Introduction: Beta-Blocker Evaluation Survival Trial (BEST) sub-analyses indicated a likely interaction between bucindolol and race disadvantaging black heart failure (HF) patients (Domanski J Cardiac Fail 2003); Arg389 homozygotes having adjusted reductions of 38% in mortality and 34% in mortality/hospitalization over other genotypes (Liggett PNAS 2006). Bucindolol is being evaluated in Arg389 genotype patients in the GENETIC-AF trial (NCT01970501). Objective: To conduct parallel (using Domanski et al and Liggett et al) ex ante economic evaluations of Arg389 genetic testing in stage III/IV HF to support bucindolol treatment decisions (if Arg389-positive) and carvedilol (if Arg389-negative) treatment versus no such testing and empirical bucindolol; using Domanski et al and Liggett et al BEST sub-analyses. Methods: In both Domanski et al and Liggett et al analyses, we used a decision tree model with time horizon of 18 months divided into 3 six-month cycles to estimate the cost-effectiveness and cost-utility of Arg389 genetic testing, considering overall survival (OS) from Domanski et al and Liggett et al BEST sub-analyses. Costs and utilities were retrieved from literature except for assumed cost for bucindolol treatment (1.5x cost of carvedilol) and genetic testing ($250). Discount rate was set at 3%/yr. Weibull distributions were fitted to OS data. Life-years (LY) and quality-adjusted life-years (QALY) were used to estimate incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR), and results were validated using probabilistic sensitivity analyses (PSA). Results: In the Domanski et-based analysis, Arg389 genetic testing versus no testing was associated with incremental gains of 0.29LYs and 0.27QALYs at incremental cost of $726; yielding ICER of US$2,503/LY and ICUR of US$2,688/QALY gained. In the Liggett et al-based analysis, Arg-389 genetic testing versus no testing was associated with incremental gains of 0.35LYs and 0.32QALYs at savings of -$1.081; for ICER of -US$3,089/LY and ICUR of -US$3,378/QALY gained. Both analyses were confirmed in PSAs. Conclusion: Arg389 genetic testing to support bucindolol treatment in stage III/IV HF patients prevails economically over bucindolol treatment without genetic testing due to superior OS. If bucindolol is priced at 1.5x the cost of carvedilol. this economic benefit is likely to disappear if bucindolol and/ or genetic testing are priced higher. The clinical and economic benefits of bucindolol treatment with versus without Arg389 genetic testing versus empiric carvedilol remains to be assessed.

This research builds upon a body of previous research on health informatics in developing countries. Early research on this area was motivated by a desire to understand the role of different health informatics applications for an effective and efficient health care delivery in developing countries. These applications range from the use of medical expert systems for clinical diagnosis to epidemiological systems at the central level. None of these looked at health information systems at the district level, especially in relation to the information needs of district health staff. Therefore, this research differs from earlier studies in three aspects. First, it looks at the planning and decision-making processes at the district level and how information support could play a crucial role in these processes. Second, it provides a critical evaluation of the existing vertical reporting systems, and through action-research demonstrates the use of an integrated health information system at the district level. Third, it applies multiple perspectives to analyse the research findings in relation to information support for district health care planning and decision making. These three perspectives are the functional perspective, organisational perspective, and the political perspective. To achieve this, the research: • uses a systemic approach to examine the health care system in The Gambia; • uses action-research to design, develop and implement an integrated district health information system in The Gambia; • uses an interpretive evaluation framework to evaluate the impact of the system development efforts in this research; • uses the theory of contextualism to reflect on the research findings over the three year period. Various themes emerged during the research. These themes would be introduced here as the contributions to knowledge arising from the completion of this research project. These include: • a demonstration of the suitability of using a systemic approach for the design, development and implementation of an integrated information system for district health care planning and decision making; • the development of a conceptual implementation framework suitable for the unique characteristics of developing countries; • a manifestation of the implications of an integrated information system for management development, decentralisation, intersectoral coordination and community participation at the district level; • suggestions for further work especially on the need to evaluate the socio-political impact of this research on the existing political and cultural structures in The Gambia.

The purpose of this study is to explore the concept of ‘Healthy Ageing’ in Hong Kong. The research attempts to explore the historical base from which ‘Healthy Ageing’ has been conceptualized in both Western and Chinese societies. This study also tries to provide an overview of literature that relevant to the ‘Healthy Ageing’ concept, and to provide an initial theoretical framework of ‘Healthy Ageing’ in a Hong Kong Chinese context. This study mainly adopts a qualitative approach in exploring the meaning of the concept. Since that ‘Healthy Ageing’ is likely to be conceptualized from the concept of health and ageing, which have been here since the early days, a method of documentary analysis on the origin of the concept and the paths leading to what it is at present has been employed. To re-construct the concept in Hong Kong, this thesis works towards an explanation of the historical base of the concept of ‘Healthy Ageing’ in both Chinese and Western societies since Hong Kong has evolved from a mixture of both cultures. Comparative cultural analysis and research’s own interpretation act as important roles in the present study to consolidate those raw documents in particular of the Chinese literature and construct a new model for the concept. Having constructed a model of ‘Healthy Ageing’, an expert in cultural studies was then interviewed at the end of May 2002 for verifying the model. Adopting a comparative cultural analysis, this study found that the fundamental elements, say physical and psychosocial well-being, in conceptualization of health in both East and West are almost the same, but manifestations and interpretations show some variations. Chinese people are apt to manifest and interpret their concept of health by an holistic approach, while the concept of health in Western societies is more likely to be manifested in a “compartmental” approach. These variations are basically derived from the differences of geo-cultural adaptations and the differences in individual lifestyles. As to the concept of ageing, this study revealed that ageing subject as a process instead of an end-stage of life-span. According to one view of human beings, life-spans can be divided into eight periods: Prenatal (pregnancy), Infancy (0-3), Early Childhood (3-6), Middle Childhood (6-12), Adolescence (12-20), Young Adulthood (20-40), Midlife (40-65) and Old Age (65+). It is a natural and integral process of growing old starting from birth and ending at death, in which a continuous process of biological, psychological and social changes will be experienced in a person’s life-course. After reconstructing health and ageing concepts, a tentative model of healthy ageing was developed in this study. In this study, healthy ageing is an holistic and dynamic concept. It is a state of interactions and adaptations between people and the environment in attaining optimal health in one’s life-span. It is a three-dimensional concept that encompasses health, health-ageing and health-ageing-environment dimensions. For the health dimension, there are six interrelated cross-life domains in achieving healthy ageing, which involve physical, psychological, social, economic, spiritual and environmental well-being. For the health-ageing dimension, people can achieve healthy ageing by attaining health in each stage of life. In this process, the health at younger stage influences the health at older stage. Thus, keeping healthy in early stage benefits the health conditions in later stages, although it cannot be said that what happens in early stage might not be unchangeable for later stages. Adopting health-promoting strategies in later stage can also provide opportunities for individuals to achieve healthy ageing. The health-ageing-environment dimension refers to the people-environment adaptation for attaining optimal health in their life-spans. Basically, people can ideally achieve healthy ageing by adopting health-promoting strategy at every stage of life. However, those favourable and unfavourable external environments will limit and change the opportunities for a person to achieve healthy ageing. To achieve optimal health in their life-spans, people are required to adjust themselves, adapting to their environment and also helping to shape the environment. Therefore, an individual-community approach is crucial for attaining healthy ageing.

Thesis (M.S.H.P.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / BACKGROUND: Percent time in therapeutic range (TTR) and INR variability are both used to measure anticoagulation control with warfarin. TTR measures anticoagulation intensity, while INR variability measures anticoagulation stability; both predict definitive clinical outcomes such as stroke, major hemorrhage. Here, we examine whether an intermediate composite measure (ICOMO) predicts warfarin associated complications better than each measure separately. We also examine how the choice of measure changes the ranking order of anticoagulation clinics (ACCs) in the Veterans Health Administration (VHA) healthcare system. METHODS: We calculated TTR and INR variability for the study sample (N=130,897 patients) from 100 VHA ACCs. We constructed ICOMO using an equally weighted method, adding standardized TTR to standardized log-transformed INR variability. We used a subset of patients anticoagulated for atrial fibrillation (N=40,404) and divided them into quintiles based on their level of control, for each anticoagulation measure. We calculated the Hazard ratios for ischemic stroke and major bleeding and compared the ability of our independent variables (TTR, log INR variability, ICOMO) to predict each outcome. We measured mean observed value (O) and mean expected value (E) for each clinic, after adjusting for important clinical and demographic variables, for each anticoagulation measure. We identified outlier anticoagulation clinics if O was one standard deviation different from its corresponding E. We measured Kappa score and Pearson correlation coefficients when ranking sites according to each anticoagulation measure. RESULTS: ICOMO predicted ischemic stroke better than TTR and log INR variability in all quintiles. ICOMO and TTR predicted major bleeding similarly except in the second-best quintile; but both measures were better than log INR variability in all quintiles. Kappa scores identifying outlier and non-outlier clinics among our three profiling measures were moderate between ICOMO and its components (0.59 for TTR and 0.54 for log INR variability) but was weak between TTR and log INR variability (0.025) CONCLUSION: ICOMO predicts ischemic stroke better over TTR and log INR variability alone but it is only better than the latter in predicting major bleeding. The choice of which measure to use for clinic profiling changes clinic rankings considerably. / 2031-01-01

There has been a well-documented and causal relationship between cigarette smoking and disease for over forty years, and at least an implicit concern over tobacco and health for decades, if not centuries prior; however, government policy on how to address tobacco as a public health issue has been erratic. At the turn of the twentieth century, when cigarettes first became a national phenomenon, the federal government imposed few if any regulations, and even encouraged the use of cigarettes. By the 1960s, government, public health entities and the tobacco industry were cooperating to try to fix the problem. Although there was great success in this early, if uneasy alliance, by the 1980s this coalition was fragmented and the search for a pragmatic solution to the tobacco problem came to an abrupt end. This dissertation is an investigation into how policy-makers, tobacco industry executives and public health officials each ignored opportunities to come to a practical solution to the problem which confronted them. The 1960s saw these groups work together to formulate a harm reduction policy approach which would lessen, if not eliminate, the concerns from each constituent group. Despite some significant early successes, this effort was derailed due to partisan positioning, misguided self-interest, and certain individual personalities. This analysis of the safer-cigarette campaign sheds light on a little explored avenue in the tobacco debate, as well as highlights the challenges of policy making in Washington.

In the United States, prescription opioids have been a major problem that contributed to the opioid crisis in the country. As dentists prescribe analgesics routinely for dental pain management, further investigation into opioid and non-opioid prescription patterns by dentists on a national level is needed. This research project aimed to examine 1) the trends in opioid and non-opioid analgesic prescriptions by dentists in the US,2) to examine the racial-ethnic disparities in receiving an opioid and non-opioid prescription from a dental professional, 3) the effect of federal Rescheduling of hydrocodone combination on opioid prescription patterns by dentists in a school setting. Data on analgesic prescriptions by dentists were obtained using medical panel survey MEPS (1996- 2015), and Boston University Henry M. Goldman School of Dental Medicine clinical repository (2010 -2019). On average about 31,206 individuals of all ages were interviewed for MEPS each year. The trend in analgesics prescription was reported weighted numbers and proportions of total and dental analgesics prescriptions were reported. Kendall tau correlation test was used to examine trends in the rate of opioid prescriptions per 100 persons over survey years. Racial differences were examined using MEPS data (2002-2015) on dental analgesic prescriptions, dental care utilization, patients’ race, and other demographic information. The outcome was analgesic prescription received. The main independent variable was the patients’ race/ethnicity. Covariates included in the analysis were gender, age, marital status, income, geographical region, and survey year. Using BUSDM data (2010-2019) we examined 12,807 patients who received an opioid prescription from a dentist. The primary outcome variables were opioid prescriptions and opioid morphine milligram equivalent (MME). The primary predictor used is the date of opioid prescription (Time before and after the intervention). To assess the effect of hydrocodone medication reclassification on the outcome variables we used an interrupted time series (ITS) analysis with a segmented regression model. Our results showed a decrease in the proportion of dental opioids out of total opioids from 9.76% in 1996 to 4.5% in 2015. Kendall tau correlation indicated an increase in prescribing rate over the years in total opioids but not in dental opioids. Racial differences were found in opioid prescriptions by dentists with whites having a lower risk of receiving an opioid analgesic compared to other racial minorities. The effect of federal rescheduling of hydrocodone combination on opioid prescription patterns by dentists showed specifically a reduction in non-hydrocodone opioids prescribing rate by morphine milligram equivalent (MME). In conclusion dentists’ contribution to the increase in prescription opioids in the United States seem to be limited compared to other health care professionals. Nevertheless, racial differences were found in whites when compared to other racial minorities. Efforts to curb the use of opioids should be encouraged even more so with evidence supporting the effectiveness of non-opioids analgesics in control of dental pain. / 2022-12-09T00:00:00Z

Objectives: Rates of maternal syphilis have increased five-fold in Brazil in the past decade. While penicillin remains the only appropriate treatment for maternal syphilis, we hypothesized that low non-treponemal titers (<1:16) may lead to reduced penicillin treatment in Brazil. Methods: Using Brazilian Ministry of Health data on women diagnosed with maternal syphilis between January 1, 2010, and December 31, 2018, we conducted a random-effects logistic regression model with a cluster correction at the state level to evaluate predictive factors of penicillin treatment. Results: We observed yearly increases in cases of pregnant women with syphilis from 2010 to 2018. There was significant variation by state: 52,451 cases were reported in São Paulo, followed by 26,838 in Rio de Janeiro. Among 215,937 cases of maternal syphilis, 91·3% received penicillin. In the random-effects model, a non-treponemal titer ≥1:16 was associated with 1·44 higher odds of receiving penicillin (95% confidence interval [CI]: 1·391·48), and prenatal care was associated with a 2·12 increased odds of receiving penicillin (95% CI: 2·022·21). Although there is an association between the absence of prenatal care and inadequate treatment for syphilis, 83·2% of women in this cohort who did not receive penicillin were engaged in prenatal care. Conclusions: Providers may inappropriately exclude low non-treponemal titers and thereby fail to use penicillin treatment in maternal syphilis. While the cause of the maternal syphilis epidemic in Brazil is multifactorial, we believe our findings can be used to develop targeted interventions throughout Brazil as well as shape public health initiatives globally. / National Institute of Mental Health / Revisión por pares

Chronic diseases such as cancer, diabetes, cardiovascular and respiratory diseases are a global concern. In recent decades, Canada has also experienced a major increase in immigration. Yet, a detailed profile of chronic disease and multimorbidity risk patterns across different immigrant populations has been lacking in Canada. The purpose of this dissertation is to identify knowledge gaps in the scientific literature on the development of chronic conditions and multimorbidity across immigrant populations in Ontario, using population-based immigrant and health data housed at ICES. The principal findings of this dissertation indicate that: 1. The risk of developing a chronic condition and multimorbidity was complex and varied by immigrants’ visa category and world region origin since: a. Refugees had the highest risk of developing a chronic condition and multimorbidity (two or more co-occurring chronic conditions) compared to long-term Ontario residents. b. There were differences in the risk of developing a chronic condition and multimorbidity by world regions of origin, when examined across different immigrant categories. 2. Hypertension and diabetes, and in combination with Chronic Obstructive Pulmonary Disease were the leading multimorbidity dyad and triad groups for all immigrant categories and long-term residents of Ontario. 3. The risk of developing a chronic condition increased among immigrants in more recent landing cohorts. The risk was highest among more recent refugees, and lower for family and economic class immigrants, when compared to long-term Ontario residents. These findings provide evidence to inform public health policy and planning by highlighting the complexity and heterogeneity of health outcomes across immigrant populations. Knowledge generated from this work will inform policies and evidence-based decision-making aimed to address the threat of chronic diseases and reduce health disparities.

This dissertation investigates how policies and financial incentives may affect the use of services within the United States health care system. The research consists of two distinct parts: Part I comprises two studies examining the impact of recently enacted state legislation regarding dense breast tissue on the use of downstream imaging; Part II delves into changes in physician reimbursement and their effect on health care delivery. Dense breast tissue is a common finding that decreases the sensitivity of mammography in detecting cancer. Some states have passed legislation requiring health care providers to notify patients with dense breast tissue that identification of early cancers may be compromised. Others have also aimed to increase access to supplemental screening tests by requiring health plans to include such follow-up options in covered benefits. The legislation has been controversial because supplemental imaging following a negative screening mammogram for patients with no other risk factors provides little benefit compared to its substantial cost. In the first study, we analyzed whether the dense breast tissue notification laws affected the probability of screening mammography follow-up by ultrasound and magnetic resonance imaging (MRI). We found strong evidence that implementing the notification legislation led to an increase in the probability of downstream breast ultrasound imaging in most states, and to an increase in the probability of downstream breast MRI in some states. In the second study, we identified specific characteristics of various state-level dense breast policies that were associated with increased use of downstream breast ultrasound imaging. In Part II of the dissertation, we assessed the extent to which changes in health care prices affect the provision of health services by physicians in various medical and surgical specialties in both Medicare and the private sector. We exploited the considerable changes in the Medicare Physician Fee schedule due to procedural code bundling that happened between 2010 and 2014 as the source of variation in health care prices. Our results showed that volume responses to changes in health care prices are inelastic and vary in both direction and magnitude by specialty and sector. / 2019-10-31T00:00:00Z

京都大学 / 0048 / 新制・論文博士 / 博士(社会健康医学) / 乙第13196号 / 論社医博第12号 / 新制||社医||10(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 福原 俊一, 教授 小泉 昭夫, 教授 佐藤 俊哉 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM