Expensive Health Research Articles

Burden of Geriatric Events Among Older Adults Undergoing Major Cancer Surgery.

Most malignancies are diagnosed in older adults who are potentially susceptible to aging-related health conditions; however, the manifestation of geriatric syndromes during surgical cancer treatment is not well quantified. Accordingly, we sought to assess the prevalence and ramifications of geriatric events during major surgery for cancer. Using Nationwide Inpatient Sample data from 2009 to 2011, we examined hospital admissions for major cancer surgery among elderly patients (ie, age ≥ 65 years) and a referent group age 55 to 64 years. From these observations, we identified geriatric events that included delirium, dehydration, falls and fractures, failure to thrive, and pressure ulcers. We then estimated the collective prevalence of these events according to age, comorbidity, and cancer site and further explored their relationship with other hospital-based outcomes. Within a weighted sample of 939,150 patients, we identified at least one event in 9.2% of patients. Geriatric events were most common among patients age ≥ 75 years, with a Charlson comorbidity score ≥ 2, and who were undergoing surgery for cancer of the bladder, ovary, colon and/or rectum, pancreas, or stomach (P < .001). Adjusting for patient and hospital characteristics, those patients who experienced a geriatric event had a greater likelihood of concurrent complications (odds ratio [OR], 3.73; 95% CI, 3.55 to 3.92), prolonged hospitalization (OR, 5.47; 95% CI, 5.16 to 5.80), incurring high cost (OR, 4.97; 95% CI, 4.58 to 5.39), inpatient mortality (OR, 3.22; 95% CI, 2.94 to 3.53), and a discharge disposition other than home (OR, 3.64; 95% CI, 3.46 to 3.84). Many older patients who receive cancer-directed surgery experience a geriatric event, particularly those who undergo major abdominal surgery. These events are linked to operative morbidity, prolonged hospitalization, and more expensive health care. As our population ages, efforts focused on addressing conditions and complications that are more common in older adults will be essential to delivering high-quality cancer care.

Paediatric challenges in Sub-Saharan Africa

The United Nations Millennium Development Goals (MDGs) project is coming to an end in 2015 and is being replaced by ambitious and aspirational Sustainable Development Goals (SDGs). Although the MDGs have been nearly achieved, this is not true in Sub-Saharan Africa where there is still unnecessarily high infant and childhood mortality and where there are many challenges to providing modern child health care. To achieve the SDGs in the next fifteen years, in low-income countries, national ministries of health and community health leaders will need to set reasonable goals and quality improvement projects. Attention needs to paid to economical, evidence-based effective health care; to education of children and youth and of health professional; health promotion and prevention of illness; a balance between expensive health care in large urban hospitals and community health projects; and most importantly to the social determinants of health. But the SDGs are achievable with coordinated and sustained national commitments and increased financial commitments from Western countries.

Chronic Illness Management in Teams of Urban Multidisciplinary Scholars (CIMTUMS) –– Part II

Background: Diabetes is a major contributor to morbidity and mortality as well as the single most expensive health care condition in the world. Numerous interventions have attempted to improve control of this disorder and reduce its complications. Traditional care for diabetes centers on an individual clinician. More recently, recognition of the central role of the patient has come into vogue. Payors, including Medicare, now cover up to 13 hours of diabetes self-management and education programs annually. Patient-centered medical home efforts add an aspect of inclusiveness, but retain a medical focus and are being increasingly advocated and trained. To date, no research has focused on the use of interprofessional learning teams simultaneously delivering care and learning to work together.

Systematic Review of Programs Treating High-Need and High-Cost People With Multiple Chronic Diseases or Disabilities in the United States, 2008-2014.

IntroductionFinding ways to provide better and less expensive health care for people with multiple chronic conditions or disability is a pressing concern. The purpose of this systematic review was to evaluate different approaches for caring for this high-need and high-cost population.MethodsWe searched Medline for articles published from May 31, 2008, through June 10, 2014, for relevant studies. Articles were considered eligible for this review if they met the following criteria: included people with multiple chronic conditions (behavioral or mental health) or disabilities (2 or more); addressed 1 or more of clinical outcomes, health care use and spending, or patient satisfaction; and compared results from an intervention group with a comparison group or baseline measurements. We extracted information on program characteristics, participant characteristics, and significant (positive and negative) clinical findings, patient satisfaction, and health care use outcomes. For each outcome, the number of significant and positive results was tabulated.ResultsTwenty-seven studies were included across 5 models of care. Of the 3 studies reporting patient satisfaction outcomes, 2 reported significant improvements; both were randomized controlled trials (RCTs). Of the 14 studies reporting clinical outcomes, 12 reported improvements (8 were RCTs). Of the 13 studies reporting health care use and spending outcomes, 12 reported significant improvements (2 were RCTs). Two models of care — care and case management and disease management — reported improvements in all 3 outcomes. For care and case management models, most improvements were related to health care use. For the disease management models, most improvements were related to clinical outcomes.ConclusionsCare and case management as well as disease management may be promising models of care for people with multiple chronic conditions or disabilities. More research and consistent methods are needed to understand the most appropriate care for these high-need and high-cost patients.

Oblique Lateral Lumbar Interbody Fusion (OLLIF): Technical Notes and Early Results of a Single Surgeon Comparative Study.

Background context: Lower back pain is one of the most prevalent and expensive health conditions in the Western world. The standard treatment, interbody fusion, is an invasive procedure that requires the stripping of muscles and soft tissue, leading to surgical morbidity. Current minimally invasive (MI) spinal fusions are technically demanding and suffer from technical limitations.Purpose: Oblique lumbar lateral interbody fusion (OLLIF) is a new technique for fusion of the lumbar spine that overcomes these complications. Outcome measures include patient demographics, reported outcomes, and surgical outcomes.Study design/Setting: Kambin's Triangle can easily be located as a silent window with an electrophysiological probe. Discectomy is performed through a single access portal with a 10 mm diameter. After a discectomy, the disc space is packed with beta-tricalcium phosphate soaked in autologous bone marrow, aspirated, and the cage is inserted. Finally, a minimally invasive posterior fixation is performed.Methods: OLLIF’s major innovation is to approach the disc through Kambin’s Triangle, aided by bilateral fluoroscopy.Results: We present data from 69 consecutive OLLIF surgeries on 128 levels with a control group of 55 consecutive open transformational lumbar interbody fusions (TLIFs) on 125 levels. For a single level OLLIF, the mean surgery time is 69 minutes (min) and blood loss is 29 ml. Surgery time was approximately twice as fast as open TLIF (mean: 135 min) and blood loss is reduced by over 80% compared to TLIF (mean: 355 ml).Conclusions: OLLIF is a minimally invasive fusion that significantly reduces surgery times compared to open surgery. OLLIF overcomes the difficulties of traditional open fusions, making it a safe and technically less demanding surgery than open or minimally invasive TLIF.

Estimation of the Risk of Somatization in Hypertensive Patients

Background: Somatization in hypertensive patients affects not only their quality of life but also their adherence to treatment and the physician-patient relationship, constituting an expensive health care issue. The possibility of estimating the risk of somatization in these patients could promote an individualized management of their manifestations.Objectives: The goal of this study was to stratify the risk of somatization in a cohort of patients with essential hypertension and to characterize the hemodynamic variables associated with the risk of somatization in hypertensive patients.Methods: A total of 120 subjects undergoing cardiovascular risk assessment were prospectively analyzed and classified in: 1) controlled hypertensive group (CHT) (57%, n=68) and 2) normotensive group (NT) (43%, n=52). The risk of somatization was evaluated using the SCL-90-R symptom ckecklist, and the anxiety and depression scales. The hemodynamic profile was determined using a validated oscillometric method.Results: The risk of somatization was higher in the CHT group independently of the presence of other emotional disorders. In subjects with higher risk of depression or anxiety, the evidence of somatization was greater (p<0.0001). In the CHT group, those who received treatment (n=38) had greater risk of somatization and of sleep disorders compared to those without treatment in the same group. Body mass index was associated with the risk of somatization (p=0.0227) and female sex was a predictor of somatization, anxiety and depression (p=0.001). A direct relationship was observed between cardiac output and depression and somatization, and between the risk of somatization and the product of heart rate and systolic blood pressure at rest.Conclusion: The estimation of the risk of somatization is feasible using a validated and reproducible tool. The frequently consulted symptoms in this condition could be associated with a higher risk of somatization, particularly linked with female sex, body mass index, drug therapy, presence of emotional abnormalities a depression and anxiety, and an hyperdynamic pattern.

Effects of Polypharmacy on Adverse Drug Reactions among Geriatric outpatients at a Tertiary Care Hospital in Karachi, A prospective cohort study.

Background: Adverse drug reactions (ADRs) present a challenging and expensive public health problem. Polypharmacy is defined according to the WHO criteria as the, ‘‘concurrent use of five or more different prescription medication’’. Elderly are more prone to adverse reactions due to comorbid conditions, longer lists of medications and sensitivity to drug effects. The aim of the study is to estimate the incidence and strength of association of ADRs due to polypharmacy among the geriatric cohort attending outpatient clinics at a tertiary care center. Methods: A hospital based prospective cohort study was conducted at ambulatory care clinics of Aga Khan University Hospital April 2012 to March 2013. One thousand geriatrics patients (age $65 years) visiting ambulatory clinics were identified. They were divided on the basis of exposure (polypharmacy vs. no polypharmacy). We followed them from the time of their enrollment (day zero) to six weeks, checking up on them once a week. Incidence was calculated and Cox Proportional Hazard Model estimates were used. Results: The final analysis was performed on 1000 elderly patients. The occurrence of polypharmacy was 70% and the incidence of ADRs was 10.5% among the study cohort. The majority (30%) of patients were unable to read or write. The use of herbal medicine was reported by 3.2% of the patients and homeopathic by 3%. Our Cox adjusted model shows that polypharmacy was 2.3 times more associated with ADRs, con-current complementary and alternative medicine (CAM) was 7.4 times and those who cannot read and write were 1.5 times more associated with ADRs. Conclusion: The incidence of ADRs due to poly pharmacy is alarmingly high. The factors associated with ADRs are modifiable. Policies are needed to design and strengthen the prescription pattern. Citation: Ahmed B, Nanji K, Mujeeb R, Patel MJ (2014) Effects of Polypharmacy on Adverse Drug Reactions among Geriatric Outpatients at a Tertiary Care Hospital in Karachi: A Prospective Cohort Study. PLoS ONE 9(11): e112133. doi:10.1371/journal.pone.0112133 Editor: Robin Dore, David Geffen School of Medicine, United States of America Received July 14, 2014; Accepted October 12, 2014; Published November 17, 2014 Copyright: 2014 Ahmed et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files. Funding: This work was supported by the University Research Council, Aga Khan University URC ID 102013MED. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * Email: junaiddrpatel@gmail.com . These authors contributed equally to this work.

Indirect and direct costs of treating patients with ankylosing spondylitis in the Brazilian public health system

IntroductionPatients with ankylosing spondylitis require a team approach from multiple professionals, various treatment modalities for continuous periods of time, and can lead to the loss of labour capacity in a young population. So, it is necessary to measure its socio-economic impact. ObjectivesTo describe the use of public resources to treat AS in a tertiary hospital after the use of biological medications was approved for treating spondyloarthritis in the Health Public System, establishing approximate values for the direct and indirect costs of treating this illness in Brazil. Material and methods93 patients selected from the ambulatory spondyloarthritis clinic at the Hospital de Clínicas of the Federal University of Paraná between September 2011 and September 2012 had their direct costs indirect treatment costs estimation. Results70 patients (75.28%) were male and 23 (24.72%) female. The mean age was 43.95 years. The disease duration was calculated based on the age of diagnosis and the mean was 8.92 years (standard deviation: 7.32); 63.44% were using anti-tumour necrotic factor drugs. Comparing male and female patients the mean Bath Ankylosing Spondylitis Disease Activity Index was 4.64 and 5.49 while the mean Bath Ankylosing Spondylitis Functional Index was 5.03 and 6.35 respectively. ConclusionsThe Brazilian public health system's spending related to ankylosing spondylitis has increased in recent years. An important part of these costs is due to the introduction of new, more expensive health technologies, as in the case of nuclear magnetic resonance and, mainly, the incorporation of anti-tumour necrotic factor therapy into the therapeutic arsenal. The mean annual direct and indirect cost to the Brazilian public health system to treat a patient with ankylosing spondylitis, according to our findings, is US$ 23,183.56.

Custos diretos e indiretos do tratamento de pacientes com espondilite anquilosante pelo sistema público de saúde brasileiro

IntroductionPatients with Ankylosing Spondylitis (AS) require a team approach from multiple professionals, various treatment modalities for continuous periods of time, and can lead to the loss of labour capacity in a young population. So, it is necessary to measure its socio‐economic impact. ObjectivesTo describe the use of public resources to treat AS in a tertiary hospital after the use of biological medications was approved for treating spondyloarthritis in the Health Public System, establishing approximate values for the direct and indirect costs of treating this illness in Brazil. Material and methods93 patients selected from the ambulatory spondyloarthritis clinic at the Hospital de Clínicas of the Federal University of Paraná between September 2011 and September 2012 had their direct costs indirect treatment costs estimation. Results70 patients (75.28%) were male and 23 (24.72%) female. The mean age was 43.95 years. The disease duration was calculated based on the age of diagnosis and the mean was 8.92 years (standard deviation: 7.32); 63.44% were using anti‐TNF drugs. Comparing male and female patients the mean BASDAI was 4.64 and 5.49 while the mean BASFI was 5.03 and 6.35 respectively. ConclusionsThe Brazilian public health system's spending related to ankylosing spondylitis has increased in recent years. An important part of these costs is due to the introduction of new, more expensive health technologies, as in the case of nuclear magnetic resonance and, mainly, the incorporation of anti‐TNF therapy into the therapeutic arsenal. The mean annual direct and indirect cost to the Brazilian public health system to treat a patient with ankylosing spondylitis, according to our findings, is US$ 23,183.56.

The impact on health of recurring migrations to the United States

Considerable research has focused on whether or not immigrants’ health declines to match that of comparable native-born people. This immigrant health convergence is hypothesized to be driven by immigrants’ acculturation to American society and habits. This is particularly problematic for a country such as the United States which combines a high number of immigrants, bad health habits among the native born, and an expensive health care system. Previous research in this literature uses the duration of an immigrant’s current stay in the United States as the measure of exposure to acculturation. Using the duration of the immigrant’s current stay in the United States implicitly assumes one long-term move. However, the largest immigrant group in the United States (Mexicans) is characterized by a pattern of repeated migration trips. This paper separates out the effects of migration duration and lifetime cumulative experience for Mexican immigrants to the United States. The empirical analysis is carried out using data from the Mexican Migration Project. The Mexican Migration Project has been collecting data on Mexican immigrants to the United States since the mid-1980s. Empirical results find that while overall time spent in the United States supports the acculturation hypothesis, single-trip migration duration has the opposite effect. The positive impact of single-trip duration on health is likely caused by recovery time needed to compensate for difficult crossings into the United States which have an even harsher effect on health if the individual undertakes short, repeated migrations. We also find that having Latino friends improves health while Anglo friends cause faster convergence and worse long-term health impacts. Both support the acculturation hypothesis. Results suggest that researchers need to focus on the cumulative impact of time spent in the United States rather than relying on just the duration of the latest trip. This suggests a much larger negative effect of migration on health than studies relying solely on migration duration. In the case of repeated migration patterns, this imposes costs on both the health care systems of the destination (USA) and source (Mexico) countries. Repeated immigration to the United States can result in acculturation which causes bad health habits to be brought back to Mexico, along with the accompanying costs these incur.

Is exposure in vivo cost-effective for chronic low back pain? A trial-based economic evaluation.

BackgroundBack pain is one of the most expensive health complaints. Comparing the economic aspects of back pain interventions may therefore contribute to a more efficient use of available resources. This study reports on a long-term cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) of two treatments as viewed from a societal perspective: 1) exposure in vivo treatment (EXP), a recently developed cognitive behavioral treatment for patients with chronic low back pain who have elevated pain-related fear and 2) the more commonly used graded activity (GA) treatment.MethodsSixty-two patients with non-specific chronic low back pain received either EXP or GA. Primary data were collected at four participating treatment centers in the Netherlands. Primary outcomes were self-reported disability (for the CEA) and quality-adjusted life years (for the CUA). Program costs, health care utilization, patient and family costs, and production losses were measured by analyzing therapy records and cost diaries. Data was gathered before, during, and after treatment, and at 6 and 12 months after treatment. Non-parametric bootstrap analyses were used to quantify the uncertainty concerning the cost-effectiveness ratio. In addition, cost-effectiveness planes and cost-effectiveness acceptability curves were performed.ResultsEXP showed a tendency to reduce disability, increase quality adjusted life years and decrease costs compared to GA. The incremental cost-effectiveness ratios of both the CEA and CUA are in favor of EXP.ConclusionsBased on these results, implementing EXP for this group of patients seems to be the best decision.Trial registrationISRCTN88087718

Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial.

BackgroundLow back pain (LBP) is one of the most prevalent and expensive health care problems in industrialised countries. LBP leads to high health care utility and productivity losses; leaving the individual, the employer, and society with substantial costs. To improve the care for LBP patients and reduce the high societal and financial burden of LBP, in 2010 the ‘Multidisciplinary care guideline for nonspecific low back pain’ was developed in the Netherlands. The current paper describes the design of a study aiming to evaluate the (cost-) effectiveness of a multifaceted strategy to implement this guideline.MethodsIn a cluster-randomised controlled trial, the (cost-) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination. Using a stepped-wedge approach, participating general practitioners, physiotherapists, and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session. The timing these clusters receive the training is the unit of randomisation. LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aimed at improving beliefs, cognitions, and self-management. The primary outcome measure of this study is patient back beliefs. Secondary outcome measures on patient level include pain, functional status, quality of life, health care utility, and productivity losses. Outcome measures on professional level include knowledge and attitude towards the guideline, and guideline adherence. A process evaluation for the implementation strategy will be performed among the health care providers and the patients. Furthermore, a qualitative subgroup analysis among patients with various ethnic backgrounds will be performed.DiscussionThis study will give insight into the (cost-) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level. The valuable information gained with this study may prove useful for policy-makers, health care providers, and researchers who are in the process of reducing the burden of back pain on individuals and society.Trial RegistrationNetherlands Trial Register (NTR): NTR4329. Registered December 20th, 2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1876-1) contains supplementary material, which is available to authorized users.

Answering the Call for a Bachelors-Prepared Nursing Workforce: An Innovative Model for Academic Progression.

Forces that have produced national reform of a fragmented, inefficient, and expensive health care services sector have also set the stage for reform of a fragmented, inefficient, and expensive system for nursing education. Changes in health care, health policy, education policy, and funding for public higher education have led to the development of new nursing education models designed to increase the number of baccalaureate-prepared nurses entering the workforce. This article describes the development and implementation of one such model that features a common concept-based curriculum and university-community college partnerships at its core. This plan increases access for nursing students across the state to earn a prelicensure bachelor of science in nursing degree and preserves the integrity and accessibility of associate degree nursing education.

FDA cigarette warning labels lower craving and elicit frontoinsular activation in adolescent smokers.

Cigarette smoking is an economically and epidemiologically expensive public health concern. Most adult smokers become addicted during adolescence, rendering it a crucial period for prevention and intervention. Although litigation claims have delayed implementation, graphic warning labels proposed by the U.S. Food and Drug Administration (FDA) may be a promising way to achieve this goal. We aimed to determine the efficacy of the labels in reducing in-scanner craving and to characterize the neurobiological responses in adolescent and adult smokers and non-smokers. While undergoing functional magnetic resonance imaging, thirty-nine 13- to 18-year-old adolescent and forty-one 25- to 30-year-old adult smokers and non-smokers rated their desire to smoke when presented with emotionally graphic warning labels and comparison non-graphic labels. Compared with adult smokers, adolescent smokers exhibited greater craving reduction in response to the warning labels. Although smokers evinced overall blunted recruitment of insula and dorsolateral prefrontal cortex (DLPFC) relative to non-smokers, an effect that was stronger in adolescent smokers, parametrically increasing activation of these regions was associated with greater craving reduction. Functional connectivity analyses suggest that greater DLPFC regulation of limbic regions predicted cigarette craving. These data underscore a prominent role of frontoinsular circuitry in predicting the efficacy of FDA graphic warning labels in craving reduction in adult and adolescent smokers.

Waste to Wealth for the Edible Bird Nest Industry

Edible bird nest (EBN) is a product obtained from the salivary excretion of different species of swiftlets during the breeding season. It is an expensive health food product. The raw EBN needs intensive cleaning before it can be consumed. Currently, EBN is increasingly used in cosmetic products. The cleaning procedure generally produced about 30 % (w/w) of waste. To date, there is no work conducted to study the composition of the waste recovered from the cleaning process and converting the waste into useful downstream products. Therefore, the aim of this study is to determine the composition of the EBN wastes and to formulate a value added facial cream product from the EBN waste. EBN waste (residues) was collected from the cleaning water of EBN samples from the swiftlet species Aerodramusfuciphagus using the centrifugation method. The chemical composition of the EBN waste (residues) was analyzed qualitatively using the FTIR technique. Similarly, the different grades of processed EBN samples (2A, 3A, 4A, 5A and biscuit white) from the swiftlet species Aerodramusfuciphagus were quantitatively analyzed using the elemental analyzer. The residual EBN showed high protein content (47.33±3.09 %) and carbohydrate content of 2.4±0.37 %. Interestingly, nitrite, nitrate and lead were not present in the EBN waste. Thus, EBN waste is considered safe to formulate a facial cream. The collagen content in EBN is good as an anti-aging beauty cream. Since the EBN is a very expensive product, the residual EBN waste has good potential to formulate a value added product without any loss in its nutritional health benefits to achieve a similar effect as EBN. The high protein content retained in EBN waste makes the wash off water from EBN washings a suitable nutrient – rich component for the formulation of health and beauty products.

Injection Augmentation for Chronic Cough

Chronic cough (CC) is a pervasive and expensive health problem in the United States. Almost as diverse as its etiologies are the available therapeutic options. When vocal fold paresis and CC coincide, injection augmentation may provide an alternative to standard medical and behavioral treatments for CC. Our objective was to assess the effect of injection augmentation in a selected group of patients with CC who had failed multiple medical and behavioral treatments. The study design is a retrospective case review. Our study group included six subjects (1 male and 5 females; aged 24-84y) who presented for laryngologic evaluation with a chief complaint of CC unresponsive to conventional medical and behavioral management. The cough severity index (CSI), reflux symptom index (RSI), dyspnea severity index (DSI), and voice handicap index-10 (VHI-10), as well as subjective evaluation were assessed before and after the injection augmentation of the vocal folds was undertaken. Five of six patients reported subjective improvement in cough. CSI scores improved in all six (average change 7.3, range 2-13). RSI and DSI scores also improved significantly after injection, whereas VHI-10 scores did not significantly change. One patient reported transient hoarseness after injection that completely resolved. One patient received injection augmentation three times, as the material resorbed and symptoms returned. Injection augmentation effected relief from CC in a select group of patients with CC refractory to previous medical and/or behavioral treatments. This intervention is a novel option for such patients and offers an alternative approach to medical treatment.

Effects of the Ten Percent Cap in Medicare Home Health Care on Treatment Intensity and Patient Discharge Status.

To estimate the effect of the 10 percent cap introduced to Medicare home health care on treatment intensity and patient discharge status. Medicare Denominator, Medicare Home Health Claims, and Medicare Provider of Services Files from 2008 through 2010. We used agency-level variation in the proportion of outlier payments prior to the implementation of the 10 percent cap to identify how home health agencies adjusted the number of home health visits and patient discharge status under the new law. Under the 10 percent cap, agencies dramatically decreased the number of service visits. Agencies also dropped relatively healthy patients and sent sicker patients to nursing homes. The drastic reduction in the number of service visits and discontinuation of relatively healthy patients from home health care suggest that the 10 percent cap improved the efficiency of home health services as intended. However, the 10 percent cap increased other types of health care expenditures by pushing sicker patients to use more expensive health services.

Remedy and Reaction: The Peculiar American Struggle over Health Care Reform

Review of: Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform, by Paul Starr. New Haven: Yale University Press, 2013. 342 pp. $17.00 paper. ISBN: 978-­‐0-­‐300-­‐18915-­‐5 By: David N. Pellow. 2015. Contemporary Sociology 44(2): 256-­‐258 “Do we have an obligation to provide health care for our citizens?” Paul Starr opens this outstanding book with this question and follows up by asking another more vexing one: why is the U.S. health care system so stubbornly unique among capitalist democracies? It is a well-­‐known and embarrassing fact that the U.S. has the most expensive health care system in the world and yet has the highest number of uninsured citizens of any western democracy. But the solution to the problem has always eluded us. The answers to Starr’s questions vary widely across the political spectrum exposing deep divides between and within the major political parties and reveals how a combination of social forces prevents the U.S. from guaranteeing what people in many other democracies view as a fundamental right. Starr’s argument is that the U.S. missed a chance to set up a general system for financing health care in the first half of the 20 th century, and when the government finally sought to do so, the nation was caught in what he calls a policy trap, in which enough of the public and health care industry leaders were satisfied with the complicated and costly system that changing it became nearly impossible. He addresses the three factors usually indicted for producing the health care crisis in the U.S.: “special interests,” national values, and “the daunting complexity of the problems of health care and health policy.” And while Starr agrees that there is some truth within each of these explanations, he challenges the claim that any one of them alone is responsible for the quagmire that is our health care system. Of the three explanations, the argument that “special interests” have prevented major health care reform carries particular weight with many observers. After all, as Starr demonstrates throughout the book, the American Medical Association and other key stakeholders actively opposed anything resembling a national health care system virtually anytime the idea emerged in U.S. politics. But that explanation is too tidy because there have been moments when health care industry leaders have supported expanded coverage proposals that they viewed as better than less appealing alternatives such as single payer. The “special interest” explanation really falls short when we discover that the public itself is split over reform because unionized workers, veterans, disabled persons, and the elderly can access Medicare, while segments of low income populations can also qualify for Medicaid. These millions of Americans may not have the best health care, but they often see themselves as “reasonably well-­‐protected” and fear losing their coverage or benefits under any major reform, particularly since they feel they have earned their way into such programs while other groups are seen as less worthy. This, I believe, is the most disturbing and revealing aspect of the health care crisis in this country and— although Starr does not draw the link—has strong echoes of the kind of divisive

Pharmacogenetics: an Emerging Therapeutic option for Bangladesh

From socioeconomic point of view adverse drug reactions (ADRs) present a challenging and expensive public health problem worldwide. Most important factors involved in this life threatening events are false diagnosis, failure of treatment, lack of proper patient counseling, lack of knowledge regarding medication use and polypharmacy. Pharmacogenetic research explores genetic variability between patients to explain observed differences in effectiveness of a drug therapy as well as adverse event profile. Thus, pharmacogenetic testings could help to prevent treatment failure and adverse drug reaction in patients. It also allows the detection and prediction of ADRs and is a tool that can reduce the risks associated with ADRs. In this particular review we will discuss how genetic variation can influence drug response and how personalized medicine can be achieved as well as some recent pharmacogenetic works carried out in Bangladesh. The aim of this review is to increase awareness of the physicians and other health care practitioners and professionals about the variation of drug response due to genetic variation. This review can help the physicians to identify genetic factors associated with ADRs with all drugs and effectively incorporate pharmacogenetics into the practice of pharmacovigilance. DOI: http://dx.doi.org/10.3329/dujps.v13i2.21902 Dhaka Univ. J. Pharm. Sci. 13(2): 207-214, 2014 (December)

Obesity management by general practitioners: the unavoidable necessity.

Nearly 62% of primary care patients are overweight or obese, and obesity is now a National Health Priority Area. Weight management interventions in primary care currently generate little more than 1 kg of weight loss per patient over a 2-year period. Consequently, further strategies are required to improve the effectiveness of weight management in primary care. The National Health and Medical Research Council (NHMRC) have released updated guidelines for the management of overweight and obese patients in primary care. However, there is some disconnect between establishment of guidelines and their implementation in practice. Barriers to GPs using guidelines for the management of obesity include low self-efficacy, perceived insufficient time in consultations and the challenge of raising the topic of a patient's weight. Nonetheless, patients prefer to receive weight management support from GPs rather than other health professionals, suggesting that the demand on GPs to support patients in weight management will continue. GPs cannot afford to side-line obesity management, as obesity is likely to be the most prevalent modifiable risk factor associated with patients' long-term health. Without further strategies to support GPs in their management of patients' weight, obesity will continue to be an expensive and long-term public health issue.