Jeremy Goldhaber-Fiebert, PhD, is an Associate Professor of Medicine, a Core Faculty Member at the Centers for Health Policy/Primary Care and Outcomes Research, and a Faculty Affiliate of the Stanford Center on Longevity and Stanford Center for International Development. His research focuses on complex policy decisions surrounding the prevention and management of increasingly common, chronic diseases and the life course impact of exposure to their risk factors. In the context of both developing and developed countries including the US, India, China, and South Africa, he has examined chronic conditions including type 2 diabetes and cardiovascular diseases, human papillomavirus and cervical cancer, tuberculosis, and hepatitis C and on risk factors including smoking, physical activity, obesity, malnutrition, and other diseases themselves. He combines simulation modeling methods and cost-effectiveness analyses with econometric approaches and behavioral economic studies to address these issues. Dr. Goldhaber-Fiebert graduated magna cum laude from Harvard College in 1997, with an A.B. in the History and Literature of America. After working as a software engineer and consultant, he conducted a year-long public health research program in Costa Rica with his wife in 2001. Winner of the Lee B. Lusted Prize for Outstanding Student Research from the Society for Medical Decision Making in 2006 and in 2008, he completed his PhD in Health Policy concentrating in Decision Science at Harvard University in 2008. He was elected as a Trustee of the Society for Medical Decision Making in 2011.

Past and current research topics:

- Type 2 diabetes and cardiovascular risk factors: Randomized and observational studies in Costa Rica examining the impact of community-based lifestyle interventions and the relationship of gender, risk factors, and care utilization.

-Cervical cancer: Model-based cost-effectiveness analyses and costing methods studies that examine policy issues relating to cervical cancer screening and human papillomavirus vaccination in countries including the United States, Brazil, India, Kenya, Peru, South Africa, Tanzania, and Thailand.

- Measles, haemophilus influenzae type b, and other childhood infectious diseases: Longitudinal regression analyses of country-level data from middle and upper income countries that examine the link between vaccination, sustained reductions in mortality, and evidence of herd immunity.

- Patient adherence: Studies in both developing and developed countries of the costs and effectiveness of measures to increase successful adherence. Adherence to cervical cancer screening as well as to disease management programs targeting depression and obesity is examined from both a decision-analytic and a behavioral economics perspective.

- Simulation modeling methods: Research examining model calibration and validation, the appropriate representation of uncertainty in projected outcomes, the use of models to examine plausible counterfactuals at the biological and epidemiological level, and the reflection of population and spatial heterogeneity.

Academic Appointments


2017-18 Courses

Stanford Advisees


All Publications

  • Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. PLoS medicine Bernard, C. L., Owens, D. K., Goldhaber-Fiebert, J. D., Brandeau, M. L. 2017; 14 (5)


    The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP).We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities.We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.

    View details for DOI 10.1371/journal.pmed.1002312

    View details for PubMedID 28542184

  • Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India. Bulletin of the World Health Organization Mohanan, M., Giardili, S., Das, V., Rabin, T. L., Raj, S. S., Schwartz, J. I., Seth, A., Goldhaber-Fiebert, J. D., Miller, G., Vera-Hernández, M. 2017; 95 (5): 343-352E


    To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme - the World Health Partners' Sky Program.We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers' performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models.The programme did not significantly improve health-care providers' knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered.Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.

    View details for DOI 10.2471/BLT.16.179556

    View details for PubMedID 28479635

  • Optimizing patient treatment decisions in an era of rapid technological advances: the case of hepatitis C treatment HEALTH CARE MANAGEMENT SCIENCE Liu, S., Brandeau, M. L., Goldhaber-Fiebert, J. D. 2017; 20 (1): 16-32
  • Cost-effectiveness of Intensive Blood Pressure Management-Is There an Additional Price to Pay?-Reply. JAMA cardiology Richman, I. B., Owens, D. K., Goldhaber-Fiebert, J. 2017

    View details for DOI 10.1001/jamacardio.2016.5837

    View details for PubMedID 28199457

  • Cost-Effectiveness of Left Ventricular Assist Devices in Ambulatory Patients With Advanced Heart Failure. JACC. Heart failure Baras Shreibati, J., Goldhaber-Fiebert, J. D., Banerjee, D., Owens, D. K., Hlatky, M. A. 2017; 5 (2): 110-119


    This study assessed the cost-effectiveness of left ventricular assist devices (LVADs) as destination therapy in ambulatory patients with advanced heart failure.LVADs improve survival and quality of life in inotrope-dependent heart failure, but data are limited as to their value in less severely ill patients.We determined costs of care among Medicare beneficiaries before and after LVAD implantation from 2009 to 2010. We used these costs and efficacy data from published studies in a Markov model to project the incremental cost-effectiveness ratio (ICER) of destination LVAD therapy compared with that of medical management. We discounted costs and benefits at 3% annually and report costs as 2016 U.S. dollars.The mean cost of LVAD implantation was $175,420. The mean cost of readmission was lower before LVAD than after ($12,377 vs. $19,465, respectively; p < 0.001), while monthly outpatient costs were similar ($3,364 vs. $2,974, respectively; p = 0.54). In the lifetime simulation model, LVAD increased quality-adjusted life-years (QALYs) (4.41 vs. 2.67, respectively), readmissions (13.03 vs. 6.35, respectively), and costs ($726,200 vs. $361,800, respectively) compared with medical management, yielding an ICER of $209,400 per QALY gained and $597,400 per life-year gained. These results were sensitive to LVAD readmission rates and outpatient care costs; the ICER would be $86,900 if these parameters were 50% lower.LVADs in non-inotrope-dependent heart failure patients improved quality of life but substantially increased lifetime costs because of frequent readmissions and costly follow-up care. LVADs may provide good value if outpatient costs and adverse events can be reduced.

    View details for DOI 10.1016/j.jchf.2016.09.008

    View details for PubMedID 28017351

  • Some Health States Are Better Than Others: Using Health State Rank Order to Improve Probabilistic Analyses MEDICAL DECISION MAKING Goldhaber-Fiebert, J. D., Jalal, H. J. 2016; 36 (8): 927-940


    Probabilistic sensitivity analyses (PSA) may lead policy makers to take nonoptimal actions due to misestimates of decision uncertainty caused by ignoring correlations. We developed a method to establish joint uncertainty distributions of quality-of-life (QoL) weights exploiting ordinal preferences over health states.Our method takes as inputs independent, univariate marginal distributions for each QoL weight and a preference ordering. It establishes a correlation matrix between QoL weights intended to preserve the ordering. It samples QoL weight values from their distributions, ordering them with the correlation matrix. It calculates the proportion of samples violating the ordering, iteratively adjusting the correlation matrix until this proportion is below an arbitrarily small threshold. We compare our method with the uncorrelated method and other methods for preserving rank ordering in terms of violation proportions and fidelity to the specified marginal distributions along with PSA and expected value of partial perfect information (EVPPI) estimates, using 2 models: 1) a decision tree with 2 decision alternatives and 2) a chronic hepatitis C virus (HCV) Markov model with 3 alternatives.All methods make tradeoffs between violating preference orderings and altering marginal distributions. For both models, our method simultaneously performed best, with largest performance advantages when distributions reflected wider uncertainty. For PSA, larger changes to the marginal distributions induced by existing methods resulted in differing conclusions about which strategy was most likely optimal. For EVPPI, both preference order violations and altered marginal distributions caused existing methods to misestimate the maximum value of seeking additional information, sometimes concluding that there was no value.Analysts can characterize the joint uncertainty in QoL weights to improve PSA and value-of-information estimates using Open Source implementations of our method.

    View details for DOI 10.1177/0272989X15605091

    View details for Web of Science ID 000385499700001

    View details for PubMedID 26377369

  • Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models. The Lancet. Global health Menzies, N. A., Gomez, G. B., Bozzani, F., Chatterjee, S., Foster, N., Baena, I. G., Laurence, Y. V., Qiang, S., Siroka, A., Sweeney, S., Verguet, S., Arinaminpathy, N., Azman, A. S., Bendavid, E., Chang, S. T., Cohen, T., Denholm, J. T., Dowdy, D. W., Eckhoff, P. A., Goldhaber-Fiebert, J. D., Handel, A., Huynh, G. H., Lalli, M., Lin, H., Mandal, S., McBryde, E. S., Pandey, S., Salomon, J. A., Suen, S., Sumner, T., Trauer, J. M., Wagner, B. G., Whalen, C. C., Wu, C., Boccia, D., Chadha, V. K., Charalambous, S., Chin, D. P., Churchyard, G., Daniels, C., Dewan, P., Ditiu, L., Eaton, J. W., Grant, A. D., Hippner, P., Hosseini, M., Mametja, D., Pretorius, C., Pillay, Y., Rade, K., Sahu, S., Wang, L., Houben, R. M., Kimerling, M. E., White, R. G., Vassall, A. 2016; 4 (11): e816-e826


    The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa.We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice.Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective.Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary.Bill & Melinda Gates Foundation.

    View details for DOI 10.1016/S2214-109X(16)30265-0

    View details for PubMedID 27720689

  • Providers' knowledge of diagnosis and treatment of tuberculosis using vignettes: evidence from rural Bihar, India. BMJ global health Mohanan, M., Goldhaber-Fiebert, J. D., Giardili, S., Vera-Hernández, M. 2016; 1 (4)


    Almost 25% of all new cases of tuberculosis (TB) worldwide are in India, where drug resistance and low quality of care remain key challenges.We conducted an observational, cross-sectional study of healthcare providers' knowledge of diagnosis and treatment of TB in rural Bihar, India, from June to September 2012. Using data from vignette-based interviews with 395 most commonly visited healthcare providers in study areas, we scored providers' knowledge and used multivariable regression models to examine their relationship to providers' characteristics.80% of 395 providers had no formal medical qualifications. Overall, providers demonstrated low levels of knowledge: 64.9% (95% CI 59.8% to 69.8%) diagnosed correctly, and 21.7% (CI 16.8% to 27.1%) recommended correct treatment. Providers seldom asked diagnostic questions such as fever (31.4%, CI 26.8% to 36.2%) and bloody sputum (11.1%, CI 8.2% to 14.7%), or results from sputum microscopy (20.0%, CI: 16.2% to 24.3%). After controlling for whether providers treat TB, MBBS providers were not significantly different, from unqualified providers or those with alternative medical qualifications, on knowledge score or offering correct treatment. MBBS providers were, however, more likely to recommend referrals relative to complementary medicine and unqualified providers (23.2 and 37.7 percentage points, respectively).Healthcare providers in rural areas in Bihar, India, have low levels of knowledge regarding TB diagnosis and treatment. Our findings highlight the need for policies to improve training, incentives, task shifting and regulation to improve knowledge and performance of existing providers. Further, more research is needed on the incentives providers face and the role of information on quality to help patients select providers who offer higher quality care.

    View details for DOI 10.1136/bmjgh-2016-000155

    View details for PubMedID 28588984

  • Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models LANCET GLOBAL HEALTH Menzies, N. A., Gomez, G. B., Bozzani, F., Chatterjee, S., Foster, N., Garcia Baena, I., Laurence, Y. V., Qiang, S., Siroka, A., Sweeney, S., Verguet, S., Arinaminpathy, N., Azman, A. S., Bendavid, E., Chang, S. T., Cohen, T., Denholm, J. T., Dowdy, D. W., Eckhoff, P. A., Goldhaber-Fiebert, J. D., Handel, A., Huynh, G. H., Lalli, M., Lin, H., Mandal, S., McBryde, E. S., Pandey, S., Salomon, J. A., Suen, S., Sumner, T., Trauer, J. M., Wagner, B. G., Whalen, C. C., Wu, C., Boccia, D., Chadha, V. K., Charalambous, S., Chin, D. P., Churchyard, G., Daniels, C., Dewan, P., Ditiu, L., Eaton, J. W., Grant, A. D., Hippner, P., Hosseini, M., Mametja, D., Pretorius, C., Pillay, Y., Rade, K., Sahu, S., Wang, L., Houben, R. M., Kimerling, M. E., White, R. G., Vassall, A. 2016; 4 (11): E816-E826
  • Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models. The Lancet. Global health Houben, R. M., Menzies, N. A., Sumner, T., Huynh, G. H., Arinaminpathy, N., Goldhaber-Fiebert, J. D., Lin, H., Wu, C., Mandal, S., Pandey, S., Suen, S., Bendavid, E., Azman, A. S., Dowdy, D. W., Bacaër, N., Rhines, A. S., Feldman, M. W., Handel, A., Whalen, C. C., Chang, S. T., Wagner, B. G., Eckhoff, P. A., Trauer, J. M., Denholm, J. T., McBryde, E. S., Cohen, T., Salomon, J. A., Pretorius, C., Lalli, M., Eaton, J. W., Boccia, D., Hosseini, M., Gomez, G. B., Sahu, S., Daniels, C., Ditiu, L., Chin, D. P., Wang, L., Chadha, V. K., Rade, K., Dewan, P., Hippner, P., Charalambous, S., Grant, A. D., Churchyard, G., Pillay, Y., Mametja, L. D., Kimerling, M. E., Vassall, A., White, R. G. 2016; 4 (11): e806-e815


    The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements.11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy.Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31-62%) and a 72% reduction in mortality (range 64-82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis.Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level.Bill and Melinda Gates Foundation.

    View details for DOI 10.1016/S2214-109X(16)30199-1

    View details for PubMedID 27720688

  • Cost-effectiveness of Intensive Blood Pressure Management. JAMA cardiology Richman, I. B., Fairley, M., Jørgensen, M. E., Schuler, A., Owens, D. K., Goldhaber-Fiebert, J. D. 2016; 1 (8): 872-879


    Among high-risk patients with hypertension, targeting a systolic blood pressure of 120 mm Hg reduces cardiovascular morbidity and mortality compared with a higher target. However, intensive blood pressure management incurs additional costs from treatment and from adverse events.To evaluate the incremental cost-effectiveness of intensive blood pressure management compared with standard management.This cost-effectiveness analysis conducted from September 2015 to August 2016 used a Markov cohort model to estimate cost-effectiveness of intensive blood pressure management among 68-year-old high-risk adults with hypertension but not diabetes. We used the Systolic Blood Pressure Intervention Trial (SPRINT) to estimate treatment effects and adverse event rates. We used Centers for Disease Control and Prevention Life Tables to project age- and cause-specific mortality, calibrated to rates reported in SPRINT. We also used population-based observational data to model development of heart failure, myocardial infarction, stroke, and subsequent mortality. Costs were based on published sources, Medicare data, and the National Inpatient Sample.Treatment of hypertension to a systolic blood pressure goal of 120 mm Hg (intensive management) or 140 mm Hg (standard management).Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.Standard management yielded 9.6 QALYs and accrued $155 261 in lifetime costs, while intensive management yielded 10.5 QALYs and accrued $176 584 in costs. Intensive blood pressure management cost $23 777 per QALY gained. In a sensitivity analysis, serious adverse events would need to occur at 3 times the rate observed in SPRINT and be 3 times more common in the intensive management arm to prefer standard management.Intensive blood pressure management is cost-effective at typical thresholds for value in health care and remains so even with substantially higher adverse event rates.

    View details for DOI 10.1001/jamacardio.2016.3517

    View details for PubMedID 27627731

  • Risk of self-reported symptoms or diagnosis of active tuberculosis in relationship to low body mass index, diabetes and their co-occurrence. Tropical medicine & international health Prince, L., Andrews, J. R., Basu, S., Goldhaber-Fiebert, J. D. 2016; 21 (10): 1272-1281


    Globally, tuberculosis prevalence has declined, but its risk factors have varied across place and time - low body mass index (BMI) has persisted while diabetes has increased. Using India's National Family Health Survey (NFHS), wave 3 and World Health Survey (WHS) data, we examined their relationships to support projection of future trends and targeted control efforts.Multivariate logistic regressions at the individual level with and without diabetes/BMI interactions assessed the relationship between tuberculosis, diabetes and low BMI and the importance of risk factor co-occurrence. Population-level analyses examined how tuberculosis incidence and prevalence varied with diabetes/low BMI co-occurrence.In NFHS, diabetic individuals had higher predicted tuberculosis risks (diabetic vs. non-diabetic: 2.50% vs. 0.63% at low BMI; 0.81% vs. 0.20% at normal BMI; 0.37% vs. 0.09% at high BMI), which were not significantly different when modelled independently or allowing for risk modification with diabetes/low BMI co-occurrence. WHS findings were generally consistent. Population-level analysis found that diabetes/low BMI co-occurrence may be associated with elevated tuberculosis risk, although its predicted effect on tuberculosis incidence/prevalence was generally ≤0.2 percentage points and not robustly statistically significant.Concerns about the additional elevation of tuberculosis risk from diabetes/low BMI co-occurrence and hence the need to coordinate tuberculosis control efforts around the nexus of co-occurring diabetes and low BMI may be premature. However, study findings robustly support the importance of individually targeting low BMI and diabetes as part of ongoing tuberculosis control efforts.

    View details for DOI 10.1111/tmi.12763

    View details for PubMedID 27495971

  • Effect Of A Large-Scale Social Franchising And Telemedicine Program On Childhood Diarrhea And Pneumonia Outcomes In India. Health affairs Mohanan, M., Babiarz, K. S., Goldhaber-Fiebert, J. D., Miller, G., Vera-Hernández, M. 2016; 35 (10): 1800-1809


    Despite the rapid growth of social franchising, there is little evidence on its population impact in the health sector. Similar in many ways to private-sector commercial franchising, social franchising can be found in sectors with a social objective, such as health care. This article evaluates the World Health Partners (WHP) Sky program, a large-scale social franchising and telemedicine program in Bihar, India. We studied appropriate treatment for childhood diarrhea and pneumonia and associated health care outcomes. We used multivariate difference-in-differences models to analyze data on 67,950 children ages five and under in 2011 and 2014. We found that the WHP-Sky program did not improve rates of appropriate treatment or disease prevalence. Both provider participation and service use among target populations were low. Our results do not imply that social franchising cannot succeed; instead, they underscore the importance of understanding factors that explain variation in the performance of social franchises. Our findings also highlight, for donors and governments in particular, the importance of conducting rigorous impact evaluations of new and potentially innovative health care delivery programs before investing in scaling them up.

    View details for PubMedID 27702952

  • Reply to R. Colomer et al. Journal of clinical oncology Durkee, B. Y., Qian, Y., Goldhaber-Fiebert, J. D., Horst, K. C. 2016; 34 (26): 3227-3228

    View details for DOI 10.1200/JCO.2016.68.4084

    View details for PubMedID 27432936

  • Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States ANNALS OF INTERNAL MEDICINE Bernard, C. L., Brandeau, M. L., Humphreys, K., Bendavid, E., Holodniy, M., Weyant, C., Owens, D. K., Goldhaber-Fiebert, J. D. 2016; 165 (1): 10-?

    View details for DOI 10.7326/M15-2634

    View details for Web of Science ID 000379215800003

  • Cost-Effectiveness of Implantable Pulmonary Artery Pressure Monitoring in Chronic Heart Failure JACC-HEART FAILURE Sandhu, A. T., Goldhaber-Fiebert, J. D., Owens, D. K., Turakhia, M. P., Kaiser, D. W., Heidenreich, P. A. 2016; 4 (5): 368-375


    This study aimed to evaluate the cost-effectiveness of the CardioMEMS (CardioMEMS Heart Failure System, St Jude Medical Inc, Atlanta, Georgia) device in patients with chronic heart failure.The CardioMEMS device, an implantable pulmonary artery pressure monitor, was shown to reduce hospitalizations for heart failure and improve quality of life in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) trial.We developed a Markov model to determine the hospitalization, survival, quality of life, cost, and incremental cost-effectiveness ratio of CardioMEMS implantation compared with usual care among a CHAMPION trial cohort of patients with heart failure. We obtained event rates and utilities from published trial data; we used costs from literature estimates and Medicare reimbursement data. We performed subgroup analyses of preserved and reduced ejection fraction and an exploratory analysis in a lower-risk cohort on the basis of the CHARM (Candesartan in Heart failure: Reduction in Mortality and Morbidity) trials.CardioMEMS reduced lifetime hospitalizations (2.18 vs. 3.12), increased quality-adjusted life-years (QALYs) (2.74 vs. 2.46), and increased costs ($176,648 vs. $156,569), thus yielding a cost of $71,462 per QALY gained and $48,054 per life-year gained. The cost per QALY gained was $82,301 in patients with reduced ejection fraction and $47,768 in those with preserved ejection fraction. In the lower-risk CHARM cohort, the device would need to reduce hospitalizations for heart failure by 41% to cost <$100,000 per QALY gained. The cost-effectiveness was most sensitive to the device's durability.In populations similar to that of the CHAMPION trial, the CardioMEMS device is cost-effective if the trial effectiveness is sustained over long periods. Post-marketing surveillance data on durability will further clarify its value.

    View details for DOI 10.1016/j.jchf.2015.12.015

    View details for Web of Science ID 000375347200006

    View details for PubMedID 26874380

    View details for PubMedCentralID PMC4851610

  • Cost-Effectiveness of Pertuzumab in Human Epidermal Growth Factor Receptor 2-Positive Metastatic Breast Cancer. Journal of clinical oncology Durkee, B. Y., Qian, Y., Pollom, E. L., King, M. T., Dudley, S. A., Shaffer, J. L., Chang, D. T., Gibbs, I. C., Goldhaber-Fiebert, J. D., Horst, K. C. 2016; 34 (9): 902-909


    The Clinical Evaluation of Pertuzumab and Trastuzumab (CLEOPATRA) study showed a 15.7-month survival benefit with the addition of pertuzumab to docetaxel and trastuzumab (THP) as first-line treatment for patients with human epidermal growth factor receptor 2 (HER2) -overexpressing metastatic breast cancer. We performed a cost-effectiveness analysis to assess the value of adding pertuzumab.We developed a decision-analytic Markov model to evaluate the cost effectiveness of docetaxel plus trastuzumab (TH) with or without pertuzumab in US patients with metastatic breast cancer. The model followed patients weekly over their remaining lifetimes. Health states included stable disease, progressing disease, hospice, and death. Transition probabilities were based on the CLEOPATRA study. Costs reflected the 2014 Medicare rates. Health state utilities were the same as those used in other recent cost-effectiveness studies of trastuzumab and pertuzumab. Outcomes included health benefits expressed as discounted quality-adjusted life-years (QALYs), costs in US dollars, and cost effectiveness expressed as an incremental cost-effectiveness ratio. One- and multiway deterministic and probabilistic sensitivity analyses explored the effects of specific assumptions.Modeled median survival was 39.4 months for TH and 56.9 months for THP. The addition of pertuzumab resulted in an additional 1.82 life-years gained, or 0.64 QALYs, at a cost of $713,219 per QALY gained. Deterministic sensitivity analysis showed that THP is unlikely to be cost effective even under the most favorable assumptions, and probabilistic sensitivity analysis predicted 0% chance of cost effectiveness at a willingness to pay of $100,000 per QALY gained.THP in patients with metastatic HER2-positive breast cancer is unlikely to be cost effective in the United States.

    View details for DOI 10.1200/JCO.2015.62.9105

    View details for PubMedID 26351332

  • An Efficient, Noniterative Method of Identifying the Cost-Effectiveness Frontier MEDICAL DECISION MAKING Suen, S., Goldhaber-Fiebert, J. D. 2016; 36 (1): 132-136

    View details for DOI 10.1177/0272989X15583496

    View details for Web of Science ID 000366910300012

    View details for PubMedID 25926282

  • Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters. Medical decision making Goldhaber-Fiebert, J. D., Brandeau, M. L. 2015; 35 (7): 818-846


    Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes.We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing.We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic.Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.

    View details for DOI 10.1177/0272989X15583845

    View details for PubMedID 25926281

  • Cost-Effectiveness of Adding Cardiac Resynchronization Therapy to an Implantable Cardioverter-Defibrillator Among Patients With Mild Heart Failure. Annals of internal medicine Woo, C. Y., Strandberg, E. J., Schmiegelow, M. D., Pitt, A. L., Hlatky, M. A., Owens, D. K., Goldhaber-Fiebert, J. D. 2015; 163 (6): 417-426


    Cardiac resynchronization therapy (CRT) reduces mortality and heart failure hospitalizations in patients with mild heart failure.To estimate the cost-effectiveness of adding CRT to an implantable cardioverter-defibrillator (CRT-D) compared with implantable cardioverter-defibrillator (ICD) alone among patients with left ventricular systolic dysfunction, prolonged intraventricular conduction, and mild heart failure.Markov decision model.Clinical trials, clinical registries, claims data from Centers for Medicare & Medicaid Services, and Centers for Disease Control and Prevention life tables.Patients aged 65 years or older with a left ventricular ejection fraction (LVEF) of 30% or less, QRS duration of 120 milliseconds or more, and New York Heart Association (NYHA) class I or II symptoms.Lifetime.Societal.CRT-D or ICD alone.Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).Use of CRT-D increased life expectancy (9.8 years versus 8.8 years), QALYs (8.6 years versus 7.6 years), and costs ($286 500 versus $228 600), yielding a cost per QALY gained of $61 700.The cost-effectiveness of CRT-D was most dependent on the degree of mortality reduction: When the risk ratio for death was 0.95, the ICER increased to $119 600 per QALY. More expensive CRT-D devices, shorter CRT-D battery life, and older age also made the cost-effectiveness of CRT-D less favorable.The estimated mortality reduction for CRT-D was largely based on a single trial. Data on patients with NYHA class I symptoms were limited. The cost-effectiveness of CRT-D in patients with NYHA class I symptoms remains uncertain.In patients with an LVEF of 30% or less, QRS duration of 120 milliseconds or more, and NYHA class II symptoms, CRT-D appears to be economically attractive relative to ICD alone when a reduction in mortality is expected.National Institutes of Health, University of Copenhagen, U.S. Department of Veterans Affairs.

    View details for DOI 10.7326/M14-1804

    View details for PubMedID 26301323

  • Cost-Effectiveness of Adding Cardiac Resynchronization Therapy to an Implantable Cardioverter-Defibrillator Among Patients With Mild Heart Failure. Annals of internal medicine Woo, C. Y., Strandberg, E. J., Schmiegelow, M. D., Pitt, A. L., Hlatky, M. A., Owens, D. K., Goldhaber-Fiebert, J. D. 2015; 163 (6): 417-426

    View details for DOI 10.7326/M14-1804

    View details for PubMedID 26301323

  • Will Divestment from Employment-Based Health Insurance Save Employers Money? The Case of State and Local Governments JOURNAL OF EMPIRICAL LEGAL STUDIES Goldhaber-Fiebert, J. D., Studdert, D. M., Farid, M. S., Bhattacharya, J. 2015; 12 (3): 343-394

    View details for DOI 10.1111/jels.12076

    View details for Web of Science ID 000360209700001

  • Cost-effectiveness of improvements in diagnosis and treatment accessibility for tuberculosis control in India INTERNATIONAL JOURNAL OF TUBERCULOSIS AND LUNG DISEASE Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2015; 19 (9): 1115-1124

    View details for DOI 10.5588/ijtld.15.0158

    View details for Web of Science ID 000359894400022

    View details for PubMedID 26260835

  • Cost-effectiveness of improvements in diagnosis and treatment accessibility for tuberculosis control in India. international journal of tuberculosis and lung disease Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2015; 19 (9): 1115-?


    Inaccurate diagnosis and inaccessibility of care undercut the effectiveness of high-quality anti-tuberculosis treatment and select for resistance. Rapid diagnostic systems, such as Xpert(®) MTB/RIF for tuberculosis (TB) diagnosis and drug susceptibility testing (DST), and programs that provide high-quality DOTS anti-tuberculosis treatment to patients in the unregulated private sector (public-private mix [PPM]), may help address these challenges, albeit at increased cost.We extended a microsimulation model of TB in India calibrated to demographic, epidemiologic, and care trends to evaluate 1) replacing DST with Xpert; 2) replacing microscopy and culture with Xpert to diagnose multidrug-resistant TB (MDR-TB) and non-MDR-TB; 3) implementing nationwide PPM; and combinations of (3) with (1) or (2).PPM (assuming costs of $38/person) and Xpert improved health and increase costs relative to the status quo. PPM alone or with Xpert cost <1 gross domestic product/capita per quality-adjusted life-year gained relative to the next best intervention, and dominated Xpert interventions excluding PPM.While both PPM and Xpert are promising tools for combatting TB in India, PPM should be prioritized over Xpert, as private sector engagement is more cost-effective than Xpert alone and, if sufficient resources are available, would substantially increase the value of Xpert if both interventions are implemented together.

    View details for DOI 10.5588/ijtld.15.0158

    View details for PubMedID 26260835

  • Quantifying demographic and socioeconomic transitions for computational epidemiology: an open-source modeling approach applied to India POPULATION HEALTH METRICS Basu, S., Goldhaber-Fiebert, J. D. 2015; 13
  • Optimizing patient treatment decisions in an era of rapid technological advances: the case of hepatitis C treatment. Health care management science Liu, S., Brandeau, M. L., Goldhaber-Fiebert, J. D. 2015: -?


    How long should a patient with a treatable chronic disease wait for more effective treatments before accepting the best available treatment? We develop a framework to guide optimal treatment decisions for a deteriorating chronic disease when treatment technologies are improving over time. We formulate an optimal stopping problem using a discrete-time, finite-horizon Markov decision process. The goal is to maximize a patient's quality-adjusted life expectancy. We derive structural properties of the model and analytically solve a three-period treatment decision problem. We illustrate the model with the example of treatment for chronic hepatitis C virus (HCV). Chronic HCV affects 3-4 million Americans and has been historically difficult to treat, but increasingly effective treatments have been commercialized in the past few years. We show that the optimal treatment decision is more likely to be to accept currently available treatment-despite expectations for future treatment improvement-for patients who have high-risk history, who are older, or who have more comorbidities. Insights from this study can guide HCV treatment decisions for individual patients. More broadly, our model can guide treatment decisions for curable chronic diseases by finding the optimal treatment policy for individual patients in a heterogeneous population.

    View details for PubMedID 26188961

  • Computing Expected Value of Partial Sample Information from Probabilistic Sensitivity Analysis Using Linear Regression Metamodeling MEDICAL DECISION MAKING Jalal, H., Goldhaber-Fiebert, J. D., Kuntz, K. M. 2015; 35 (5): 584-595


    Decision makers often desire both guidance on the most cost-effective interventions given current knowledge and also the value of collecting additional information to improve the decisions made (i.e., from value of information [VOI] analysis). Unfortunately, VOI analysis remains underused due to the conceptual, mathematical, and computational challenges of implementing Bayesian decision-theoretic approaches in models of sufficient complexity for real-world decision making. In this study, we propose a novel practical approach for conducting VOI analysis using a combination of probabilistic sensitivity analysis, linear regression metamodeling, and unit normal loss integral function-a parametric approach to VOI analysis. We adopt a linear approximation and leverage a fundamental assumption of VOI analysis, which requires that all sources of prior uncertainties be accurately specified. We provide examples of the approach and show that the assumptions we make do not induce substantial bias but greatly reduce the computational time needed to perform VOI analysis. Our approach avoids the need to analytically solve or approximate joint Bayesian updating, requires only one set of probabilistic sensitivity analysis simulations, and can be applied in models with correlated input parameters.

    View details for DOI 10.1177/0272989X15578125

    View details for Web of Science ID 000356431100004

    View details for PubMedID 25840900

  • Uptake and utilization of directly acting antiviral medications for hepatitis C infection in US veterans JOURNAL OF VIRAL HEPATITIS Gidwani, R., Barnett, P. G., Goldhaber-Fiebert, J. D., Asch, S. M., Lo, J., Dally, S. K., Owens, D. K. 2015; 22 (5): 489-495


    New drugs therapies have revolutionized the treatment of hepatitis C virus (HCV) infection. The objectives of this study were to evaluate uptake and utilization of boceprevir and telaprevir in the Department of Veterans Affairs (VA). We evaluated whether therapies conformed to response-guided protocols, whether they replaced standard interferon plus ribavirin treatment, and whether IL-28B was used to guide treatment. We performed an administrative data-based analysis of all patients receiving pharmacologic treatment for HCV in VA from October 2009 to July 2013. There were 12 737 new HCV prescriptions in VA during this time, with 5564 boceprevir or telaprevir prescriptions (44%) and 7173 prescriptions (56%) written for standard interferon plus ribavirin treatment. Prescriptions for the new treatments heavily favoured boceprevir vs telaprevir (83% vs 17%). Sixty-two percent (62%) of boceprevir-treated patients completed their minimum-specified protocol, while 69.2% of telaprevir-treated patients completed their minimum-specified protocol. From October 2010 to July 2012, 4090 patients had an IL-28B test; less than 16% of these tests guided subsequent HCV prescriptions. Uptake of boceprevir and telaprevir was rapid; the number of patients initiating treatment approximately doubled in the period after their introduction. While new prescriptions favor boceprevir or telaprevir over standard interferon plus ribavirin therapy, there appears to still be a strong role of interferon plus ribavirin in treating HCV patients. This work can inform our understanding of how other new effective HCV therapies will be used, their diffusion, and the timing of their diffusion in actual clinical practice.

    View details for DOI 10.1111/jvh.12344

    View details for Web of Science ID 000352566200005

    View details for PubMedID 25417805

  • The Know-Do Gap in Quality of Health Care for Childhood Diarrhea and Pneumonia in Rural India JAMA PEDIATRICS Mohanan, M., Vera-Hernandez, M., Das, V., Giardili, S., Goldhaber-Fiebert, J. D., Rabin, T. L., Raj, S. S., Schwartz, J. I., Seth, A. 2015; 169 (4): 349-357


    In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners' knowledge of appropriate care and the actual care delivered (the know-do gap).To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India.We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs).For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners' characteristics. We also examined correct treatment recommended by practitioners with both methods.Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia.Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.

    View details for DOI 10.1001/jamapediatrics.2014.3445

    View details for Web of Science ID 000354995600018

    View details for PubMedID 25686357

  • Modeling and calibration for exposure to time-varying, modifiable risk factors: the example of smoking behavior in India. Medical decision making Goldhaber-Fiebert, J. D., Brandeau, M. L. 2015; 35 (2): 196-210


    Risk factors increase the incidence and severity of chronic disease. To examine future trends and develop policies addressing chronic diseases, it is important to capture the relationship between exposure and disease development, which is challenging given limited data.To develop parsimonious risk factor models embeddable in chronic disease models, which are useful when longitudinal data are unavailable.The model structures encode relevant features of risk factors (e.g., time-varying, modifiable) and can be embedded in chronic disease models. Calibration captures time-varying exposures for the risk factor models using available cross-sectional data. We illustrate feasibility with the policy-relevant example of smoking in India.The model is calibrated to the prevalence of male smoking in 12 Indian regions estimated from the 2009-2010 Indian Global Adult Tobacco Survey. Nelder-Mead searches (250,000 starting locations) identify distributions of starting, quitting, and restarting rates that minimize the difference between modeled and observed age-specific prevalence. We compare modeled life expectancies to estimates in the absence of time-varying risk exposures and consider gains from hypothetical smoking cessation programs delivered for 1 to 30 years.Calibration achieves concordance between modeled and observed outcomes. Probabilities of starting to smoke rise and fall with age, while quitting and restarting probabilities fall with age. Accounting for time-varying smoking exposures is important, as not doing so produces smaller estimates of life expectancy losses. Estimated impacts of smoking cessation programs delivered for different periods depend on the fact that people who have been induced to abstain from smoking longer are less likely to restart.The approach described is feasible for important risk factors for numerous chronic diseases. Incorporating exposure-change rates can improve modeled estimates of chronic disease outcomes and of the long-term effects of interventions targeting risk factors.

    View details for DOI 10.1177/0272989X13518272

    View details for PubMedID 24477078

  • Quantifying demographic and socioeconomic transitions for computational epidemiology: an open-source modeling approach applied to India. Population health metrics Basu, S., Goldhaber-Fiebert, J. D. 2015; 13: 19-?


    Demographic and socioeconomic changes such as increasing urbanization, migration, and female education shape population health in many low- and middle-income countries. These changes are rarely reflected in computational epidemiological models, which are commonly used to understand population health trends and evaluate policy interventions. Our goal was to create a "backbone" simulation modeling approach to allow computational epidemiologists to explicitly reflect changing demographic and socioeconomic conditions in population health models.We developed, evaluated, and "open-sourced" a generalized approach to incorporate longitudinal, commonly available demographic and socioeconomic data into epidemiological simulations, illustrating the feasibility and utility of our approach with data from India. We constructed a series of nested microsimulations of increasing complexity, calibrating each model to longitudinal sociodemographic and vital registration data. We then selected the model that was most consistent with the data (i.e., greater accuracy) while containing the fewest parameters (i.e., greater parsimony). We validated the selected model against additional data sources not used for calibration.We found that standard computational epidemiology models that do not incorporate demographic and socioeconomic trends quickly diverged from past mortality and population size estimates, while our approach remained consistent with observed data over decadal time courses. Our approach additionally enabled the examination of complex relations between demographic, socioeconomic and health parameters, such as the relationship between changes in educational attainment or urbanization and changes in fertility, mortality, and migration rates.Incorporating demographic and socioeconomic trends in computational epidemiology is feasible through the "open source" approach, and could critically alter population health projections and model-based evaluations of health policy interventions in unintuitive ways.

    View details for DOI 10.1186/s12963-015-0053-1

    View details for PubMedID 26236157

  • Sofosbuvir-Based Treatment Regimens for Chronic, Genotype 1 Hepatitis C Virus Infection in US Incarcerated Populations A Cost-Effectiveness Analysis ANNALS OF INTERNAL MEDICINE Liu, S., Watcha, D., Holodniy, M., Goldhaber-Fiebert, J. D. 2014; 161 (8): 546-U43

    View details for DOI 10.7326/M14-0602

    View details for Web of Science ID 000343906800014

  • Sofosbuvir-based treatment regimens for chronic, genotype 1 hepatitis C virus infection in U.S. incarcerated populations: a cost-effectiveness analysis. Annals of internal medicine Liu, S., Watcha, D., Holodniy, M., Goldhaber-Fiebert, J. D. 2014; 161 (8): 546-553


    Prevalence of chronic hepatitis C virus (HCV) infection is high among incarcerated persons in the United States. New, short-duration, high-efficacy therapies may expand treatment eligibility in this population.To assess the cost-effectiveness of sofosbuvir for HCV treatment in incarcerated populations.Markov model.Published literature and expert opinion.Treatment-naive men with chronic, genotype 1 HCV monoinfection.Lifetime.Societal.No treatment, 2-drug therapy (pegylated interferon and ribavirin), or 3-drug therapy with either boceprevir or sofosbuvir. For inmates with short remaining sentences (<1.5 years), only no treatment or sofosbuvir 3-drug therapy was feasible; for those with long sentences (≥1.5 years; mean, 10 years), all strategies were considered. After release, eligible persons could receive sofosbuvir 3-drug therapy.Discounted costs (in 2013 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.The strategies yielded 13.12, 13.57, 14.43, and 15.18 QALYs, respectively, for persons with long sentences. Sofosbuvir produced the largest absolute reductions in decompensated cirrhosis (16%) and hepatocellular carcinoma (9%), resulting in 2.1 additional QALYs at an added cost exceeding $54,000 compared with no treatment. For persons with short sentences, sofosbuvir cost $25,700 per QALY gained compared with no treatment; for those with long sentences, it dominated other treatments, costing $28,800 per QALY gained compared with no treatment.High reinfection rates in prison attenuated cost-effectiveness for persons with long sentences.Data on sofosbuvir's long-term effectiveness and price are limited. The analysis did not consider women, Hispanic persons, or patients co-infected with HIV or hepatitis B virus.Sofosbuvir-based treatment is cost-effective for incarcerated persons, but affordability is an important consideration.National Institutes of Health.

    View details for DOI 10.7326/M14-0602

    View details for PubMedID 25329202

  • Exploration and adoption of evidence-based practice by US child welfare agencies CHILDREN AND YOUTH SERVICES REVIEW Horwitz, S. M., Hurlburt, M. S., Goldhaber-Fiebert, J. D., Palinkas, L. A., Rolls-Reutz, J., Zhang, J., Fisher, E., Landsverk, J. 2014; 39: 147-152
  • Explaining variations in state foster care maintenance rates and the implications for implementing new evidence-based programs CHILDREN AND YOUTH SERVICES REVIEW Goldhaber-Fiebert, J. D., Babiarz, K. S., Garfield, R. L., Wulczyn, F., Landsverk, J., Horwitz, S. M. 2014; 39: 183-206
  • Cost-effectiveness of tolvaptan in autosomal dominant polycystic kidney disease. Annals of internal medicine Erickson, K. F., Chertow, G. M., Goldhaber-Fiebert, J. D. 2014; 160 (2): 143-?

    View details for DOI 10.7326/L14-5001-7

    View details for PubMedID 24445704

  • Cost-Effectiveness of Treatment of Diabetic Macular Edema ANNALS OF INTERNAL MEDICINE Pershing, S., Enns, E. A., Matesic, B., Owens, D. K., Goldhaber-Fiebert, J. D. 2014; 160 (1): 18-?
  • Cost-effectiveness of treatment of diabetic macular edema. Annals of internal medicine Pershing, S., Enns, E. A., Matesic, B., Owens, D. K., Goldhaber-Fiebert, J. D. 2014; 160 (1): 18-29


    Macular edema is the most common cause of vision loss among patients with diabetes.To determine the cost-effectiveness of different treatments of diabetic macular edema (DME).Markov model.Published literature and expert opinion.Patients with clinically significant DME.Lifetime.Societal.Laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor, or a combination of both.Discounted costs, gains in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).All treatments except laser monotherapy substantially reduced costs, and all treatments except triamcinolone monotherapy increased QALYs. Laser treatment plus a VEGF inhibitor achieved the greatest benefit, gaining 0.56 QALYs at a cost of $6975 for an ICER of $12 410 per QALY compared with laser treatment plus triamcinolone. Monotherapy with a VEGF inhibitor achieved similar outcomes to combination therapy with laser treatment plus a VEGF inhibitor. Laser monotherapy and triamcinolone monotherapy were less effective and more costly than combination therapy.VEGF inhibitor monotherapy was sometimes preferred over laser treatment plus a VEGF inhibitor, depending on the reduction in quality of life with loss of visual acuity. When the VEGF inhibitor bevacizumab was as effective as ranibizumab, it was preferable because of its lower cost.Long-term outcome data for treated and untreated diseases are limited.The most effective treatment of DME is VEGF inhibitor injections with or without laser treatment. This therapy compares favorably with cost-effective interventions for other conditions.Agency for Healthcare Research and Quality.

    View details for DOI 10.7326/M13-0768

    View details for PubMedID 24573663

  • Disease control implications of India's changing multi-drug resistant tuberculosis epidemic. PloS one Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2014; 9 (3)


    Multi-drug resistant tuberculosis (MDR TB) is a major health challenge in India that is gaining increasing public attention, but the implications of India's evolving MDR TB epidemic are poorly understood. As India's MDR TB epidemic is transitioning from a treatment-generated to transmission-generated epidemic, we sought to evaluate the potential effectiveness of the following two disease control strategies on reducing the prevalence of MDR TB: a) improving treatment of non-MDR TB; b) shortening the infectious period between the activation of MDR TB and initiation of effective MDR treatment.We developed a dynamic transmission microsimulation model of TB in India. The model followed individuals by age, sex, TB status, drug resistance status, and treatment status and was calibrated to Indian demographic and epidemiologic TB time trends. The main effectiveness measure was reduction in the average prevalence reduction of MDR TB over the ten years after control strategy implementation. We find that improving non-MDR cure rates to avoid generating new MDR cases will provide substantial non-MDR TB benefits but will become less effective in reducing MDR TB prevalence over time because more cases will occur from direct transmission - by 2015, the model estimates 42% of new MDR cases are transmission-generated and this proportion continues to rise over time, assuming equal transmissibility of MDR and drug-susceptible TB. Strategies that disrupt MDR transmission by shortening the time between MDR activation and treatment are projected to provide greater reductions in MDR prevalence compared with improving non-MDR treatment quality: implementing MDR diagnostic improvements in 2017 is expected to reduce MDR prevalence by 39%, compared with 11% reduction from improving non-MDR treatment quality.As transmission-generated MDR TB becomes a larger driver of the MDR TB epidemic in India, rapid and accurate MDR TB diagnosis and treatment will become increasingly effective in reducing MDR TB cases compared to non-MDR TB treatment improvements.

    View details for DOI 10.1371/journal.pone.0089822

    View details for PubMedID 24608234

  • Extended Abstract: Combining Statistical Analysis and Markov Models with Public Health Data to Infer Age-Specific Background Mortality Rates for Hepatitis C Infection in the US International Conference for Smart Health (ICSH) Liu, S., Cipriano, L. E., Goldhaber-Fiebert, J. D. SPRINGER-VERLAG BERLIN. 2014: 148–149
  • Tuberculosis treatment discontinuation and symptom persistence: an observational study of Bihar, India's public care system covering >100,000,000 inhabitants. BMC public health Babiarz, K. S., Suen, S., Goldhaber-Fiebert, J. D. 2014; 14: 418-?


    The effectiveness of India's TB control programs depend critically on patients completing appropriate treatment. Discontinuing treatment prior to completion can leave patients infectious and symptomatic. Developing strategies to reduce early discontinuation requires characterizing its patterns and their link to symptom persistence.The 2011 BEST-TB survey (360 clusters, 11 districts) sampled patients (n = 1007) from Bihar's public healthcare system who had initiated treatment >6 months prior to being interviewed, administering questionnaires to patients about TB treatment duration and symptoms, prior treatment, and sociodemographic characteristics. Multivariate logistic regression models estimated the risk of treatment discontinuation for these characteristics. Similar models estimated probabilities of symptom persistence to 25 weeks post-treatment initiation adjusting for the same predictors and treatment duration. All models included district fixed effects, robust standard errors, and adjustments for the survey sampling design. Treatment default timing and symptom persistence relied solely on self-report.24% of patients discontinued treatment prior to 25 weeks. Higher likelihood of discontinuation occurred in those who had failed to complete previous TB treatment episodes (aOR: 4.77 [95% CI: 1.98-11.53]) and those seeing multiple providers (3.67 per provider [1.94-6.95]). Symptoms persisted in 42% of patients discontinuing treatment within 5 weeks versus 28% for completing 25 weeks of treatment. Symptom persistence was more likely for those with prior TB treatment (aOR: 5.05 [1.90-13.38]); poorer patients (2.94 [1.51-5.72]); and women (1.79 [1.07-2.99]). Predictors for treatment discontinuation prior to 16 weeks were similar.Premature TB treatment discontinuation and symptom persistence is particularly high among individuals who have failed to complete treatment for a prior episode. Strategies to identify and promote treatment completion in this group appear promising. Likewise, effective TB regimens of shortened duration currently in trials may eventually help to achieve higher treatment completion rates.

    View details for DOI 10.1186/1471-2458-14-418

    View details for PubMedID 24886314

  • Disease Control Implications of India's Changing Multi-Drug Resistant Tuberculosis Epidemic. PloS one Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2014; 9 (3)

    View details for DOI 10.1371/journal.pone.0089822

    View details for PubMedID 24608234

  • Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Annals of emergency medicine Delgado, M. K., Staudenmayer, K. L., Wang, N. E., Spain, D. A., Weir, S., Owens, D. K., Goldhaber-Fiebert, J. D. 2013; 62 (4): 351-364 e19


    STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.

    View details for DOI 10.1016/j.annemergmed.2013.02.025

    View details for PubMedID 23582619

  • Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Annals of emergency medicine Delgado, M. K., Staudenmayer, K. L., Wang, N. E., Spain, D. A., Weir, S., Owens, D. K., Goldhaber-Fiebert, J. D. 2013; 62 (4): 351-364 e19

    View details for DOI 10.1016/j.annemergmed.2013.02.025

    View details for PubMedID 23582619

  • Cost-effectiveness of preoperative imaging for appendicitis after indeterminate ultrasonography in the second or third trimester of pregnancy. Obstetrics and gynecology Kastenberg, Z. J., Hurley, M. P., Luan, A., Vasu-Devan, V., Spain, D. A., Owens, D. K., Goldhaber-Fiebert, J. D. 2013; 122 (4): 821-829


    To assess the cost-effectiveness of diagnostic laparoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) after indeterminate ultrasonography in pregnant women with suspected appendicitis.A decision-analytic model was developed to simulate appendicitis during pregnancy taking into consideration the health outcomes for both the pregnant women and developing fetuses. Strategies included diagnostic laparoscopy, CT, and MRI. Outcomes included positive appendectomy, negative appendectomy, maternal perioperative complications, preterm delivery, fetal loss, childhood cancer, lifetime costs, discounted life expectancy, and incremental cost-effectiveness ratios.Magnetic resonance imaging is the most cost-effective strategy, costing $6,767 per quality-adjusted life-year gained relative to CT, well below the generally accepted $50,000 per quality-adjusted life-year threshold. In a setting where MRI is unavailable, CT is cost-effective even when considering the increased risk of radiation-associated childhood cancer ($560 per quality-adjusted life-year gained relative to diagnostic laparoscopy). Unless the negative appendectomy rate is less than 1%, imaging of any type is more cost-effective than proceeding directly to diagnostic laparoscopy.Depending on imaging costs and resource availability, both CT and MRI are potentially cost-effective. The risk of radiation-associated childhood cancer from CT has little effect on population-level outcomes or cost-effectiveness but is a concern for individual patients. For pregnant women with suspected appendicitis, an extremely high level of clinical diagnostic certainty must be reached before proceeding to operation without preoperative imaging.

    View details for DOI 10.1097/AOG.0b013e3182a4a085

    View details for PubMedID 24084540

  • Cost-effectiveness of tolvaptan in autosomal dominant polycystic kidney disease. Annals of internal medicine Erickson, K. F., Chertow, G. M., Goldhaber-Fiebert, J. D. 2013; 159 (6): 382-389


    Chinese translationIn the TEMPO (Tolvaptan Efficacy and Safety in Management of Autosomal Dominant Polycystic Kidney Disease and Its Outcomes) trial, tolvaptan significantly reduced expansion of kidney volume and loss of kidney function.To determine how the benefits of tolvaptan seen in TEMPO may relate to longer-term health outcomes, such as progression to end-stage renal disease (ESRD) and death, and cost-effectiveness.A decision-analytic model.Published literature from 1993 to 2012.Persons with early autosomal dominant polycystic kidney disease.Lifetime.Societal.Patients received tolvaptan therapy until death, development of ESRD, or liver complications or no tolvaptan therapy.Median age at ESRD onset, life expectancy, discounted quality-adjusted life-years and lifetime costs (in 2010 U.S. dollars), and incremental cost-effectiveness ratios.Tolvaptan prolonged the median age at ESRD onset by 6.5 years and increased life expectancy by 2.6 years. At $5760 per month, tolvaptan cost $744 100 per quality-adjusted life-year gained compared with standard care.For patients with autosomal dominant polycystic kidney disease that progressed more slowly, the cost per quality-adjusted life-year gained was even greater for tolvaptan.Although TEMPO followed patients for 3 years, the main analysis assumed that clinical benefits persisted over patients' lifetimes.Assuming that the benefits of tolvaptan persist in the longer term, the drug may slow progression to ESRD and reduce mortality rates. However, barring an approximately 95% reduction in price, cost-effectiveness does not compare favorably with many other commonly accepted medical interventions.National Institutes of Health and Agency for Healthcare Research and Quality.

    View details for DOI 10.7326/0003-4819-159-6-201309170-00004

    View details for PubMedID 24042366

  • Cost-effectiveness of tolvaptan in autosomal dominant polycystic kidney disease. Annals of internal medicine Erickson, K. F., Chertow, G. M., Goldhaber-Fiebert, J. D. 2013; 159 (6): 382-389
  • Analyzing Screening Policies for Childhood Obesity MANAGEMENT SCIENCE Yang, Y., Goldhaber-Fiebert, J. D., Wein, L. M. 2013; 59 (4): 782-795
  • Cost-Effectiveness of Statins for Primary Cardiovascular Prevention in Chronic Kidney Disease JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Erickson, K. F., Japa, S., Owens, D. K., Chertow, G. M., Garber, A. M., Goldhaber-Fiebert, J. D. 2013; 61 (12): 1250-1258


    The authors sought to evaluate the cost-effectiveness of statins for primary prevention of myocardial infarction (MI) and stroke in patients with chronic kidney disease (CKD).Patients with CKD have an elevated risk of MI and stroke. Although HMG Co-A reductase inhibitors (“statins”) may prevent cardiovascular events in patients with non–dialysis-requiring CKD, adverse drug effects and competing risks could materially influence net effects and clinical decision-making.We developed a decision-analytic model of CKD and cardiovascular disease (CVD) to determine the cost-effectiveness of low-cost generic statins for primary CVD prevention in men and women with hypertension and mild-to-moderate CKD. Outcomes included MI and stroke rates, discounted quality-adjusted life years (QALYs) and lifetime costs (2010 USD), and incremental cost-effectiveness ratios.For 65-year-old men with moderate hypertension and mild-to-moderate CKD, statins reduced the combined rate of MI and stroke, yielded 0.10 QALYs, and increased costs by $1,800 ($18,000 per QALY gained). For patients with lower baseline cardiovascular risks, health and economic benefits were smaller; for 65-year-old women, statins yielded 0.06 QALYs and increased costs by $1,900 ($33,400 per QALY gained). Results were sensitive to rates of rhabdomyolysis and drug costs. Statins are less cost-effective when obtained at average retail prices, particularly in patients at lower CVD risk.Although statins reduce absolute CVD risk in patients with CKD, the increased risk of rhabdomyolysis, and competing risks associated with progressive CKD, partly offset these gains. Low-cost generic statins appear cost-effective for primary prevention of CVD in patients with mild-to-moderate CKD and hypertension.

    View details for DOI 10.1016/j.jacc.2012.12.034

    View details for Web of Science ID 000316751100006

    View details for PubMedID 23500327

  • Cost-Effectiveness Analysis of Risk-Factor Guided and Birth-Cohort Screening for Chronic Hepatitis C Infection in the United States PLOS ONE Liu, S., Cipriano, L. E., Holodniy, M., Goldhaber-Fiebert, J. D. 2013; 8 (3)


    No consensus exists on screening to detect the estimated 2 million Americans unaware of their chronic hepatitis C infections. Advisory groups differ, recommending birth-cohort screening for baby boomers, screening only high-risk individuals, or no screening. We assessed one-time risk assessment and screening to identify previously undiagnosed 40-74 year-olds given newly available hepatitis C treatments.A Markov model evaluated alternative risk-factor guided and birth-cohort screening and treatment strategies. Risk factors included drug use history, blood transfusion before 1992, and multiple sexual partners. Analyses of the National Health and Nutrition Examination Survey provided sex-, race-, age-, and risk-factor-specific hepatitis C prevalence and mortality rates. Nine strategies combined screening (no screening, risk-factor guided screening, or birth-cohort screening) and treatment (standard therapy-peginterferon alfa and ribavirin, Interleukin-28B-guided (IL28B) triple-therapy-standard therapy plus a protease inhibitor, or universal triple therapy). Response-guided treatment depended on HCV genotype. Outcomes include discounted lifetime costs (2010 dollars) and quality adjusted life-years (QALYs). Compared to no screening, risk-factor guided and birth-cohort screening for 50 year-olds gained 0.7 to 3.5 quality adjusted life-days and cost $168 to $568 per person. Birth-cohort screening provided more benefit per dollar than risk-factor guided screening and cost $65,749 per QALY if followed by universal triple therapy compared to screening followed by IL28B-guided triple therapy. If only 10% of screen-detected, eligible patients initiate treatment at each opportunity, birth-cohort screening with universal triple therapy costs $241,100 per QALY. Assuming treatment with triple therapy, screening all individuals aged 40-64 years costs less than $100,000 per QALY.The cost-effectiveness of one-time birth-cohort hepatitis C screening for 40-64 year olds is comparable to other screening programs, provided that the healthcare system has sufficient capacity to deliver prompt treatment and appropriate follow-on care to many newly screen-detected individuals.

    View details for DOI 10.1371/journal.pone.0058975

    View details for Web of Science ID 000316549400032

    View details for PubMedID 23533595

  • The Utility of Childhood and Adolescent Obesity Assessment in Relation to Adult MEDICAL DECISION MAKING Goldhaber-Fiebert, J. D., Rubinfeld, R. E., Bhattacharya, J., Robinson, T. N., Wise, P. H. 2013; 33 (2): 163-175


    High childhood obesity prevalence has raised concerns about future adult health, generating calls for obesity screening of young children.To estimate how well childhood obesity predicts adult obesity and to forecast obesity-related health of future US adults.Longitudinal statistical analyses; microsimulations combining multiple data sets.National Longitudinal Survey of Youth, Population Study of Income Dynamics, and National Health and Nutrition Evaluation Surveys.The authors estimated test characteristics and predictive values of childhood body mass index to identify 2-, 5-, 10-, and 15 year-olds who will become obese adults. The authors constructed models relating childhood body mass index to obesity-related diseases through middle age stratified by sex and race.Twelve percent of 18-year-olds were obese. While screening at age 5 would miss 50% of those who become obese adults, screening at age 15 would miss 9%. The predictive value of obesity screening below age 10 was low even when maternal obesity was included as a predictor. Obesity at age 5 was a substantially worse predictor of health in middle age than was obesity at age 15. For example, the relative risk of developing diabetes as adults for obese white male 15-year-olds was 4.5 versus otherwise similar nonobese 15-year-olds. For obese 5-year-olds, the relative risk was 1.6.Main results do not include Hispanics due to sample size. Past relationships between childhood and adult obesity and health may change in the future.Early childhood obesity assessment adds limited information to later childhood assessment. Targeted later childhood approaches or universal strategies to prevent unhealthy weight gain should be considered.

    View details for DOI 10.1177/0272989X12447240

    View details for Web of Science ID 000316684200006

    View details for PubMedID 22647830

  • Performance of serum biomarkers for the early detection of invasive aspergillosis in febrile, neutropenic patients: a multi-state model. PloS one Schwarzinger, M., Sagaon-Teyssier, L., Cabaret, O., Bretagne, S., Cordonnier, C., Pautas, C., Maury, S., Hicheri, Y., Botterel, F., Foulet, F., Vekhoff, A., Chaoui, D., Cornet, M., Agnamey, P., Farhat, H., Castaigne, S., Eloy, O., Suarez, F., Buzyn, A., Delarue, R., Challier, S., Dhedin, N., Aljijakli, A., Delabesse, E., Datry, A., Isnard, F., Fouillard, L., Poirot, J., Meliani, L., Adès, L., Bouges-Michel, C., Deniau, M., Kuhnowski, F., Dreyfus, F., Paugam, A., Baixench, M., Leclercq, R., Reman, O., Duhamel, C., Bourrhis, J., Chehata, S., Chachati, I., Foissaud, V., Macnab, C., Tilly, H., Leprêtre, S., Gray, C., Raffoux, E., Lacroix, C., Goldhaber-Fiebert, J. D., Bendavid, E., Farley, B. J. 2013; 8 (6)


    The performance of serum biomarkers for the early detection of invasive aspergillosis expectedly depends on the timing of test results relative to the empirical administration of antifungal therapy during neutropenia, although a dynamic evaluation framework is lacking.We developed a multi-state model describing simultaneously the likelihood of empirical antifungal therapy and the risk of invasive aspergillosis during neutropenia. We evaluated whether the first positive test result with a biomarker is an independent predictor of invasive aspergillosis when both diagnostic information used to treat and risk factors of developing invasive aspergillosis are taken into account over time. We applied the multi-state model to a homogeneous cohort of 185 high-risk patients with acute myeloid leukemia. Patients were prospectively screened for galactomannan antigenemia twice a week for immediate treatment decision; 2,214 serum samples were collected on the same days and blindly assessed for (1->3)- β-D-glucan antigenemia and a quantitative PCR assay targeting a mitochondrial locus.The usual evaluation framework of biomarker performance was unable to distinguish clinical benefits of β-glucan or PCR assays. The multi-state model evidenced that the risk of invasive aspergillosis is a complex time function of neutropenia duration and risk management. The quantitative PCR assay accelerated the early detection of invasive aspergillosis (P = .010), independently of other diagnostic information used to treat, while β-glucan assay did not (P = .53).The performance of serum biomarkers for the early detection of invasive aspergillosis is better apprehended by the evaluation of time-varying predictors in a multi-state model. Our results provide strong rationale for prospective studies testing a preemptive antifungal therapy, guided by clinical, radiological, and bi-weekly blood screening with galactomannan antigenemia and a standardized quantitative PCR assay.

    View details for DOI 10.1371/journal.pone.0065776

    View details for PubMedID 23799048

  • Palm oil taxes and cardiovascular disease mortality in India: economic-epidemiologic model. BMJ (Clinical research ed.) Basu, S., Babiarz, K. S., Ebrahim, S., Vellakkal, S., Stuckler, D., Goldhaber-Fiebert, J. D. 2013; 347: f6048-?

    View details for DOI 10.1136/bmj.f6048

    View details for PubMedID 24149818

  • Palm oil taxes and cardiovascular disease mortality in India: economic-epidemiologic model. BMJ (Clinical research ed.) Basu, S., Babiarz, K. S., Ebrahim, S., Vellakkal, S., Stuckler, D., Goldhaber-Fiebert, J. D. 2013; 347: f6048-?


    To examine the potential effect of a tax on palm oil on hyperlipidemia and on mortality due to cardiovascular disease in India.Economic-epidemiologic model.A microsimulation model of mortality due to myocardial infarction and stroke among Indian populations was constructed, incorporating nationally representative data on systolic blood pressure, total cholesterol, tobacco smoking, diabetes, and cardiovascular event history, and stratified by age, sex, and urban/rural residence. Household expenditure data were used to estimate the change in consumption of palm oil following changes in oil price and the potential substitution of alternative oils that might occur after imposition of a tax. A 20% excise tax on palm oil purchases was simulated over the period 2014-23.The model was used to project future mortality due to myocardial infarction and stroke, as well as the potential effect of a tax on food insecurity, accounting for the effect of increased food prices.A 20% tax on palm oil purchases would be expected to avert approximately 363 000 (95% confidence interval 247 000 to 479 000) deaths from myocardial infarctions and strokes over the period 2014-23 in India (1.3% reduction in cardiovascular deaths) if people do not substitute other oils for reduced palm oil consumption. Given estimates of substitution of palm oil with other oils following a 20% price increase for palm oil, the beneficial effects of increased polyunsaturated fat consumption would be expected to enhance the projected reduction in deaths to as much as 421 000 (256 000 to 586 000). The tax would be expected to benefit men more than women and urban populations more than rural populations, given differential consumption and cardiovascular risk. In a scenario incorporating the effect of taxation on overall food expenditures, the tax may increase food insecurity by <1%, resulting in 16 000 (95% confidence interval 12 000 to 22 000) deaths.Curtailing palm oil intake through taxation may modestly reduce hyperlipidemia and cardiovascular mortality, but with potential distributional consequences differentially benefiting male and urban populations, as well as affecting food security.

    View details for DOI 10.1136/bmj.f6048

    View details for PubMedID 24149818

  • Analyzing Screening Policies for Childhood Obesity Management Science Yan Yang, Jeremy D. Goldhaber-Fiebert, Lawrence M. Wein 2013; 59 (April): 782-795
  • Screening and Rapid Molecular Diagnosis of Tuberculosis in Prisons in Russia and Eastern Europe: A Cost-Effectiveness Analysis PLOS MEDICINE Winetsky, D. E., Negoescu, D. M., Demarchis, E. H., Almukhamedova, O., Dooronbekova, A., Pulatov, D., Vezhnina, N., Owens, D. K., Goldhaber-Fiebert, J. D. 2012; 9 (11)


    Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission.We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics.In prisons of the FSU, annual screening of the general inmate population with sputum PCR most effectively reduces TB and MDR-TB prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual MMR is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time.

    View details for DOI 10.1371/journal.pmed.1001348

    View details for Web of Science ID 000311888800014

    View details for PubMedID 23209384

  • Evaluating Child Welfare Policies with Decision-Analytic Simulation Models ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH Goldhaber-Fiebert, J. D., Bailey, S. L., Hurlburt, M. S., Zhang, J., Snowden, L. R., Wulczyn, F., Landsverk, J., Horwitz, S. M. 2012; 39 (6): 466-477


    The objective was to demonstrate decision-analytic modeling in support of Child Welfare policymakers considering implementing evidence-based interventions. Outcomes included permanency (e.g., adoptions) and stability (e.g., foster placement changes). Analyses of a randomized trial of KEEP-a foster parenting intervention-and NSCAW-1 estimated placement change rates and KEEP's effects. A microsimulation model generalized these findings to other Child Welfare systems. The model projected that KEEP could increase permanency and stability, identifying strategies targeting higher-risk children and geographical regions that achieve benefits efficiently. Decision-analytic models enable planners to gauge the value of potential implementations.

    View details for DOI 10.1007/s10488-011-0370-z

    View details for Web of Science ID 000309862900006

    View details for PubMedID 21861204

  • Mental Health Services Use by Children Investigated by Child Welfare Agencies PEDIATRICS Horwitz, S. M., Hurlburt, M. S., Goldhaber-Fiebert, J. D., Heneghan, A. M., Zhang, J., Rolls-Reutz, J., Fisher, E., Landsverk, J., Stein, R. E. 2012; 130 (5): 861-869


    To examine the rates and predictors of mental health services use for a nationally representative cohort of youths who had been investigated for alleged maltreatment.Data came from caregiver and caseworker baseline and 18-month interviews in the second National Survey of Child and Adolescent Well-being. These interviews took place from March 2008 to September 2008 and September 2010 to March 2011. Data on family and child characteristics and service use were gathered and examined by using weighted univariate and multivariate analyses.Children had numerous challenges: 61.8% had a previous report of maltreatment, 46.3% had poor socialization skills, and 23.9% had a mental health problem measured by the Child Behavior Checklist (CBCL). At baseline, 33.3% received some mental health service and this varied by age, with younger children receiving fewer services. This percentage decreased to 30.9% at the 18-month follow-up, although the youngest children had increases in services use. For younger children, race/ethnicity, out-of-home placement, chronic physical health problems, low adaptive behaviors, and CBCL scores in the clinical range were related to use. For children ≥ 11, out-of-home placement, high CBCL scores, and family risk factors predicted services use at 18 months.Mental health services utilization increases as young children come into contact with schools and medical providers or have more intensive involvement with child welfare. Minority children receive fewer services adjusting for need. Over the 18-month follow-up, there was a decrease in service use that may be a result of the tremendous financial challenges taking place in the United States.

    View details for DOI 10.1542/peds.2012-1330

    View details for Web of Science ID 000310505900055

    View details for PubMedID 23045565

  • Assessing Screening Policies for Childhood Obesity OBESITY Wein, L. M., Yang, Y., Goldhaber-Fiebert, J. D. 2012; 20 (7): 1437-1443


    To address growing concerns over childhood obesity, the United States Preventive Services Task Force (USPSTF) recently recommended that children undergo obesity screening beginning at age 6. An Expert Committee recommends starting at age 2. Analysis is needed to assess these recommendations and investigate whether there are better alternatives. We model the age- and sex-specific population-wide distribution of BMI through age 18 using National Longitudinal Survey of Youth (NLSY) data. The impact of treatment on BMI is estimated using the targeted systematic review performed to aid the USPSTF. The prevalence of hypertension and diabetes at age 40 are estimated from the Panel Study of Income Dynamics (PSID). We fix the screening interval at 2 years, and derive the age- and sex-dependent BMI thresholds that minimize adult disease prevalence, subject to referring a specified percentage of children for treatment yearly. We compare this optimal biennial policy to biennial versions of the USPSTF and Expert Committee recommendations. Compared to the USPSTF recommendation, the optimal policy reduces adult disease prevalence by 3% in relative terms (the absolute reductions are <1%) at the same treatment referral rate, or achieves the same disease prevalence at a 28% reduction in treatment referral rate. If compared to the Expert Committee recommendation, the reductions change to 6 and 40%, respectively. The optimal policy treats mostly 16-year olds and few children under age 14. Our results suggest that adult disease is minimized by focusing childhood obesity screening and treatment on older adolescents.

    View details for DOI 10.1038/oby.2011.373

    View details for Web of Science ID 000305840200015

    View details for PubMedID 22240724

  • Accounting for Biases When Linking Empirical Studies and Simulation Models MEDICAL DECISION MAKING Goldhaber-Fiebert, J. D. 2012; 32 (3): 397-399

    View details for DOI 10.1177/0272989X12441398

    View details for Web of Science ID 000304704300004

    View details for PubMedID 22593033

  • New Protease Inhibitors for the Treatment of Chronic Hepatitis C A Cost-Effectiveness Analysis ANNALS OF INTERNAL MEDICINE Liu, S., Cipriano, L. E., Holodniy, M., Owens, D. K., Goldhaber-Fiebert, J. D. 2012; 156 (4): 279-U68


    Chronic hepatitis C virus is difficult to treat and affects approximately 3 million Americans. Protease inhibitors increase the effectiveness of standard therapy, but they are costly. A genetic assay may identify patients most likely to benefit from this treatment advance.To assess the cost-effectiveness of new protease inhibitors and an interleukin (IL)-28B genotyping assay for treating chronic hepatitis C virus.Decision-analytic Markov model.Published literature and expert opinion.Treatment-naive patients with chronic, genotype 1 hepatitis C virus monoinfection.Lifetime.Societal.Strategies are defined by the use of IL-28B genotyping and type of treatment (standard therapy [pegylated interferon with ribavirin]; triple therapy [standard therapy and a protease inhibitor]). Interleukin-28B-guided triple therapy stratifies patients with CC genotypes to standard therapy and those with non-CC types to triple therapy.Discounted costs (in 2010 U.S. dollars) and quality-adjusted life-years (QALYs); incremental cost-effectiveness ratios.For patients with mild and advanced fibrosis, universal triple therapy reduced the lifetime risk for hepatocellular carcinoma by 38% and 28%, respectively, and increased quality-adjusted life expectancy by 3% and 8%, respectively, compared with standard therapy. Gains from IL-28B-guided triple therapy were smaller. If the protease inhibitor costs $1100 per week, universal triple therapy costs $102,600 per QALY (mild fibrosis) or $51,500 per QALY (advanced fibrosis) compared with IL-28B-guided triple therapy and $70,100 per QALY (mild fibrosis) and $36,300 per QALY (advanced fibrosis) compared with standard therapy.Results were sensitive to the cost of protease inhibitors and treatment adherence rates.Data on the long-term comparative effectiveness of the new protease inhibitors are lacking.Both universal triple therapy and IL-28B-guided triple therapy are cost-effective when the least-expensive protease inhibitor are used for patients with advanced fibrosis.Stanford University.

    View details for Web of Science ID 000300607600005

    View details for PubMedID 22351713

  • Diabetes, Its Treatment, and Catastrophic Medical Spending in 35 Developing Countries DIABETES CARE Smith-Spangler, C. M., Bhattacharya, J., Goldhaber-Fiebert, J. D. 2012; 35 (2): 319-326


    To assess the individual financial impact of having diabetes in developing countries, whether diabetic individuals possess appropriate medications, and the extent to which health insurance may protect diabetic individuals by increasing medication possession or decreasing the risk of catastrophic spending.Using 2002-2003 World Health Survey data (n = 121,051 individuals; 35 low- and middle-income countries), we examined possession of medications to treat diabetes and estimated the relationship between out-of-pocket medical spending (2005 international dollars), catastrophic medical spending, and diabetes. We assessed whether health insurance modified these relationships.Diabetic individuals experience differentially higher out-of-pocket medical spending, particularly among individuals with high levels of spending (excess spending of $157 per year [95% CI 130-184] at the 95th percentile), and a greater chance of incurring catastrophic medical spending (17.8 vs. 13.9%; difference 3.9% [95% CI 0.2-7.7]) compared with otherwise similar individuals without diabetes. Diabetic individuals with insurance do not have significantly lower risks of catastrophic medical spending (18.6 vs. 17.7%; difference not significant), nor were they significantly more likely to possess diabetes medications (22.8 vs. 20.6%; difference not significant) than those who were otherwise similar but without insurance. These effects were more pronounced and significant in lower-income countries.In low-income countries, despite insurance, diabetic individuals are more likely to experience catastrophic medical spending and often do not possess appropriate medications to treat diabetes. Research into why policies in these countries may not adequately protect people from catastrophic spending or enhance possession of critical medications is urgently needed.

    View details for DOI 10.2337/dc11-1770

    View details for Web of Science ID 000299856000024

    View details for PubMedID 22238276

  • Multi-Country Analysis of Palm Oil Consumption and Cardiovascular Disease Mortality for Countries at Different Stages of Economic Development: 1980-1997 GLOBALIZATION AND HEALTH Chen, B. K., Seligman, B., Farquhar, J. W., Goldhaber-Fiebert, J. D. 2011; 7


    Cardiovascular diseases represent an increasing share of the global disease burden. There is concern that increased consumption of palm oil could exacerbate mortality from ischemic heart disease (IHD) and stroke, particularly in developing countries where it represents a major nutritional source of saturated fat.The study analyzed country-level data from 1980-1997 derived from the World Health Organization's Mortality Database, U.S. Department of Agriculture international estimates, and the World Bank (234 annual observations; 23 countries). Outcomes included mortality from IHD and stroke for adults aged 50 and older. Predictors included per-capita consumption of palm oil and cigarettes and per-capita Gross Domestic Product as well as time trends and an interaction between palm oil consumption and country economic development level. Analyses examined changes in country-level outcomes over time employing linear panel regressions with country-level fixed effects, population weighting, and robust standard errors clustered by country. Sensitivity analyses included further adjustment for other major dietary sources of saturated fat.In developing countries, for every additional kilogram of palm oil consumed per-capita annually, IHD mortality rates increased by 68 deaths per 100,000 (95% CI [21-115]), whereas, in similar settings, stroke mortality rates increased by 19 deaths per 100,000 (95% CI [-12-49]) but were not significant. For historically high-income countries, changes in IHD and stroke mortality rates from palm oil consumption were smaller (IHD: 17 deaths per 100,000 (95% CI [5.3-29]); stroke: 5.1 deaths per 100,000 (95% CI [-1.2-11.0])). Inclusion of other major saturated fat sources including beef, pork, chicken, coconut oil, milk cheese, and butter did not substantially change the differentially higher relationship between palm oil and IHD mortality in developing countries.Increased palm oil consumption is related to higher IHD mortality rates in developing countries. Palm oil consumption represents a saturated fat source relevant for policies aimed at reducing cardiovascular disease burdens.

    View details for DOI 10.1186/1744-8603-7-45

    View details for Web of Science ID 000300306700001

    View details for PubMedID 22177258

  • Cost Effectiveness of Fibrosis Assessment Prior to Treatment for Chronic Hepatitis C Patients PLOS ONE Liu, S., Schwarzinger, M., Carrat, F., Goldhaber-Fiebert, J. D. 2011; 6 (12)


    Chronic hepatitis C (HCV) is a liver disease affecting over 3 million Americans. Liver biopsy is the gold standard for assessing liver fibrosis and is used as a benchmark for initiating treatment, though it is expensive and carries risks of complications. FibroTest is a non-invasive biomarker assay for fibrosis, proposed as a screening alternative to biopsy.We assessed the cost-effectiveness of FibroTest and liver biopsy used alone or sequentially for six strategies followed by treatment of eligible U.S. patients: FibroTest only; FibroTest with liver biopsy for ambiguous results; FibroTest followed by biopsy to rule in; or to rule out significant fibrosis; biopsy only (recommended practice); and treatment without screening. We developed a Markov model of chronic HCV that tracks fibrosis progression. Outcomes were expressed as expected lifetime costs (2009 USD), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER).Treatment of chronic HCV without fibrosis screening is preferred for both men and women. For genotype 1 patients treated with pegylated interferon and ribavirin, the ICERs are $5,400/QALY (men) and $6,300/QALY (women) compared to FibroTest only; the ICERs increase to $27,200/QALY (men) and $30,000/QALY (women) with the addition of telaprevir. For genotypes 2 and 3, treatment is more effective and less costly than all alternatives. In clinical settings where testing is required prior to treatment, FibroTest only is more effective and less costly than liver biopsy. These results are robust to multi-way and probabilistic sensitivity analyses.Early treatment of chronic HCV is superior to the other fibrosis screening strategies. In clinical settings where testing is required, FibroTest screening is a cost-effective alternative to liver biopsy.

    View details for DOI 10.1371/journal.pone.0026783

    View details for Web of Science ID 000298171400004

    View details for PubMedID 22164204

  • Economic evaluation research in the context of Child Welfare policy: A structured literature review and recommendations CHILD ABUSE & NEGLECT Goldhaber-Fiebert, J. D., Snowden, L. R., Wulczyn, F., Landsverk, J., Horwitz, S. M. 2011; 35 (9): 722-740


    With over 1 million children served by the US Child Welfare system at a cost of $20 billion annually, this study examines the economic evaluation literature on interventions to improve outcomes for children at risk for and currently involved with the system, identifies areas where additional research is needed, and discusses the use of decision-analytic modeling to advance Child Welfare policy and practice.The review included 19 repositories of peer-reviewed and non-peer-reviewed "gray" literatures, including items in English published before November, 2009. Original research articles were included if they evaluated interventions based on costs and outcomes. Review articles were included to assess the relevance of these techniques over time and to highlight the increasing discussion of methods needed to undertake such research. Items were categorized by their focus on: interventions for the US Child Welfare system; primary prevention of entry into the system; and use of models to make long-term projections of costs and outcomes.Searches identified 2,640 articles, with 49 ultimately included (19 reviews and 30 original research articles). Between 1988 and 2009, reviews consistently advocated economic evaluation and increasingly provided methodological guidance. 21 of the original research articles focused on Child Welfare, while 9 focused on child mental health. Of the 21 Child Welfare articles, 81% (17) focused on the US system. 47% (8/17) focused exclusively on primary prevention, though 83% of the US system, peer-reviewed articles focused exclusively on prevention (5/6). 9 of the 17 articles included empirical follow-up (mean sample size: 264 individuals; mean follow-up: 3.8 years). 10 of the 17 articles used modeling to project longer-term outcomes, but 80% of the articles using modeling were not peer-reviewed. Although 60% of modeling studies included interventions for children in the system, all peer-reviewed modeling articles focused on prevention.Methodological guidance for economic evaluations in Child Welfare is increasingly available. Such analyses are feasible given the availability of nationally representative data on children involved with Child Welfare and evidence-based interventions.Policy analyses considering the long-term costs and effects of interventions to improve Child Welfare outcomes are scarce, feasible, and urgently needed.

    View details for DOI 10.1016/j.chiabu.2011.05.012

    View details for Web of Science ID 000295946000007

    View details for PubMedID 21944552

  • The Business Case for Quality Improvement Oral Anticoagulation for Atrial Fibrillation CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Rose, A. J., Berlowitz, D. R., Ash, A. S., Ozonoff, A., Hylek, E. M., Goldhaber-Fiebert, J. D. 2011; 4 (4): 416-424


    The potential to save money within a short time frame provides a more compelling "business case" for quality improvement than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation.Our population consisted of 67 077 Veterans Health Administration patients anticoagulated for atrial fibrillation between October 1, 2006, and September 30, 2008. We simulated the number of adverse events and their associated costs and utilities, both before and after various degrees of improvement in percent time in therapeutic range (TTR). The simulation had a 2-year time horizon, and costs were calculated from the perspective of the payer. In the base-case analysis, improving TTR by 5% prevented 1114 adverse events, including 662 deaths; it gained 863 quality-adjusted life-years and saved $15.9 million compared with the status quo, not accounting for the cost of the quality improvement program. Improving TTR by 10% prevented 2087 events, gained 1606 quality-adjusted life-years, and saved $29.7 million. In sensitivity analyses, costs were most sensitive to the estimated risk of stroke and the expected stroke reduction from improved TTR. Utilities were most sensitive to the estimated risk of death and the expected mortality benefit from improved TTR.A quality improvement program to improve anticoagulation control probably would be cost-saving for the payer, even if it were only modestly effective in improving control and even without considering the value of improved health. This study demonstrates how to make a business case for a quality improvement initiative.

    View details for DOI 10.1161/CIRCOUTCOMES.111.960591

    View details for Web of Science ID 000292872500008

    View details for PubMedID 21712521

  • Diabetes mellitus and tuberculosis in countries with high tuberculosis burdens: individual risks and social determinants INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Goldhaber-Fiebert, J. D., Jeon, C. Y., Cohen, T., Murray, M. B. 2011; 40 (2): 417-428


    A growing body of evidence supports the role of type 2 diabetes as an individual-level risk factor for tuberculosis (TB), though evidence from developing countries with the highest TB burdens is lacking. In developing countries, TB is most common among the poor, in whom diabetes may be less common. We assessed the relationship between individual-level risk, social determinants and population health in these settings.We performed individual-level analyses using the World Health Survey (n = 124,607; 46 countries). We estimated the relationship between TB and diabetes, adjusting for gender, age, body mass index, education, housing quality, crowding and health insurance. We also performed a longitudinal country-level analysis using data on per-capita gross domestic product and TB prevalence and incidence and diabetes prevalence for 1990-95 and 2003-04 (163 countries) to estimate the relationship between increasing diabetes prevalence and TB, identifying countries at risk for disease interactions.In lower income countries, individuals with diabetes are more likely than non-diabetics to have TB [univariable odds ratio (OR): 2.39; 95% confidence interval (CI): 1.84-3.10; multivariable OR: 1.81; 95% CI: 1.37-2.39]. Increases in TB prevalence and incidence over time were more likely to occur when diabetes prevalence also increased (OR: 4.7; 95% CI: 1.0-22.5; OR: 8.6; 95% CI: 1.9-40.4). Large populations, prevalent TB and projected increases in diabetes make countries like India, Peru and the Russia Federation areas of particular concern.Given the association between diabetes and TB and projected increases in diabetes worldwide, multi-disease health policies should be considered.

    View details for DOI 10.1093/ije/dyq238

    View details for Web of Science ID 000289165800020

    View details for PubMedID 21252210

  • Screening with OGTT alone or in combination with the Indian diabetes risk score or genotyping of TCF7L2 to detect undiagnosed type 2 diabetes in Asian Indians INDIAN JOURNAL OF MEDICAL RESEARCH Mohan, V., Goldhaber-Fiebert, J. D., Radha, V., Gokulakrishnan, K. 2011; 133 (3): 294-299


    With increasing number of people with diabetes worldwide, particularly in India, it is necessary to search for low cost screening methods. We compared the effectiveness and costs of screening for undiagnosed type 2 diabetes mellitus (T2DM), using oral glucose tolerance testing (OGTT) alone, or following a positive result from the Indian Diabetes Risk Score (IDRS) or following a positive result from genotyping of the TCF7L2 polymorphisms in Asian Indians.In subjects without known diabetes (n=961) recruited from the Chennai Urban Rural Epidemiology Study (CURES), OGTT, IDRS, and genotyping of rs12255372 (G/T) and rs7903146(C/T) of TCF7L2 polymorphisms were done. IDRS includes four parameters: age, abdominal obesity, family history of T2DM and physical activity.OGTT identified 72 subjects with newly diagnosed diabetes (NDD), according to the World Health Organization criteria of fasting plasma glucose ≥ 126 mg/dl or a plasma glucose ≥ 200 mg/dl, 2 h after 75 g oral glucose load. IDRS screening (cut-off ≥ 60) yielded 413 positive subjects, which included 54 (75%) of the 72 NDD subjects identified by OGTT. Genotyping yielded 493 positive subjects which only included 36 (50%) of the 72 NDD subjects showing less discriminatory power. Screening with both SNPs missed 27 (37.5%) NDD subjects identified by IDRS. In contrast, IDRS missed only 9 (12.5%) of the NDD subjects identified by genotyping. Total screening cost for OGTT alone, or with IDRS were rs 384,400 and 182,810 respectively. Comparing OGTT alone to IDRS followed by OGTT, the incremental cost per additional NDD subject detected by doing OGTT on everyone was rs 11,199 (rs 201,590 for detecting additional 18 NDD subjects).For screening a population of subjects without diagnosed diabetes in India, a simple diabetes risk score is more effective and less expensive than genotyping or doing OGTT on the whole population.

    View details for Web of Science ID 000289322400010

    View details for PubMedID 21441683

  • Quantifying Child Mortality Reductions Related to Measles Vaccination PLOS ONE Goldhaber-Fiebert, J. D., Lipsitch, M., Mahal, A., Zaslavsky, A. M., Salomon, J. A. 2010; 5 (11)


    This study characterizes the historical relationship between coverage of measles containing vaccines (MCV) and mortality in children under 5 years, with a view toward ongoing global efforts to reduce child mortality.Using country-level, longitudinal panel data, from 44 countries over the period 1960-2005, we analyzed the relationship between MCV coverage and measles mortality with (1) logistic regressions for no measles deaths in a country-year, and (2) linear regressions for the logarithm of the measles death rate. All regressions allowed a flexible, non-linear relationship between coverage and mortality. Covariates included birth rate, death rates from other causes, percent living in urban areas, population density, per-capita GDP, use of the two-dose MCV, year, and mortality coding system. Regressions used lagged covariates, country fixed effects, and robust standard errors clustered by country. The likelihood of no measles deaths increased nonlinearly with higher MCV coverage (ORs: 13.8 [1.6-122.7] for 80-89% to 40.7 [3.2-517.6] for ≥95%), compared to pre-vaccination risk levels. Measles death rates declined nonlinearly with higher MCV coverage, with benefits accruing more slowly above 90% coverage. Compared to no coverage, predicted average reductions in death rates were -79% at 70% coverage, -93% at 90%, and -95% at 95%.40 years of experience with MCV vaccination suggests that extremely high levels of vaccination coverage are needed to produce sharp reductions in measles deaths. Achieving sustainable benefits likely requires a combination of extended vaccine programs and supplementary vaccine efforts.

    View details for DOI 10.1371/journal.pone.0013842

    View details for Web of Science ID 000283838600016

    View details for PubMedID 21079809

    View details for PubMedCentralID PMC2973966

  • Empirically Evaluating Decision-Analytic Models VALUE IN HEALTH Goldhaber-Fiebert, J. D., Stout, N. K., Goldie, S. J. 2010; 13 (5): 667-674


    Model-based cost-effectiveness analyses support decision-making. To augment model credibility, evaluation via comparison to independent, empirical studies is recommended.We developed a structured reporting format for model evaluation and conducted a structured literature review to characterize current model evaluation recommendations and practices. As an illustration, we applied the reporting format to evaluate a microsimulation of human papillomavirus and cervical cancer. The model's outputs and uncertainty ranges were compared with multiple outcomes from a study of long-term progression from high-grade precancer (cervical intraepithelial neoplasia [CIN]) to cancer. Outcomes included 5 to 30-year cumulative cancer risk among women with and without appropriate CIN treatment. Consistency was measured by model ranges overlapping study confidence intervals.The structured reporting format included: matching baseline characteristics and follow-up, reporting model and study uncertainty, and stating metrics of consistency for model and study results. Structured searches yielded 2963 articles with 67 meeting inclusion criteria and found variation in how current model evaluations are reported. Evaluation of the cervical cancer microsimulation, reported using the proposed format, showed a modeled cumulative risk of invasive cancer for inadequately treated women of 39.6% (30.9-49.7) at 30 years, compared with the study: 37.5% (28.4-48.3). For appropriately treated women, modeled risks were 1.0% (0.7-1.3) at 30 years, study: 1.5% (0.4-3.3).To support external and projective validity, cost-effectiveness models should be iteratively evaluated as new studies become available, with reporting standardized to facilitate assessment. Such evaluations are particularly relevant for models used to conduct comparative effectiveness analyses.

    View details for DOI 10.1111/j.1524-4733.2010.00698.x

    View details for Web of Science ID 000280674200021

    View details for PubMedID 20230547

  • Inpatient treatment of diabetic patients in Asia: evidence from India, China, Thailand and Malaysia DIABETIC MEDICINE Goldhaber-Fiebert, J. D., Li, H., Ratanawijitrasin, S., Vidyasagar, S., Wang, X. Y., Aljunid, S., Shah, N., Wang, Z., Hirunrassamee, S., Bairy, K. L., Wang, J., Saperi, S., Nur, A. M., Eggleston, K. 2010; 27 (1): 101-108


    The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.

    View details for DOI 10.1111/j.1464-5491.2009.02874.x

    View details for Web of Science ID 000273451900015

    View details for PubMedID 20121896

  • Program Spending to Increase Adherence: South African Cervical Cancer Screening PLOS ONE Goldhaber-Fiebert, J. D., Denny, L. A., De Souza, M., Kuhn, L., Goldie, S. J. 2009; 4 (5)


    Adherence is crucial for public health program effectiveness, though the benefits of increasing adherence must ultimately be weighed against the associated costs. We sought to determine the relationship between investment in community health worker (CHW) home visits and increased attendance at cervical cancer screening appointments in Cape Town, South Africa.We conducted an observational study of 5,258 CHW home visits made in 2003-4 as part of a community-based screening program. We estimated the functional relationship between spending on these visits and increased appointment attendance (adherence). Increased adherence was noted after each subsequent CHW visit. The costs of making the CHW visits was based on resource use including both personnel time and vehicle-related expenses valued in 2004 Rand. The CHW program cost R194,018, with 1,576 additional appointments attended. Adherence increased from 74% to 90%; 55% to 87%; 48% to 77%; and 56% to 80% for 6-, 12-, 24-, and 36-month appointments. Average per-woman costs increased by R14-R47. The majority of this increase occurred with the first 2 CHW visits (90%, 83%, 74%, and 77%; additional cost: R12-R26).We found that study data can be used for program planning, identifying spending levels that achieve adherence targets given budgetary constraints. The results, derived from a single disease program, are retrospective, and should be prospectively replicated.

    View details for DOI 10.1371/journal.pone.0005691

    View details for Web of Science ID 000266415100005

    View details for PubMedID 19492097

  • Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention CANADIAN JOURNAL OF ANAESTHESIA-JOURNAL CANADIEN D ANESTHESIE Goldhaber-Fiebert, S. N., Goldhaber-Fiebert, J. D., Rosow, C. E. 2009; 56 (1): 35-45


    Optimizing patient safety by improving the training of physicians is a major challenge of medical education. In this pilot study, we hypothesized that a brief lecture, targeted to rare but potentially dangerous situations, could improve anesthesia practitioners' knowledge levels with significant retention of learning at six months.In this paired controlled trial, anesthesia residents and attending physicians at Massachusetts General Hospital took the same 14-question multiple choice examination three times: at baseline, immediately after a brief lecture, and six months later. The lecture covered material on seven "intervention" questions; the remaining seven were "control" questions. The authors measured immediate knowledge acquisition, defined as the change in percentage of correct answers on intervention questions between baseline and post-lecture, and measured learning retention as the difference between baseline and six months. Both measurements were corrected for change in performance on control questions.Fifty of the 89 subjects completed all three examinations. The post-lecture increase in percentage of questions answered correctly, adjusted for control, was 22.2% [95% confidence interval (CI) 16.0-28.4%; P < 0.01], while the adjusted increase at six months was 7.9% (95% CI 1.1-14.7%; P = 0.024).A brief lecture improved knowledge, and the subjects retained a significant amount of this learning at six months. Exposing residents or other practitioners to this type of inexpensive teaching intervention may help them to avoid preventable uncommon errors that are rooted in unfamiliarity with the situation or the equipment. The methods used for this study may also be applied to compare the effect of various other teaching modalities while, at the same time, preserving participant anonymity and making adjustments for ongoing learning.

    View details for DOI 10.1007/s12630-008-9002-9

    View details for Web of Science ID 000263012800006

    View details for PubMedID 19247776

  • Trade-offs in cervical cancer prevention - Balancing benefits and risks ARCHIVES OF INTERNAL MEDICINE Stout, N. K., Goldhaber-Fiebert, J. D., Ortendahl, J. D., Goldie, S. J. 2008; 168 (17): 1881-1889


    New screening and vaccination technologies will provide women with more options for cervical cancer prevention. Because the risk of cervical cancer diminishes with effective routine screening, women may wish to consider additional attributes, such as the likelihood of false-positive results and diagnostic procedures for mild abnormalities likely to resolve without intervention in their screening choices.We used an empirically calibrated simulation model of cervical cancer in the United States to assess the benefits and potential risks associated with prevention strategies differing by primary screening test, triage test for abnormal results (cytologic testing, human papillomavirus [HPV] DNA test), and screening frequency. Outcomes included colposcopy referrals, cervical intraepithelial neoplasia (CIN) types 1 and 2 or 3, lifetime cancer risk, and quality-adjusted life expectancy.Across strategies, colposcopy referrals and diagnostic workups varied 3-fold, although diagnostic rates of CIN 2 or 3 were similar and 95% of positive screening test results were for mild abnormalities likely to resolve on their own. For a representative group of a thousand 20-year-old women undergoing triennial screening for 10 years, we expect 1038 colposcopy referrals (7 CIN 2 or 3 diagnoses) from combined cytologic and HPV DNA testing and fewer than 200 referrals (6-7 CIN 2 or 3 diagnoses) for strategies that use triage testing. Similarly, for a thousand 40-year-old women, combined cytologic and HPV DNA testing led to 489 referrals (9 CIN 2 or 3), whereas alternative strategies resulted in fewer than 150 referrals (7-8 CIN 2 or 3). Using cytologic testing followed by triage testing in younger women minimizes both diagnostic workups and positive HPV test results, whereas in older women diagnostic workups are minimized with HPV DNA testing followed by cytologic triage testing.Clinically relevant information highlighting trade-offs among cervical cancer prevention strategies allows for inclusion of personal preferences into women's decision making about screening and provides additional dimensions to the construction of clinical guidelines.

    View details for Web of Science ID 000259393000007

    View details for PubMedID 18809815

  • Cost-effectiveness of cervical cancer screening with human papillomavirus DNA testing and HPV-16,18 vaccination JOURNAL OF THE NATIONAL CANCER INSTITUTE Goldhaber-Fiebert, J. D., Stout, N. K., Salomon, J. A., Kuntz, K. M., Goldie, S. J. 2008; 100 (5): 308-320


    The availability of human papillomavirus (HPV) DNA testing and vaccination against HPV types 16 and 18 (HPV-16,18) motivates questions about the cost-effectiveness of cervical cancer prevention in the United States for unvaccinated older women and for girls eligible for vaccination.An empirically calibrated model was used to assess the quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (2004 US dollars per QALY) of screening, vaccination of preadolescent girls, and vaccination combined with screening. Screening varied by initiation age (18, 21, or 25 years), interval (every 1, 2, 3, or 5 years), and test (HPV DNA testing of cervical specimens or cytologic evaluation of cervical cells with a Pap test). Testing strategies included: 1) cytology followed by HPV DNA testing for equivocal cytologic results (cytology with HPV test triage); 2) HPV DNA testing followed by cytology for positive HPV DNA results (HPV test with cytology triage); and 3) combined HPV DNA testing and cytology. Strategies were permitted to switch once at age 25, 30, or 35 years.For unvaccinated women, triennial cytology with HPV test triage, beginning by age 21 years and switching to HPV testing with cytology triage at age 30 years, cost $78,000 per QALY compared with the next best strategy. For girls vaccinated before age 12 years, this same strategy, beginning at age 25 years and switching at age 35 years, cost $41,000 per QALY with screening every 5 years and $188,000 per QALY screening triennially, each compared with the next best strategy. These strategies were more effective and cost-effective than screening women of all ages with cytology alone or cytology with HPV triage annually or biennially.For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations.

    View details for DOI 10.1093/jnci/djn019

    View details for Web of Science ID 000253796800008

    View details for PubMedID 18314477

  • Cost-effectiveness of HPV 16, 18 vaccination in Brazil VACCINE Goldie, S. J., Kim, J. J., Kobus, K., Goldhaber-Fiebert, J. D., Salomon, J., O'Shea, M. K., Xavier Bosch, F., de Sanjose, S., Franco, E. L. 2007; 25 (33): 6257-6270


    We use an empirically calibrated model to estimate the cost-effectiveness of cervical cancer prevention in Brazil, a country with a high cervical cancer burden. Assuming 70% coverage, HPV 16, 18 vaccination of adolescent girls is expected to reduce the lifetime risk of cancer by approximately 42.7% (range, 33.2-53.5%); screening three times per lifetime is expected to reduce risk by 21.9-30.7% depending on the screening test, and a combined approach of vaccination and screening is expected to reduce cancer risk by a mean of 60.8% (range, 52.8-70.1%). In Brazil; provided the cost per vaccinated woman is less than I$ 25, implying a per dose cost of approximately I$ 5, vaccination before age 12, followed by screening three times per lifetime between ages 35 and 45, would be considered very cost-effective using the country's per capita gross domestic product as a cost-effectiveness threshold. Assuming a coverage rate of 70%, this strategy would be expected to prevent approximately 100,000 cases of invasive cervical cancer over a 5-year period. Vaccination strategies identified as cost-effective may be unaffordable in countries with similar socioeconomic profiles as Brazil without assistance; these results can provide guidance to the global community by identifying health investments of highest priority and with the greatest promise.

    View details for DOI 10.1016/j.vaccine.2007.05.058

    View details for Web of Science ID 000248905900014

    View details for PubMedID 17606315

  • Modeling human papillomavirus and cervical cancer in the United States for analyses of screening and vaccination. Population health metrics Goldhaber-Fiebert, J. D., Stout, N. K., Ortendahl, J., Kuntz, K. M., Goldie, S. J., Salomon, J. A. 2007; 5: 11-?


    To provide quantitative insight into current U.S. policy choices for cervical cancer prevention, we developed a model of human papillomavirus (HPV) and cervical cancer, explicitly incorporating uncertainty about the natural history of disease.We developed a stochastic microsimulation of cervical cancer that distinguishes different HPV types by their incidence, clearance, persistence, and progression. Input parameter sets were sampled randomly from uniform distributions, and simulations undertaken with each set. Through systematic reviews and formal data synthesis, we established multiple epidemiologic targets for model calibration, including age-specific prevalence of HPV by type, age-specific prevalence of cervical intraepithelial neoplasia (CIN), HPV type distribution within CIN and cancer, and age-specific cancer incidence. For each set of sampled input parameters, likelihood-based goodness-of-fit (GOF) scores were computed based on comparisons between model-predicted outcomes and calibration targets. Using 50 randomly resampled, good-fitting parameter sets, we assessed the external consistency and face validity of the model, comparing predicted screening outcomes to independent data. To illustrate the advantage of this approach in reflecting parameter uncertainty, we used the 50 sets to project the distribution of health outcomes in U.S. women under different cervical cancer prevention strategies.Approximately 200 good-fitting parameter sets were identified from 1,000,000 simulated sets. Modeled screening outcomes were externally consistent with results from multiple independent data sources. Based on 50 good-fitting parameter sets, the expected reductions in lifetime risk of cancer with annual or biennial screening were 76% (range across 50 sets: 69-82%) and 69% (60-77%), respectively. The reduction from vaccination alone was 75%, although it ranged from 60% to 88%, reflecting considerable parameter uncertainty about the natural history of type-specific HPV infection. The uncertainty surrounding the model-predicted reduction in cervical cancer incidence narrowed substantially when vaccination was combined with every-5-year screening, with a mean reduction of 89% and range of 83% to 95%.We demonstrate an approach to parameterization, calibration and performance evaluation for a U.S. cervical cancer microsimulation model intended to provide qualitative and quantitative inputs into decisions that must be taken before long-term data on vaccination outcomes become available. This approach allows for a rigorous and comprehensive description of policy-relevant uncertainty about health outcomes under alternative cancer prevention strategies. The model provides a tool that can accommodate new information, and can be modified as needed, to iteratively assess the expected benefits, costs, and cost-effectiveness of different policies in the U.S.

    View details for PubMedID 17967185

  • Chapter 18: Public health policy for cervical cancer prevention: the role of decision science, economic evaluation, and mathematical modeling. Vaccine Goldie, S. J., Goldhaber-Fiebert, J. D., Garnett, G. P. 2006; 24: S3 155-63


    Several factors are changing the landscape of cervical cancer control, including a better understanding of the natural history of human papillomavirus (HPV), reliable assays for detecting high-risk HPV infections, and a soon to be available HPV-16/18 vaccine. There are important differences in the relevant policy questions for different settings. By synthesizing and integrating the best available data, the use of modeling in a decision analytic framework can identify those factors most likely to influence outcomes, can guide the design of future clinical studies and operational research, can provide insight into the cost-effectiveness of different strategies, and can assist in early decision-making when considered with criteria such as equity, public preferences, and political and cultural constraints.

    View details for PubMedID 16950003

  • Public health policy for cervical cancer prevention: The role of decision science, economic evaluation, and mathematical modeling VACCINE Goldie, S. J., Goldhaber-Fiebert, J. D., Garnett, G. P. 2006; 24: 155-163
  • Estimating the cost of cervical cancer screening in five developing countries. Cost effectiveness and resource allocation : C/E Goldhaber-Fiebert, J. D., Goldie, S. J. 2006; 4: 13-?


    Cost-effectiveness analyses (CEAs) can provide useful information to policymakers concerned with the broad allocation of resources as well as to local decision makers choosing between different options for reducing the burden from a single disease. For the latter, it is important to use country-specific data when possible and to represent cost differences between countries that might make one strategy more or less attractive than another strategy locally. As part of a CEA of cervical cancer screening in five developing countries, we supplemented limited primary cost data by developing other estimation techniques for direct medical and non-medical costs associated with alternative screening approaches using one of three initial screening tests: simple visual screening, HPV DNA testing, and cervical cytology. Here, we report estimation methods and results for three cost areas in which data were lacking.To supplement direct medical costs, including staff, supplies, and equipment depreciation using country-specific data, we used alternative techniques to quantify cervical cytology and HPV DNA laboratory sample processing costs. We used a detailed quantity and price approach whose face validity was compared to an adaptation of a US laboratory estimation methodology. This methodology was also used to project annual sample processing capacities for each laboratory type. The cost of sample transport from the clinic to the laboratory was estimated using spatial models. A plausible range of the cost of patient time spent seeking and receiving screening was estimated using only formal sector employment and wages as well as using both formal and informal sector participation and country-specific minimum wages. Data sources included primary data from country-specific studies, international databases, international prices, and expert opinion. Costs were standardized to year 2000 international dollars using inflation adjustment and purchasing power parity.Cervical cytology laboratory processing costs were I$1.57-3.37 using the quantity and price method compared to I$1.58-3.02 from the face validation method. HPV DNA processing costs were I$6.07-6.59. Rural laboratory transport costs for cytology were I$0.12-0.64 and I$0.14-0.74 for HPV DNA laboratories. Under assumptions of lower resource efficiency, these estimates increased to I$0.42-0.83 and I$0.54-1.06. Estimates of the value of an hour of patient time using only formal sector participation were I$0.07-4.16, increasing to I$0.30-4.80 when informal and unpaid labor was also included. The value of patient time for traveling, waiting, and attending a screening visit was I$0.68-17.74. With the total cost of screening for cytology and HPV DNA testing ranging from I$4.85-40.54 and I$11.30-48.77 respectively, the cost of the laboratory transport, processing, and patient time accounted for 26-66% and 33-65% of the total costs. From a payer perspective, laboratory transport and processing accounted for 18-48% and 25-60% of total direct medical costs of I$4.11-19.96 and I$10.57-28.18 respectively.Cost estimates of laboratory processing, sample transport, and patient time account for a significant proportion of total cervical cancer screening costs in five developing countries and provide important inputs for CEAs of alternative screening modalities.

    View details for PubMedID 16887041

  • Cost-effectiveness of cervical-cancer screening in five developing countries NEW ENGLAND JOURNAL OF MEDICINE Goldie, S. J., Gaffikin, L., Goldhaber-Fiebert, J. D., Gordillo-Tobar, A., Levin, C., Mahe, C., Wright, T. C. 2005; 353 (20): 2158-2168


    Cervical-cancer screening strategies that involve the use of conventional cytology and require multiple visits have been impractical in developing countries.We used computer-based models to assess the cost-effectiveness of a variety of cervical-cancer screening strategies in India, Kenya, Peru, South Africa, and Thailand. Primary data were combined with data from the literature to estimate age-specific incidence and mortality rates for cancer and the effectiveness of screening for and treatment of precancerous lesions. We assessed the direct medical, time, and program-related costs of strategies that differed according to screening test, targeted age and frequency, and number of clinic visits required. Single-visit strategies involved the assumption that screening and treatment could be provided in the same day. Outcomes included the lifetime risk of cancer, years of life saved, lifetime costs, and cost-effectiveness ratios (cost per year of life saved).The most cost-effective strategies were those that required the fewest visits, resulting in improved follow-up testing and treatment. Screening women once in their lifetime, at the age of 35 years, with a one-visit or two-visit screening strategy involving visual inspection of the cervix with acetic acid or DNA testing for human papillomavirus (HPV) in cervical cell samples, reduced the lifetime risk of cancer by approximately 25 to 36 percent, and cost less than 500 dollars per year of life saved. Relative cancer risk declined by an additional 40 percent with two screenings (at 35 and 40 years of age), resulting in a cost per year of life saved that was less than each country's per capita gross domestic product--a very cost-effective result, according to the Commission on Macroeconomics and Health.Cervical-cancer screening strategies incorporating visual inspection of the cervix with acetic acid or DNA testing for HPV in one or two clinical visits are cost-effective alternatives to conventional three-visit cytology-based screening programs in resource-poor settings.

    View details for Web of Science ID 000233288600008

    View details for PubMedID 16291985

  • The costs of reducing loss to follow-up in South African cervical cancer screening. Cost effectiveness and resource allocation : C/E Goldhaber-Fiebert, J. D., Denny, L. E., De Souza, M., Wright, T. C., Kuhn, L., Goldie, S. J. 2005; 3: 11-?


    This study was designed to quantify the resources used in reestablishing contact with women who missed their scheduled cervical cancer screening visits and to assess the success of this effort in reducing loss to follow-up in a developing country setting.Women were enrolled in this Cape Town, South Africa-based screening study between 2000 and 2003, and all had scheduled follow-up visits in 2003. Community health worker (CHW) time, vehicle use, maintenance, and depreciation were estimated from weekly logs and cost accounting systems. The percentage of women who attended their scheduled visit, those who attended after CHW contact(s), and those who never returned despite attempted contact(s) were determined. The number of CHW visits per woman was also estimated.3,711 visits were scheduled in 2003. Of these, 2,321 (62.5%) occurred without CHW contact, 918 (24.8%) occurred after contact(s), and 472 (12.7%) did not occur despite contact(s). Loss to follow-up was reduced from 21% to 6%, 39% to 10%, and 50% to 24% for 6, 12, and 24-month visits. CHWs attempted 3,200 contacts in 530 trips. On average, 3 CHWs attempted to contact 6 participants over each 111 minute trip. The per-person cost (2003 Rand) for these activities was 12.75, 24.92, and 40.50 for 6, 12, and 24-month visits.CHW contact with women who missed scheduled visits increased their return rate. Cost-effectiveness analyses aimed at policy decisions about cervical cancer screening in developing countries should incorporate these findings.

    View details for PubMedID 16288646

  • Papanicolaou screening in developing countries AMERICAN JOURNAL OF CLINICAL PATHOLOGY Goldhaber-Fiebert, J. D. 2005; 124 (2): 314-315

    View details for Web of Science ID 000230770200021

    View details for PubMedID 16116686

  • Male involvement in cardiovascular preventive healthcare in two rural Costa Rican communities PREVENTIVE MEDICINE Goldhaber-Fiebert, J. D., Goldhaber-Fiebert, S. N., Andorsky, D. J. 2005; 40 (6): 690-695


    Gender differences in health system usage can lead to differences in the incidence of morbidity and mortality. We conducted a pilot screening targeted towards men to evaluate gender differences in cardiovascular disease risk factor detection and time since last clinic visit.Three evening sessions in two communities screened 148 people, mean age 47.7 years. Height, weight, body mass index, blood pressure, blood glucose, and total cholesterol were measured. A questionnaire on past medical history was administered. Participants with elevated measurements were referred to appropriate care.Men accounted for 60.1% of those screened; 65.5% of the group was overweight, and 22.3% was obese with 42.6% hypertension, 39.2% hypercholesterolemia, and 2.7% high blood glucose. Among men aged 35 to 65, 65.2% were overweight, 20.3% obese, 46.4% hypertensive, 42.0% hypercholesterolemic, and 1.5% with high blood glucose. Within the last 2 years, 53.3% of men and 9.1% of women aged 35 to 65 had not visited a doctor (P = 0.004).A significant portion of those screened had elevated cardiovascular disease risk factors. Given that men visited doctors significantly less frequently, efforts to involve men in prevention of cardiovascular disease within these communities are warranted.

    View details for DOI 10.1016/j.ypmed.2004.09.009

    View details for Web of Science ID 000229006700011

    View details for PubMedID 15850866

  • Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica DIABETES CARE Goldhaber-Fiebert, J. D., Goldhaber-Fiebert, S. N., Tristan, M. L., Nathan, D. M. 2003; 26 (1): 24-29


    The prevalence of type 2 diabetes, especially in developing countries, has grown over the past decades. We performed a controlled clinical study to determine whether a community-based, group-centered public health intervention addressing nutrition and exercise can ameliorate glycemic control and associated cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica.A total of 75 adults with type 2 diabetes, mean age 59 years, were randomly assigned to the intervention group or the control group. All participants received basic diabetes education. The subjects in the intervention group participated in 11 weekly nutrition classes (90 min each session). Subjects for whom exercise was deemed safe also participated in triweekly walking groups (60 min each session). Glycosylated hemoglobin, fasting plasma glucose, total cholesterol, triglycerides, HDL and LDL cholesterol, height, weight, BMI, and blood pressure were measured at baseline and the end of the study (after 12 weeks).The intervention group lost 1.0 +/- 2.2 kg compared with a weight gain in the control group of 0.4 +/- 2.3 kg (P = 0.028). Fasting plasma glucose decreased 19 +/- 55 mg/dl in the intervention group and increased 16 +/- 78 mg/dl in the control group (P = 0.048). Glycosylated hemoglobin decreased 1.8 +/- 2.3% in the intervention group and 0.4 +/- 2.3% in the control group (P = 0.028).Glycemic control of type 2 diabetic patients can be improved through community-based, group-centered public health interventions addressing nutrition and exercise. This pilot study provides an economically feasible model for programs that aim to improve the health status of people with type 2 diabetes.

    View details for Web of Science ID 000185504900004

    View details for PubMedID 12502654