Joshua Graff Zivin

Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.

Objective:There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. Design:A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Methods:Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. Results:In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). Conclusion:These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.

Temperature and the Allocation of Time: Implications for Climate Change

We estimate the impacts of temperature on time allocation by exploiting plausibly exogenous variation in temperature over time within counties. Temperature increases at the higher end of the distribution reduce hours worked in industries with high exposure to climate and reduce time allocated to outdoor leisure for the nonemployed, with this time reallocated to indoor leisure. At the lower end of the distribution, time allocated to labor is nonresponsive to temperature increases, but outdoor leisure increases while indoor leisure decreases as temperature warms. We also find suggestive evidence of short-run adaptation to higher temperatures through temporal substitutions and acclimatization.

Cost-Utility Analysis of Telemedicine and Ophthalmoscopy for Retinopathy of Prematurity Management

OBJECTIVE To evaluate the cost-effectiveness of telemedicine and standard ophthalmoscopy for retinopathy of prematurity (ROP) management. METHODS Models were developed to represent ROP examination and treatment using telemedicine and standard ophthalmoscopy. Cost-utility analysis was performed using decision analysis, evidence-based outcome data from published literature, and present value modeling. Visual outcome data were converted to patient preference-based time trade-off utility values based on published literature. Costs of disease management were determined based on 2006 Medicare reimbursements. Costs per quality-adjusted life year gained by telemedicine and ophthalmoscopy for ROP management were compared. One-way sensitivity analysis was performed on the following variables: discount rate (0%-7%), incidence of treatment-requiring ROP (1%-20%), sensitivity and specificity of ophthalmoscopic diagnosis (75%-100%), percentage of readable telemedicine images (75%-100%), and sensitivity and specificity of telemedicine diagnosis (75%-100%). RESULTS For infants with birth weight less than 1500 g using a 3% discount rate for costs and outcomes, the costs per quality-adjusted life year gained were

Uncertainty and Technological Change in Medicine

3193 with telemedicine and

Effectiveness and Cost-effectiveness of Four Treatment Modalities for Substance Disorders: A Propensity Score Analysis

5617 with standard ophthalmoscopy. Sensitivity analysis resulted in ranges of costs per quality-adjusted life year from

Gray Matters: Fetal Pollution Exposure and Human Capital Formation

1235 to

Insect Population Dynamics, Pesticide Use, and Farmworker Health

18,898 for telemedicine and from

Acute skin toxicity-related, out-of-pocket expenses in patients with breast cancer treated with external beam radiotherapy A descriptive, exploratory study

2171 to

Costs and Cost Effectiveness of a Health Care Provider–Directed Intervention to Promote Colorectal Cancer Screening

27,215 for ophthalmoscopy. CONCLUSIONS Telemedicine is more cost-effective than standard ophthalmoscopy for ROP management. Both strategies are highly cost-effective compared with other health care interventions.

Eavesdropping Selects for Conspicuous Signals

�� At the heart of Kenneth Arrow’s landmark article on the economics of medical care is the pervasive influence of uncertainty, both in regard to the occurrence of disease and to the efficacy of treatment. These uncertainties, as Arrow contends, have led to the following distortions in the operation of health care: (1) health insurance schemes that have insulated patients and physicians from the financial implications of their medical decisions (i.e., the moral hazard argument), and (2) delegation of medical care decisions from patients to physicians because of the extreme information asymmetry between the two parties (the principal agent theory). These arguments are made with little reference to technology or technological change, issues that Arrow explores in numerous other works (1962, 1969). Yet these issues of moral hazard and agency provide a significant thrust behind technological development in medicine. In the past forty years, physicians have faced strong clinical, economic, and social incentives to adopt and use new technologies in management of disease. The insulation of patients from true medical costs through insurance has compounded these effects. The growth of insurance has led to strong, positive feedback to the R&D sector, which fueled such rapid technological change that both the quality and costs of U.S. health care bear little resemblance to those prevailing at the time of Arrow’s writing. This essay explores the dynamics of technological change in medicine