Ana P. Johnson-Masotti

Healthy Naturally Occurring Retirement Communities: A Low-Cost Approach to Facilitating Healthy Aging

Naturally occurring retirement communities (NORCs) are broadly defined as communities where individuals either remain or move when they retire. Using the determinants of health model as a base, we hypothesize that some environmental determinants have a different impact on people at different ages. Health benefits to living within NORCs have been observed and likely vary depending upon where the specific NORC exists on the NORC to healthy-NORC spectrum. Some NORC environments are healthier than others for seniors, because the NORC environment has characteristics associated with better health for seniors. Health benefits within healthy NORCs are higher where physical and social environments facilitate greater activity and promote feelings of well-being. Compared to the provision of additional medical or social services, healthy NORCs are a low-cost community-level approach to facilitating healthy aging. Municipal governments should pursue policies that stimulate and support the development of healthy NORCs.

Secondary HIV transmission rates in a mixed-gender sample

Information about the sexual behaviour of HIV-infected individuals is needed to predict the course of the sexually transmitted HIV epidemic in the US. The present study provides model-based estimates of the secondary transmission rate (i.e. the number of infections expected among the sex partners of already infected individuals) for a sample of HIV-positive persons in Atlanta. A mathematical model was used to estimate the secondary transmission rate of HIV infection for a sample of HIV-positive men and women in Atlanta, based on their self-reported sexual behaviour, extrapolated over a 15-year horizon. Separate rates were calculated for different transmission routes, including: from women to men-who-have-sex-with women (MSW) and from men-who-have-sex-with-men (MSM) to other MSM. Sensitivity analyses were conducted to assess the impact of different parametric and modelling assumptions. Restricted to the sub-sample that reported transmission risk behaviours, the mean number of secondary infections was 0.14 for transmission from women to MSW; 0.31 for transmission from MSW to women; and 0.84 for MSM to MSM transmission. Bisexual men were at especially high transmission risk, with 1.59 and 0.54 secondary infections expected among their male and female partners, respectively. The main analysis indicates that, in this sample, each current infection will lead to fewer than one future infection for all groups other than bisexual men, which suggests that the epidemic is contracting in this community, although this analysis cannot rule out the possibility of a growing epidemic among MSM. This method can be used to identify groups at high risk for HIV transmission and thereby to better target HIV prevention resources.

Ethical Issues in Cost-Effectiveness Analysis.

Cost-effectiveness analysis provides important information about the economic efficiency of health-related programs that can help health care decision makers choose between competing alternatives. Ethical concerns (such as equity and other issues of fairness) are critical to any discussion of health care resource allocation, as are the political and societal context in which such decisions are made and implemented. Here, we present an overview of ethical and other concerns raised by the use of cost-effectiveness analysis in health care resource allocation decision-making. We review the philosophical and theoretical foundations of cost-effectiveness analysis and describe some of the ethical assumptions and implications that are embedded in, and result from, the use of this economic analysis technique. Finally, we consider how the social and political context of health-related decision affects the usefulness of the results derived from cost-effectiveness analyses.

Cost-effectiveness of an HIV risk reduction intervention for adults with severe mental illness

Small-group HIV prevention interventions that focus on individual behavioural change have been shown to be especially effective in reducing HIV risk among persons with severe mental illness. Because economic resources to fund HIV prevention efforts are limited, health departments, community planning groups and other key decision-makers need reliable information on the cost and cost-effectiveness (not solely on effectiveness) of different HIV prevention interventions. This study used an economic evaluation technique known as cost-utility analysis to assess the cost-effectiveness of three related cognitive-behavioural HIV risk reduction interventions: a single-session, one-on-one intervention; a multi-session small-group intervention; and a multi-session small-group intervention that taught participants to act as safer sex advocates to their peers. For men, all three interventions were cost-effective, but advocacy training was the most cost-effective of the three. For women, only the single-session intervention was cost-effective. The gender differences observed here highlight the importance of focusing on gender issues when delivering HIV prevention interventions to men and women who are severely mentally ill.

An economic analysis of management strategies for closed and open grade I tibial shaft fractures

Background Closed and open grade I (low-energy) tibial shaft fractures are a common and costly event, and the optimal management for such injuries remains uncertain. Methods We explored costs associated with treatment of low-energy tibial fractures with either casting, casting with therapeutic ultrasound, or intramedullary nailing (with and without reaming) by use of a decision tree. Results From a governmental perspective, the mean associated costs were USD 3,400 for operative management by reamed intramedullary nailing, USD 5,000 for operative management by non-reamed intramedullary nailing, USD 5,000 for casting, and USD 5,300 for casting with therapeutic ultrasound. With respect to the financial burden to society, the mean associated costs were USD 12,500 for reamed intramedullary nailing, USD 13,300 for casting with therapeutic ultrasound, USD 15,600 for operative management by non-reamed intramedullary nailing, and USD 17,300 for casting alone. Interpretation Our analysis suggests that, from an economic standpoint, reamed intramedullary nailing is the treatment of choice for closed and open grade I tibial shaft fractures. Considering financial burden to society, there is preliminary evidence that treatment of low-energy tibial fractures with therapeutic ultrasound and casting may also be an economically sound intervention.

Decision-Making in HIV Prevention Community Planning: An Integrative Review

Since 1994, the Centers for Disease Control and Prevention has required that the 65 health department grantees that receive funding for HIV prevention interventions engage in a community planning process to involve affected communities in local prevention decision making; to increase the use of epidemiological data to target HIV prevention resources; and to ensure that the planning process takes into account scientific information on the effectiveness and efficiency of different HIV interventions. Local community planning groups are charged with identifying and prioritizing unmet HIV prevention needs in their communities, as well as prioritizing prevention interventions designed to address these needs. Their recommendations, in turn, form the basis for the local health departments request for HIV prevention funding from the Centers for Disease Control and Prevention.Given the community planning processs central role in the allocation of federal HIV prevention funds, it is critical that sound decision-making procedures inform this process. In this article, we review the basics of the community planning prioritization process and summarize the decision-making experiences of community planning groups across the US. We then describe several priority-setting tools and decision analytic models that have been developed to assist in HIV community planning prioritization and discuss their strengths and weaknesses. Finally, we offer suggestions for improving the decision-analytic basis for HIV prevention community planning.

Cost-Effectiveness of an HIV Prevention Intervention for Mentally Ill Adults

Adults with severe mental illness are at high risk for human immunodeficiency virus (HIV) infection and transmission. Small-group interventions that focus on sexual communication, condom use skills, and motivation to practice safer sex have been shown to be effective at helping mentally ill persons reduce their risk for HIV. However, the cost-effectiveness of these interventions has not been established. We evaluated the cost-effectiveness of a 9-session small-group intervention for women with mental illness recruited from community mental health clinics in Milwaukee, Wisconsin. We used standard techniques of cost–utility analysis to determine the cost per quality-adjusted life year (QALY) saved by the intervention. This analysis indicated that the intervention cost

Cost-Effectiveness of the NIMH Multisite HIV Prevention Intervention

679 per person, and over

A Review of the Cost-Effectiveness of Interventions to Prevent Sexual Transmission of HIV in the United States

136,000 per QALY saved. When the analysis was restricted to the subset of women who reported having engaged in vaginal or anal intercourse in the 3 months prior to the baseline assessment, the cost per QALY saved dropped to approximately

Cost-effectiveness of a community-level HIV risk reduction intervention for women living in low-income housing developments.

71,000. These estimates suggest that this intervention is marginally cost-effective in comparison with other health promotion interventions, especially if high-risk, sexual-active women are preferentially recruited.