PURPOSE: Poor blood pressure control remains a common problem that contributes to significant cardiovascular morbidity and mortality, particularly among African Americans. We explored antihypertensive medication adherence and other factors that may explain racial differences in blood pressure control.

METHODS: Baseline data were obtained from the Veteran's Study to Improve The Control of Hypertension, a randomized controlled trial designed to improve blood pressure control. Clinical, demographic, and psychosocial factors relating to blood pressure control were examined.

RESULTS: A total of 569 patients who were African American (41%) or white (59%) were enrolled in the study. African Americans were more likely to have inadequate baseline blood pressure control than whites (63% vs 50%; odds ratio = 1.70; 95% confidence interval [CI] 1.20-2.41). Among 20 factors related to blood pressure control, African Americans also had a higher odds ratio of being nonadherent to their medication, being more functionally illiterate, and having a family member with hypertension compared with whites. Compared with whites, African Americans also were more likely to perceive high blood pressure as serious and to experience the side effect of increased urination compared with whites. Adjusting for these differences reduced the odds ratio of African Americans having adequate blood pressure control to 1.59 (95% confidence interval 1.09-2.29).

CONCLUSIONS: In this sample of hypertensive patients who have good access to health care and medication benefits, African Americans continued to have lower levels of blood pressure control despite considering more than 20 factors related to blood pressure control. Interventions designed to improve medication adherence need to take race into account. Patients' self-reports of failure to take medications provide an opportunity for clinicians to explore reasons for medication nonadherence, thereby improving adherence and potentially blood pressure control.

Background: The Geriatric Evaluation and Management study was developed to assess the impact of a comprehensive geriatric assessment service on the care of the elderly.

Objectives: We sought to evaluate the cost and clinical impact of inpatient units and outpatient clinics for geriatric evaluation and management.

Research Design: We undertook a prospective, randomized, controlled trial using a 2 × 2 factorial design, with 1-year follow-up.

Subjects: A total of 1388 participants hospitalized on either a medical or surgical ward at 11 participating Veterans Affairs medical centers were randomized to receive either inpatient geriatric unit (GEMU) or usual inpatient care (UCIP), followed by either outpatient care from a geriatric clinic (GEMC) versus usual outpatient care (UCOP).

Measures: We measured health care utilization and costs.

Results: Patients assigned to the GEMU had a significantly decreased rate of nursing home placement (odds ratio = 0.65; P = 0.001). Neither the GEMU nor GEMC had any statistically significant improvement effects on survival and only modest effects on health status. There were statistically insignificant mean cost savings of $1027 (P = 0.29) per patient for the GEMU and $1665 (P = 0.69) per patient for the GEMC.

Conclusions: Inpatient or outpatient geriatric evaluation and management units didn't increase the costs of care. Although there was no effect on survival and only modest effects on SF-36 scores at 1-year follow-up, there was a statistically significant reduction in nursing home admissions for patients treated in the GEMU.

This issue of CHP/PCOR's quarterly newsletter, which covers news from the fall 2005 quarter, includes articles about:

• a study concluding that the implantable cardioverter defibrillator -- one of the most expensive medical devices on the market -- is worth its high cost, in appropriate patients, because it prevents sudden cardiac deaths;
• the evolution and broad application of the Quality Indicators, a set of practical tools developed by CHP/PCOR researchers that are used by hundreds of U.S. hospitals, medical groups, health insurers, state health agencies and business coalitions to screen for quality problems;
• a study finding that the Internet can be a valuable tool to help patients with stigmatized illnesses (such as mental illness) find information about and seek treatment for their illness;
• CHP/PCOR-hosted seminars on global health themes, given by Jack Chow of the World Health Organization -- who discussed combating malaria, TB and HIV/AIDS -- and Dean Jamison of the NIH's Fogarty International Center, who discussed evaluating countries' performance on health; and
• a prestigious national award won by two CHP/PCOR trainees at the annual meeting of the Society for Medical Decision Making.

Abstract

Recent innovations in biomedicine seem poised to revolutionize medical practice. At the same time, disease and disability are increasing among younger populations. This paper considers how these confluent trends will affect the elderly's health status and health care spending over the next thirty years. Because healthier people live longer, cumulative Medicare spending varies little with a beneficiary's disease and disability status upon entering Medicare. On the other hand, ten of the most promising medical technologies are forecast to increase spending greatly. It is unlikely that a "silver bullet" will emerge to both improve health and dramatically reduce medical spending.

To allocate HIV prevention resources effectively, it is important to have information about the effectiveness of alternative prevention programs as a function of expenditure. We refer to this relationship as the ldquoproduction functionrdquo for a prevention program. Few studies of HIV prevention programs have reported this relationship. This paper demonstrates the value of such information. We present a simple model for allocating HIV prevention resources, and apply the model to an illustrative HIV prevention resource allocation problem. We show that, without sufficient information about prevention program production functions, suboptimal decisions may be made. We show that epidemiologic data, such as estimates of HIV prevalence or incidence, may not provide enough information to support optimal allocation of HIV prevention resources. Our results suggest that good allocations can be obtained based on fairly basic information about prevention program production functions: an estimate of fixed cost plus a single estimate of cost and resulting risk reduction. We find that knowledge of production functions is most important when fixed cost is high and/or when the budget is a significantly constraining factor. We suggest that, at the minimum, future data collection on prevention program effectiveness should include fixed and variable cost estimates for the intervention when implemented at a ldquotypicalrdquo level, along with a detailed description of the intervention and detailed description of costs by category.

Analyzing a variety of cross-national and sub-national data, we argue that high adult mortality reduces economic growth by shortening time horizons. Higher adult mortality is associated with increased levels of risky behavior, higher fertility, and lower investment in physical and human capital. Furthermore, the feedback effect from economic prosperity to better health care implies that mortality could be the source of a poverty trap. In our regressions, adult mortality explains almost all of Africa's growth tragedy. Our analysis also underscores grim forecasts of the long-run economic costs of the ongoing AIDS epidemic.

Background: Diagnostic sensitivity is calculated as the number of correct diagnoses divided by the sum of correct diagnoses plus the number of missed or false negative diagnoses. Because missed diagnoses are generally detected during clinical follow up or at necropsy, the low necropsy rates seen in current practice may result in overestimates of diagnostic performance. Using three target conditions (aortic dissection, pulmonary embolism, and active tuberculosis), the prevalence of clinically missed cases among necropsied and non-necropsied deaths was estimated and the impact of low necropsy rates on the apparent sensitivity of antemortem diagnosis determined.

Methods: After reviewing case series for each target condition, the most recent study that included cases first detected at necropsy was selected and the reported sensitivity of clinical diagnosis adjusted by estimating the total number of cases that would have been detected had all decedents undergone necropsy. These estimates were based on available data for necropsy rates, time period, country (US v non-US), and case mix.

Results: For all three target diagnoses, adjusting for the estimated prevalence of clinically missed cases among non-necropsied deaths produced sensitivity values outside the 95% confidence interval for the originally reported values, and well below sensitivities reported for the diagnostic tests that are usually used to detect these conditions. For active tuberculosis the sensitivity of antemortem diagnosis decreased from an apparent value of 96% to a corrected value of 83%, with a plausible range of 42-91%; for aortic dissection the sensitivity decreased from 86% to 74%; and for pulmonary embolism the reduction fell only modestly from 97% to 91% but was still lower than generally reported values of 98% or more.

Conclusions: Failure to adjust for the prevalence of missed cases among non-necropsied deaths may substantially overstate the performance of diagnostic tests and antemortem diagnosis in general, especially for conditions with high early case fatality.

This paper compares the relative efficiency of health care providers in managing patients with severe chronic illnesses over fixed periods of time. To minimize the contribution of differences in severity of illness to differences in care management, we evaluate performance over fixed intervals prior to death for patients who died during a five-year period, 1999-2003. Medicare spending, hospital bed and full-time equivalent (FTE) physician inputs, and utilization varied extensively between regions, among hospitals located within a given region, and among hospitals belonging to a given hospital system. The data point to important opportunities to improve efficiency.