Jody L. Sindelar

Treatment adherence and risk of death after a myocardial infarction

The relation of treatment adherence to mortality after a myocardial infarction was investigated among 2175 participants in the Beta Blocker Heart Attack Trial, which had data for measures of treatment adherence, clinical severity, and the psychological and social features that may influence post-infarction mortality. Overall, patients who did not adhere well to treatment regimen (ie, who took less than or equal to 75% of prescribed medication) were 2.6 times more likely than good adherers to die within a year of follow-up (95% confidence interval, 1.2, 5.6). Poor adherers had an increased risk of death whether they were on propranolol (OR = 3.1) or placebo (OR = 2.5). Furthermore, this increased risk of death for poor adherers was not accounted for by measures of the severity of myocardial infarction, sociodemographic features (eg, race, marital status, education), smoking, or psychological characteristics (high life-stress or social isolation).

Employment, Unemployment, and Problem Drinking

The misuse of alcohol is estimated to result in enormous economic costs, composed largely of reduced labor market productivity. However, there has been debate on this issue. The purpose of this paper is to help to resolve this debate by presenting sound structural estimates of the relationship between measures of problem drinking and of employment and unemployment. The analysis is based on the 1988 Alcohol Supplement of the National Health Interview Survey. We find that for both men and women, problem drinking results in reduced employment and increased unemployment.

Alcoholism, Work, and Income

This article reports on an empirical analysis of the relationships between alcoholism and income and working. We show that the relationships between alcoholism and labor market success have important age or life-cycle dimensions. We present evidence that alcoholism may affect income more by restricting labor market participation than by affecting the wages of workers. Finally, we demonstrate that the effects of alcoholism on earnings depend on the extent to which one controls for other covariates associated with alcoholism; as such, we suggest that there may be important indirect as well as direct effects of alcoholism on labor market success.

Spousal Concordance in Health Behavior Change

OBJECTIVE This study examines the degree to which a married individuals health habits and use of preventive medical care are influenced by his or her spouses behaviors. STUDY DESIGN Using longitudinal data on individuals and their spouses, we examine changes over time in the health habits of each person as a function of changes in his or her spouses health habits. Specifically, we analyze changes in smoking, drinking, exercising, cholesterol screening, and obtaining a flu shot. DATA SOURCE This study uses data from the Health and Retirement Study (HRS), a nationally representative sample of individuals born between 1931 and 1941 and their spouses. Beginning in 1992, 12,652 persons (age-eligible individuals as well as their spouses) from 7,702 households were surveyed about many aspects of their life, including health behaviors, use of preventive services, and disease diagnosis. SAMPLE The analytic sample includes 6,072 individuals who are married at the time of the initial HRS survey and who remain married and in the sample at the time of the 1996 and 2000 waves. PRINCIPAL FINDINGS We consistently find that when one spouse improves his or her behavior, the other spouse is likely to do so as well. This is found across all the behaviors analyzed, and persists despite controlling for many other factors. CONCLUSIONS Simultaneous changes occur in a number of health behaviors. This conclusion has prescriptive implications for developing interventions, treatments, and policies to improve health habits and for evaluating the impact of such measures.

Benefit-Cost Analysis of Addiction Treatment: Methodological Guidelines and Empirical Application Using the DATCAP and ASI

OBJECTIVE To provide detailed methodological guidelines for using the Drug Abuse Treatment Cost Analysis Program (DATCAP) and Addiction Severity Index (ASI) in a benefit-cost analysis of addiction treatment. DATA SOURCES/STUDY SETTING A representative benefit-cost analysis of three outpatient programs was conducted to demonstrate the feasibility and value of the methodological guidelines. STUDY DESIGN Procedures are outlined for using resource use and cost data collected with the DATCAP. Techniques are described for converting outcome measures from the ASI to economic (dollar) benefits of treatment. Finally, principles are advanced for conducting a benefit-cost analysis and a sensitivity analysis of the estimates. DATA COLLECTION/EXTRACTION METHODS The DATCAP was administered at three outpatient drug-free programs in Philadelphia, PA, for 2 consecutive fiscal years (1996 and 1997). The ASI was administered to a sample of 178 treatment clients at treatment entry and at 7-months postadmission. PRINCIPAL FINDINGS The DATCAP and ASI appear to have significant potential for contributing to an economic evaluation of addiction treatment. The benefit-cost analysis and subsequent sensitivity analysis all showed that total economic benefit was greater than total economic cost at the three outpatient programs, but this representative application is meant to stimulate future economic research rather than justifying treatment per se. CONCLUSIONS This study used previously validated, research-proven instruments and methods to perform a practical benefit-cost analysis of real-world treatment programs. The study demonstrates one way to combine economic and clinical data and offers a methodological foundation for future economic evaluations of addiction treatment.

The emergent problem of ambulance misuse

STUDY OBJECTIVE The primary objective was to determine whether rates of ambulance misuse varied systematically by type of health insurance. The secondary objective was to determine whether the level of service provided in the ambulance varied by ambulance company ownership. DESIGN Survey. SETTING A 175-bed community hospital in central Connecticut. PARTICIPANTS One hundred forty-five records were selected randomly for study from the records of the 488 patients presenting to the hospital emergency department within a 45-day period. OUTCOME MEASURES The urgency of presenting complaint and the use of life support measures within the ambulance were obtained from each ambulance run form. Type of health insurance, clinical data, and disposition were obtained from ED records. Ambulance use was deemed unnecessary if the patients presenting complaint was nonurgent, the patient was ambulatory, and the patient was not ultimately hospitalized. Advanced life support measures were deemed unnecessary if they were applied to patients with nonurgent complaints. RESULTS Patients with private insurance made appropriate use of ambulances in 77.8% of cases, patients with Medicare did so in 65.8% of cases, and patients with Medicaid did so in 14.7% of cases. These results were statistically significant at P < .001. Among patients with Medicare, ambulance misuse was more common among nursing home residents. Approximately 20% of the observed misuse was related to alcohol intoxication. Although it did not reach statistical significance, we noted a higher frequency of inappropriate use of advanced life support measures in patients brought to the ED by a private ambulance service than for those brought by a municipal service. CONCLUSION Ambulance misuse is common in the studied community and may be related to the broader problem of the provision of care to the poor or otherwise underserved. Our results raise several interesting questions for further research.

Differential use of medical care by sex.

Women spend about 50 percent more on average on medical care than men, although men who are hospitalized stay 50 percent longer than women. This study empirically tests several hypotheses that may account for these differences. Results show that these differences are explained by the fact that men may be more able to substitute home for market medical care. Men may also have a lower return to the prior use of medical care because men are more likely to suffer from causes against which medical care is not effective. Potential differences in the value of time do not account for the differences in utilization of medical care.

Cost Analysis of Clinic and Office-based Treatment of Opioid Dependence: Results with Methadone and Buprenorphine in Clinically Stable Patients

The cost of providing and receiving treatment for opioid dependence can determine its adoption. To compare the cost of clinic-based methadone (MC, n=23), office-based methadone (MO, n=21), and office-based buprenorphine (BO, n=34) we performed an analysis of treatment and patient costs over 6 months of maintenance in patients who had previously been stabilized for at least 1 year. We performed statistical comparisons using ANOVA and chi-square tests and performed a sensitivity analysis varying cost estimates and intensity of clinical contact. The cost of providing 1 month of treatment per patient was

Alcoholism and Income: The Role of Indirect Effects

147 (MC),

Paying for performance: the power of incentives over habits.

220 (MO) and