Jay H. Glasser

The Medicine and Public Health Initiative: Ten Years Later

Abstract The Medicine and Public Health Initiative (MPHI) was created jointly 10 years ago by the American Medical Association and the American Public Health Association to bridge the nearly century-wide gulf between the respective disciplines. We review the history of MPHI and its growing significance in light of recent terrorism events. We report on current MPHI activities by examining three bellwether states—California, Florida, and Texas—as well as international sites. Upon its inception, MPHI was rapidly embraced and nationally disseminated. Sustainability 10 years later in the post-911 world requires renewed commitment by all collaborators. In order to meet the numerous health challenges facing our nation, from terrorism to chronic disease, and for MPHI to be successful, medicine and public health must work in tandem.

The Houston Vision Assessment Test (HVAT): An assessment of validity

PURPOSE. Cataract surgery is one of the most successful procedures in medicine, and outcome is typically measured by a single factor – improvement in visual acuity. Health-related functional outcome testing, which quantifies the patients self-reported perception of impairment, can be integrated with objective clinical findings. Based on the patients self-assessed lifestyle impairment, the physician and patient together can make an informed decision on the treatment that is most likely to benefit the patient. METHOD. A functional outcome test (the Houston Vision Assessment Test – HVAT, copyrighted 1990, 1992) was evaluated in a cataract population of 149 patients from seven study centers. Test results were correlated with objective ophthalmic endpoints. The HVAT divides an estimated total impairment into subcomponents of Visual Impairment (correctable by cataract surgery) and non-visual Physical Impairments (co-morbidities not affected by cataract surgery). RESULTS. In this prospective study, the average Visual Impairment score improved by 19 points (65%) following cataract extraction (the mean HVAT Visual Impairment score was 29 points before surgery and 10 points at 5 months post-surgery, a change of 65%). Physical Impairment remained unchanged by surgery. Visual acuity was a poor predictor of Visual Impairment. CONCLUSIONS. The HVAT has 11 simple questions. It may be self-administered and is available on the Internet: http://www.DHAC.com. The physician may err if his decision in favor of cataract surgery is based only on visual acuity. The HVAT has the potential to guide the decision-making process between patient and physician.

Gender gaps in life expectancy: generalized trends and negative associations with development indices in OECD countries

BACKGROUND Life expectancy (LE) is a major marker of individual survival. It also serves as a guide to highlight both the progress and the gaps in total social and societal health. Comparative LE in concert with measures of gender-specific experience, indices of empowerment and societal happiness and development offer a comparative tool to examine trends and similarities of societal progress as seen through the lens of cross-national experience. METHODS To determine the gender gaps in LE (GGLE) trends, we performed a longitudinal analysis, covering a period of 49 years (1960-2008). To examine the association of GGLE with development indices, we used the 2007 GGLE data, the newest happiness data mostly drawn from 2006; the 2006 Human Development Index (HDI) data and the 2006 Gender Empowerment Measure (GEM) data. RESULTS It revealed that most of the Organization for Economic Co-operation and Development (OECD) countries had a GGLE trend that occurred in an inverted U-curve fashion. We divided them into three subgroups based on the peak years of respective GGLE. The earlier the peak year, the happier the countries, the higher the HDI and the smaller the current GGLE are. Association analysis indicates that Happiness, HDI and GEM are all negatively associated with GGLE. CONCLUSION This pattern suggests that GGLE undergoes three phases of growth, peak and stability and decline. Japan will soon be seeing its GGLE gradually shrinking in the foreseeable future. The continuing increases in Happiness, HDI and GEM are associated with a decrease in GGLE, which should be carefully taken into consideration.

Medical technology assessment: adequate questions, appropriate methods, valuable answers

Medical Technology Assessment begins with carefully posing the appropriate questions to be examined. Specification of the critical assessment provides the framework for the design to provide the answers. This paper addresses the Technology Assessment process as a sequence of the above steps. The practical requisites of the diversity of questions, the economic, and study design considerations generated are addressed in a systems analysis model of input-process-outcome. Applications and the relative merits of such design consideration are discussed and illustrated. The questions related to medical technologies may come from different groups of people directly or indirectly interested, and having active or passive relationship to a given technology. There are 4 basic issues from which the detailed questions derive. These are the issues of need, effectiveness, safety and cost. The timing of asking questions in the life-cycle of a technology and the adequacy of the answers determines the choice of methods, the extent of an evaluation and the quality of the responses. The reliability, external validity, generalizability, and the clarity of conclusions are the characteristics of a practical and valuable assessment.

Assessing Hospital Nursing Staff Retention and Turnover A Life Table Approach

This research applied the life table technique to nursing personnel data in two types of hospitals to illustrate how administrators can examine patterns of continued employment. Although a large proportion of nurses were short-stay employees, the teaching hospital was found to have a higher retention rate than the community hospital corporation. The retention patterns are examined by personal and professional characteristics, as well as by reason for termination. Implications of our findings are discussed with respect to policy concerns related to hiring, retention, productivitv, and staff development.

The aims and methods of technology assessment

Technology Assessment (T.A.) is viewed as a dynamic process. The paper emphasizes the basic aims of T.A. as an assessment and synthesis process. Specific areas of system analysis and the tracking of technology are presented with respect to T.A. priorities, stage of development, and the collateral use of the basic techniques of quantitative analysis in the context of community health. An information system, in conjunction with the role of new approaches to T.A. such as Meta-Analysis are discussed. Several examples from the literature are presented by way of illustration.

Life table analysis of membership in an HMO retention

The retention patterns of the Kaiser Foundation Health Plan (Oregon Region) were studied over a six-year period using a life table analysis. A 5% random sample, consisting of subscriber units that were enrolled at the initiation of the study or subsequently joined during the six-year period, were followed with respect to enrollment retention. The analysis presented here focuses on the 2,112 subscribers enrolled during the 1967–1970 period. These subscribers were characterized by the year they joined the plan and by their age and sex.The analyses showed that age of the subscriber and length of time on the plan consistently affected the probability of continued enrollment. The sex of the subscriber and the initial year of enrollment showed only a slight differential effect. A general pattern of high attrition in the first year, but rapid slackening thereafter, existed in all subgroup specific analyses.The utility of the analyses and the impact of the effect of differential membership retention on the plan are discussed.

Controlling influenza A (H1N1) in China: Bayesian or frequentist approach.

This article discusses two approaches to controlling the newly identified influenza A (H1N1): via Bayesian and frequentist statistical reasoning. This study reviewed the measures implemented in China as an example to illustrate these two approaches. Since May 2009, China has deployed strict controlling mechanisms based on the strong prior Bayesian assumption that the origin of influenza A (H1N1) was from outside China and as such strict border control would keep the virus from entering China. After more than 4 months of hard work by Chinese health professionals and officials, the number of confirmed influenza A (H1N1) has increased steadily against the expectations of the general public. Taking into account the great financial burden in maintaining strict measures, Chinese health authorities have slowly adjusted their policies of controlling influenza A (H1N1) in China according to frequentist reasoning since July 2009.

U.S. Pharmacy Policy: A Public Health Perspective on Safety and Cost

A public health perspective based on social justice and a population health point of view emphasizes pharmacy policy innovations regarding safety and costs. Such policies that effectively reduce costs include controlling profits, establishing profit targets, extending prescription providers, revising prescription classification schemes, emphasizing generic medications, and establishing formularies. Public education and universal programs may reduce costs, but co-pays and “cost-sharing” do not. Switching medications to over-the-counter (OTC) status, pill splitting, and importing medication from abroad are poor substitutes for authentic public health pharmacy policy. Where policy changes yield savings, public health insists that these savings should be used to increase access and improve population health. In the future, pharmacy policies may emphasize public health accountability more than individual liberty because of potential cost savings to society. Fear of litigation, as an informal mechanism of focusing manufacturers attention on safety, is inefficient; public health pharmacy policy regarding safety looks toward a more active regulatory role on the part of government. A case study of direct-to-consumer advertising illustrates the complexity of public health pharmacy policy.

Catastrophic health insurance and HMO's

The catastrophic health insurance bills introduced during the 96th U.S. Congress failed to consider the current role that Health Maintenance Organizations (HMOs) play in providing catastrophic protection and the potential negative impact such legislation may have on their competitive position. This article demonstrates that HMOs are providing this coverage by using the simulated health care expenditures for families in one HMO. The estimated proportion of families that incur catastrophic expenditures varies from 0.3 to 14.4% depending on the definition used for catastrophic. The paper closes with a discussion of the potential adverse impact that the legislation would have had on HMOs.