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.     

The gambling market in the Federal Republic of Germany and the helpseeking of pathological gamblers

The development of the gambling market in the Federal Republic of Germany since the middle of the seventies and data on pathological gamblers seeking help are described. The continuously increasing supply, together with increases in turnover, was followed-with some temporal delay-by an increase in the number of gamblers who sought advice and treatment. Preliminary measures taken by the health authorities as well as some consequences of pathological gambling are discussed.This article is a translation of a German article published in: Deutsche Hauptstelle gegen die Suchtgefahren (1990): Jahrbuch '91 zur Frage der Suchtgefahren. Hamburg: Neuland-Verlag.     

Toward a formal theory of interactive resocialization: The case of adoptive parenthood

Resocialization is pulled out of its structuralist roots and recast into an interactionist framework. Building on a substantive theory of the resocialization experience of becoming an adoptive parent, three theoretical properties of interactionist resocialization are presented. These can be summarized as involving unlearning and relearning some aspects of a core identity; the interpretation and active reconstruction of that identity which has reciprocal effects on all actors involved; and finally, the effects of both situational and trans-situational norms that give shape to the resocialization experience. Suggestions are made for other substantive areas of research that could be used for comparative analysis in order to further refine a formal theory of interactionist resocialization.     

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.     

Estimating the Rayleigh distribution scale parameter from doubly censored samples—Some comments

In a recent paper in this journal, Lee, Kapadia and Brock (1980) developed maximum likelihood (ML) methods for estimating the scale parameter of the Rayleigh distribution from doubly censored samples. They reported convergence difficulties in attempting to solve numerically the nonlinear likelihood equation (LE). To mitigate these difficulties, they employed approximations to simplify the LE, but found that the solution of the resulting simplified equation can give rise to parameter estimates of erratic accuracy. We show that the use of approximations to simplify the LE is unnecessary. In fact, under suitable parametric transformation, the log-likelihood function is strictly concave, the ML estimate always exists, is unique and finite. Furthermore, the LE is easy to solve numerically. A numerical example is given to illustrate the computations involved.     

Benefits of preventive dentistry in children: Cost factors and public policy

Dental caries in children is now recognized as a preventable disease. The use of fluoride and sealants has produced a major reduction in caries prevalence among school aged children in the United States and other countries. A portion of the child population who are educationally and socioeconomically disadvantaged are not fully receiving these benefits. Public policy, insurance and medicaid groups must be made aware of these preventative measures and strategies developed to implement them.