Improving the contributions of technology assessment to the health care system of the U.S.A.

Summary Based on 14 case studies of highly effective therapies and the reasons they succeeded less frequently than they could, we propose a variety of steps to improve the health care system of the U.S.A. Whatever proposal emerges from current national debates until innovations are shown to be safe and effective, they should not be supported; when slightly better technologies are much more expensive than other good ones we need to consider appropriate choices carefully; simplified billing and bookkeping would reduce our costs; when a technology is rapidly introduced cautionnary measures may be needed; tracking immunization and repairing their omissions requires a new system; educational programs such as seen effective in hypertension should be applied in other areas such as vaccination; in organ transplantation the nation should consider “presumed consent”; our payment system sometimes creates perverse incentives and therefore needs review; and the preferences of the public in allocation of health resources need to be discovered once the public is informed about the issues. Research supported by Andrew W. Mellon Foundation.     

A screening system for tardive dyskinesia: development and implementation.

1. Most diagnosed cases of tardive dyskinesia (TD) are mildly inconvenient to the patient, but some can be severe or life-threatening. The primary goal of intervention should be early identification of abnormal movements related to TD and the prescribing of an appropriate medication regimen. 2. Unless specific training occurs and a specific monitoring system is in place, TD movements may be missed. However, not all movements are necessarily related to TD. 3. Although screening and monitoring are valuable, nothing is more important than prevention. New medications must be developed that do not carry the risk of TD, and other approaches to treat TD must be developed.     

Integrating Career and Personal Counseling

Career and personal counseling are inextricably intertwined. Career problems have a strong emotional component. Career indecision and procrastination may be better interpreted as zeteophobia, the fear of career exploration. Trait and factor theory pictures career counseling as unrealistically simplistic and leads neophytes to view it as boring. Training all counselors to integrate career and personal counseling would lead to better service for clients.     

The analysis of incomplete data using stochastic covariates

In the development of many diseases there are often associated random variables which continuously reflect the progress of a subject towards the final expression of the disease (failure). At any given time these processes, which we call stochastic covariates, may provide information about the current hazard and the remaining time to failure. Likewise, in situations when the specific times of key prior events are not known, such as the time of onset of an occult tumour or the time of infection with HIV-1, it may be possible to identify a stochastic covariate which reveals, indirectly, when the event of interest occurred. The analysis of carcinogenicity trials which involve occult tumours is usually based on the time of death or sacrifice and an indicator of tumour presence for each animal in the experiment. However, the size of an occult tumour observed at the endpoint represents data concerning tumour development which may convey additional information concerning both the tumour incidence rate and the rate of death to which tumour-bearing animals are subject. We develop a stochastic model for tumour growth and suggest different ways in which the effect of this growth on the hazard of failure might be modelled. Using a combined model for tumour growth and additive competing risks of death, we show that if this tumour size information is used, assumptions concerning tumour lethality, the context of observation or multiple sacrifice times are no longer necessary in order to estimate the tumour incidence rate. Parametric estimation based on the method of maximum likelihood is outlined and is applied to simulated data from the combined model. The results of this limited study confirm that use of the stochastic covariate tumour size results in more precise estimation of the incidence rate for occult tumours.     

Recurrent pain in college students.

The authors investigated the prevalence of recurrent pain in a college student sample. Of the 1,564 students surveyed, 467 (29%) indicated that they had experienced recurrent pain at an intensity that was mostly in the mild-to-moderate range. Students who reported having recurrent pain were significantly older and more depressed than students who did not indicate they suffered from recurrent pain. Pain intensity was positively correlated (r = .14) with depression among the students who reported having recurrent pain. Implications of the findings for future research, treatment, and health promotion efforts are discussed.     

Gender-specific changes in students' sexual behaviors and attitudes at a southeastern university between 1973 and 1988.

This study investigated the gender-specific, self-reported sexual behaviors and attitudes of never-married college students attending a southeastern university in 1973 and 1988. Data were collected by means of a mailed questionnaire that remained essentially unchanged for both years. The authors found that both men and women reported an increase in heterosexual relationships that included sexual intercourse and a decrease in nonsexual relationships with the other gender. The majority of the students perceived themselves as adequately informed about sexuality and satisfied with their relationships, although the proportion of men who reported being satisfied with their relationships declined over the 15 years. The students indicated that sexuality education should focus primarily on information about AIDS and on preparation for marriage.     

Testing for state and local government job queues

Bivariate probit estimates with partial observability identify the factors influencing the worker’s decision to seek a state or local government job and the factors influencing the government’s decision to hire particular workers. The estimates routinely confirm the presence of a local job queue but confirm the presence of a state job queue only when the role of unionization is explicitly recognized. Our results suggest that the net benefits from local and state government employment are greater than those from private sector employment. The estimates also indicate that local governments disproportionately hire racial minorities relative to the local governments’ pool of applicants but indicate no such relationship for state governments. The authors thank Dale Belman, Jugal Ghorai, and Matt Higgins for help on this and related work. We also thank the referee and the editor for useful suggestions.