIV-1 is the only rapid enzyme immunoassay (EIA) approved for diagnostic use in the United States. To evaluate the feasibility of using SUDS in public clinics and to validate the test's performance in a public health laboratory, we conducted blinded SUDS testing on plasma sent for HIV testing. From 19 March through 30 June 1993, 1,923 consecutive samples from a sexually transmitted diseases clinic and an HIV counseling and testing clinic were tested on site with SUDS. Tests done in the first two weeks with a malfunctioning centrifuge n = 402) and those done when there were excessively high temperatures in the laboratory (n = 53) were analyzed separately. Of 1,466 tests, 39 were positive by both SUDS and EIA (with Western blot [immunoblot] confirmation) and 7 were SUDS positive and EIA negative. Western blotting was used as the "gold standard" to adjudicate these discrepancies. There were no SUDS-negative and EIA-positive tests. Compared with that of EIA (with Western blot confirmation), the sensitivity of SUDS was 100% (95% confidence interval, 88.8 to 100%) and the specificity was 99.5% (95% confidence interval, 98.9 to 99.8%). The positive predictive value of SUDS was 88% in the STD clinic and 81% in the HIV counseling and testing clinic. There was a 7.7-fold increase in false positives, from 0.48 to 3.7%, when there was inadequate centrifugation and when the temperature exceeded the manufacturer's recommendations. Rapid, on-site HIV testing by the SUDS assay is feasible and practical in public health settings. The test can be performed accurately, at reasonable cost, and within the time frame of a typical clinic visit. Caution should be used, however, as two conditions adversely affected the accuracy of this test: inadequate specimen preparation and elevated temperature.

AIDS Serodiagnosis↗