1
|
Hasan MZ, Rabbani MG, Akter O, Mehdi GG, Ahmed MW, Ahmed S, Chowdhury ME. Patient Satisfaction With the Health Care Services of a Government-Financed Health Protection Scheme in Bangladesh: Cross-Sectional Study. JMIR Form Res 2024; 8:e49815. [PMID: 38656783 DOI: 10.2196/49815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 10/07/2023] [Accepted: 11/22/2023] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Since 2016, the government of Bangladesh has been piloting a health protection scheme known as Shasthyo Surokhsha Karmasuchi (SSK), which specifically targets households living below the poverty line. This noncontributory scheme provides enrolled households access to inpatient health care services for 78 disease groups. Understanding patients' experiences with health care utilization from the pilot SSK scheme is important for enhancing the quality of health care service delivery during the national-level scale-up of the scheme. OBJECTIVE We aimed to evaluate patient satisfaction with the health care services provided under the pilot health protection scheme in Bangladesh. METHODS A cross-sectional survey was conducted with the users of the SSK scheme from August to November 2019. Patients who had spent a minimum of 2 nights at health care facilities were selected for face-to-face exit interviews. During these interviews, we collected information on patients' socioeconomic characteristics, care-seeking experiences, and level of satisfaction with various aspects of health care service delivery. To measure satisfaction, we employed a 5-point Likert scale (very satisfied, 5; satisfied, 4; neither satisfied nor dissatisfied, 3; dissatisfied, 2; very dissatisfied, 1). Descriptive statistics, statistical inferential tests (t-test and 1-way ANOVA), and linear regression analyses were performed. RESULTS We found that 55.1% (241/438) of users were either very satisfied or satisfied with the health care services of the SSK scheme. The most satisfactory indicators were related to privacy maintained during diagnostic tests (mean 3.91, SD 0.64), physicians' behaviors (mean 3.86, SD 0.77), services provided at the registration booth (mean 3.86, SD 0.62), confidentiality maintained regarding diseases (mean 3.78, SD 0.72), and nurses' behaviors (mean 3.60, SD 0.83). Poor satisfaction was identified in the interaction of patients with providers about illness-related information (mean 2.14, SD 1.40), availability of drinking water (mean 1.46, SD 0.76), cleanliness of toilets (mean 2.85, SD 1.04), and cleanliness of the waiting room (mean 2.92, SD 1.09). Patient satisfaction significantly decreased by 0.20 points for registration times of 16-30 minutes and by 0.32 points for registration times of >30 minutes compared with registration times of ≤15 minutes. Similarly, patient satisfaction significantly decreased with an increase in the waiting time to obtain services. However, the satisfaction of users significantly increased if they received a complete course of medicines and all prescribed diagnostic services. CONCLUSIONS More than half of the users were satisfied with the services provided under the SSK scheme. However, there is scope for improving user satisfaction. To improve the satisfaction level, the SSK scheme implementation authorities should pay attention to reducing the registration time and waiting time to obtain services and improving the availability of drugs and prescribed diagnostic services. The authorities should also ensure the supply of drinking water and enhance the cleanliness of the facility.
Collapse
Affiliation(s)
- Md Zahid Hasan
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Md Golam Rabbani
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Orin Akter
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Gazi Golam Mehdi
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | | | - Sayem Ahmed
- Health Economics and Health Technology Assessment, School of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | | |
Collapse
|
2
|
Hasan MZ, Ahmed S, Mehdi GG, Ahmed MW, Arifeen SE, Chowdhury ME. The effectiveness of a government-sponsored health protection scheme in reducing financial risks for the below-poverty-line population in Bangladesh. Health Policy Plan 2024; 39:281-298. [PMID: 38164712 DOI: 10.1093/heapol/czad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 11/09/2023] [Indexed: 01/03/2024] Open
Abstract
The Government of Bangladesh is piloting a non-contributory health protection scheme called Shasthyo Surokhsha Karmasuchi (SSK) to increase access to quality essential healthcare services for the below-poverty-line (BPL) population. This paper assesses the effect of the SSK scheme on out-of-pocket expenditure (OOPE) for healthcare, catastrophic health expenditure (CHE) and economic impoverishment of the enrolled population. A comparative cross-sectional study was conducted in Tangail District, where the SSK was implemented. From August 2019 to March 2020, a total of 2315 BPL households (HHs) (1170 intervention and 1145 comparison) that had at least one individual with inpatient care experience in the last 12 months were surveyed. A household is said to have incurred CHE if their OOPE for healthcare exceeds the total (or non-food) HH's expenditure threshold. Multiple regression analysis was performed using OOPE, incidence of CHE and impoverishment as dependent variables and SSK membership status, actual BPL status and benefits use status as the main explanatory variables. Overall, the OOPE was significantly lower (P < 0.01) in the intervention areas (Bangladeshi Taka (BDT) 23 366) compared with the comparison areas (BDT 24 757). Regression analysis revealed that the OOPE, CHE incidence at threshold of 10% of total expenditure and 40% of non-food expenditure and impoverishment were 33% (P < 0.01), 46% (P < 0.01), 42% (P < 0.01) and 30% (P < 0.01) lower, respectively, in the intervention areas than in the comparison areas. Additionally, HHs that utilized SSK benefits experienced even lower OOPE by 92% (P < 0.01), CHE incidence at 10% and 40% threshold levels by 72% (P < 0.01) and 59% (P < 0.01), respectively, and impoverishment by 27% at 10% level of significance. These findings demonstrated the significant positive effect of the SSK in reducing financial burdens associated with healthcare utilization among the enrolled HHs. This illustrates the importance of the nationwide scaling up of the scheme in Bangladesh to reduce the undue financial risk of healthcare utilization for those in poverty.
Collapse
Affiliation(s)
- Md Zahid Hasan
- Health Systems and Population Studies Division, icddr,b, Dhaka 1212, Bangladesh
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds LS2 9NL, UK
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds LS2 9NL, UK
| | - Sayem Ahmed
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, 90 Byres Road, Glasgow G12 8TB, UK
- Centre for Health Economics and Medicines Evaluation, Bangor University, Ardudwy, Normal Site, Holyhead Road, Gwynedd, Wales LL57 2PZ, UK
| | - Gazi Golam Mehdi
- Health Systems and Population Studies Division, icddr,b, Dhaka 1212, Bangladesh
| | | | - Shams El Arifeen
- Maternal and Child Health Division, icddr,b, Dhaka 1212, Bangladesh
| | | |
Collapse
|
3
|
Hasan MZ, Ahmed S, Islam Z, Dorin F, Rabbani MG, Mehdi GG, Ahmed MW, Tahsina T, Mahmood SS, Islam Z. Costs of services and funding gap of the Bangladesh National Tuberculosis Control Programme 2016-2022: An ingredient based approach. PLoS One 2023; 18:e0286560. [PMID: 37267308 DOI: 10.1371/journal.pone.0286560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Bangladesh National Tuberculosis (TB) Control Programme (NTP) has deployed improved diagnostic technologies which may drive up the programme costs. We aimed to estimate the supply-side costs associated with the delivery of the NTP and the funding gap between the cost of implementation and available funding for the Bangladesh NTP. METHODS An ingredient-based costing approach was applied using WHO's OneHealth Tool software. We considered 2016, as the base year and projected cost estimates up to 2022 using information on NTP planned activities. Data were collected through consultative meetings with experts and officials/managers, review of documents and databases, and visits to five purposively selected TB healthcare facilities. The estimated costs were compared with the funds allocated to the NTP between 2018 and 2022 to estimate the funding gap. FINDINGS The estimated total cost of NTP was US$ 49.22 million in 2016, which would increase to US$ 146.93 million in 2022. Human resources (41.1%) and medicines and investigations/ supplies (38.0%) were the major two cost components. Unit costs were highest for treating extensively drug-resistant TB at US$ 7,422.4 in 2016. Between 2018-2022, NTP would incur US$ 536.8 million, which is US$ 235.18 million higher than the current allocation for NTP. CONCLUSION Our results indicated a funding gap associated with the NTP in each of the years between 2018-2022. Policy planners should advocate for additional funding to ensure smooth delivery of TB services in the upcoming years. The cost estimates of TB services can also be used for planning and budgeting for delivering TB services in similar country contexts.
Collapse
Affiliation(s)
- Md Zahid Hasan
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Sayem Ahmed
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Zeenat Islam
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Dorin
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Golam Rabbani
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Gazi Golam Mehdi
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Wahid Ahmed
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tazeen Tahsina
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shehrin Shaila Mahmood
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ziaul Islam
- Health Economics and Financing, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| |
Collapse
|
4
|
Hasan MZ, Ahmed MW, Mehdi GG, Khan JAM, Islam Z, Chowdhury ME, Ahmed S. Factors affecting the healthcare utilization from Shasthyo Suroksha Karmasuchi scheme among the below-poverty-line population in one subdistrict in Bangladesh: a cross sectional study. BMC Health Serv Res 2022; 22:885. [PMID: 35804366 PMCID: PMC9270808 DOI: 10.1186/s12913-022-08254-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Financing healthcare through out-of-pocket (OOP) payment is a major barrier in accessing healthcare for the poor people. The Health Economics Unit (HEU) of the Ministry of Health and Family Welfare of the government of Bangladesh has developed Shasthyo Suroksha Karmasuchi (SSK), a health protection scheme, with the aim of reducing OOP expenditure and improving access of the below-poverty-line (BPL) population to healthcare. The scheme started piloting in 2016 at Kalihati sub-district of Tangail District. Our objective was to assess healthcare utilization by the enrolled BPL population and to identify the factors those influencing their utilization of the scheme. METHOD A cross-sectional household survey was conducted from July to September 2018 in the piloting sub-district. A total of 806 households were surveyed using a semi-structured questionnaire. Information on illness and sources of healthcare service were captured for the last 90 days before the survey. Multiple logistic regression models were applied to determine the factors related to utilization of healthcare from the SSK scheme and other medically trained providers (MTPs) by the SSK members for both inpatient and outpatient care. RESULT A total of 781 (24.6%) people reported of suffering from illness of which 639 (81.8%) sought healthcare from any sources. About 8.0% (51 out of 639) of them sought healthcare from SSK scheme and 28.2% from other MTPs within 90 days preceding the survey. Households with knowledge about SSK scheme were more likely to utilize healthcare from the scheme and less likely to utilize healthcare from other MTPs. Non-BPL status and suffering from an accident/injury were significantly positively associated with utilization of healthcare from SSK scheme. CONCLUSION Among the BPL population, healthcare utilization from the SSK scheme was very low compared to that of other MTPs. Effective strategies should be in place for improving knowledge of BPL population on SSK scheme and the benefits package of the scheme should be updated as per the need of the target population. Such initiative can be instrumental in increasing utilization of the scheme and ultimately will reduce the barriers of OOP payment among BPL population for accessing healthcare.
Collapse
Affiliation(s)
- Md Zahid Hasan
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh. .,Leeds Institute of Health Sciences, University of Leeds, 6 Clarendon Way, Woodhouse, LS2 9NL, Leeds, UK.
| | - Mohammad Wahid Ahmed
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Gazi Golam Mehdi
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Jahangir A M Khan
- Health Economics and Policy Unit, School of Public Health and Community Medicine, University of Gothenburg, Medicinaregatan 18A, 405 30, Gothenburg, Sweden
| | - Ziaul Islam
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mahbub Elahi Chowdhury
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Sayem Ahmed
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| |
Collapse
|
5
|
Li X, Ahmed MW, Banu A, Bartram C, Crowe B, Downie EJ, Emamian M, Feldman G, Gao H, Godagama D, Grießhammer HW, Howell CR, Karwowski HJ, Kendellen DP, Kovash MA, Leung KKH, Markoff DM, McGovern JA, Mikhailov S, Pywell RE, Sikora MH, Silano JA, Sosa RS, Spraker MC, Swift G, Wallace P, Weller HR, Whisnant CS, Wu YK, Zhao ZW. Proton Compton Scattering from Linearly Polarized Gamma Rays. Phys Rev Lett 2022; 128:132502. [PMID: 35426711 DOI: 10.1103/physrevlett.128.132502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/14/2021] [Accepted: 03/18/2022] [Indexed: 06/14/2023]
Abstract
Differential cross sections for Compton scattering from the proton have been measured at scattering angles of 55°, 90°, and 125° in the laboratory frame using quasimonoenergetic linearly (circularly) polarized photon beams with a weighted mean energy value of 83.4 MeV (81.3 MeV). These measurements were performed at the High Intensity Gamma-Ray Source facility at the Triangle Universities Nuclear Laboratory. The results are compared to previous measurements and are interpreted in the chiral effective field theory framework to extract the electromagnetic dipole polarizabilities of the proton, which gives α_{E1}^{p}=13.8±1.2_{stat}±0.1_{BSR}±0.3_{theo},β_{M1}^{p}=0.2∓1.2_{stat}±0.1_{BSR}∓0.3_{theo} in units of 10^{-4} fm^{3}.
Collapse
Affiliation(s)
- X Li
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - M W Ahmed
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- Department of Mathematics and Physics, North Carolina Central University, Durham, North Carolina, 27707, USA
| | - A Banu
- Department of Physics and Astronomy, James Madison University, Harrisonburg, Virginia 22807, USA
| | - C Bartram
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27516, USA
| | - B Crowe
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- Department of Mathematics and Physics, North Carolina Central University, Durham, North Carolina, 27707, USA
| | - E J Downie
- Institute for Nuclear Studies, Department of Physics, The George Washington University, Washington, D.C. 20052, USA
| | - M Emamian
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - G Feldman
- Institute for Nuclear Studies, Department of Physics, The George Washington University, Washington, D.C. 20052, USA
| | - H Gao
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - D Godagama
- Department of Physics and Astronomy, University of Kentucky, Lexington, Kentucky 40506, USA
| | - H W Grießhammer
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Institute for Nuclear Studies, Department of Physics, The George Washington University, Washington, D.C. 20052, USA
| | - C R Howell
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - H J Karwowski
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27516, USA
| | - D P Kendellen
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - M A Kovash
- Department of Physics and Astronomy, University of Kentucky, Lexington, Kentucky 40506, USA
| | - K K H Leung
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- Department of Physics and Astronomy, Montclair State University, Montclair, New Jersey 07043, USA
| | - D M Markoff
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- Department of Mathematics and Physics, North Carolina Central University, Durham, North Carolina, 27707, USA
| | - J A McGovern
- Theoretical Physics Group, Department of Physics and Astronomy, University of Manchester, Manchester M13 9PL, United Kingdom
| | - S Mikhailov
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - R E Pywell
- Department of Physics and Engineering Physics, University of Saskatchewan, Saskatoon, Saskatchewan, S7N 5E2, Canada
| | - M H Sikora
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- Institute for Nuclear Studies, Department of Physics, The George Washington University, Washington, D.C. 20052, USA
| | - J A Silano
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27516, USA
| | - R S Sosa
- Department of Mathematics and Physics, North Carolina Central University, Durham, North Carolina, 27707, USA
| | - M C Spraker
- Department of Physics and Astronomy, University of North Georgia, Dahlonega, Georgia 30597, USA
| | - G Swift
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - P Wallace
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - H R Weller
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - C S Whisnant
- Department of Physics and Astronomy, James Madison University, Harrisonburg, Virginia 22807, USA
| | - Y K Wu
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| | - Z W Zhao
- Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708-0308, USA
| |
Collapse
|
6
|
Ahmed S, Hasan MZ, Ali N, Ahmed MW, Haq E, Shabnam S, Chowdhury M, Gahan B, Bousquet C, Khan JAM, Islam Z. Effectiveness of health voucher scheme and micro-health insurance scheme to support the poor and extreme poor in selected urban areas of Bangladesh: An assessment using a mixed-method approach. PLoS One 2021; 16:e0256067. [PMID: 34723992 PMCID: PMC8559931 DOI: 10.1371/journal.pone.0256067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/29/2021] [Indexed: 11/19/2022] Open
Abstract
Background National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes. Methods HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care. Results Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme. Conclusion HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider’s costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage.
Collapse
Affiliation(s)
- Sayem Ahmed
- Mathematical Modelling Group, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
- * E-mail:
| | - Md. Zahid Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nausad Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Bangladesh Institute of Development Studies (BIDS), Agargaon, Dhaka, Bangladesh
| | - Mohammad Wahid Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | | | | | | | - Jahangir A. M. Khan
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
- Health Economics and Policy Unit, School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ziaul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| |
Collapse
|
7
|
Ahmed S, Ahmed MW, Hasan MZ, Mehdi GG, Islam Z, Rehnberg C, Niessen LW, Khan JAM. Assessing the incidence of catastrophic health expenditure and impoverishment from out-of-pocket payments and their determinants in Bangladesh: evidence from the nationwide Household Income and Expenditure Survey 2016. Int Health 2021; 14:84-96. [PMID: 33823538 PMCID: PMC8769950 DOI: 10.1093/inthealth/ihab015] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 02/01/2021] [Accepted: 03/08/2021] [Indexed: 12/04/2022] Open
Abstract
Background Out-of-pocket (OOP) payments for healthcare have been increasing steadily in Bangladesh, which deteriorates the financial risk protection of many households. Methods We aimed to investigate the incidence of catastrophic health expenditure (CHE) and impoverishment from OOP payments and their determinants. We employed nationally representative Household Income and Expenditure Survey 2016 data with a sample of 46 076 households. A household that made OOP payments of >10% of its total or 40% of its non-food expenditure was considered to be facing CHE. We estimated the impoverishment using both national and international poverty lines. Multiple logistic models were employed to identify the determinants of CHE and impoverishment. Results The incidence of CHE was estimated as 24.6% and 10.9% using 10% of the total and 40% of non-food expenditure as thresholds, respectively, and these were concentrated among the poor. About 4.5% of the population (8.61 million) fell into poverty during 2016. Utilization of private facilities, the presence of older people, chronic illness and geographical location were the main determinants of both CHE and impoverishment. Conclusion The financial hardship due to OOP payments was high and it should be reduced by regulating the private health sector and covering the care of older people and chronic illness by prepayment-financing mechanisms.
Collapse
Affiliation(s)
- Sayem Ahmed
- Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.,Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City 700000, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Mohammad Wahid Ahmed
- Health Economics and Financing Research, Health Systems and Population Studies Division, icddr, b, Dhaka, Bangladesh
| | - Md Zahid Hasan
- Health Economics and Financing Research, Health Systems and Population Studies Division, icddr, b, Dhaka, Bangladesh
| | - Gazi Golam Mehdi
- Health Economics and Financing Research, Health Systems and Population Studies Division, icddr, b, Dhaka, Bangladesh
| | - Ziaul Islam
- Health Economics and Financing Research, Health Systems and Population Studies Division, icddr, b, Dhaka, Bangladesh
| | - Clas Rehnberg
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Louis W Niessen
- Liverpool School of Tropical Medicine, Liverpool, UK.,Department of International Health, Johns Hopkins School of Public Health, USA
| | - Jahangir A M Khan
- Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.,School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
8
|
Ahmed S, Sarma H, Hasan Z, Rahman M, Ahmed MW, Islam MA, Djimeu EW, Mbuya MNN, Ahmed T, Khan JAM. Cost-effectiveness of a market-based home fortification of food with micronutrient powder programme in Bangladesh. Public Health Nutr 2021; 24:s59-s70. [PMID: 33118899 PMCID: PMC8042576 DOI: 10.1017/s1368980020003602] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/12/2020] [Accepted: 09/01/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We estimated the cost-effectiveness of home fortification with micronutrient powder delivered in a sales-based programme in reducing the prevalence of Fe deficiency anaemia among children 6-59 months in Bangladesh. DESIGN Cross-sectional interviews with local and central-level programme staff and document reviews were conducted. Using an activity-based costing approach, we estimated start-up and implementation costs of the programme. The incremental cost per anaemia case averted and disability-adjusted life years (DALY) averted were estimated by comparing the home fortification programme and no intervention scenarios. SETTING The home fortification programme was implemented in 164 upazilas (sub-districts) in Bangladesh. PARTICIPANTS Caregivers of child 6-59 months and BRAC staff members including community health workers were the participants for this study. RESULTS The home fortification programme had an estimated total start-up cost of 35·46 million BDT (456 thousand USD) and implementation cost of 1111·63 million BDT (14·12 million USD). The incremental cost per Fe deficiency anaemia case averted and per DALY averted was estimated to be 1749 BDT (22·2 USD) and 12 558 BDT (159·3 USD), respectively. Considering per capita gross domestic product (1516·5 USD) as the cost-effectiveness threshold, the home fortification programme was highly cost-effective. The programme coverage and costs for nutritional counselling of the beneficiary were influential parameters for cost per DALY averted in the one-way sensitivity analysis. CONCLUSIONS The market-based home fortification programme was a highly cost-effective mechanism for delivering micronutrients to a large number of children in Bangladesh. The policymakers should consider funding and sustaining large-scale sales-based micronutrient home fortification efforts assuming the clear population-level need and potential to benefit persists.
Collapse
Affiliation(s)
- Sayem Ahmed
- Health Systems and Population Studies Division, icddr,b, Dhaka1212, Bangladesh
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
- Liverpool School of Tropical Medicine, Pembroke Place, LiverpoolL3 5QA, United Kingdom
| | - Haribondhu Sarma
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
- Research School of Population Health, The Australian National University, Acton, Australia
| | - Zahid Hasan
- Health Systems and Population Studies Division, icddr,b, Dhaka1212, Bangladesh
| | - Mahfuzur Rahman
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | | | - Eric W Djimeu
- Global Alliance for Improve Nutrition, Dhaka, Bangladesh
| | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Jahangir AM Khan
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
- Liverpool School of Tropical Medicine, Pembroke Place, LiverpoolL3 5QA, United Kingdom
- Health Economics and Policy Unit, School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
9
|
Ahmed S, Hasan MZ, Laokri S, Jannat Z, Ahmed MW, Dorin F, Vargas V, Khan JAM. Technical efficiency of public district hospitals in Bangladesh: a data envelopment analysis. Cost Eff Resour Alloc 2019; 17:15. [PMID: 31367193 PMCID: PMC6657139 DOI: 10.1186/s12962-019-0183-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 07/10/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND District hospitals (DHs) provide secondary level of healthcare to a wide range of population in Bangladesh. Efficient utilization of resources in these secondary hospitals is essential for delivering health services at a lower cost. Therefore, we aimed to estimate the technical efficiency of the DHs in Bangladesh. METHODS We used input-oriented data envelopment analysis method to estimate the variable returns to scale (VRS) and constant returns to scale (CRS) technical efficiency of the DHs using data from Local Health Bulletin, 2015. In this model, we considered workforce as well as number of inpatient beds as input variables and number of inpatient, outpatient, and maternal services provided by the DHs as output variables. A Tobit regression model was applied for assessing the association of institutional and environmental characteristics with the technical efficiency scores. RESULTS The average scale, VRS, and CRS technical efficiency of the DHs were estimated to 85%, 92%, and 79% respectively. Population size, poverty headcount, bed occupancy ratio, administrative divisions were significantly associated with the technical efficiency of the DHs. The mean VRS and CRS technical efficiency demonstrated that the DHs, on an average, could reduce their input mix by 8% and 21% respectively while maintaining the same level of output. CONCLUSION Since the average technical efficiency of the DHs was 79%, there is little scope for overall improvements in these facilities by adjusting inputs. Therefore, we recommend to invest further in the DHs for improvement of services. The Ministry of Health and Family Welfare (MoHFW) should improve the efficiency in resource allocation by setting an input-mix formula for DHs considering health and socio-economic indicators (e.g., population density, poverty, bed occupancy ratio). The formula can be designed by learning from the input mix in the more efficient DHs. The MoHFW should conduct this kind of benchmarking study regularly to assess the efficiency level of health facilities which may contribute to reduce the wastage of resources and consequently to provide more affordable and accessible public hospital care.
Collapse
Affiliation(s)
- Sayem Ahmed
- Health Systems and Population Studies Division, icddr,b, Dhaka, 1212 Bangladesh
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, SE-171 77 Stockholm, Sweden
- Department of Tropical Biology, Liverpool School of Tropical Medicine, Liverpool, L3 5QA UK
| | - Md. Zahid Hasan
- Health Systems and Population Studies Division, icddr,b, Dhaka, 1212 Bangladesh
| | - Samia Laokri
- Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112 USA
| | - Zerin Jannat
- Department of Economics, Stockholm University, SE-106 91 Stockholm, Sweden
| | | | - Farzana Dorin
- Health Systems and Population Studies Division, icddr,b, Dhaka, 1212 Bangladesh
| | - Veronica Vargas
- Alberto Hurtado University, Santiago, Chile
- The Lakshmi Mittal And Family South Asia Institute, Harvard University, Cambridge, MA 02138 USA
| | - Jahangir A. M. Khan
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, SE-171 77 Stockholm, Sweden
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA UK
| |
Collapse
|
10
|
Ahmed S, Hasan MZ, MacLennan M, Dorin F, Ahmed MW, Hasan MM, Hasan SM, Islam MT, Khan JAM. Measuring the efficiency of health systems in Asia: a data envelopment analysis. BMJ Open 2019; 9:e022155. [PMID: 30918028 PMCID: PMC6475137 DOI: 10.1136/bmjopen-2018-022155] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 12/01/2018] [Accepted: 01/08/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study aims to estimate the technical efficiency of health systems in Asia. SETTINGS The study was conducted in Asian countries. METHODS We applied an output-oriented data envelopment analysis (DEA) approach to estimate the technical efficiency of the health systems in Asian countries. The DEA model used per-capita health expenditure (all healthcare resources as a proxy) as input variable and cross-country comparable health outcome indicators (eg, healthy life expectancy at birth and infant mortality per 1000 live births) as output variables. Censored Tobit regression and smoothed bootstrap models were used to observe the associated factors with the efficiency scores. A sensitivity analysis was performed to assess the consistency of these efficiency scores. RESULTS The main findings of this paper demonstrate that about 91.3% (42 of 46 countries) of the studied Asian countries were inefficient with respect to using healthcare system resources. Most of the efficient countries belonged to the high-income group (Cyprus, Japan, and Singapore) and only one country belonged to the lower middle-income group (Bangladesh). Through improving health system efficiency, the studied high-income, upper middle-income, low-income and lower middle-income countries can improve health system outcomes by 6.6%, 8.6% and 8.7%, respectively, using the existing level of resources. Population density, bed density, and primary education completion rate significantly influenced the efficiency score. CONCLUSION The results of this analysis showed inefficiency of the health systems in most of the Asian countries and imply that many countries may improve their health system efficiency using the current level of resources. The identified inefficient countries could pay attention to benchmarking their health systems within their income group or other within similar types of health systems.
Collapse
Affiliation(s)
- Sayem Ahmed
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Md Zahid Hasan
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mary MacLennan
- Department of Social Policy, London School of Economics and Political Science, London, United Kingdom
| | - Farzana Dorin
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Wahid Ahmed
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Mehedi Hasan
- Institute for Social Science Research, The University of Queensland, Indooroopilly, Queensland, Australia
| | - Shaikh Mehdi Hasan
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Jahangir A M Khan
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
11
|
Ahmed S, Hasan MZ, Ahmed MW, Dorin F, Sultana M, Islam Z, Mirelman AJ, Rehnberg C, Khan JAM, Chowdhury ME. Evaluating the implementation related challenges of Shasthyo Suroksha Karmasuchi (health protection scheme) of the government of Bangladesh: a study protocol. BMC Health Serv Res 2018; 18:552. [PMID: 30012139 PMCID: PMC6048757 DOI: 10.1186/s12913-018-3337-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 06/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapidly increasing healthcare costs and the growing burden of non-communicable diseases have increased the out-of-pocket (OOP) spending (63.3% of total health expenditure) in Bangladesh. This increasing OOP spending for healthcare has catastrophic economic impact on households. To reduce this burden, the Health Economics Unit (HEU) of the Ministry of Health and Family Welfare has developed the Shasthyo Surokhsha Karmasuchi (SSK) health protection scheme for the below-poverty line (BPL) population. The key actors in the scheme are HEU, contracted scheme operator and hospital. Under this scheme, each enrolled household is provided 50,000 BDT (620 USD) coverage per year for healthcare services against a government financed premium of 1000 BDT (12 USD). This initiative faces some challenges e.g., delays in scheme activities, registering the targeted population, low utilization of services, lack of motivation of the providers, and management related difficulties. It is also important to estimate the financial requirement for nationwide scale-up of this project. We aim to identify these implementation-related challenges and provide feedback to the project personnel. METHODS This is a concurrent process documentation using mixed-method approaches. It will be conducted in the rural Kalihati Upazila where the SSK is being implemented. To validate the BPL population selection process, we will estimate the positive predictive value. A community survey will be conducted to assess the knowledge of the card holders about SSK services. From the SSK information management system, numbers of different services utilized by the card holders will be retrieved. Key-informant interviews with personnel from three key actors will be conducted to understand the barriers in the implementation of the project as per plan and gather their suggestions. To estimate the project costs, all inputs to be used will be identified, quantified and valued. The nationwide scale-up cost of the project will be estimated by applying economic modeling. DISCUSSION SSK is the first ever government initiated health protection scheme in Bangladesh. The study findings will enable decision makers to gain a better understanding of the key challenges in implementation of such scheme and provide feedback towards the successful implementation of the program.
Collapse
Affiliation(s)
- Sayem Ahmed
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh. .,Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.
| | - Md Zahid Hasan
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mohammad Wahid Ahmed
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Farzana Dorin
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Marufa Sultana
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.,School of Health and Social Development, Deakin University, Melbourne, Australia
| | - Ziaul Islam
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | | | - Clas Rehnberg
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Jahangir A M Khan
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mahbub Elahi Chowdhury
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| |
Collapse
|
12
|
Sarker AR, Sultana M, Mahumud RA, Ahmed S, Ahmed MW, Hoque ME, Islam Z, Gazi R, Khan JAM. Effects of occupational illness on labor productivity: A socioeconomic aspect of informal sector workers in urban Bangladesh. J Occup Health 2016; 58:209-15. [PMID: 27010089 PMCID: PMC5356968 DOI: 10.1539/joh.15-0219-fs] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: The informal sector is the dominant area of employment and the economy for any developing country including Bangladesh. The cost of productivity loss due to absence from work or presenteeism with illness has rarely been examined in the Bangladesh context. This current study, therefore, attempted to examine the impact of ill health of informal sector workers on labor productivity, future earning, and healthcare-related expenditure. Methodology: A cross-sectional survey was conducted among three occupational groups of informal workers (rickshaw pullers, shopkeepers and restaurant workers) that were generally found in all urban areas in Bangladesh. A total of 557 informal workers were surveyed for this study. Results: Most of the respondents (57%) reported that they had been affected by some type of illness for the last six months. The overall average healthcare expenditure of informal workers was US$48.34, while restaurant workers expended more (US$53.61). Self reported sickness absenteeism was highest (50.37days) in the case of shop keepers, followed by rickshaw pullers (49.31 days), in the last six months. Considering the income loss due to illness in the past six months, the rickshaw pullers were exposed to the highest income loss (US$197.15), followed by the shop keepers (US$151.39). Conclusions: Although the informal sector contributes the most to the economy of Bangladesh, the workers in this sector have hardly any financial protection. This study provides critical clues to providing financial and social protection to informal sector workers in Bangladesh.
Collapse
Affiliation(s)
- Abdur Razzaque Sarker
- Health Economics & Financing Research Group, International Centre for Diarrhoeal Disease Research
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Laskaris G, Ye Q, Lalremruata B, Ye QJ, Ahmed MW, Averett T, Deltuva A, Dutta D, Fonseca AC, Gao H, Golak J, Huang M, Karwowski HJ, Mueller JM, Myers LS, Peng C, Perdue BA, Qian X, Sauer PU, Skibiński R, Stave S, Tompkins JR, Weller HR, Witała H, Wu YK, Zhang Y, Zheng W. First measurements of spin-dependent double-differential cross sections and the Gerasimov-Drell-Hearn Integrand from 3He(γ,n)pp at incident photon energies of 12.8 and 14.7 MeV. Phys Rev Lett 2013; 110:202501. [PMID: 25167400 DOI: 10.1103/physrevlett.110.202501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Indexed: 06/03/2023]
Abstract
The first measurement of the three-body photodisintegration of longitudinally polarized (3)He with a circularly polarized γ-ray beam was carried out at the High Intensity γ-ray Source facility located at Triangle Universities Nuclear Laboratory. The spin-dependent double-differential cross sections and the contributions from the three-body photodisintegration to the (3)He Gerasimov-Drell-Hearn integrand are presented and compared with state-of-the-art three-body calculations at the incident photon energies of 12.8 and 14.7 MeV. The data reveal the importance of including the Coulomb interaction between protons in three-body calculations.
Collapse
Affiliation(s)
- G Laskaris
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - Q Ye
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - B Lalremruata
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - Q J Ye
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - M W Ahmed
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA and Department of Mathematics and Physics, North Carolina Central University, Durham, North Carolina 27707, USA
| | - T Averett
- College of William and Mary, Williamsburg, Virginia 23187, USA
| | - A Deltuva
- Centro de Física Nuclear da Universidade de Lisboa, P-1649-003 Lisboa, Portugal
| | - D Dutta
- Mississippi State University, Mississippi State, Mississippi 39762, USA
| | - A C Fonseca
- Centro de Física Nuclear da Universidade de Lisboa, P-1649-003 Lisboa, Portugal
| | - H Gao
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - J Golak
- M. Smoluchowski Institute of Physics, Jagiellonian University, PL-30059 Kraków, Poland
| | - M Huang
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - H J Karwowski
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics and Astronomy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - J M Mueller
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - L S Myers
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - C Peng
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - B A Perdue
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - X Qian
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - P U Sauer
- Institut für Theoretische Physik, Leibniz Universität Hannover, D-30167 Hannover, Germany
| | - R Skibiński
- M. Smoluchowski Institute of Physics, Jagiellonian University, PL-30059 Kraków, Poland
| | - S Stave
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - J R Tompkins
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics and Astronomy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - H R Weller
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - H Witała
- M. Smoluchowski Institute of Physics, Jagiellonian University, PL-30059 Kraków, Poland
| | - Y K Wu
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - Y Zhang
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| | - W Zheng
- Triangle Universities Nuclear Laboratory, Durham, North Carolina 27708, USA and Department of Physics, Duke University, Durham, North Carolina 27708, USA
| |
Collapse
|
14
|
Zimmerman WR, Ahmed MW, Bromberger B, Stave SC, Breskin A, Dangendorf V, Delbar T, Gai M, Henshaw SS, Mueller JM, Sun C, Tittelmeier K, Weller HR, Wu YK. Unambiguous identification of the second 2+ state in 12C and the structure of the Hoyle state. Phys Rev Lett 2013; 110:152502. [PMID: 25167256 DOI: 10.1103/physrevlett.110.152502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/01/2013] [Indexed: 05/28/2023]
Abstract
The second J(π)=2+ state of 12C, predicted over 50 years ago as an excitation of the Hoyle state, has been unambiguously identified using the 12C(γ,α0)(8)Be reaction. The alpha particles produced by the photodisintegration of 12C were detected using an optical time projection chamber. Data were collected at beam energies between 9.1 and 10.7 MeV using the intense nearly monoenergetic gamma-ray beams at the HIγS facility. The measured angular distributions determine the cross section and the E1-E2 relative phases as a function of energy leading to an unambiguous identification of the second 2+ state in 12C at 10.03(11) MeV, with a total width of 800(130) keV and a ground state gamma-decay width of 60(10) meV; B(E2:2(2)+→0(1)+)=0.73(13)e(2) fm(4) [or 0.45(8) W.u.]. The Hoyle state and its rotational 2+ state that are more extended than the ground state of 12C presents a challenge and constraints for models attempting to reveal the nature of three alpha-particle states in 12C. Specifically, it challenges the ab initio lattice effective field theory calculations that predict similar rms radii for the ground state and the Hoyle state.
Collapse
Affiliation(s)
- W R Zimmerman
- Department of Physics, University of Connecticut, Storrs, Connecticut 06269-3046, USA and Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
| | - M W Ahmed
- Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA and Department of Mathematics and Physics, North Carolina Central University, Durham, North Carolina 27707, USA
| | - B Bromberger
- Physikalisch-Technische Bundesanstalt, 38116 Braunschweig, Germany
| | - S C Stave
- Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
| | - A Breskin
- Department of Particle Physics and Astrophysics, Weizmann Institute of Science, 76100 Rehovot, Israel
| | - V Dangendorf
- Physikalisch-Technische Bundesanstalt, 38116 Braunschweig, Germany
| | - Th Delbar
- Department of Physics, Universite Catholique de Louvain, 1348 Louvain-la-Neuve, Belgium
| | - M Gai
- Department of Physics, University of Connecticut, Storrs, Connecticut 06269-3046, USA and Department of Physics, Yale University, New Haven, Connecticut 06520-8124, USA
| | - S S Henshaw
- Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
| | - J M Mueller
- Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
| | - C Sun
- Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
| | - K Tittelmeier
- Physikalisch-Technische Bundesanstalt, 38116 Braunschweig, Germany
| | - H R Weller
- Department of Physics, University of Connecticut, Storrs, Connecticut 06269-3046, USA and Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
| | - Y K Wu
- Triangle Universities Nuclear Laboratory and Department of Physics, Duke University, Durham, North Carolina 27708-0308, USA
| |
Collapse
|
15
|
Majumder MI, Haque MM, Ahmed MW, Alam MN, Rahman MW, Akter F, Basher A, Maude RJ, Faiz MA. Melioidosis in an adult male. Mymensingh Med J 2013; 22:413-416. [PMID: 23715373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Infection with Burkholderia pseudomallei has been described, albeit rarely, patients in Bangladesh. Infection usually follows percutaneous inoculation or inhalation of the causative bacterium, which is present in soil and surface water in the endemic region. A 35-year-young male farmer presented with prolonged fever and significant weight loss. Patient gradually deteriorated despite getting different antibiotics including intravenous ceftriaxone and metronidazole. Panels of investigations were done which revealed no diagnostic confirmation except uncontrolled diabetes and multiple abscesses in different organs. Melioidosis was suspected and serum samples were positive for Burkholderia pseudomallei antibody. The case illustrates the importance of non-specific nature of the clinical presentation and high index of suspicion of uncommon diseases like melioidosis where the disease has not been considered as an endemic.
Collapse
Affiliation(s)
- M I Majumder
- Department of Medicine, Sir Salimullah Medical College (SSMC), Mitford Hospital, Dhaka, Bangladesh
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Raut R, Tornow W, Ahmed MW, Crowell AS, Kelley JH, Rusev G, Stave SC, Tonchev AP. Photodisintegration cross section of the reaction (4)He(γ,p)(3)H between 22 and 30 MeV. Phys Rev Lett 2012; 108:042502. [PMID: 22400829 DOI: 10.1103/physrevlett.108.042502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Indexed: 05/31/2023]
Abstract
The two-body photodisintegration cross section of (4)He into a proton and triton was measured with monoenergetic photon beams in 0.5 MeV energy steps between 22 and 30 MeV. High-pressure (4)He-Xe gas scintillators of various (4)He/Xe ratios served as targets and detectors. Pure Xe gas scintillators were used for background studies. A NaI detector together with a plastic scintillator paddle was employed for determining the incident photon flux. Our comprehensive data set follows the trend of the theoretical calculations of the Trento group very well, although our data are consistently lower in magnitude by about 5%. However, they differ significantly from the majority of the previous data, especially from the recent data of Shima et al. The latter data had put into question the validity of theoretical approaches used to calculate core-collapse supernova explosions and big-bang nucleosynthesis abundances of certain light nuclei.
Collapse
Affiliation(s)
- R Raut
- Duke University, Durham, North Carolina 27708-0308, USA
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Henshaw SS, Ahmed MW, Feldman G, Nathan AM, Weller HR. New method for precise determination of the isovector giant quadrupole resonances in nuclei. Phys Rev Lett 2011; 107:222501. [PMID: 22182024 DOI: 10.1103/physrevlett.107.222501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Indexed: 05/31/2023]
Abstract
The intense, nearly monoenergetic, 100% polarized γ-ray beams available at the HIγS facility, along with the realization that the E1-E2 interference term that appears in the Compton scattering polarization observable has opposite signs in the forward and backward angles, make it possible to obtain an order-of-magnitude improvement in the determination of the parameters of the isovector giant quadrupole resonance (IVGQR). Accurate IVGQR parameters will lead to a more detailed knowledge of the symmetry energy in the nuclear equation of state which is important for understanding nuclear matter under extreme conditions such as those present in neutron stars. Our new method is demonstrated for the case of (209)Bi.
Collapse
Affiliation(s)
- S S Henshaw
- Department of Physics and Triangle Universities Nuclear Laboratory, Duke University, TUNL Box 90308, Durham, North Carolina 27708-0308, USA
| | | | | | | | | |
Collapse
|
18
|
Pietralla N, Berant Z, Litvinenko VN, Hartman S, Mikhailov FF, Pinayev IV, Swift G, Ahmed MW, Kelley JH, Nelson SO, Prior R, Sabourov K, Tonchev AP, Weller HR. Parity measurements of nuclear levels using a free-electron-laser generated gamma-ray beam. Phys Rev Lett 2002; 88:012502. [PMID: 11800940 DOI: 10.1103/physrevlett.88.012502] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2001] [Indexed: 05/23/2023]
Abstract
The quality and intensity of gamma rays at the High Intensity gamma-ray Source are shown to make nuclear resonance fluorescence studies possible at a new level of precision and efficiency. First experiments have been carried out using an intense (10(7) gamma/s) beam of 100% linearly polarized, nearly monoenergetic, gamma rays on the semimagic nucleus (138)Ba. Negative parity quantum numbers have been assigned to 18 dipole excitations of (138)Ba between 5.5 MeV and 6.5 MeV from azimuthal gamma-intensity asymmetries.
Collapse
Affiliation(s)
- N Pietralla
- A.W. Wright Nuclear Structure Laboratory, Yale University, New Haven, Connecticut 06520, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
BACKGROUND Signal-averaged ECG (SAECG) reproducibility is reported to have a component that is independent of residual noise. Methods and Results-In group 1, multiple paired SAECGs were obtained to noise levels of 0.3+/-0.1 and 0.5+/-0.2 microV. For the 0.5- and 0. 3-microV noise recordings, QRS duration (QRSd) was 101.2+/-11.3 and 104.6+/-9.6 ms, respectively (P<0.0001), and the differences in paired QRSd (DeltaQRSd) were normally distributed, with variances of 11.4 and 26.2 ms(2) (P<0.0001). Paired SAECGs were obtained in group 2 patients without and with late potentials; DeltaQRSd variance was 3.3 and 217.9 ms(2) (P<0.0001). In group 3, >/=10 SAECGs were acquired at noise levels of 0.2 to 0.8 microV, in 0.1-microV increments. QRSd increased as noise level decreased. The variance was greater in low-noise (0.2 to 0.4 microV) versus higher-noise (0. 5 to 0.8 microV) recordings. In group 4, SAECGs were analyzed with bidirectional and Bispec filters, with no difference in QRSd between the 2 filters and a normally distributed DeltaQRSd. A computer simulation demonstrated that alterations in the phase relationship of noise to signal results in a normal distribution of signal end points. CONCLUSIONS Within the acceptable noise range for SAECG, lower noise results in longer QRSd and larger variance, suggesting that more accurate recordings may have less reproducibility. The random timing of noise relative to signal results in the distribution/variance of repeated measurements. Statistical strategies may be used to reduce some of this variance and may enhance the diagnostic utility of SAECG.
Collapse
Affiliation(s)
- J J Goldberger
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA.
| | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
Heart rate variability analysis has been used to derive indices of sympathetic tone. As different sympathetic stimuli may give rise to divergent changes in heart rate variability, this study was designed to characterize the factors responsible for these divergent responses. Twelve healthy subjects (7 males, age 24.8 +/- 3.1 years) were evaluated. Five-minute electrocardiographic recordings were obtained at baseline, following upright tilt, and during isoproterenol infusion (25 ng/kg per min) under control conditions and following parasympathetic blockade. Data were acquired during spontaneous respiration and when breathing was timed with a metronome (15 breaths/min). Under control conditions, both upright tilt and isoproterenol infusion resulted in significant decreases in the SD and MSSD from baseline values of 69 +/- 3 ms and 64 +/- 5 ms to 48 +/- 4 ms and 21 +/- 5 ms during tilt and 44 +/- 4 ms and 20 +/- 5 ms during isoproterenol infusion, respectively. LF power also significantly increased from 0.47 +/- 0.17 ln (beats/min)2 at baseline to 1.90 +/- 0.20. In (beats/min)2 and 1.34 +/- 0.18. In (beats/min)2 during tilt and isoproterenol infusion, respectively. No change in HF power was noted. Following parasympathetic blockade, all heart rate variability parameters were significantly decreased. No significant change from baseline in the SD, MSSD, or HF power was noted with either tilt or isoproterenol infusion. The LF power increased only with tilt from a baseline value of -3.17 +/- 0.17 in (beats/min)2 to -0.41 +/- 0.19 in (beats/min)2. Similar changes were noted during spontaneous respiration and metronome breathing. These findings demonstrate that the response of the sinus node to beta-adrenergic stimulation depends on the mode of stimulation. In addition, the associated level of parasympathetic tone affects the observed changes in heart rate variability that are associated with sympathetic stimulation.
Collapse
Affiliation(s)
- Y H Kim
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | | | | |
Collapse
|
21
|
Abstract
The purpose of this study was to assess the effects of autonomic stimulation and blockade on noise levels and to compare the noise measurements in the ST and TP segments of the signal-averaged ECG. Five-minute electrocardiographic data were recorded in 14 normal volunteers (8 males and 6 females; mean age 28.5 +/- 5.0 years) on two separate days (day 1-baseline, epinephrine infusion, isoproterenol infusion, beta-blockade, and combined adrenergic and parasympathetic blockade; day 2-baseline, phenylephrine infusion, parasympathetic blockade, and during phenylephrine infusion following atropine). Signal averaging was done off-line on 100 beats and noise was measured in both the ST and TP segments as the standard deviation of voltage in the segment of interest. For all conditions tested, the mean noise level measured in the ST segment (0.46 +/- 0.16 microV) was significantly less than that measured in the TP segment (0.52 +/- 0.24 microV; P = 0.0003), but there was good correlation between the noise measured in the ST and the TP segment (R2 = 0.62, P < 0.0001). Noise increased with isoproterenol infusion and decreased following adrenergic blockade. In addition, day 2 baseline noise was less than baseline noise on day 1. Finally, neither parasympathetic stimulation or blockade nor alpha-adrenergic stimulation significantly affected signal-averaged electrocardiography (SAECG) noise levels. Thus, the data support the notion that enhanced sympathetic tone increases noise levels and beta-adrenergic blockade may decrease noise levels, likely due to effects from muscle sympathetic nerve activity. These findings are important since the target population for the SAECG are patients with myocardial infarction and congestive heart failure, conditions associated with increased sympathetic tone, which may in turn impact on the reproducibility or technical aspects of the SAECG. In addition, because noise in the ST and TP segments are highly correlated and the noise measured in the ST segment is less than that in the TP segment, uniform adoption of noise measurement in the ST segment seems most appropriate.
Collapse
Affiliation(s)
- M W Ahmed
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | | | | |
Collapse
|
22
|
Abstract
INTRODUCTION Time-and frequency-domain measurements of heart rate variability have been used as indices of parasympathetic tone. However, studies of the effect of parasympathetic stimulation on these indices in humans have yielded conflicting results. METHODS AND RESULTS This study evaluated the effects of parasympathetic stimulation on heart rate variability. Twelve normal subjects (7 males, 5 females; age 24.8 +/- 3.4 years) were evaluated in the Clinical Research Center. Five-minute ECG recordings were obtained at baseline and during graded phenylephrine infusions (0.3 and 0.6 micrograms/kg per min). Recordings were made during spontaneous respiration and when breathing was timed with a metronome at 15 cycles/min. Heart rate variability analysis was performed using standard time- and frequency-domain parameters. Graded phenylephrine infusion resulted in a progressive increase in blood pressure and RR interval but no consistent changes in heart rate variability for the group. The results during normal versus metronome breathing were similar. Stepwise linear regression analysis revealed that the phenylephrine-induced changes in heart rate variability were inversely correlated with the baseline heart rate variability and not related to the baseline RR interval or the phenylephrine-induced change in RR interval. CONCLUSION These findings suggest that the respiratory variation in "parasympathetic effect" typically observed at the sinus node can be either increased or decreased by parasympathetic stimulation, depending on the initial level of parasympathetic tone and the intensity of stimulation. This resolves the previously conflicting data. Thus, evaluation of parasympathetic tone using heart rate variability techniques should be cautiously undertaken.
Collapse
Affiliation(s)
- J J Goldberger
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | | | | |
Collapse
|
23
|
Abstract
OBJECTIVES This study sought to evaluate the effects of autonomic stimulation and blockade on the signal-averaged P wave duration. BACKGROUND Signal-averaged P wave duration has been shown to have prognostic implications for patients prone to develop atrial fibrillation, but autonomic influences on the signal-averaged P wave duration have not been studied. METHODS In 14 healthy volunteers (8 men, 6 women; mean [ +/- SD] age 28.5 +/- 4.8 years, range 22 to 38), signal-averaged P wave duration was measured on day 1 at baseline, during sympathetic stimulation with infusions of epinephrine (50 ng/kg body weight per min) and isoproterenol (50 ng/kg per min), beta-blockade with propranolol (0.2 mg/kg) and autonomic blockade with propranolol followed by atropine (0.04 mg/kg). On a second day, 10 of the 14 subjects returned for repeat baseline recordings and recordings during parasympathetic blockade with atropine (0.04 mg/kg). Signal averaging was performed using a P wave template. Both unfiltered and filtered (least-squares fit filter with 100-ms window) P wave durations were measured. Day to day and interobserver variability were assessed by calculation of intraclass correlation coefficients. RESULTS The mean ( +/- SD) baseline filtered P wave duration on day 1 was 141 +/- 10 ms. Isoproterenol infusion significantly shortened the P wave duration to 110 +/- 16 ms (p < 0.001), and epinephrine resulted in significant prolongation to 150 +/- 10 ms (p < 0.05). Beta-adrenergic blockade increased the P wave duration to 153 +/- 10 ms (p < 0.005). Autonomic blockade shortened the P wave duration to 143 +/- 16 ms (p < 0.05 vs. beta-blockade). On the second day, the mean baseline P wave duration was slightly longer (144 +/- 10 ms, p < 0.02). Parasympathetic blockade with atropine resulted in mild shortening of the P wave duration to 136 +/- 15 ms (p < 0.1). Interobserver reproducibility was excellent (intraclass correlation coefficient 0.99). Day to day reproducibility was good (intraclass correlation coefficient 0.56). CONCLUSIONS The signal-averaged P wave duration is not a fixed variable because it may change significantly under different autonomic conditions. This has important implications for the application of this test to the heterogeneous population susceptible to atrial fibrillation.
Collapse
Affiliation(s)
- A N Cheema
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | | | | |
Collapse
|
24
|
Abstract
OBJECTIVES The aim of this study was to evaluate and compare the effects of physiologic and pharmacologic sympathetic stimulation on time and frequency domain indexes of heart rate variability. BACKGROUND Measurements of heart rate variability have been used as indexes of sympathetic tone. To date, the effects of circulating catecholamines on heart rate variability have not been evaluated. METHODS Fourteen normal subjects (eight men, six women, mean [+/- SD] age 28.5 +/- 4.8 years) were evaluated. Five-minute electrocardiographic recordings were obtained in triplicate after physiologic and pharmacologic sympathetic stimulation: during upright tilt, after maximal exercise, during epinephrine and isoproterenol infusions at 50 ng/kg body weight per min, during beta-adrenergic blockade and during combined beta-adrenergic and parasympathetic blockade. RESULTS Beta-adrenergic stimulation resulted in a significant decrease in time domain measures of heart rate variability. The frequency domain indexes showed variable responses, depending on the individual stimulus. Tilt caused an increase in low frequency power and in the ratio of low to high frequency power. These changes were not necessarily observed with other conditions of beta-adrenergic stimulation. Double blockade suppressed baseline heart rate variability, but beta-adrenergic blockade had no significant effect. Time domain measures of heart rate variability demonstrated excellent reproducibility over the three recordings, but the frequency domain variables demonstrated fair to excellent reproducibility. CONCLUSIONS These findings suggest that different modes of beta-adrenergic stimulation may result in divergent heart rate variability responses. Thus, current heart rate variability techniques cannot be used as general indexes of "sympathetic" tone. Studies utilizing heart rate variability to quantify sympathetic tone need to consider this.
Collapse
Affiliation(s)
- M W Ahmed
- Department of Medicine, Northwestern University, Chicago, Illinois
| | | | | | | |
Collapse
|
25
|
Abstract
Time and frequency domain measurements of heart rate variability have been used as indexes of parasympathetic tone. This study evaluates the effects of parasympathetic stimulation on these indexes. Ten normal subjects (5 females, 5 males; age 27.4 +/- 5.1 yr) were evaluated in the Clinical Research Center. Five-minute electrocardiographic recordings were obtained at baseline and during 1) combined alpha-adrenergic stimulation with baroreflex-increased cardiac parasympathetic activity produced by phenylephrine infusion; 2) parasympathetic blockade (atropine 0.04 mg/kg); and 3) isolated alpha-adrenergic stimulation produced by phenylephrine infusion after parasympathetic blockade. The infusion rate of phenylephrine was titrated to increase the systolic blood pressure by 20-30 mmHg. Heart rate variability analysis was performed using standard time and frequency domain parameters. Phenylephrine infusion resulted in a decrease in the time domain measures and in the high-frequency power. After parasympathetic blockade, alpha-adrenergic stimulation had no significant effect on the heart rate variability parameters. These findings suggest that the heart rate variability parameters traditionally associated with parasympathetic tone do not always reliably measure parasympathetic tone, since they decrease with baroreflex parasympathetic stimulation.
Collapse
Affiliation(s)
- J J Goldberger
- Department of Medicine, Northwestern University, Chicago, Illinois 60611
| | | | | | | |
Collapse
|
26
|
Abstract
BACKGROUND Signal-averaged ECG is a noninvasive test designed to detect "late potentials." The effects of alterations in autonomic tone on the signal-averaged ECG have not been evaluated systematically. METHODS AND RESULTS The effects of autonomic stimulation and blockade on the signal-averaged ECG were evaluated in 14 healthy subjects (8 men and 6 women; age, 28.5 +/- 4.8 years) on 2 separate days. The signal-averaged ECG was recorded at baseline and after physiological and pharmacologic beta-adrenergic stimulation (tilt, exercise, and epinephrine and isoproterenol infusions), sequential and combined beta-adrenergic and parasympathetic blockade, and alpha-adrenergic stimulation before and after parasympathetic blockade. Analysis was performed with a bidirectional filter (40-Hz high-pass). Significant changes in the signal-averaged QRS duration from baseline (105.1 +/- 12.0 milliseconds) were noted with tilt (96.8 +/- 8.8 milliseconds), tilt after double blockade (97.5 +/- 9.0 milliseconds), epinephrine (110.5 +/- 11.8 milliseconds), and isoproterenol (99.6 +/- 12.6 milliseconds). Changes in the root-mean-square voltage of the terminal 40 milliseconds and the low-amplitude (< 40 microV) signal duration paralleled the changes in the QRS duration. CONCLUSIONS The signal-averaged ECG does not measure only "fixed" parameters but rather is altered under a variety of physiological and pharmacologic conditions. Upright tilt leads to shortening of the QRS duration before and after autonomic blockade; thus, the decrease in QRS duration with tilt may be related to factors other than changes in autonomic tone. These findings have implications for interpretation of the results of signal-averaged ECG.
Collapse
Affiliation(s)
- J J Goldberger
- Department of Medicine, Northwestern University, Chicago, Ill
| | | | | | | |
Collapse
|