Shinyi Wu

Language Access Services for Latinos with Limited English Proficiency: Lessons Learned from Hablamos Juntos

Shinyi Wu — Tue, 20 Nov 2007 15:40:30 PST

Reducing the Risk of Falls and Fall-related Injuries among Older People

David A. Ganz — Tue, 20 Nov 2007 14:52:22 PST

This paper reviews approaches to preventing falls in older adults at the individual, community and national levels. We find extensive evidence to support fall prevention at the individual level, with exercise programs and multifactorial evaluation and intervention showing the most promise. Good data also exist to support community-level fall prevention strategies, and several national fall-prevention programs are ongoing. Officials in countries implementing fall-prevention programs should monitor their efforts for effectiveness and sustainability, so that program design can be improved based on sound evidence, and so that results and lessons may provide guidance for other countries. Over the long term, only activated communities will be able to achieve the full benefit of the fall prevention strategies that we have reviewed.

. A Cost-Effective National HIV Prevention Strategy for the United States

Shinyi Wu — Tue, 13 Nov 2007 15:41:35 PST

Relative to the magnitude of the epidemic, government funds available for HIV prevention are scarce. To optimize use of funds, we applied a mathematical model of the cost of HIV prevention interventions using national data on HIV risk-group size and HIV prevalence. This procedure suggested an allocation of funds across nine interventions to potentially prevent an estimated 20,000 infections annually, compared with the estimated 7,300 infections potentially prevented through four interventions now recommended by the Centers for Disease Control and Prevention (CDC). The optimal allocation will involve a combination of intensive interventions for high-prevalence populations and inexpensive large-scale interventions for lower-prevalence populations.

The Value of Screening for Sexually Transmitted Diseases in an HIV Clinic.

Shinyi Wu — Tue, 13 Nov 2007 15:31:24 PST

Summary: Because bacterial sexually transmitted diseases (STDs) facilitate HIV transmission, screening for and treatment of STDs among HIV-infected persons should prevent HIV spread to partners. Before screening programs for gonorrhea and Chlamydia infection should be widely established in HIV clinics, it is useful to know the prevalence of these infections. This study analyzed the results of a urine-based screening program for gonorrhea and Chlamydia in a New Orleans HIV clinic and compared the positivity rates to the prevalence in the local community. Among persons screened in the HIV clinic, 1.7% (46/2629) had gonorrhea and 2.1% (56/2629) had Chlamydia infection. Among persons aged 18-29 years, the test positivity for gonorrhea was similar in the HIV clinic to that of persons in sociodemographically similar community samples (3.1 versus 2.4%, adjusted odds ratio 1.6, P = 0.11) and the test positivity for Chlamydia infection was lower (5.4% versus 10.5%, adjusted odds ratio 0.6, P < 0.01). Based on a previously published mathematical model, it was estimated that treatment of all 46 gonorrhea and 56 Chlamydia infections in the HIV clinic may have averted 9 HIV infections among sex partners and saved far more in future medical costs than the cost of the screening. Routine screening for gonorrhea and Chlamydia infection should be considered in HIV clinics.

Structural Interventions to Prevent HIV/Sexually Transmitted Disease: Are They Cost-Effective for Women in the Southern United States?

Shinyi Wu — Tue, 13 Nov 2007 14:52:09 PST

Background: Structural interventions are theoretically promising for populations with a low prevalence of HIV, because they can reach large numbers of people to influence their social norms and collective risky behaviors for a relatively low cost per person. Because HIV transmission is continuing to increase among women in the southern United States, interventions to stem this epidemic are particularly warranted. This study explores whether structural interventions may be a cost-effective way to prevent HIV in this population. Methods: We used the cost-effectiveness estimator, "Maximizing the Benefit" to determine the relative cost-effectiveness of 6 structural HIV prevention interventions. "Maximizing the Benefit" is a spreadsheet tool using mathematical models to estimate the cost per HIV infection prevented taking into account the epidemiologic contexts, behavioral change as a result of an intervention, and the costs of intervention. We applied estimates of HIV prevalence related to blacks in the southern United States. Results: All the structural interventions were cost-effective compared with average lifetime treatment costs of HIV, but mass media, condom availability, and alcohol taxes theoretically prevented the largest numbers of HIV infections. Conclusions: Although the assumptions used in cost-effectiveness estimates have many limitations, they do allow for a relative comparison of different interventions and help to inform policy decisions related to the allocation of HIV prevention resources. Structural interventions hold the greatest promise in reducing HIV transmission among low-prevalence populations.

Comparing the Cost-Effectiveness of HIV Prevention Interventions

Shinyi Wu — Tue, 13 Nov 2007 14:39:50 PST

Objective: Communities need to identify cost-effective interventions for HIV prevention to optimize limited resources. Methods: The authors developed a spreadsheet tool using Bernoulli and proportionate change models to estimate the relative cost-effectiveness for 26 HIV prevention interventions including biomedical interventions, structural interventions, and interventions designed to change risk behaviors of individuals. They also conducted sensitivity analyses to assess patterns of the cost-effectiveness across different populations using various assumptions. Results: The 2 factors most strongly determining the cost-effectiveness of the different interventions were the HIV prevalence of the population at risk and the cost per person reached. In low-prevalence populations (eg, heterosexuals) the most cost-effective interventions were structural interventions (eg, mass media, condom distribution), whereas in high-prevalence populations (eg, men who have sex with men) individually focused interventions to change risk behavior were also relatively cost-effective. Among the most cost-effective interventions overall were showing videos in STD clinics and raising alcohol taxes. School-based HIV prevention programs appeared to be the least cost-effective. Needle exchange and needle deregulation programs were relatively cost-effective only when injection drug users have a high HIV prevalence. Conclusions: Comparing estimates of the cost-effectiveness of HIV interventions provides insight that can help local communities maximize the impact of their HIV prevention resources.

HIV PREVENTION CASE MANAGEMENT IS NOT COST-EFFECTIVE

Shinyi Wu — Mon, 12 Nov 2007 15:46:44 PST

Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care

Shinyi Wu — Mon, 12 Nov 2007 15:30:06 PST

Background: Experts consider health information technology key to improving efficiency and quality of health care. Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care. Data Sources: The authors systematically searched the Englishlanguage literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005. Study Selection: Descriptive and comparative studies and systematic reviews of health information technology. Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs. Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited. Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited. Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.

An Evaluation of an Adult Asthma BTS Collaborative and the Effect of Patient Self-Management

M Schonlau — Mon, 12 Nov 2007 12:38:58 PST

Purpose: To examine whether a collaborative to improve asthma care influences process and outcomes of care in adult asthmatics. Method: Pre- and Post-intervention evaluation of 185 patients in 6 intervention clinics and 3 matched control sites that participated in the evaluation of the Institute for Healthcare Improvement Breakthrough Series (BTS) Collaborative for asthma care. The intervention consisted of three two-day educational sessions for teams dispatched by participating sites followed by three "action" periods over the course of a year. Results: Overall process of asthma care improved significantly in the intervention compared to the control group (change of 10% versus 1%, p=0.003). Patients in the intervention group were more likely to attend educational sessions (20% versus 5%, p=0.03). Having a written action plan, goal setting, peak flow monitoring and use of long-term controller medications increased between 2% and 19% (not significant) and asthma-related knowledge was unchanged for the two groups. Patients in the BTS collaborative were significantly more likely to be satisfied with provider communication (62% vs. 39%, p=0.02). HRQoL, asthma specific quality of life, number of bed days due to asthma related illness and acute service use were not significantly different between the two groups. Conclusions: The intervention was associated with improved process of care measures that have been linked with better outcomes. Patients benefited through increased satisfaction with communication. Follow-up of patients who participated in the intervention may have been too brief to detect significant improvement in health-related outcomes.

The Role of Perceived Team Effectiveness in Improving Chronic Illness Care

Shinyi Wu — Mon, 12 Nov 2007 12:38:38 PST

Background/Objectives: The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. Study Setting and Methods: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care. Results: A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made. Conclusions: The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.