The determinants of individual health care expenditures in prison: evidence from Switzerland

A comparison of statistical methods for allocating disease costs in the presence of interactions

We consider the non-trivial problem of estimating a health cost repartition among diseases from patients' hospital stays' global costs in the presence of multimorbidity, that is, when the patients may suffer from more than one disease. The problem is even harder in the presence of interactions among the disease costs, that is, when the costs of having, for example, two diseases simultaneously do not match the sum of the basic costs of having each disease alone, generating an extra cost which might be either positive or negative. In such a situation, there might be no "true solution" and the choice of the method to be used to solve the problem will depend on how one wishes to allocate the extra costs among the diseases. In this article, we study mathematically how different methods proceed in this regard, namely ordinary least squares (OLS), generalized linear models (GLM), and an iterative proportional repartition (IPR) algorithm, in a simple case with only two diseases. It turned out that only IPR allowed to retrieve the total costs and the unambiguous solution that one would have in a setting without interaction, that is, when no extra cost has to be allocated, while OLS and GLM may produce some negative health costs. Also, contrary to OLS, IPR is taking into account the basic costs of the diseases for the allocation of the extra cost. We conclude that IPR seems to be the most natural method to solve the problem, at least among those considered.

Leprosy in a prison population: A new active search strategy and a prospective clinical analysis

BACKGROUND

This study evaluates an active search strategy for leprosy diagnosis based on responses to a Leprosy Suspicion Questionnaire (LSQ), and analyzing the clinical, immunoepidemiological and follow-up aspects for individuals living in a prison population.

METHODS

A cross-sectional study based on a questionnaire posing 14 questions about leprosy symptoms and signs that was distributed to 1,400 prisoners. This was followed by dermatoneurological examination, anti-PGL-I serology and RLEP-PCR. Those without leprosy were placed in the Non-leprosy Group (NLG, n = 1,216) and those diagnosed with clinical symptoms of leprosy were placed in the Leprosy Group (LG, n = 34).

FINDINGS

In total, 896 LSQ were returned (64%), and 187 (20.9%) of the responses were deemed as positive for signs/symptoms, answering 2.7 questions on average. Clinically, 1,250 (89.3%) of the prisoners were evaluated resulting in the diagnosis of 34 new cases (LG), based on well-accepted clinical signs and symptoms, a new case detection rate of 2.7% within this population, while the NLG were comprised of 1,216 individuals. The confinement time medians were 39 months in the LG while it was 36 months in the NLG (p>0.05). The 31 leprosy cases who responded to the questionnaire (LSQ+) had an average of 1.5 responses. The symptoms "anesthetized skin area" and "pain in nerves" were most commonly mentioned in the LG while "tingling, numbness in the hands/feet", "sensation of pricks and needles", "pain in nerves" and "spots on the skin" responses were found in more than 30% of questionnaires in the NLG. Clinically, 88.2% had dysesthetic macular skin lesions and 97.1% presented some peripheral nerve impairment, 71.9% with some degree of disability. All cases were multibacillary, confirming a late diagnosis. Anti-PGL-I results in the LG were higher than in the NLG (p<0.0001), while the RLEP-PCR was positive in 11.8% of the patients.

INTERPRETATION

Our findings within the penitentiary demonstrated a hidden prevalence of leprosy, although the individuals diagnosed were likely infected while living in their former communities and not as a result of exposure in the prison. The LSQ proved to be an important screening tool to help identify leprosy cases in prisons.

Estimating Health Cost Repartition Among Diseases in the Presence of Multimorbidity

We consider the nontrivial problem of estimating the health cost repartition among different diseases in the common case where the patients may have multiple diseases. To tackle this problem, we propose to use an iterative proportional repartition (IPR) algorithm, a nonparametric method which is simple to understand and to implement, allowing (among other) to avoid negative cost estimates and to retrieve the total health cost by summing up the estimated costs of the different diseases. This method is illustrated with health costs data from Switzerland and is compared in a simulation study with other methods such as linear regression and general linear models. In the case of an additive model without interactions between disease costs, a situation where the truth is clearly defined such that the methods can be compared on an objective basis, the IPR algorithm clearly outperformed the other methods with respect to efficiency of estimation in all the settings considered. In the presence of interactions, the situation is more complex and will deserve further investigation.

The Costs of Healthcare in Prison and Custody: Systematic Review of Current Estimates and Proposed Guidelines for Future Reporting

Aims: We aimed to review prison healthcare expenditure internationally. Objectives: To systematically review healthcare spending on prisoners worldwide, examine comparability between countries, and develop guidelines to improve reporting. Methods: Five bibliographic indexes (International Monetary Fund, ProQuest: Statistical Abstracts of the World, PubMed, Google Scholar, and JSTOR) were searched for the costs of prison and prison healthcare, supplemented with country-specific searches for the 20 countries with the highest prison populations. Information on overall healthcare costs, their breakdown by categories, and their proportion to overall prison expenditure was extracted. PRISMA guidelines were followed. Results: Prison healthcare expenditure data was identified for 10 countries, and overall operating costs were reported for 12 countries. The most commonly reported healthcare cost was for primary medical care. Healthcare costs reporting varied widely, and few countries were comparable. We developed a set of guidelines for consistent and transparent reporting of healthcare costs. Conclusions: Few countries report the costs of healthcare services in prison. When reported, there is a lack of clarity and consistency as to what is included. Using the proposed reporting guidelines would enable national trends and international comparisons to be investigated, and any recommended benchmarks to be monitored.