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BACKGROUND:Comorbidity adjustment is an important component of health services research and clinical prognosis. When adjusting for comorbidities in statistical models, researchers can include comorbidities individually or through the use of summary measures such as the Charlson Comorbidity Index or Elixhauser score. We examined the conditions under which individual versus summary measures are most appropriate. METHODS:We provide an analytic proof of the utility of comorbidity summary measures when used in place of individual comorbidities. We compared the use of the Charlson and Elixhauser scores versus individual comorbidities in prognostic models using a SEER-Medicare data example. We examined the ability of summary comorbidity measures to adjust for confounding using simulations. RESULTS:We devised a mathematical proof that found that the comorbidity summary measures are appropriate prognostic or adjustment mechanisms in survival analyses. Once one knows the comorbidity score, no other information about the comorbidity variables used to create the score is generally needed. Our data example and simulations largely confirmed this finding. CONCLUSIONS:Summary comorbidity measures, such as the Charlson Comorbidity Index and Elixhauser scores, are commonly used for clinical prognosis and comorbidity adjustment. We have provided a theoretical justification that validates the use of such scores under many conditions. Our simulations generally confirm the utility of the summary comorbidity measures as substitutes for use of the individual comorbidity variables in health services research. One caveat is that a summary measure may only be as good as the variables used to create it.

Despite cardiovascular diseases and cancer being the leading causes of premature mortality in the Caribbean region, there is limited local research available to guide a comprehensive response to this epidemic. To evaluate cardiovascular disease and cancer research in the Caribbean using abstracts presented at the Caribbean Public Health Agency's (CARPHA) meeting - the longest running annual research conference in the region. Study data (population, intervention/exposure, comparison and outcome) were extracted from abstracts published for the 2006 to 2018 meetings. Additionally, institutional affiliation and geographic location of the first author, countries involved, sample size, study design and use of specialized testing/biomarkers were also extracted. Data were analysed using STATA version 14. A total of 1,512 abstracts, 728 posters and 784 oral presentations were reviewed. Research on cancer and cardiovascular disease comprised approximately 15% of all abstracts published annually over the review period. Most of the cardiovascular disease studies had cross sectional or survey designs (46%), with very few laboratory-based studies (<2%) and no intervention studies/clinical trials. For cancer research, 30% were cross-sectional studies/audits, 11% were case control studies, 5% were lab based and there were no clinical trials. Almost a quarter of the cardiovascular disease / cancer abstracts over the period originated from Trinidad and Tobago (26%), with Jamaica and Barbados contributing 18% and 15% respectively. These finding highlight the need for additional studies that can provide evidence for interventions and policy to address the region's high cardiovascular disease and cancer burden. A Regional Centre of Research Excellence could support capacity development to facilitate this process.

A recently opened “time capsule” from the 1930’s reveals how the marketing of a prominent textbook on International Relations (IR) was done then and how one opinion-leading scholar responded to that textbook’s marketing, but especially, to its overall approach. The textbook was Simonds and Emeny’s The Great Powers in World Politics (1935), putatively the “most widely sold book in its field.” The scholar was Quincy Wright, one of IR’s founders and most distinguished interwar figures. This essay shares the time capsule’s background, then assesses its fascinating contents, focusing particularly on Professor Wright’s scholarly response, which until now has remained undocumented. In the interwar period, higher education was a much smaller domain than it is today, and the IR field was in its nascency. Even so, IR textbooks were being written and their publishers were already manifesting aggressive and sophisticated advocacy. In that environment, Quincy Wright proved an engaged but critical audience, having by then developed quite robust views on his subject and how it should be studied. A review of this textbook episode offers compelling vignettes of both interwar IR’s milieu and one of its most intriguing personalities. More specifically, an examination of this incident underscores the importance of a discipline’s textbooks, enriches our understanding of Quincy Wright as intellectual, scholar, and teacher, and powerfully reminds us that the questions with which Wright and the IR discipline engaged almost a century ago remain salient and their answers highly contested. Moreover, revisionist accounts of Quincy Wright’s scholarship and IR’s early stages find strong support.

ObjectiveSurveillance following colorectal cancer (CRC) resection uses optical colonoscopy (OC) to detect intraluminal disease and CT to detect extracolonic recurrence. CT colonography (CTC) might be an efficient use of resources in this situation because it allows for intraluminal and extraluminal evaluations with one test.DesignWe developed a simulation model to compare lifetime costs and benefits for a cohort of patients with resected CRC. Standard of care involved annual CT for 3 years and OC for years 1, 4 and every 5 years thereafter. For the CTC-based strategy, we replace CT+OC at year 1 with CTC. Patients with lesions greater than 6 mm detected by CTC underwent OC. Detection of an adenoma 10 mm or larger was followed by OC at 1 year, then every 3 years thereafter. Test characteristics and costs for CTC were derived from a clinical study. Medicare costs were used for cancer care costs as well as alternative test costs. We discounted costs and effects at 3% per year.ResultsFor persons with resected stage III CRC, the standard-of-care strategy was more costly (US$293) and effective (2.6 averted CRC cases and 1.1 averted cancer deaths per 1000) than the CTC-based strategy, with an incremental cost-effectiveness ratio of US$55 500 per quality-adjusted life-year gained. Our analysis was most sensitive to the sensitivity of CTC for detecting polyps 10 mm or larger and assumptions about disease progression.ConclusionIn a simulation model, we found that replacing the standard-of-care approach to postdiagnostic surveillance with a CTC-based strategy is not an efficient use of resources in most situations.

Purpose. As part of a clinical trial comparing the utility of computed tomographic colonography (CTC) and optical colonoscopy (OC) for post colorectal cancer resection surveillance, we explored the diagnostic yield and costs of a strategy of CTC followed by OC if a polyp is observed (abbreviated CTC_S), versus OC 1 year following curative bowel resection, using the detection of actionable polyps on OC as the criterion. Methods. Using data from 231 patients who underwent same-day CTC followed by OC, we created a decision tree that outlined the choices and outcomes at 1-year clinical follow-up. Colorectal polyp prevalence, sensitivity, and specificity of CTC were compared with five exemplary studies and meta-analyses. Detection criteria were derived for ≥6 mm or ≥10 mm polyps. OC was the gold standard. Costs were gleaned from cataloging components of the cases at the principal investigator’s institution. Analyses included marginal cost of the OC strategy to detect additional actionable polyps and number of polyps missed per 10,000 patients. Results. At our prevalence of 0.156 for ≥6 mm (0.043 ≥10 mm), CTC_S would miss 779 ≥6 mm actionable polyps per 10,000 patients (≥10 mm: 173 per 10,000). Cost to detect an additional ≥6 mm polyp in this cohort is $5,700 (≥10 mm: $28,000). Sensitivity analyses demonstrate that any improvement in performance characteristics would raise the cost of OC to detect more actionable polyps. Similar results were seen using Medicare costs, or when literature values were used for performance characteristics. Conclusion. At an action threshold of ≥6 mm, OC costs at least $5,700 per extra polyp detected relative to CTC_S in patients undergoing surveillance after colorectal cancer surgery, on the order of incremental cost-effectiveness ratios found for other clinical problems involving short-term events.

Cost-Effectiveness Analysis of Telemedicine to Evaluate Diabetic Retinopathy in a Prison Population Noriaki Aoki , MD 1 2 , Kim Dunn , MD 1 3 , Tsuguya Fukui , MD 4 , J. Robert Beck , MD 5 , William J. Schull , PHD 3 and Helen K. Li , MD 6 1 School of Health Information Sciences, University of Texas Health Science Center–Houston, Houston, Texas 2 Center for Health Service, Outcomes Research and Development–Japan (CHORD-J), Tokyo, Japan 3 The Schull Institute, Houston, Texas 4 Department of General Medicine and Clinical Epidemiology, Kyoto University Graduate School of Medicine, Kyoto, Japan 5 Department of Information Science and Technology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 6 Department of Ophthalmology and Visual Sciences, the University of Texas Medical Branch, Galveston, Texas Address correspondencereprint requests to Noriaki Aoki, MD, PhD, MS, FJSIM Assistant Professor, School of Health Information Sciences, University of Texas, Health Science Center–Houston, 7000 Fannin, UCT-600, Houston, TX 77030. E-mail: noriaki.aoki{at}uth.tmc.edu Abstract OBJECTIVE —A cost-effectiveness analysis was conducted to investigate the clinical and economic impact of teleophthalmology in evaluating diabetic retinopathy in prison inmates with type 2 diabetes. RESEARCH DESIGN AND METHODS —Based on a hypothetical teleophthalmology system to evaluate diabetic retinopathy patients with type 2 diabetes in a prison care setting, a Markov decision model was developed with probability and cost data derived primarily from published epidemiological and outcome studies. A 40-year-old African-American man with type 2 diabetes was used as a reference case subject. The number of quality-adjusted life-years (QALYs) gained was used as the clinical outcome, and the cost in U.S. dollars from the year 2003 was used as the economic outcome. Teleophthalmology and nonteleophthalmology strategies were compared using an expected QALYs calculation and two types of sensitivity analyses: probabilistic and traditional n -way sensitivity analyses. RESULTS —The teleophthalmology strategy dominates in the cost-effectiveness analysis for the reference case subject: $16,514/18.73 QALYs for teleophthalmology and $17,590/18.58 QALYs for nonteleophthalmology. Ninety percent of the Monte Carlo simulations showed cost effectiveness (annual cost/QALYs ≤$50,000) in the teleophthalmology strategy based on an assumed inmate population. Teleophthalmology is the better strategy if the number of diabetic inmates in the prison community is >500. CONCLUSIONS —Our cost-effectiveness analysis demonstrates that teleophthalmology holds great promise to reduce the cost of inmate care and reduce blindness caused by diabetic retinopathy in type 2 diabetic patients. ICER, incremental-effectiveness ratio NNS, number needed to screen QALY, quality-adjusted life-year UTMB, University of Texas Medical Branch at Galveston Footnotes The authors have no financial interests in the products or devices mentioned in this study. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted January 26, 2004. Received May 8, 2003. DIABETES CARE

Symbolizing immortality and diversity, banyans are the national spiritual trees of India and Indonesia. We photographed apparent human figures embedded in banyans that served as evidence for questions concerning the origins of religion in archaic peoples and the use of art as a means of personal spiritual development. Two primary questions guided this inquiry. First, did the appearance of human forms in the banyans serve archaic peoples as a source of spirituality and religious belief? In this study, the photographs were treated as “sacred objects” for exploring possible phenomena and states of consciousness through which archaic peoples may have developed religious beliefs. Second, how can art be used to commune with nature for personal spiritual development? This study involved our suspension of disbelief in the supernatural, aesthetic criticism of each photograph, and provisional identification of the categories of spirits they might represent, including fertility and procreation, death, wisdom, and mythological animals. We compared our understanding of the identity of these deities with Hindu beliefs about the banyan, notably their depiction of gods as embedded in the trees, just as our photographs portrayed. We developed a relationship with the spirits that gave rise to spontaneous dialogues that were enlightening and stimulated our spiritual self-development. Our research motivated us to support and sustain the life of banyan trees and the protection of nature in general.

Background/Aims: Diverse samples in clinical trials can make findings more generalizable. We sought to characterize the prevalence of clinical trials in the United States that required English fluency for participants to enroll in the trial. Methods: We randomly chose over 10,000 clinical trial protocols registered with ClinicalTrials.gov and examined the inclusion and exclusion criteria of the trials. We compared the relationship of clinical trial characteristics with English fluency inclusion requirements. We merged the ClinicalTrials.gov data with US Census and American Community Survey data to investigate the association of English-language restrictions with ZIP-code-level demographic characteristics of participating institutions. We used Chi-squared tests, t-tests, and logistic regression models for analyses. Results: English fluency requirements have been increasing over time, from 1.7% of trials having such requirements before 2000 to 9.0% after 2010 (p < 0.001 from Chi-squared test). Industry-sponsored trials had low rates of English fluency requirements (1.8%), while behavioral trials had high rates (28.4%). Trials opening in the Northeast of the United States had the highest regional English requirement rates (10.7%), while trials opening in more than one region had the lowest (3.3%, p < 0.001). Since 1995, trials opening in ZIP codes with larger Hispanic populations were less likely to have English fluency requirements (odds ratio = 0.92 for each 10% increase in proportion of Hispanics, 95% confidence interval = 0.86–0.98, p = 0.013). Trials opening in ZIP codes with more residents self-identifying as Black/African American (odds ratio = 1.87, 95% confidence interval = 1.36–2.58, p < 0.001 for restricted cubic spline term) or Asian (odds ratio = 1.16 for linear term, 95% confidence interval = 1.07–1.25, p < 0.001) were more likely to have English fluency requirements. ZIP codes with higher poverty rates had trials with more English-language restrictions (odds ratio = 1.06 for a 10% poverty rate increase, 95% confidence interval = 1.001–1.11, p = 0.045). There was a statistically significant interaction between year and intervention type, such that the increase in English fluency requirements was more common for some interventions than for others. Conclusion: The proportion of clinical trials registered with ClinicalTrials.gov that have English fluency requirements for study inclusion has been increasing over time. English-language restrictions are associated with a number of characteristics, including the demographic characteristics of communities in which the sponsoring institutions are located.

This article recounts the author's experience of teaching International Law as a \"blended\" or \"hybrid\" course. In hybrid teaching, a significant portion of the learning activities is moved online, and time traditionally spent in the classroom is reduced but not eliminated. The article first briefly reviews the literature on international law pedagogy. Next, it describes the particular context within which the author redesigned the author's traditional course. It thereafter highlights the key aspects of the author's redesigned course. Finally, it shares some practical lessons that the author has learned and more general conclusions that the author has reached in hybrid teaching.