An estimate of chronic disease burden and some economic consequences among the elderly Hong Kong population

Economic Burden of Major Diseases in China in 2013

Studies on the economic burden of disease (EBD) can estimate the social benefits of preventing or curing disease. The majority of studies focus on the economic burden of a single or regional disease; however, holistic or national research is rare in China. Estimating the national EBD can provide evidence for policy makers. We used the top-down method to assess the economic burden of 30 types of diseases between urban and rural areas in China. The two-step model was used to evaluate the direct economic burden of disease (DEBD), while the human capital method was used to assess the indirect economic burden of disease (IEBD). The total economic burden of 30 types of diseases in China was between $13.39 and 803.00 billion in 2013. The average total economic burden of disease (TEBD) in cities was $81.39 billion, while diseases in villages accounted for $50.26 billion. The range of direct and indirect EBD was $5.77-494.52 billion, and the range in urban areas was $0.61-20.34 billion. The direct and indirect EBD in rural areas accounted for $5.88-277.76 billion and $0.59-11.39 billion, respectively. There was a large difference between the economic burden of different diseases. The economic burden of urban diseases was more significant than the burden for the rural. The top five most economically burdensome diseases were myocardial infarction coronary artery bypass, acute myocardial infarction, cerebral hemorrhage, acute upper gastrointestinal bleeding and acute appendicitis.

Factors affecting fear of falls in patients with chronic stroke

Objective: The aim of this study was to find the factors associated with fear of falls in patients having chronic stroke.Methods: Inclusion criterion was subjects with cerebral stroke for more than 3 months. A structured interview of 82 subjects was conducted with a questionnaire with questions regarding personal factors such as gender, side affected, number of comorbidities, and setting of physical therapy sessions. Depression was assessed using Patient Health Questionnaire-9, lower extremity motor function was assessed using Fugl-Meyer scale, and functional mobility was assessed using Timed Up and Go. Chi-square analysis was done on the above factors to find significant factors followed by logistic regression of the factors found significant in Chi square.Results: Lower extremity Fugl-Meyer score was significantly associated with fear of falls (p value 0.047 with Odds ratio of 1.136, 95% CI 1.002-1.287) in patients having chronic stroke while treatment factors, such as setting of physical therapy sessions, and personal factors, such as gender, side affected, number of comorbidities, depression, functional mobility, or use of walking aid, were not found to have significant association.Conclusion: The lower extremity Fugl-Meyer score is associated with fear of falls in patients having chronic stroke.

Prevention of Dabigatran-Related Gastrointestinal Bleeding With Gastroprotective Agents: A Population-Based Study

BACKGROUND & AIMS

Use of dabigatran, an inhibitor of thrombin, increases the risk of gastrointestinal bleeding (GIB). However, it is not clear whether gastroprotective agents (GPAs) prevent GIB in dabigatran users. We investigated the risk of GIB and the role of gastroprotective agents (including proton pump inhibitors and histamine type-2-receptor antagonists) in patients using dabigatran.

METHODS

We performed a retrospective cohort study using a population-wide database managed by the Hong Kong Hospital Authority. Patients newly prescribed dabigatran from 2010 through 2013 were included in the analysis. Poisson regression was used to assess the risk of GIB in dabigatran users by incidence rate ratio (IRR), adjusted for patient characteristics, comorbidities, and concurrent medications.

RESULTS

Among the 5041 patients newly prescribed dabigatran, 124 (2.5%) developed GIB during follow-up evaluation (4.2/100 patient-years). The risk of GIB in this population increased among patients 75 years and older (IRR, 2.47; 95% confidence interval [CI], 1.66-3.68), patients with a history of peptic ulcers or GIB (IRR, 2.31; 95% CI, 1.54-3.46), and patients who used aspirin (IRR, 1.52; 95% CI, 1.03-2.24). Concomitant use of gastroprotective agents was associated with a reduced risk of GIB (IRR, 0.52; 95% CI, 0.35-0.77). Subcategory analysis showed that use of proton pump inhibitors (IRR, 0.53; 95% CI, 0.31-0.91) or histamine type-2-receptor antagonists (IRR, 0.61; 95% CI, 0.40-0.94) were associated with a lower risk of GIB. Further analysis showed that the risk reduction by gastroprotective agents was significant for only upper GIB (IRR, 0.29; 95% CI, 0.15-0.54), and only for patients with a prior history of peptic ulcers or GIB (IRR, 0.14; 95% CI, 0.06-0.30).

CONCLUSIONS

In the Hong Kong population, use of gastroprotective agents was associated with a reduced risk of GIB in patients taking dabigatran. The association was stronger for upper GIB than lower GIB, and in patients with a prior history of peptic ulcers or GIB.

Determinants of medication adherence and blood pressure control among hypertensive patients in Hong Kong: a cross-sectional study

INTRODUCTION

Despite effective treatments, suboptimal medication adherence substantially hinders blood pressure (BP) control among hypertensive patients. This study aimed to evaluate the determinants of medication adherence and BP control among hypertensive patients in Hong Kong.

METHODS

A cross-sectional study was conducted. Adult patients aged>18years taking at least one type of antihypertensive drugs were recruited from four clinics in Hong Kong. Each patient completed a self-administered questionnaire, including socio-demographic variables and items related to knowledge, illness perception and medication adherence. Medication adherence was measured by the eight-item Morisky Medication Adherence Scale (MMAS-8), with a score>6 defined as "good adherence". BP was measured, and optimal control was defined as systolic BP<140mmHg and diastolic BP<90mmHg.

RESULTS

Among 2445 patients, 55.1% and 52.5% had optimal medication adherence and BP control, respectively. Binary logistic regression analyses were conducted with optimal medication adherence and BP control, respectively, as the outcome variables. Advanced age (adjusted odds ratio [aOR] 1.012, 95% CI 1.002-1.022, p=0.014), unemployment (aOR for employed 0.782, 95% CI 0.628-0.975, p=0.029), and good self-perceived health status (aOR 2.155, 95% CI 1.711-2.714, p<0.001) were associated with good adherence; whereas being married (aOR 1.265, 95% CI 1.038-1.542, p=0.020) and having no co-morbidity (aOR for morbidity count 0.713, 95% CI 0.639-0.796, p<0.001) were associated with optimal BP control.

CONCLUSION

Evidence-based, adherence-enhancing interventions should be targeted on younger subjects; employed patients; and those with poor self-perceived health status. Patients who are single and those with comorbidities should be closely monitored for their BP control.

Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) accounts for around 4% of all public hospital annual admissions in Hong Kong. By year 2020, COPD will be ranked fifth among the conditions with the highest burden to the society. This study identifies admission and unplanned readmission of COPD patients, factors affecting unplanned readmission, and estimates its cost burden on the public healthcare system in Hong Kong.

METHODS

This is a retrospective study analyzing COPD admissions to all public hospitals in Hong Kong. All admission episodes to acute medical wards with the principal diagnosis of COPD (ICD-9:490-492, 494-496) from January 2006 to December 2007 were captured. Unplanned readmission was defined as an admission which followed a previous admission within 30 days.

RESULTS

In 2006 and 2007, 65497 (8.0%) of episodes from medical wards were identified as COPD admissions, and among these, 15882 (24.2%) were unplanned readmissions. The mean age of COPD patients was 76.81 ± 9.59 years and 77% were male. Unplanned readmission was significantly associated with male gender, receiving public assistance and living in nursing homes while no association was found with the Charlson comorbidity index. Patients who were readmitted unplanned had a significant longer acute length of stay (β = 0.3894, P < 0.001) after adjustment for other covariates.

CONCLUSIONS

Unplanned readmission of COPD patients has a huge impact on the public healthcare system. A systematic approach in programme provision and a good discharge planning process targeting on COPD patients who are at high risk of unplanned readmission are essential.

Aging and utilization of hospital services in Hong Kong: retrospective cohort study

OBJECTIVES

We tested the hypotheses firstly that people dying in older age groups do not use hospital services more than those dying in younger age groups in the previous 3 years before death; secondly, that there may be compression of morbidity demonstrated by a decline in the use of hospital services among people in the last 3 years before death in the older age groups.

METHODS

We extracted mortality data from all hospitals of the Hospital Authority and analyzed the data using negative binomial regression with duration of hospital stay before death as the outcome variables; age, gender, year of death (period), and birth cohort were predictor variables.

RESULTS

People dying in older age groups do not use in patient hospital services more than younger age groups in the 3 years before death. However, they do use more AED services. No compression in morbidity was demonstrated.

CONCLUSIONS

Data obtained from this retrospective study may be used to project future usage for each type of service as a result of changing age structure of the population.

Systematic review: the global incidence and prevalence of peptic ulcer disease

BACKGROUND

Peptic ulcer disease (PUD) is most commonly associated with Helicobacter pylori infection and the use of acetylsalicylic acid (ASA) and nonsteroidal anti-inflammatory drugs (NSAIDs). The management of H. pylori infection has improved radically in recent years; however, the prescription of ASA and NSAIDs has increased over the same period.

AIM

To evaluate the current global incidence and prevalence of PUD by systematic review of the literature published over the last decade.

METHODS

Systematic searches of PubMed, EMBASE and the Cochrane library.

RESULTS

The annual incidence rates of PUD were 0.10-0.19% for physician-diagnosed PUD and 0.03-0.17% when based on hospitalization data. The 1-year prevalence based on physician diagnosis was 0.12-1.50% and that based on hospitalization data was 0.10-0.19%. The majority of studies reported a decrease in the incidence or prevalence of PUD over time.

CONCLUSIONS

Peptic ulcer disease remains a common condition, although reported incidence and prevalence are decreasing. This decrease may be due to a decrease in H. pylori-associated PUD.

Impact of caregiving on health and quality of life: a comparative population-based study of caregivers for elderly persons and noncaregivers

This study aims to investigate the impact of caregiving on the health status and quality of life (QOL) of primary informal caregivers (PCGs) of elderly care recipients in Hong Kong. A total of 246 PCGs and 492 matched noncaregiver (NCG) controls were identified in a population-based cross-sectional study through random telephone dialing. Their health status and QOL were assessed based on structured questionnaires and Short Form 36 (SF-36) Health Survey. Multiple conditional logistic regression analysis showed that compared with NCGs, PCGs had significantly increased risks for reporting worse health, more doctor visits, anxiety and depression, and weight loss. Female PCGs were more likely to report chronic diseases, symptoms, and insomnia. PCGs, particularly women, had significantly lower scores in all eight domains of SF-36 Health Survey. High caregiver burden score (Zarit Burden Scale) was positively associated with adverse physical and psychological health and poorer QOL. The results indicate that PCGs, particularly women, had an adverse physical and psychological health profile and poorer QOL compared with NCGs.

Impact of Falls on the Balance, Gait, and Activities of Daily Living Functioning in Community-Dwelling Chinese Older Adults

OBJECTIVE

The objective of the present study was to investigate the impact of incident falls on the balance, gait, and Activities of Daily Living functioning in community-dwelling older adults.

METHODS

This was a population-based, 1-year prospective cohort study in older adults. We performed baseline assessment of potential predictors, the 1-year occurrence of falls, and then 1-year reassessment of the following outcome measures: the Barthel Index (BI), Lawton's Instrumental Activities of Daily Living (IADL) scale, gait speed, and Tinetti Balance and Gait Evaluation's total mobility score (TMS). At 1 year of follow-up, participants who had declined by > or = 1 standard deviation (SD) below the baseline mean value of each outcome measure were classified as "decliners."

RESULTS

Of the 1517 participants, 93.5% (n = 1419) completed the 1-year follow-up reassessment of BI and IADL. For gait speed and TMS, respectively, 88.2% (n = 1338) and 88.3% (n = 1339) completed the 1-year outcome assessment. Fallers, particularly recurrent fallers, experienced significantly greater 1-year declines in the four functional measures. Multivariate logistic regression analyses showed that an incident fall was a significant independent predictor for decliners in the BI, Lawton's IADL score, gait speed, and TMS after adjustment of all significant confounding factors. The relative risks of an incident fall as an independent predictor for decliners in the BI, IADL score, gait speed, and TMS were 2.4 (95% confidence interval [CI], 1.4-4.0; p =.01), 2.9 (95% CI, 1.7-5.2; p <.001), 2.4 (95% CI, 1.5-3.8; p <.001), and 4.6 (95% CI, 2.7-7.8; p <.001), respectively.

CONCLUSIONS

Incident falls have a significant negative impact on the balance, gait, and Activities of Daily Living functioning in community-dwelling older adults.

Cost-of-illness studies : a review of current methods

The number of cost-of-illness (COI) studies has expanded considerably over time. One outcome of this growth is that the reported COI estimates are inconsistent across studies, thereby raising concerns over the validity of the estimates and methods. Several factors have been identified in the literature as reasons for the observed variation in COI estimates. To date, the variation in the methods used to calculate costs has not been examined in great detail even though the variations in methods are a major driver of variation in COI estimates. The objective of this review was to document the variation in the methodologies employed in COI studies and to highlight the benefits and limitations of these methods. The review of COI studies was implemented following a four-step procedure: (i) a structured literature search of MEDLINE, JSTOR and EconLit; (ii) a review of abstracts using pre-defined inclusion and exclusion criteria; (iii) a full-text review using pre-defined inclusion and exclusion criteria; and (iv) classification of articles according to the methods used to calculate costs. This review identified four COI estimation methods (Sum_All Medical, Sum_Diagnosis Specific, Matched Control and Regression) that were used in categorising articles. Also, six components of direct medical costs and five components of indirect/non-medical costs were identified and used in categorising articles.365 full-length articles were reflected in the current review following the structured literature search. The top five cost components were emergency room/inpatient hospital costs, outpatient physician costs, drug costs, productivity losses and laboratory costs. The dominant method, Sum_Diagnosis Specific, was a total costing approach that restricted the summation of medical expenditures to those related to a diagnosis of the disease of interest. There was considerable variation in the methods used within disease subcategories. In several disease subcategories (e.g. asthma, dementia, diabetes mellitus), all four estimation methods were represented, and in other cases (e.g. HIV/AIDS, obesity, stroke, urinary incontinence, schizophrenia), three of the four estimation methods were represented. There was also evidence to suggest that the strengths and weaknesses of each method were considered when applying a method to a specific illness. Comparisons and assessments of COI estimates should consider the method used to estimate costs both as an important source of variation in the reported COI estimates and as a marker of the reliability of the COI estimate.

A Randomized, Controlled Trial of an Intensive Community Nurse–Supported Discharge Program in Preventing Hospital Readmissions of Older Patients with Chronic Lung Disease

OBJECTIVES

To evaluate the effectiveness of an intensive community nurse (CN)-supported discharge program in preventing hospital readmissions of older patients with chronic lung disease (CLD).

DESIGN

Randomized, controlled trial.

SETTING

Two acute hospitals in the same health region in Hong Kong.

PARTICIPANTS

One hundred fifty-seven hospitalized patients aged 60 and older with a primary diagnosis of CLD and at least one hospital admission in the previous 6 months.

INTERVENTION

CNs made home visits within 7 days of discharge, then weekly for 4 weeks and monthly until 6 months. CNs coordinated closely with a geriatric or respiratory specialist in hospital. Subjects had telephone access to CNs during normal working hours from Monday to Saturday.

MEASUREMENTS

The primary outcome was the rate of unplanned readmission within 6 months. The secondary outcomes were the rate of unplanned readmission within 28 days, number of unplanned readmissions, hospital bed days, accident and emergency room attendance, functional and psychosocial status, and caregiver burden.

RESULTS

One hundred forty hospitalized patients completed the trial. Intervention group subjects had a higher rate of unplanned readmission within 6 months than control group subjects (76% vs 62%, P=.080, chi2 test). There was no significant group difference in any of the secondary outcomes except that intervention group subjects did better on social handicap scores.

CONCLUSION

There was no evidence that an intensive CN-supported discharge program can prevent hospital readmissions in older patients with CLD.

Economic analysis of celecoxib versus diclofenac plus omeprazole for the treatment of arthritis in patients at risk of ulcer disease

AIM

To evaluate the economic impact of celecoxib therapy vs. diclofenac plus omeprazole therapy for the treatment of arthritis in Chinese patients with a high risk of bleeding, from the perspective of a public health organization in Hong Kong.

METHODS

The medical records of 287 Chinese arthritic patients with a history of bleeding ulcers who had previously participated in a randomised study of celecoxib 200 mg twice daily and extended-release diclofenac 75 mg twice daily plus 20 mg of omeprazole daily for 6 months were reviewed.

RESULTS

Compared to the diclofenac plus omeprazole group, the average total direct cost per patient in the celecoxib group showed a significant reduction of 11%, from HK 10,915 (range HK dollars 10,915-57,899) to HK dollars 9714 (range HK dollars 9714-89,770) (P<0.0001) (1 US dollars=7.8 HK dollars). The median direct medical cost for routine management in the celecoxib group was significantly lower (11%) than that for the diclofenac plus omeprazole group [HK dollars 10,915 (range 10,915-28,048) vs. HK dollars 9714 (range HK dollars 6946-26,179) (P<0.0001)]. In patients who experienced recurrent bleeding, the celecoxib group showed a significantly higher median cost of management of recurrent bleeding than the diclofenac plus omeprazole group [HK dollars 8466 (range 572-29,851) vs. HK dollars 23,210 (range HK dollars 12,318-65,823)] (P=0.036).

CONCLUSIONS

Celecoxib therapy appears to cost less compared with diclofenac plus omeprazole for treatment of arthritis in Chinese patients with a high risk of bleeding.

Arthritis treatment in Hong Kong--cost analysis of celecoxib versus conventional NSAIDS, with or without gastroprotective agents

BACKGROUND

Selective cyclo-oxygenase-2 inhibitors have been reported to cause fewer gastrointestinal complications when compared with conventional, non-selective, non-steroidal anti-inflammatory drugs (NSAIDs).

AIM

To analyse the cost of celecoxib (selective cyclo-oxygenase-2 inhibitor) and conventional NSAID regimens for the treatment of osteoarthritis and rheumatoid arthritis from the perspective of a public health organization in Hong Kong.

METHODS

A decision tree was used to analyse the cost of celecoxib, NSAID alone, NSAID plus histamine2-receptor antagonist, NSAID plus misoprostol and NSAID plus proton pump inhibitor over 6 months. Model outcomes were no gastrointestinal toxicity, gastrointestinal discomfort, symptomatic ulcer, anaemia with occult bleeding and serious gastrointestinal complications. The clinical probabilities were estimated from clinical trials. Resource utilization for gastrointestinal events was determined locally. Sensitivity analysis was performed.

RESULTS

The 6-month costs per base-case analysis were as follows: NSAID plus histamine2-receptor antagonist, 1404 HK dollars (1 US dollar = 7.8 HK dollars); celecoxib, 1545 HK dollars; NSAID alone, 1610 HK dollars; NSAID plus misoprostol, 2213 HK dollars; NSAID plus proton pump inhibitor, 2857 HK dollars. The model was sensitive to the patients' underlying gastrointestinal risk scores, daily cost of NSAID regimen, risk ratio of NSAID plus histamine2-receptor antagonist for symptomatic ulcer, daily cost of celecoxib and daily cost of histamine2-receptor antagonist.

CONCLUSIONS

Celecoxib appeared to be the least costly alternative in patients with intermediate to high gastrointestinal risk for the treatment of osteoarthritis and rheumatoid arthritis in Hong Kong.

Chronic disease, functional status, and self-ascribed causes of disabilities among noninstitutionalized older people in Spain

BACKGROUND

A major component of disability is related to chronic disease, but the study of self-reported causes of disability could add new aspects in understanding this process. The main objective of this work was to determine the associations between chronic diseases and disability and to describe the pattern of self-reported causes of the disabilities present in older persons.

METHODS

We carried out a survey in a probabilistic sample of people aged 65 and older of the city of Madrid. The initial sample size was 1001. Subjects were interviewed in their homes. We asked about the presence of 14 chronic conditions. Self-reported difficulty and dependence in 9 noninstrumental activities of daily living (ADLs) were ascertained. Subjects were asked to report the main cause responsible for the disability. Multivariate logistic regression models were constructed to estimate the association of each chronic condition with the probability of having disability.

RESULTS

Final sample size was 772 people (overall response rate 77.0%). Interviews answered by proxies were 7.5%. Only 4.5% declared no chronic condition. Osteoarthitis/rheumatism was the most prevalent condition (56.8%). In addition, 63.2% were independent, 21.3% were independent with difficulty (in at least one ADL), and 15.5% were dependent (in at least one ADL). Subjects attributed to osteoarthitis and to aging 41.8% and 17.1% of all disabilities, respectively. Chronic conditions strongly associated with disability were cerebrovascular disease (adjusted odds ratio [OR]: 3.51 [95% confidence interval: 1.44-8.60]), depression/anxiety disorders (OR: 2.72 [1.83-4.05]), and diabetes (OR: 2.18 [1.24-3.83]).

CONCLUSIONS

Cerebrovascular diseases, depression/anxiety disorders, and diabetes were the conditions more clearly related to disability. On the other hand, a large proportion of subjects attribute their disabilities to osteoarthritis and old age.

Economic analysis of four triple regimens for the treatment of Helicobacter pylori-related peptic ulcer disease in in-patient and out-patient settings in Hong Kong

BACKGROUND

One-week triple regimens have been shown to be effective for the treatment of Helicobacter pylori-related peptic ulcer disease.

AIM

To conduct an economic analysis of four triple regimens for the treatment of H. pylori-related peptic ulcer disease from the perspective of a public health organization in Hong Kong.

METHODS

Records of 200 patients with H. pylori-related peptic ulcer disease, who had previously participated in a randomized comparison of ranitidine bismuth citrate (RBC) with amoxicillin and clarithromycin (RAC), omeprazole with amoxicillin and clarithromycin (OAC), RBC with metronidazole and tetracycline (RMT), or, colloidal bismuth subcitrate with metronidazole and tetracycline (BMT) in either in-patient or out-patient setting were reviewed.

RESULTS

Fifty patients were excluded because of incomplete documentation or lack of peptic ulcer. In the out-patient group (n=72), the median direct costs of the RAC group (HK $ 5094) were lower those of the BMT (HK $ 5400), RMT (HK $ 5394), or OAC (HK $ 5440) groups, but the difference was significant only between the RAC and BMT groups (P < 0.05). In the in-patient group (n=78), the median direct costs of the RMT group (HK $ 8524) were significantly lower than those of the OAC (HK $ 13 871) and RAC (HK $ 12 092) groups (P < 0.05), but were similar to those of the BMT group (HK $ 8758).

CONCLUSIONS

RAC and RMT are the least costly regimens for out-patient and in-patient treatment, respectively, of H. pylori-related peptic ulcer disease in Hong Kong.