The Military Health Services System (MHSS) is one of the largest health care systems in the United States comprising over 115 hospitals, 471 clinics and an annual operating budget in excess of 15 billion dollars. In 1993, Congress directed the Secretary of Defense to implement a model of health care reform emphasizing the principles of managed care and regional contracting as cost containment tools, while improving the uniformity of aocess and benefit structure. The TRICARE program was proposed by the Department of Defense (DOD) and approved by Congress in 1994. TRICARE presents a triple option of a health maintenance organization, preferred provider organization, or a fee for service indemnity plan. The health maintenance organization option presents the greatest potential for cost savings to DOD through utilization management and large-scale, regional contracting to augment variability in the MRSS access and benefit structure. A twenty-four month population-based time series design presented significant changes in the utilization of ambulatory health services when subjects enrolled in a program grounded in managed competition within a budget. Improved access to an integrated health care system, including shifts to more cost-effective portals was found among the broader population as well as high-risk chronic subjects. The findings validate the theoretical constructs of managed competition under global budgets, previously untested in the literature. The data also refute concerns for high-risk populations to be undeserved and undercared for in managed care models of delivery. The DOD program with its variant of the Health Alliance or Health Insurance Purchasing Cooperative demonstrates that access to a national uniform benefit package, movement toward universal coverage, community rating, and cost-conscious decision making among consumers is a feasible mechanism for achieving the objectives of health care reform. The initial findings from DOD health care reform offer the first empirical and applied outcome evidence from one of the most important theoretical developments in health care policy and economics in the twentieth century.

The objectives of this study were to assess the construct validity and predictive validity of a previously published comorbidity classification scheme designed for use with administrative data. The scheme groups non-primary discharge diagnoses into a set of thirty comorbidity indicators, which may be used to describe and compare populations with respect to burden of comorbid illness. The scheme was developed on a large population of hospitalized patients in California in 1992 (training population) and the predictive effect of the indicators estimated with respect to the outcomes length of stay, hospital charges, and in-hospital death. The current study drew data from the Massachusetts Hospital Case Mix Data Base of 1992 (testing population). The effect of the comorbidity indicators on each outcome was estimated by fitting ordinary least squares regression (OLSR) models of length of stay and hospital charges, as well as logistic regression models of in-hospital mortality, to the testing population. The estimated effect of the comorbidity indicators on each outcome, adjusted for demographics and characteristics of index hospitalization, was compared between the training and testing populations. The characteristics of the testing population were largely similar to those of the training population. The relationship between burden of comorbid illness (as measured by the number of comorbidity indicators per patient) and the outcomes was comparable in the two populations. The estimated adjusted effect of the comorbidity indicators and the predictive ability of the OLSR models were comparable in the training and testing population with respect to the outcomes length of stay and charges. The estimated adjusted effect of the comorbidity indicators on in-hospital death was not comparable in the two populations. The results support construct validity and predictive validity of the comorbidity classification in Massachusetts discharge data in 1992. Other aspects of baseline risk must be accounted for separately. The estimated adjusted effect of the indicators in the training population on the outcomes length of stay and charges, but not in-hospital death, is generalizable to Massachusetts' discharge data and may be further generalizable. Practical application of the comorbidity indicators for comorbidity adjustment in epidemiological research should be further explored.

The intrauterine device (IUD) is a safe, effective, convenient, reliable, inexpensive, and cost-effective form of reversible contraception. It rivals female sterilization, injectables, and implants with respect to effectiveness in pregnancy prevention. Once inserted, IUDs are nearly maintenance free; some IUDs can even be used for over a decade. In many settings however, the utilization of this form of contraception is poor and a number of barriers to usage exist. These barriers often relate to lack of knowledge and misperceptions among both potential users and healthcare providers. The IUD is a reliable option that may be an ideal form of contraception for many women in South Africa. In order to make this method available on a wider scale, it is necessary to provide correct information to women and health care professionals and to increase the availability and use of this highly effective method. We conducted a cross-sectional descriptive study designed to assess the current knowledge, attitudes, and practices of potential users and health care providers with respect to the IUD. We recruited 205 women between 15 to 49 years of age who were attending family planning and ST! care services at four primary level public clinics (two in the more urban Western Cape Province and two in the rural Eastern Cape Province in South Africa). In addition, we interviewed 32 providers from 12 clinics (six clinics per province). Ethical approval for this research was obtained from both the University of Cape Town and Walter Sisulu University (formerly the University of the Transkei). Permission was also given by the local and provincial health services. Among clients, knowledge of the IUD was poor. About 26% of women had heard of the IUD. After the method was explained to them, 89.7% of women believed that there were advantages to using the IUD and 72.7% of women said that they would consider using the JUD in the future. Also, women thought the IUD was an easier contraceptive method to use than oral contraceptive pills, injectables, male and female condoms, and female sterilization. Logistic regression modelling showed that, after adjusting for level of education, being from the Western Cape, older age, and having heard of emergency contraception all independently predicted awareness of the IUD method. For the most part, providers knew how the IUD worked to prevent pregnancy; however, providers were lacking in more detailed knowledge about the method and had misinformation about the IUD. Almost all (93 .6%) of providers recognized their need for more information and training about the IUD. Providers reported that barriers to IUD usage in South Africa were lack of knowledge of the method on the part of providers (84.4%), a lack of trained providers to insert or remove the IUD (62.5%), limited availability of the device at health facilities (56.3%), and a lack of knowledge on the part of potential users (46.9%). Despite these barriers, 81 % of providers believed women would be interested in the IUD if they knew about it and 73.3% believed the IUD should be promoted in South Africa. Our results suggest that the IUD would be a welcome addition to the contraceptive method mix in South Africa and that both clients and providers would be interested in this method. It is clear that awareness campaigns among women seeking contraception would be necessary for building support and publicizing the IUD. It will also be necessary to train and educate providers, focusing on up to date information, dispelling myths, and proper insertion and removal techniques. South Africa could re-introduce the IUD into the contraceptive method mix and increase women's choice by adding this valuable, viable, and sustainable option to the contraceptive method mix. The findings of this study, which was requested by the provincial health services, will be used to inform policy and as a starting point for assessing the feasibility and acceptability of a greater role for the IUD in the contraceptive method mix in South Africa.

Background: According to the National Cancer Registry of South Africa 600-700 new cases of paediatric cancers have been reported every year for the past 25 years. While in the year 2000 HIV/AIDS was responsible for 42 479 deaths in children under five. However support for and research in general for the paediatric intermediate care (encompasses palliative, sub-acute and respite care) needed by these children remains sparse. Costing studies are even rarer, with the few studies conducted in South Africa reporting a broad range of average costs per inpatient day. Methods: A retrospective cost analysis for the period April 2014-March 2015 was undertaken from the provider perspective. Costs of paediatric intermediate care were estimated for an intermediate stepdown facility and a tertiary hospital in Cape Town, South Africa. A step down costing approach was employed, and the costs were inflated to 2016 values and expressed in Rand and USD using an exchange rate of 1 USD = R14.87. Results: Cost per inpatient day was USD 713.09 at the hospital and USD 695.17 at the step-down facility. The cost for a paediatric patient who is HIV/TB co-infected was USD 7130.94 and USD 6951.67 at the hospital and step-down facility respectively, assuming an average length of stay (ALOS) of 10 days. For a patient who has a terminal brain carcinoma the cost was USD 19966.63 and USD 19464.69 at the hospital and step-down facility respectively, assuming an ALOS of 28 days. Personnel costs accounted for 60% of the total cost at the hospital, compared to only 17% of the total costs at the step-down facility. Overhead costs accounted for 12.33% at the step-down facility, almost 3 times that of the hospital (4.48%). Conclusions: The study highlights that the drivers of cost are not uniform across settings. Providing intermediate care at a step-down facility can be more cost-saving than providing this care at a hospital, there are however areas in which more savings could be realized. The costs presented in this study were considerably higher than those found in other studies, however, the paucity of cost data available in the area of paediatric intermediate care makes comparisons difficult.

Individuals with Lynch Syndrome (LS) have a 25% to 75% lifetime risk of colorectal cancer and the cancer generally presents at an early age. Establishing the costs of strategies to prevent or delay the onset of cancer is, thus, desirable. This study compared the cost of two screening approaches - colonoscopy only (Strategy 1) versus genetic testing for LS followed by colonoscopy for the individuals that tested positive for LS (Strategy 2). A comparative cost analysis was conducted at a tertiary hospital, from the health provider perspective, using a micro-costing, ingredient approach. Probands that were selected, according to the Revised Bethesda Criteria, for genetic testing between 01 November 2014 and 30 October 2015, and their first degree relatives (high risk relatives) were evaluated according to Strategy 1 and Strategy 2. Total costs per strategy were estimated and compared. Sensitivity analyses were performed on adherence rates to colonoscopy, positivity rates of relatives and discount rates. A total of 40 families were studied. The total cost for Strategy 1 amounted to R4 932 718 ($332 617) compared to R390 308 ($26 319) for Strategy 2 (Discount rate 3%; Adherence 75% and Positivity rate of relatives 45%). Base case analysis indicated a difference of 92% less in the total cost for Strategy 2 compared to Strategy 1. Univariate sensitivity analyses showed that the difference in cost between the two strategies was not sensitive to changes in discount rates, adherence rates or positivity rates of relatives. Compared to colonoscopy screening only, colonoscopy combined with genetic testing presented a less costly option by identifying patients at high risk of colorectal cancer for screening. Testing of relatives should be facilitated since, compared to probands, genetic testing of relatives is less costly and is likely to have more benefit. Effectiveness of the screening programmes should be established through further research.

This project assessed the cost and cost-effectiveness of hypertension management in South Africa within the context of a text messaging-based intervention (StAR* study) conducted in an urban public-sector clinic in Cape Town. The StAR* study is a community randomized trial that investigated the effect of adherence support via short messaging service (SMS) on treatment adherence and patient outcomes for the management of hypertension at Vanguard CHC in Cape Town (Bobrow et al. 2016). Patients received behavioral text messages as reminders for them to collect and take their medication on time. The StAR* study, consisted of three arms that ran in parallel: participants in the control arm received unrelated messages; patients in the information-only arm received one-way information messages twice a week; and patients in the interactive arm received interactive SMS-texts at the same frequency as those in the information only arm (Bobrow et al. 2016). Patients in the interactive arm could respond to the messages and trigger a response from the healthcare provider. The text messaging based intervention was shown to improve hypertension outcomes over a 12-month period in hypertension patients by improving adherence and retention in care. The study showed, in the one-way intervention arm an improvement in adherence (measured by medication refill rates) and a small reduction in systolic blood pressure (2.2mm Hg reduction over 12months) (Bobrow et al. 2016). In this study, we assessed the cost and cost effectiveness of the StAR* intervention under routine care management at Vanguard CHC. We also assessed the cost of hypertension management from the health system perspective and the cost of accessing hypertension care from the patient perspective. A combination of the ingredients approach and step-down costing was used to cost hypertension care from a health system perspective while a questionnaire was administered to 250 patients to estimate patient costs. The primary outcomes were the average cost of hypertension care and the incremental cost of the text message-based adherence intervention (StAR* intervention), compared to usual care, per millimetre of mercury (mmHg) reduction in systolic blood pressure. Results of the study show that the average health system cost for hypertension management is R262 per visit and the patient cost of accessing hypertension care is R172 per visit. The text messaging based intervention was found to have low implementation costs in this pilot phase. The monthly incremental cost of the text messaging based intervention cost was R4 per person. The incremental cost-effectiveness ratio of the intervention was R22 per mm Hg reduction. This study provides the first contemporary assessment of hypertension management costs and the cost-effectiveness of mobile-based hypertension adherence support in South Africa. Future work will seek to estimate the long-term cost-effectiveness of this intervention and the cost of scaling it to the provincial and national levels.

No description available.

Breast cancer is the second leading cause of cancer death in United States women, estimated to be diagnosed in 1 out of 8 women in their lifetime. Screening mammography detects breast cancer in its pre-clinical stages when treatment strategies have the greatest chance of success, and is currently the only population-wide prevention method proven to reduce the morbidity and mortality associated with breast cancer. Research has shown that the majority of women are not screened annually, with estimates ranging from 6% - 30% of eligible women receiving all available annual mammograms over a 5-year or greater time frame. Health behavior theorists believe that perception of risk/susceptibility to a disease influences preventive health behavior, in this case, screening mammography. The purpose of this dissertation is to examine the association between breast cancer risk perception and repeat screening mammography using a structural equation modeling (SEM) framework. A series of SEM multivariate regressions were conducted using selfreported, nationally representative data from the 2005 National Health Interview Survey. Interaction contrasts were tested to measure the potential moderating effects of variables which have been shown to be predictive of mammography use (physician recommendation, economic barriers, structural barriers, race/ethnicity) on the association between breast cancer risk perception and repeat mammography, while controlling for the covariates of age, income, region, nativity, and educational level. Of the variables tested for moderation, results of the SEM analyses identify physician recommendation as the only moderator of the relationship between risk perception and repeat mammography, thus the potentially most effective point of intervention to increase mammography screening, and decrease the morbidity and mortality associated with breast cancer. These findings expand the role of the physician from recommendation to one of attenuating the effect of risk perception and increasing repeat screening. The long range application of the research is the use of the SEM methodology to identify specific points of intervention most likely to increase preventive behavior in population-wide research, allowing for the most effective use of intervention funds.

Environmental mercury pollution of the Valley of a Thousand Hills area of KwaZulu-Natal, South Africa, in particular the river system below the Thor Chemicals mercury recycling plant, has been a topic of heated debate for a number of years. Thor Chemicals was established as a mercury recycling plant in the mid-1980' s and it processed mercury waste imported from various countries. A number of factory workers were subsequently exposed to high levels of mercury vapour causing the death of a worker. Upon investigation it was found that in addition to the occupational exposures of workers, mercury waste had been discharged into the river systems of the Valley of a Thousand Hills. During the 1998 South African Parliamentary session, questions were raised regarding the lack of adequate monitoring and research directed at quantifying human health risks in the region. A number of Government departments were accused of apathy and incompetence in adequately addressing the issue. Fish forms an important part of the diet of the local community living in the Valley of a Thousand Hills. Children, in particular, are frequently observed fishing in the rivers, thus placing these individuals at risk should the fish be contaminated with mercury. The aims of this study were: to determine the extent of environmental mercury pollution of the river system downstream from the Thor Chemicals plant, and to quantify the human health risk associated with fish consumption in the region. Samples of streambed sediment, algae, cattle hair, fish and human hair, were obtained from the study area as well as from a control area upstream from the Thor Chemicals plant. These were analysed to determine the concentration of mercury in each sample. Mercury levels in the study group were compared to mercury levels in the control areas.

No description available.