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Kovács SD. Patient autonomy in the era of the sustainability crisis. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024:10.1007/s11019-024-10214-x. [PMID: 38850497 DOI: 10.1007/s11019-024-10214-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Abstract
In the realm of medical ethics, the foundational principle of respecting patient autonomy holds significant importance, often emerging as a central concern in numerous ethically complex cases, as authorizing medical assistance in dying or healthy limb amputation on patient request. Even though advocates for either alternative regularly utilize prima facie principles to resolve ethical dilemmas, the interplay between these principles is often the core of the theoretical frameworks. As the ramifications of the sustainability crisis become increasingly evident, there is a growing need to integrate awareness for sustainability into medical decision-making, thus reintroducing potential conflict with patient autonomy. The contention of this study is that the ethical standards established in the 20th century may not adequately address the challenges that have arisen in the 21st century. The author suggests an advanced perception of patient autonomy that prioritizes fostering patients' knowledge, self-awareness, and sense of responsibility, going beyond a sole focus on their intrinsic values. Empowering patients could serve as a tool to align patient autonomy, beneficence, and the aim to reduce resource consumption.
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Affiliation(s)
- Szilárd Dávid Kovács
- Institute of Behavioural Sciences, Semmelweis University, Budapest, 1089, Hungary.
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Mulligan K, Baid D, Doctor JN, Phelps CE, Lakdawalla DN. Risk preferences over health: Empirical estimates and implications for medical decision-making. JOURNAL OF HEALTH ECONOMICS 2024; 94:102857. [PMID: 38232447 DOI: 10.1016/j.jhealeco.2024.102857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
Mainstream health economic theory implies that an expected gain in health-related quality of life (HRQoL) produces the same value for consumers, regardless of baseline health. Several strands of recent research call this implication into question. Generalized Risk-Adjusted Cost-Effectiveness (GRACE) demonstrates theoretically that baseline health status influences value, so long as consumers are not risk-neutral over health. Prior empirical literature casts doubt on risk-neutral expected utility-maximization in the health domain. We estimate utility over HRQoL in a nationally representative U.S. population and use our estimates to measure risk preferences over health. We find that individuals are risk-seeking at low levels of health, become risk-averse at health equal to 0.485 (measured on a 0-1 scale), and are most risk-averse at perfect health (coefficient of relative risk aversion = 4.51). We develop the resulting implications for medical decision making, cost-effectiveness analyses, and the proper theory of health-related decision making under uncertainty.
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Affiliation(s)
- Karen Mulligan
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Drishti Baid
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Charles E Phelps
- Department of Economics, University of Rochester, 238 Harkness Hall, 280 Hutchison Road, Box 270156, Rochester, NY, 14627, USA
| | - Darius N Lakdawalla
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA; School of Pharmacy, University of Southern California, 1985 Zonal Ave, Los Angeles, CA, 90089, USA.
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Zhu XB, Niu ZH, Fan WM, Sheng CS, Chen Q. Type 2 diabetes mellitus and the risk of male infertility: a Mendelian randomization study. Front Endocrinol (Lausanne) 2023; 14:1279058. [PMID: 38152129 PMCID: PMC10752377 DOI: 10.3389/fendo.2023.1279058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/15/2023] [Indexed: 12/29/2023] Open
Abstract
Objective To assess the causal effect of type 2 diabetes mellitus (T2DM) on male infertility (MI) and erectile dysfunction (ED) by Mendelian randomization (MR) analysis. Methods Data for T2DM, MI, and ED were obtained from genome-wide association studies (GWAS) involving 298, 957, 73, 479, and 223, 805 Europeans, respectively. We performed univariate MR analysis using MR Egger, Weighted median (WM) and Inverse variance weighted (IVW) methods to assess causal effects among the three. Through the Genotype Tissue Expression (GTEx) database, single-nucleotide polymorphisms (SNPs) that affect the expression levels of T2DM-related genes were located using expression quantitative trait loci (eQTL). Results MR analysis showed a significant causal relationship between T2DM and ED (WM, OR: 1.180, 95%CI: 1.010-1.378, P = 0.037; IVW, OR: 1.190, 95%CI: 1.084-1.300, P < 0.001). There is also a significant causal relationship between T2DM and MI (MR Egger, OR: 0.549, 95%CI: 0.317-0.952, P = 0.037; WM, OR: 0.593, 95%CI: 0.400, P = 0.010; IVW, OR: 0.767, 95%CI: 0.600-0.980, P = 0.034). ED may not cause MI (P > 0.05). We also found that rs6585827 corresponding to the PLEKHA1 gene associated with T2DM is an eQTL variant affecting the expression of this gene. Conclusion T2DM has a direct causal effect on ED and MI. The level of PLEKHA1 expression suppressed by rs6585827 is potentially associated with a lower risk of T2DM.
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Affiliation(s)
- Xiao-Bin Zhu
- Department of Gynecology and Obstetrics, Reproductive Medical Center, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Hong Niu
- Department of Gynecology and Obstetrics, Reproductive Medical Center, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei-Min Fan
- Department of Gynecology and Obstetrics, Reproductive Medical Center, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chang-Sheng Sheng
- Department of Cardiovascular Medicine, Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluation, Shanghai Key Lab of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qian Chen
- Department of Gynecology and Obstetrics, Reproductive Medical Center, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Yuan S, Wu Y. Effectiveness and cost-effectiveness of six GLP-1RAs for treatment of Chinese type 2 diabetes mellitus patients that inadequately controlled on metformin: a micro-simulation model. Front Public Health 2023; 11:1201818. [PMID: 37744474 PMCID: PMC10513082 DOI: 10.3389/fpubh.2023.1201818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Objective To systematically estimate and compare the effectiveness and cost-effectiveness of the glucagon-like peptide-1 receptor agonists (GLP-1RAs) approved in China and to quantify the relationship between the burden of diabetic comorbidities and glycosylated hemoglobin (HbA1c) or body mass index (BMI). Methods To estimate the costs (US dollars, USD) and quality-adjusted life years (QALY) for six GLP-1RAs (exenatide, loxenatide, lixisenatide, dulaglutide, semaglutide, and liraglutide) combined with metformin in the treatment of patients with type 2 diabetes mellitus (T2DM) which is inadequately controlled on metformin from the Chinese healthcare system perspective, a discrete event microsimulation cost-effectiveness model based on the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME) simulation model was developed. A cohort of 30,000 Chinese patients was established, and one-way sensitivity analysis and probabilistic sensitivity analysis (PSA) with 50,000 iterations were conducted considering parameter uncertainty. Scenario analysis was conducted considering the impacts of research time limits. A network meta-analysis was conducted to compare the effects of six GLP-1RAs on HbA1c, BMI, systolic blood pressure, and diastolic blood pressure. The incremental net monetary benefit (INMB) between therapies was used to evaluate the cost-effectiveness. China's per capita GDP in 2021 was used as the willingness-to-pay threshold. A generalized linear model was used to quantify the relationship between the burden of diabetic comorbidities and HbA1c or BMI. Results During a lifetime, the cost for a patient ranged from USD 42,092 with loxenatide to USD 47,026 with liraglutide, while the QALY gained ranged from 12.50 with dulaglutide to 12.65 with loxenatide. Compared to exenatide, the INMB of each drug from highest to lowest were: loxenatide (USD 1,124), dulaglutide (USD -1,418), lixisenatide (USD -1,713), semaglutide (USD -4,298), and liraglutide (USD -4,672). Loxenatide was better than the other GLP-1RAs in the base-case analysis. Sensitivity and scenario analysis results were consistent with the base-case analysis. Overall, the price of GLP-1RAs most affected the results. Medications with effective control of HbA1c or BMI were associated with a significantly smaller disease burden (p < 0.05). Conclusion Loxenatide combined with metformin was identified as the most economical choice, while the long-term health benefits of patients taking the six GLP-1RAs are approximate.
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Affiliation(s)
| | - Yingyu Wu
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
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Hao J, Yao Q, Lin Y, Sun Y, Zhang B, Hu M, Zhang J, Zhao N, Pei J, Liu Z, Zhu C. Cost-effectiveness of two screening strategies based on Chinese diabetes risk score for pre-diabetes in China. Front Public Health 2022; 10:1018084. [PMID: 36530668 PMCID: PMC9747942 DOI: 10.3389/fpubh.2022.1018084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/14/2022] [Indexed: 12/05/2022] Open
Abstract
Objective Studies have shown that screening for pre-diabetes mellitus (pre-DM) is essential to prevent type 2 diabetes mellitus (T2DM). This study evaluates the cost-effectiveness of two screening strategies that apply the Chinese Diabetes Risk Score (CDRS) to screen for pre-DM in China. Methods A Markov microsimulation model was conducted from a social perspective, and the input parameters were obtained from published literature or publicly available data. Two screening strategies for pre-DM based on CDRS were built and compared with the control group to determine the cost-effective strategy. The screening strategy of the control group was screening for pre-DM by fasting plasma glucose (FPG) test in adults undergoing annual health examination and no screening in adults without an annual health examination (status quo). Two screening strategies were strategy 1: screening for pre-DM using CDRS in all adults (including with or without an annual health examination); and strategy 2: supplemental self-screening for pre-DM using CDRS in adults without an annual health examination, based on the status quo. We focus on the cumulative prevalence of T2DM and the incremental cost-effectiveness ratio which signifies the cost per case of T2DM prevented. We also evaluated the cost-effectiveness from the health system perspective. One-way and probabilistic sensitivity analyses were conducted to verify the robustness of the results. Results The costs a case of T2DM prevented for strategy 1 compared with the control group and strategy 2 were $299.67 (95% CI 298.88, 300.46) and $385.89 (95% CI 381.58, 390.20), respectively. In addition, compared with the control group, the cost of strategy 2 to prevent a case of T2DM was $272.23 (95% CI 271.50, 272.96). Conclusions Screening for pre-DM using CDRS in all adults was the most cost-effective health policy. We suggest that medical institutions replace FPG with CDRS for pre-DM screening; at the same time, self-screening for pre-DM using CDRS is widely promoted among adults without an annual health examination. There were still some disputes about how CDRS is included in the health examination projects, so strategy 2 should be considered as an alternative screening strategy. Findings provide a reference for the application of the CDRS in pre-DM screening and contribute to T2DM prevention.
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Affiliation(s)
- Jingjing Hao
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Qiang Yao
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yidie Lin
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yue Sun
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Baiyang Zhang
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Meijing Hu
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jing Zhang
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing, China
| | - Ningxuan Zhao
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jiao Pei
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Zhonghua Liu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China,*Correspondence: Zhonghua Liu
| | - Cairong Zhu
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China,Cairong Zhu
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Dahal PK, Rawal LB, Mahumud RA, Paudel G, Sugishita T, Vandelanotte C. Economic Evaluation of Health Behavior Interventions to Prevent and Manage Type 2 Diabetes Mellitus in Asia: A Systematic Review of Randomized Controlled Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10799. [PMID: 36078539 PMCID: PMC9518060 DOI: 10.3390/ijerph191710799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 06/15/2023]
Abstract
Health behavior interventions implemented in Asian countries often lack economic evaluations that effectively address the problems of type 2 diabetes mellitus. This review systematically assessed the existing literature on economic evaluation of health behavior interventions to prevent and manage type 2 diabetes mellitus for people living in Asian countries. Eligible studies were identified through a search of six bibliographic databases, namely, PubMed, Scopus, Public Health Database by ProQuest, Cumulative Index to Nursing and Allied Health Literature Complete, Web of Science, and Google Scholar. Randomized controlled trials of health behavior interventions and studies published in the English language from January 2000 to May 2022 were included in the review. The search yielded 3867 records, of which 11 studies were included in the review. All included studies concluded that health behavior interventions were cost-effective. Eight of these studies undertook an evaluation from a health system perspective, two studies used both societal and health system perspectives, and one study utilized a societal and multi-payer perspective. This review identified the time horizon, direct and indirect medical costs, and discount rates as the most important considerations in determining cost effectiveness. These findings have implications in extending health behavior interventions to prevent and manage type 2 diabetes mellitus in low-resource settings, and are likely to yield the most promising outcomes for people with type 2 diabetes mellitus.
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Affiliation(s)
- Padam Kanta Dahal
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney, NSW 2000, Australia or
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Rockhampton, QLD 4702, Australia
| | - Lal B. Rawal
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney, NSW 2000, Australia or
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Rockhampton, QLD 4702, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Sydney, NSW 2751, Australia
| | - Rashidul Alam Mahumud
- NHRMC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Grish Paudel
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney, NSW 2000, Australia or
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Rockhampton, QLD 4702, Australia
| | - Tomohiko Sugishita
- Section of Global Health, Division of Public Health, Department of Public Health, Tokyo Women’s Medical University, Tokyo 162-8666, Japan
| | - Corneel Vandelanotte
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Rockhampton, QLD 4702, Australia
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Fan J, Peng T, Hui J, Ding W, He B, Zhang H, Wei A. Erectile Dysfunction in Type-2 Diabetes Mellitus Patients: Predictors of Early Detection and Treatment. Urol Int 2021; 105:986-992. [PMID: 33951654 DOI: 10.1159/000514700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/24/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE To identify risk factors and potential predictors of erectile dysfunction (ED) in type-2 diabetes mellitus (T2DM) patients for early detection and treatment. METHODS A retrospective cohort was used to assess the clinical data of 105 diabetic patients with ED from May 2019 to April 2020 age-matched to 105 diabetic patients without ED. Potential risk factors that could contribute to ED were compared between the groups. Erectile function was evaluated using the International Index of Erectile Function-5 questionnaire. RESULTS There were higher rates of diabetic peripheral neuropathy (p = 0.036) and retinopathy (p < 0.001), longer duration of diabetes (p < 0.001), lower estimated glomerular filtration rate (p = 0.010) values, and higher uric acid (p < 0.001) and C-reactive protein (p = 0.001) levels in the ED group compared to the non-ED group. Multivariate logistic analysis identified uric acid, diabetic retinopathy, and T2DM course as independent predictors of diabetic ED. Diabetics with retinopathy and T2DM for ≥49 months were 3.028 and 3.860 times more likely to have ED, respectively. Uric acid values ≥392.5 μmol/L were associated with 18.638 times greater risk of having ED, though the values were within normal range. CONCLUSION In T2DM patients, higher uric acid (≥392.5 μmol/L), longer diabetes duration (≥49 months), and the presence of diabetic retinopathy were important and reliable predictors for diabetic ED. For patients who have high risk factors for developing ED, diligent screening and early treatment are necessary.
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Affiliation(s)
- Junhong Fan
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tianwen Peng
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jialiang Hui
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei Ding
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Department of Urology, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Binglin He
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Haibo Zhang
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Anyang Wei
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Zhou X, Zhang P. Response to Comment on Zhou et al. Cost-effectiveness of Diabetes Prevention Interventions Targeting High-risk Individuals and Whole Populations: A Systematic Review. Diabetes Care 2020;43:1593-1616. Diabetes Care 2020; 43:e206-e207. [PMID: 33218987 DOI: 10.2337/dci20-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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