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At least 19 recordsLinked to original sources
PubMed1999

Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease.

BACKGROUND: The appropriate roles for several diagnostic tests for coronary disease are uncertain. OBJECTIVE: To evaluate the cost-effectiveness of alternative approaches to diagnosis of coronary disease. DESIGN: Meta-analysis of the accuracy of alternative diagnostic tests plus decision analysis to assess the health outcomes and costs of alternative diagnostic strategies for patients at intermediate pretest risk for coronary disease. DATA SOURCES: Studies of test accuracy that met inclusion criteria; published information on treatment effectiveness and disease prevalence. TARGET POPULATION: Men and women 45, 55, and 65 years of age with a 25% to 75% pretest risk for coronary disease. TIME HORIZON: 30 years. PERSPECTIVE: Societal. INTERVENTIONS: Diagnostic strategies were initial angiography and initial testing with one of five noninvasive tests--exercise treadmill testing, planar thallium imaging, single-photon emission computed tomography (SPECT), stress echocardiography, and positron emission tomography (PET)--followed by coronary angiography if noninvasive test results were positive. Testing was followed by observation, medical treatment, or revascularization. OUTCOME MEASURES: Life-years, quality-adjusted life-years (QALYs), costs, and costs per QALY. RESULTS OF BASE-CASE ANALYSIS: Life expectancy varied little with the initial diagnostic test; for a 55-year-old man, the best-performing test increased life expectancy by 7 more days than the worst-performing test. More sensitive tests increased QALYs more. Echocardiography improved health outcomes and reduced costs relative to stress testing and planar thallium imaging. The incremental cost-effectiveness ratio was $75,000/QALY for SPECT relative to echocardiography and was greater than $640,000 for PET relative to SPECT. Compared with SPECT, immediate angiography had an incremental cost-effectiveness ratio of $94,000/QALY. RESULTS OF SENSITIVITY ANALYSIS: Qualitative findings varied little with age, sex, pretest probability of disease, or the test indeterminancy rate. Results varied most with sensitivity to severe coronary disease. CONCLUSIONS: Echocardiography, SPECT, and immediate angiography are cost-effective alternatives to PET and other diagnostic approaches. Test selection should reflect local variation in test accuracy.

Adult↗
PubMed2000

The cost-effectiveness of sildenafil.

BACKGROUND: Coverage of sildenafil by health insurance plans is a contentious issue. OBJECTIVE: To evaluate the cost-effectiveness of sildenafil treatment for erectile dysfunction. DESIGN: A Markov decision model to estimate the incremental cost-effectiveness of sildenafil compared with no drug therapy. DATA SOURCES: Values for the efficacy and safety of sildenafil and quality-of-life utilities were obtained from the published medical literature. Base-case values were chosen to bias against sildenafil use. TARGET POPULATION: Men 60 years of age with erectile dysfunction. TIME HORIZON: Lifetime. PERSPECTIVE: Societal and third-party payer. INTERVENTION: Sildenafil or no treatment in identical hypothetical cohorts. OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: The cost per QALY gained for sildenafil treatment compared with no therapy was $11,290 from the societal perspective and $11,230 from the third-party payer perspective. RESULTS OF SENSITIVITY ANALYSIS: From the societal perspective, the cost per QALY gained associated with sildenafil was less than $50,000 if treatment-related morbidity was less than 0.8% per year, mortality was less than 0.55% per year, treatment was successful in more than 40.2% of patients, or sildenafil cost less than $244 per month. The results were sensitive to variation of erectile dysfunction utilities, but cost per QALY gained was less than $50,000 if successful treatment increased utility values by 0.05 or more on a scale of 0 (death) to 1 (perfect health). CONCLUSIONS: In an analysis biased against use of sildenafil, the cost-effectiveness of sildenafil treatment compared favorably with that of accepted therapies for other medical conditions.

3',5'-Cyclic-GMP Phosphodiesterases↗
PubMed2002

How to reach clients of female sex workers: a survey by surprise in brothels in Dakar, Senegal.

OBJECTIVE: To describe the sampling techniques and survey procedures used in identifying male clients who frequent brothels to buy sexual services from female sex workers in Dakar, Senegal, with the aim of measuring the prevalence of human immunodeficiency virus (HIV) infection and investigating related risk behaviours. METHODS: Surveys were conducted in seven brothels in Dakar, Senegal. Clients were identified "by surprise" and interviewed and requested to donate saliva for HIV testing. RESULTS: Of the 1450 clients of prostitutes who were solicited to enter the study, 1140 (79.8%) agreed to be interviewed; 1083 (95%) of these clients provided saliva samples for testing. Of the samples tested, 47 were positive for HIV-1 or HIV-2, giving an HIV prevalence of 4.4%. CONCLUSION: The procedures adopted were successful in reaching the target population. Men present in the brothels could not deny being there, and it proved possible to explain the purpose of the study and to gain their confidence. Collection of saliva samples was shown to be an excellent method for performing HIV testing in difficult field conditions where it is hard to gain access to the population under study. The surveying of prostitution sites is recommended as a means of identifying core groups for HIV infection with a view to targeting education programmes more effectively. In countries such as Senegal, where the prevalence of HIV infection is still low, interventions among commercial sex workers and their clients may substantially delay the onset of a larger epidemic in the general population.

Contact Tracing↗
PubMed1996

Reproductive health and AIDS prevention in sub-Saharan Africa: the case for increased male participation.

Reproduction is a dual commitment, but so often in much of the world, it is seen as wholly the woman's responsibility. She bears the burden not only of pregnancy and childbirth but also the threats from excessive child bearing, some responsibility for contraception, infertility investigation and often undiagnosed sexually transmitted diseases (STDs) including AIDS. Failure to target men in reproductive health interventions has weakened the impact of reproductive health care programmes. The paper proposes that sophisticated and dynamic strategies in Africa and elsewhere which target women's reproductive health and research (such as control of STDs including AIDS, family planning, infertility investigation) require complementary linkage to the study and education of men. Men's perceptions, as well as determinants of sexual behavioural change and the socioeconomic context in which STDs, including AIDS, become rife, should be reviewed. There is a need to study and foster change to reduce or prevent poor reproductive health outcomes; to identify behaviours which could be adversely affecting women's reproductive health. Issues of gender, identity and tolerance as expressed through sexuality and procreation need to be amplified in the context of present risks in reproductive health. Researchers and providers often ignore the social significance of men. This paper reviews the impact of male dominance, as manifested through reproductive health and sexual decisions, against the background of present reproductive health problems. A research agenda should define factors at both macro and micro levels that interact to adversely impinge on reproductive health outcomes. This should be followed up by well-developed causal models of the determinants of positive reproductive health-promoting behaviours. Behaviour specific influences in sexual partnership include the degree of interpersonal support towards prevention, for example, of STDs, unwanted pregnancy or maternal deaths. Perceived efficacy and situational variables influencing male compliance in, say, condom use, form part of the wider study that addresses men. Thus preventive reproductive health initiatives and information should move from the female alone to both sexes. Women need men as partners in reproductive health who understand the risks they might be exposed to and strategies for their prevention.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Using existing health care systems to respond to the AIDS epidemic: research and recommendations for Chile.

Chile is a country with a relatively low prevalence of HIV infection, where successful prevention has the potential to change the future course of the epidemic. A controversial national prevention strategy based upon public education has emerged in response to characterizations of the epidemic as well-dispersed with a growing involvement of heterosexuals. This characterization is not consistent with the observed facts. There is a comparatively well-organized health care system in Santiago that is doing a good job of detecting HIV infection and already has in place the elements of a targeted intervention scheme. Chile should place priority on the use of the existing health care infrastructure for implementing both the traditional public health interventions for sexually transmitted diseases (contact tracing and partner notification) and the AIDS-necessitated strategy of focused counseling and education.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Factors that determine prevalence of use of contraceptive methods for men.

Globally, men have not shared equally with women the responsibility for fertility regulation. While family planning efforts have been directed almost exclusively toward women, the lack of male involvement may also reflect the limited options available to men. Current methods for men are either coitus-dependent, such as the condom or withdrawal, or permanent, such as vasectomy. The 20-year history of social science research on male contraceptive methods is examined here in terms of the human and method factors related to the acceptability of hypothetical methods and the prevalence of use of existing methods. New male methods, particularly if reversible, may alter men's willingness to accept or share responsibility for the control of fertility. Research opportunities in the areas of gender, decision-making, communication, health education, and service delivery will be enhanced when methods for women and men are comparable.

Contraception↗
PubMed2001

Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Pinede L, Ninet J, Duhaut P et al for the Investigators of the 'Durée Optimale du Traitement Antivitamines K' (DOTAVK) study. Circulation 2001; 103: 2453-60.

QUESTION: Is anticoagulant treatment for calf vein thrombosis for 6 weeks duration associated with acceptable recurrence and safety outcomes? Is anticoagulant therapy for 3 months duration for proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) associated with acceptable recurrence and safety outcomes? POPULATION: Men and women with a first episode of symptomatic calf vein thrombosis or proximal DVT confirmed by ultrasound or venography, or PE confirmed by lung scan or angiography. Patients with pregnancy, thrombophilia, severe PE, and cancer were excluded. DESIGN AND METHODS: After treatment with heparin and oral anticoagulants targeting an INR of 2-3, patients with calf DVT were randomized to 6 weeks (n = 105) versus 3 months (n = 92) of treatment, and patients with proximal DVT and/or PE were randomized to 3 months (n = 270) versus 6 months (n = 269) of treatment. The outcome events were recurrences and major, minor, or fatal bleeding complications. The mean follow-up time was 12 months. RESULTS: A total of 736 patients were enrolled. For calf vein thrombosis the recurrence of DVT or PE after 6 weeks of therapy was 2/105 (2.0%) versus 3/92 (3.4%) with 3 months of therapy, relative risk of 0.58 (95% CI: 0.10-3.36). The rates of major bleeding were 1/105 (1.0%) and 3/92 (3.4%) respectively, relative risk of 0.29 (95% CI: 0.03-2.72). For proximal DVT or PE, the recurrence rate after 3 months of therapy was 21/270 (8.1%) versus 23/269 (8.7%) after 6 months of treatment, relative risk of 0.93 (95% CI: 0.53-1.65). The rates of major bleeding were 5/270 (1.9%) versus 7/269 (2.6%) respectively, relative risk of 0.73 (95% CI: 0.24-2.27). CONCLUSION: After isolated calf vein DVT, 6 weeks of oral anticoagulation is sufficient. For proximal DVT or PE, 3 and 6 months of anticoagulant therapy is equivalent. For patients with temporary risk factors who have a low risk of recurrence, 3 months of treatment seems to be sufficient.

Administration, Oral↗
PubMedDate not supplied

The costs of body mass index levels in an employed population.

We studied 3,066 First Chicago NBD employees by using health risk appraisals and personnel data to determine the direct and indirect costs (in 1996 dollars) associated with varying levels of body mass index (BMI). The BMI is the most widely used measure of weight adjusted by height. We found that as BMI increases, so do the number of sick days, medical claims and health care costs and that the mean annual health care costs for the BMI "at risk" population (men with a BMI of > or = 27.8 kg/m2, women > or = 27.3 kg/m2) was $2,274 versus $1,499 for the "not at risk" group. Major differences in health care costs were observed for employees 45 years old and older, particularly among the women in this age group. Analysis was completed for those employees with and without a risk for BMI. A "J-shaped" curve between medical claims costs and BMI exists, with the low point occurring at about 25 to 27 kg/m2. We conclude that indirect and direct costs to an employer increase with increasing BMI. Employers may benefit from helping employees achieve a healthier weight. The initial target population should be those who are at highest risk of complications from obesity.

Adult↗
PubMed1998

All-cause mortality and cardiovascular disease mortality in three American Indian populations, aged 45-74 years, 1984-1988. The Strong Heart Study.

Community mortality surveillance for 1984-1988 was conducted by researchers of the Strong Heart Study, which examined the incidence, prevalence, and risk factors of cardiovascular disease in three American Indian populations, aged 45-74 years, in Arizona, Oklahoma, and South/North Dakota. All-cause and cardiovascular disease mortality rates were determined through the use of death certificate data. Cardiovascular disease deaths were confirmed by independent systematic review of medical records. In all three populations, men had higher all-cause and cardiovascular disease mortality rates than did women. Oklahoma exhibited slightly lower 5-year, age-adjusted, all-cause mortality (96/1,000) than did Arizona (107/1,000) and South/North Dakota (114/1,000). The leading cause of death among both sexes in Oklahoma and in South/North Dakota was cardiovascular disease. Diabetes mellitus led among Arizona women. The other major causes of death were cancer, liver disease including cirrhosis, and injury. When compared with the rates in each state, average annual all-cause mortality rates were higher for the American Indian populations in almost every age group. The all-cause annual mortality rates in the three Indian populations were close to rates in the US black population and higher than the rates of the entire US population and of US whites. This trend was amplified in the 45- to 64-year age group. Only in the 65- to 74-year age group did mortality rates in the Indian population approach those of the US population. Cardiovascular disease mortality rates were close to the US averages in Arizona and Oklahoma, but they were more than two times higher in South/North Dakota among those between 45 and 64 years of age. Thus, American Indians in Arizona, Oklahoma, and South/North Dakota exhibit high all-cause mortality rates. In particular, the South/North Dakota population cardiovascular disease death rate appears to present a potential target for community-based programs to intervene on known risk factors to promote healthy lifestyles.

Aged↗
PubMed2003

Mental disorder and serious violence: the victims.

BACKGROUND: Media representation of violence by people with mental disorder tends toward images of random, serious violence to strangers. Studies of general psychiatric patients do not support this representation, but include few cases of serious or homicidal violence. This study describes the relationship of mentally disordered offenders to victims of an attack that was serious enough to result in the offender's detention in a high-security hospital. Hypotheses tested were that perpetrators of stranger violence would be more likely than those targeting people they know to be male, nonwhite, and younger and have a violence history and less likely to have psychotic features. METHOD: A clinical register and record study of all patients with an index offense of interpersonal violence who were resident in English high-security hospitals Jan. 1, 1993, to June 30, 1993, was conducted. RESULTS: Among 887 men and 88 women, 33% had attacked strangers. After adjustment for the high proportion of men in this male-dominated population, men were still more likely than women to have attacked strangers. There was no independent association between stranger victimization and perpetrator's age, ethnic group, or violence history. Stranger victimization was, however, more likely to have been committed by those with personality disorder than those with psychosis. The most serious violence and homicide were more likely to be against intimates than strangers. CONCLUSION: Among patients selected for high risk to the public, high rates of stranger victimization would be expected. The rates appeared, however, only slightly higher than in other reported patient samples and lower than in an untreated sample. The safety of people close to such patients urgently needs improvement.

Adult↗
PubMedDate not supplied

Sexual behaviour and condom acceptance among Nigerian drivers.

A survey of 180 randomly selected drivers was carried out in June 1994 in Ilorin, Nigeria in order to gain information about high-risk sexual behaviours, to ascertain condom use and to identify obstacles to condom acceptance so as to facilitate the design of an intervention to prevent Sexually Transmitted Diseases/Acquired Immuno-deficiency Disease in this target population. Data was collected through face-to-face interview. Three-quarters of the respondents were married. Multiplicity of sexual partners including casual and commercial contacts, was common. Half of the respondents engaged in high-risk sexual behaviour and a high proportion of them (60 percent) reported unwillingness to use the condom. This was mainly due to general dislike and lack of knowledge of the method. Risk perception was poor. These findings support the need for male reproductive health services especially for this sub-population.

Acquired Immunodeficiency Syndrome↗