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Background: It is commonly believed that the pathophysiology of obesity arises from adiposity. In this paper, I forward a complementary explanation; this pathophysiology arises not from adiposity alone, but also from the psychological stress induced by the social stigma associated with being obese. Methods: In this study, I pursue novel lines of evidence to explore the possibility that obesity associated stigma produces obesity-associated medical conditions. I also entertain alternative hypotheses that might explain the observed relationships. Results: I forward four lines of evidence supporting the hypothesis that psychological stress plays a role in the adiposity-health association. First, body mass index (BMI) is a strong predictor of serological biomarkers of stress. Second, obesity and stress are linked to the same diseases. Third, body norms appear to be strong determinants of morbidity and mortality among obese persons; obese whites and women – the two groups most affected by weight-related stigma in surveys – disproportionately suffer from excess mortality. Finally, statistical models suggest that the desire to lose weight is an important driver of weight-related morbidity when BMI is held constant. Conclusion: Obese persons experience a high degree of stress, and this stress plausibly explains a portion of the BMI-health association. Thus, the obesity epidemic may, in part, be driven by social constructs surrounding body image norms.

"The field's bestselling reference, updated with the latest tools, data, and techniques Cost-Effectiveness Analysis in Health is a practical introduction to the tools, methods, and procedures used worldwide to perform cost-effective research. Covering every aspect of a complete cost-effectiveness analysis, this book shows you how to find which data you need, where to find it, how to analyze it, and how to prepare a high-quality report for publication. Designed for the classroom or the individual learner, the material is presented in simple and accessible language for those who lack a biostatistics or epidemiology background, and each chapter includes real-world examples and "tips and tricks" that highlight key information. Exercises throughout allow you to test your understanding with practical application, and the companion website features downloadable data sets for students, as well as lecture slides and a test bank for instructors. This new third edition contains new discussion on meta-analysis and advanced modeling techniques, a long worked example using visual modeling software TreeAge Pro, and updated recommendations from the U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine. Cost-effectiveness analysis is used to evaluate medical interventions worldwide, in both developed and developing countries. This book provides process-specific instruction in a concise, structured format to give you a robust working knowledge of common methods and techniques. Develop a thoroughly fleshed-out research project Work accurately with costs, probabilities, and models Calculate life expectancy and quality-adjusted life years Prepare your study and your data for publication Comprehensive analysis skills are essential for students seeking careers in public health, medicine, biomedical research, health economics, health policy, and more. Cost-Effectiveness Analysis in Health walks you through the process from a real-world perspective to help you build a skillset that's immediately applicable in the field"--Provided by publisher

This paper examines social entrepreneurship in a Burmese refugee community as it strives to provide primary education to its children. Despite facing discrimination and fearing Thai authorities, our project leaders exemplified social entrepreneurship, most notably building social capital and agency within the refugee community, and surprisingly resolving intractable problems. Key processes included helping parents claim ownership of the program, depoliticizing the children's access to education, and encouraging high expectations of school performance. Social relationships built an internally sustainable project at virtually no cost and established bridges across antipathetic parties. We argue that the social entrepreneurship model is useful in contexts where poor communities cannot access non-governmental organizations or government agencies.

Various multifaceted interventions have been developed in response to the overwhelming burden of congestive heart failure and its costs. These interventions range from improvements in the delivery of inpatient care (e.g., by assigning multidisciplinary teams to the care of a patient or ensuring that clinical practice guidelines are followed) to comprehensive discharge planning that includes home health care. While it is intuitive that such interventions improve care, few have been evaluated in randomized controlled trials and fewer still include data on costs. In this article, the authors review the findings of randomized controlled trials of interventions designed to improve the quality of life, decrease hospital admissions, and decrease costs associated with heart disease. They conclude that inpatient-based multifaceted interventions appear to be effective and inexpensive. Future studies should attempt to tease interventions apart to ascertain which are the most effective. Formal cost-effectiveness analyses are also needed.

Background. Although educational attainment is a well-recognized covariate of health status, it is rarely thought of as a tool to be used to improve health. Since fewer than 40% of U.S. citizens have a college degree, it may be possible for the government to improve the health status of the population by assuming a larger burden of the cost of postsecondary education. This paper examines the costs and health effects of a government subsidy for public postsecondary education institutions. Methods. All high school graduates in 1997 were included in a decision analysis model as a hypothetical cohort. Data from the U.S. Department of Education, the World Health Organization, and the National Center for Health Statistics were used as model inputs. Results. Relative to the present educational system, a federal subsidy for public and private colleges equal to the amount now paid by students for tuition and living expenses would save $6,176 and avert 0.0018 of a disability-adjusted life-year (DALY) per person annually if enrollment increased 5%. The overall savings among 1997 high school graduates would be $17.1 bil lion and 4,992 DALYs would be averted per year relative to the present educational system. If enrollment increased by just 3%, $3,743 would be saved and 0.0011 DALYs would be averted per person. An enrollment increase of 7% would lead to savings of $8,610 and 0.0025 DALYs would be averted per person relative to the present educational system. Conclusions. If the government were to offer a full subsidy for college tuition at public universities, both lives and money would be saved, so long as enrollment levels increased. Providing a free postsecondary education for students attending public schools may be more cost-effective than most health investments.

Shared needle and syringe use among injection drug users continues to be a major mode of transmission of HIV. Needle and syringe exchange (NSE) may be a viable strategy to reduce the transmission of the virus; yet the difficulty in measuring the actual efficacy of NSE has limited attempts to evaluate the cost-effectiveness of the intervention. Using data specific to the Lower East Side Harm Reduction Center in New York City, we assessed the cost-effectiveness of NSE over a range of conservative estimates of efficacy, obtained from both longitudinal and small-area studies. A decision-analysis model was created to compare the outcomes and costs associated with NSE. Model inputs included the cost of living with HIV and the seroprevalence of HIV among injection drug users in New York City. This analysis was conducted from both the government and societal perspectives. Tested over a range of conservative parameter estimates, NSE appears to save money and lives. The NSE program we evaluated cost $502 per client and produced a gain of 0.01 quality adjusted life years per client. It also reduced HIV treatment costs by $325,000 per case of HIV averted, and averted 4–7 HIV infections per 1000 clients, producing a net cost savings.

Objectives. We estimated the costs associated with reducing class sizes in kindergarten through grade 3 as well as the effects of small class sizes on selected outcomes such as quality-adjusted life-years and future earnings. Methods. We used multiple data sets to predict changes in the outcomes assessed according to level of educational attainment. We then used a Markov model to estimate future costs and benefits incurred and quality-adjusted life-years gained per additional high school graduate produced over time. Results. From a societal perspective (incorporating earnings and health outcomes), class-size reductions would generate a net cost savings of approximately $168 000 and a net gain of 1.7 quality-adjusted life-years for each high school graduate produced by small classes. When targeted to low-income students, the estimated savings would increase to $196 000 per additional graduate. From a governmental perspective (incorporating public expenditures and revenues), the results of reducing class sizes ranged from savings in costs to an additional cost of $15000 per quality-adjusted life-year gained. Conclusions. Reducing class sizes may be more cost-effective than most public health and medical interventions.

Objectives. We estimated the costs associated with reducing class sizes in kindergarten through grade 3 as well as the effects of small class sizes on selected outcomes such as quality-adjusted life-years and future earnings. Methods. We used multiple data sets to predict changes in the outcomes assessed according to level of educational attainment. We then used a Markov model to estimate future costs and benefits incurred and quality-adjusted life-years gained per additional high school graduate produced over time. Results. From a societal perspective (incorporating earnings and health outcomes), class-size reductions would generate a net cost savings of approximately $168 000 and a net gain of 1.7 quality-adjusted life-years for each high school graduate produced by small classes. When targeted to low-income students, the estimated savings would increase to $196 000 per additional graduate. From a governmental perspective (incorporating public expenditures and revenues), the results of reducing class sizes ranged from savings in costs to an additional cost of $15000 per quality-adjusted life-year gained. Conclusions. Reducing class sizes may be more cost-effective than most public health and medical interventions.

Abstract Background We set out to describe the risk of hospitalization from heart disease, stroke, and diabetes among persons born in India, all foreign-born persons, and U.S.-born persons residing in New York City. Methods We examined billing records of 1,083,817 persons hospitalized in New York City during the year 2000. The zip code of each patient's residence was linked to corresponding data from the 2000 U.S. Census to obtain covariates not present in the billing records. Using logistic models, we evaluated the risk of hospitalization for heart disease, stroke and diabetes by country of origin. Results After controlling for covariates, Indian-born persons are at similar risk of hospitalization for heart disease (RR = 1.02, 95% confidence interval 1.02, 1.03), stroke (RR = 1.00, 95% confidence interval, 0.99, 1.01), and diabetes mellitus (RR = 0.96 95% confidence interval 0.94, 0.97) as native-born persons. However, Indian-born persons are more likely to be hospitalized for these diseases than other foreign-born persons. For instance, the risk of hospitalization for heart disease among foreign-born persons is 0.70 (95% confidence interval 0.67, 0.72) and the risk of hospitalization for diabetes is 0.39 (95% confidence interval 0.37, 0.42) relative to native-born persons. Conclusions South Asians have considerably lower rates of hospitalization in New York than reported in countries with national health systems. Access may play a role. Clinicians working in immigrant settings should nonetheless maintain a higher vigilance for these conditions among Indian-born persons than among other foreign-born populations.

Background: We set out to describe the risk of hospitalization from heart disease, stroke, and diabetes among persons born in India, all foreign-born persons, and U.S.-born persons residing in New York City. Methods: We examined billing records of 1,083,817 persons hospitalized in New York City during the year 2000. The zip code of each patient's residence was linked to corresponding data from the 2000 U.S. Census to obtain covariates not present in the billing records. Using logistic models, we evaluated the risk of hospitalization for heart disease, stroke and diabetes by country of origin. Results: After controlling for covariates, Indian-born persons are at similar risk of hospitalization for heart disease (RR = 1.02, 95% confidence interval 1.02, 1.03), stroke (RR = 1.00, 95% confidence interval, 0.99, 1.01), and diabetes mellitus (RR = 0.96 95% confidence interval 0.94, 0.97) as nativeborn persons. However, Indian-born persons are more likely to be hospitalized for these diseases than other foreign-born persons. For instance, the risk of hospitalization for heart disease among foreign-born persons is 0.70 (95% confidence interval 0.67, 0.72) and the risk of hospitalization for diabetes is 0.39 (95% confidence interval 0.37, 0.42) relative to native-born persons. Conclusions: South Asians have considerably lower rates of hospitalization in New York than reported in countries with national health systems. Access may play a role. Clinicians working in immigrant settings should nonetheless maintain a higher vigilance for these conditions among Indian-born persons than among other foreign-born populations.

Background Autonomous vehicles (AVs) will radically re-shape the health and well-being of people in the United States in good ways and bad. We set out to estimate a reasonable time-to-adoption using cost-effectivenessmodels to estimate the point at which AVs become reasonably safe and affordable for widespread adoption. Methods We used Waymo data (previously, Google Self-Driving Car Project) and a microsimulation model to explore projected costs and safety issues today and five years from today to get a sense of the speed of consumer adoption were AVs brought to the market. Results The adoption of AVs for private use was associated with an ICER of 1,396,110/QALY gained today, a figure that would decline to 173,890/QALY gained 5-years in the future. However, AV taxis are both less expensive and potentially already safer than human-piloted taxis. Conclusions While AVs are not unlikely to be used a family vehicles any time soon, it would make economic sense to adopt them as taxis today. Legislation enhancing the benefits while mitigating the potential harmful health impacts of AV taxis is needed with some urgency.

The Oregon Health Study was a groundbreaking experiment in which uninsured participants were randomized to either apply for Medicaid or stay with their current care.