Evidencing value of public health programmes to enable sustainable investment for health & wellbeing

Issue

Global sustainability challenges related to health, inequity, the environment and the economy require urgent innovative action and focus on prevention. Fair evidence-informed prioritisation of scarce resources is pivotal to ensure sustainable investment policies and practices. It is key to capture the value and return on investment of public health (prevention) programmes in order to show their wider benefit to people, communities, society, economy and our planet.

Description

The Evidencing Value project builds on a global and national drive towards measuring the value of health services and interventions. The World Health Organization Collaborating Centre for Investment in Health and Well-being (WHO CC) is developing an innovative approach and digital solution to assess the holistic (economic, social and environmental) value and return on investment of public health programmes. It uses a Social Return on Investment (SROI) approach, which involves key stakeholders from the beginning and measures what matters most. This helps to identify the wider impact and outcomes of different health protection, disease prevention and health promotion programmes. The evidence is embedded in an interactive digital database to inform investment prioritisation and quality improvement.

Results

Project outputs include: (i) structured evidence repository detailing the value of public health services and interventions; (ii) interactive digital database for storage, manipulation and presentation of data; (iii) SROI pilots; and (iv) generalised framework for investing in public health/prevention to be used by other public bodies and countries.

Lessons

It is essential to understand the wider impact and value of public health programmes to facilitate Universal Health Coverage and sustainable investment for health and wellbeing. This project uses an innovative approach and digital solution to enable evidence informed resource allocation and decision-making focused on prevention.

Key messages

Evidencing value of public health supports the case for investing in prevention. Using innovative methods and digital solutions is essential to inform sustainable investment for health.

Predictors of major bleeding in peri-procedural anticoagulation management

BACKGROUND

Appropriate periprocedural management for chronically anticoagulated patients requires assessment of patient-specific thrombosis and bleeding risks. However, predictors of post-procedure bleeding are unknown.

OBJECTIVES

To determine the 3-month cumulative incidence and independent predictors of peri-procedural bleeding in chronically anticoagulated patients requiring temporary warfarin interruption for an invasive procedure.

METHODS

In a protocol driven, cohort study design, all patients referred to the Mayo Clinic Thrombophilia Center for peri-procedural anticoagulation management (1997-2007; n = 2182), were followed forward in time to determine the 3-month cumulative incidence of peri-procedural bleeding (Kaplan-Meier product limit) and potential predictors of bleeding (Cox proportional hazards). Decisions to 'bridge' with low-molecular-weight heparin were based on estimated thromboembolism and bleeding risk.

RESULTS

Indications for chronic anticoagulation included venous thromboembolism (38%), atrial fibrillation (30%) and mechanical heart valves (27%). Of these, 1496 (69%) patients received bridging therapy. The 3-month cumulative incidence rates of major and overall bleeding were 2.1% and 5.1%, respectively. Major bleeding occurred more frequently in patients receiving bridging therapy (3% vs. 1%; P = 0.017). Independent predictors (hazard ratio; 95% confidence interval) of major bleeding included mitral mechanical heart valve (2.2; 1.1-4.3), active cancer (1.8; 1.0-3.1), prior bleeding history (2.6; 1.5-4.5) and re-initiation of heparin therapy within 24 h after the procedure (1.9; 1.1-3.4).

CONCLUSION

Factors predisposing to peri-procedural bleeding are primarily patient-specific. Premature heparin re-initiation is an avoidable provider-specific variable to consider.

The connection between water and energy in cities: a review

We have only rudimentary understanding of the complex and pervasive connections between water and energy in cities. As water security now threatens energy and economic security, this is a major omission. Understanding the water-energy nexus is necessary if we want to contribute to solving water and energy issues simultaneously; if we want to stop moving problems from one resource dimension to another. This is particularly relevant in the Australian context where energy use for water supplies is forecast to rapidly escalate, growing around 300% from 2007 levels, by 2030. This paper presents a literature review with an aim of characterising the research to date with a particular focus on cities, the major centres of consumption and growth. It systematically analyses a wide range of papers and summarises the diverse objectives, dimensions, and scale of the research to-date together with knowledge gaps. There are many major gaps. These include energy use associated with water in industrial and commercial operations as well as socio-political perspectives. A major gap is the lack of a unifying theoretical framework and consistent methodology for analysis. This is considered a prerequisite for quantitative trans-city comparisons.

H5N1 highly pathogenic avian influenza in Southeast Asia

Since the first H5N1 highly pathogenic avian influenza virus (HPAIV) infection in the region in August 2003, Cambodia, Laos, Malaysia, Myanmar, Indonesia, Thailand and Vietnam have all recorded outbreaks of the disease. The HPAIV continues to occur in some countries in Southeast Asia despite control programmes encompassing surveillance, vaccination and stamping out strategies. A number of strains have been circulating in the region since the first outbreaks in 2003, and although the source of the initial outbreaks in domestic poultry is not known, the continuing propagation of disease in the region is primarily the result of the movement of domestic poultry and poultry products, and people. A comprehensive approach using all the strategies available to break the chain of transmission of the virus in poultry will be needed to achieve lasting disease control.

Optical birefringence study of the ferroelectric phase transition in lithium niobate tantalate mixed crystals: LiNb(1-x)Ta(x)O(3)

The optical birefringence of a complete solid-solution series of lithium niobate-tantalate crystals has been measured as a function of temperature. It is found that, irrespective of composition, the high-temperature paraelectric phase has a birefringence close to +0.063, suggesting that this value arises purely from the oxygen octahedra in the crystal structure. It is also observed that a small addition of lithium niobate to the tantalate produces a crystal that has zero birefringence at room temperature.

A cross-sectional survey of Australian chicken farms to identify risk factors associated with seropositivity to Newcastle-disease virus

Several outbreaks of virulent Newcastle-disease occurred in Australia in 1998-2000. We conducted a cross-sectional survey of 753 Australian chicken farms to identify risk factors associated with the seroprevalence of chicken flocks with Newcastle-disease virus (NDV). We had a 99.7% response rate to the survey and the overall prevalence of NDV seropositive farms was 39.8%. Associations were analysed for the layer, chicken-meat and breeder production sectors in sector-specific logistic-regression models using 187, 198 and 146 farms, respectively. In the layer sector, increased risk of seroprevalence was associated with increasing age of the chickens, and decreased risk when the nearest-neighbour poultry farm was >10 km distant (odds ratio (OR)=0.30). In the chicken-meat sector, increased risk of seroprevalence was associated with location in the Sydney basin (OR=13.67), eastern Victoria (OR=26.10) or western Victoria (OR=5.43), and decreased risk when the nearest-neighbour poultry farm was greater than 0.5 km distant (OR=0.34). In the breeder sector, increased risk of seroprevalence was associated with increasing age of the chickens, the presence of wild birds on the farm (OR=5.28) and location in eastern Victoria (OR=16.19). A conditional logistic-regression for 112 pairs of farms matched for age, survey region and production sector identified a distance of >1.0 km to the nearest-neighbour poultry farm (OR=0.24) and ownership by owner 2 (OR=0.02), owner 5 (OR=0.11) or owner 9 (OR=0.25) as significant in reducing the risk of NDV seroprevalence. Our survey found that high levels of biosecurity and hygiene practices had been adopted by most farms.

An X-ray diffraction study of the effects of heat treatment on bone mineral microstructure

A series of human cortical bone specimens has been heated to temperatures up to 1200 degrees C and the mineral content examined in detail by X-ray diffraction. Line profile analysis of the diffraction data has been undertaken to characterise the microstructural (crystallite size and microstrain) features of the mineral at each temperature. Individual profile fitting of several maxima from each diffractogram has also provided precise lattice parameters of the apatite at each temperature. The apatite did not show any significant decomposition over the temperature range although CaO was increasingly formed at temperatures above 600 degrees C. Both finite crystallite size and microstrain contributed significantly to the diffraction peak broadening below 600 degrees C. When heated to > 800 degrees C, the small, rod-like mineral crystallites changed from a highly anisotropically strained state to one with significantly larger equidimensional crystals possessing little microstrain. The findings are discussed in the context of graft bone substitutes and surgical heating of bone.

Efficacy of a competitive enzyme-linked immunosorbent assay (cELISA) for estimating prevalence of immunity to rabbit haemorrhagic disease virus (RHDV) in populations of Australian wild rabbits (Oryctolagus cuniculus)

This study examines the efficacy of a cELISA in estimating the prevalence of immunity to rabbit haemorrhagic disease virus (RHDV) in wild rabbits in Australia. Rabbits (n = 343) captured from six locations in Victoria and Queensland were experimentally challenged with a lethal oral dose (1500 50%-lethal doses, LD50) of RHDV. Death or survival to challenge was used to determine the performance characteristics of the test. The diagnostic specificity, sensitivity and accuracy were highly variable between sites, making it difficult to select a representative cut-off value for all sites that achieved a reasonable level of accuracy for the prediction of surviving and non-surviving rabbits. Estimates of prevalence of immunity were biased owing to effects of site of capture (time of capture) and age structure of the population. Using predictive equations, the best estimates of survival were ±10% but these results came from a limited range of sites, all of which had survival in the range 49–70%. The cELISA will determine whether the RHDV is present in rabbit populations but it should be used with caution when estimating the prevalence of immunity to RHDV. The cELISA may thus be limited in its application for examining the epidemiology of RHDV in Australian rabbit populations.

Comparative pathology of the diseases caused by Hendra and Nipah viruses

Information on the pathogenesis and transmissibility of Hendra and Nipah viruses was obtained by comparing their histopathology. Both viruses induced syncytial cells in vascular tissues and they were primarily vasotropic and/or neurotropic, generating interstitial pneumonia or encephalitis. Nipah virus in pigs was also epitheliotropic in respiratory epithelium and thus contagious.

Laboratory diagnosis of Nipah and Hendra virus infections

Although Hendra and Nipah viruses emerged to cause novel zoonotic infections only recently, there now exists a strong but poorly documented diagnostic capability for both. This review gives an overview of the development of the tests, the tests currently recommended, their shortcomings and the perceived priorities for needed test improvements.

Nipah virus infection in bats (order Chiroptera) in peninsular Malaysia

Nipah virus, family Paramyxoviridae, caused disease in pigs and humans in peninsular Malaysia in 1998-99. Because Nipah virus appears closely related to Hendra virus, wildlife surveillance focused primarily on pteropid bats (suborder Megachiroptera), a natural host of Hendra virus in Australia. We collected 324 bats from 14 species on peninsular Malaysia. Neutralizing antibodies to Nipah virus were demonstrated in five species, suggesting widespread infection in bat populations in peninsular Malaysia.

Nipah virus: a recently emergent deadly paramyxovirus

A paramyxovirus virus termed Nipah virus has been identified as the etiologic agent of an outbreak of severe encephalitis in people with close contact exposure to pigs in Malaysia and Singapore. The outbreak was first noted in late September 1998 and by mid-June 1999, more than 265 encephalitis cases, including 105 deaths, had been reported in Malaysia, and 11 cases of encephalitis or respiratory illness with one death had been reported in Singapore. Electron microscopic, serologic, and genetic studies indicate that this virus belongs to the family Paramyxoviridae and is most closely related to the recently discovered Hendra virus. We suggest that these two viruses are representative of a new genus within the family Paramyxoviridae. Like Hendra virus, Nipah virus is unusual among the paramyxoviruses in its ability to infect and cause potentially fatal disease in a number of host species, including humans.

Quality of life in stoma patients

BACKGROUND

Patients with stomas face many difficulties both physical and psychological. Little is known about the long-term problems and the impact on patient lifestyle of a permanent stoma. This study was designed to address the problems faced by patients with stomas.

METHODS

Patients were identified from the Stoma Care Department records for the years 1985 to 1992 and were contacted by mail. A questionnaire was designed to assess postoperative care, quality of life issues, and equipment problems. Responses were recorded on either a visual analog scale, a choice of yes-or-no alternatives, or by selection from a list of responses.

RESULTS

A total of 542 eligible patients were contacted, and 391 replies were received. Major stomal problems included rashes (51 percent), leakage (36 percent), and ballooning (90 percent of patients with ileostomy). The majority of patients experienced some change in lifestyle (80 percent), and more than 40 percent of patients had problems with their sex lives.

CONCLUSION

Many patients cope extremely well with a stoma; however, some patients experience considerable difficulty and distress. Improved preoperative assessment and counseling with longer follow-up by the stoma department would be helpful in the management of these patients and probably would contribute to improvement in the quality of their lives.

Dietary intake after pancreatectomy

BACKGROUND

Nutritional intake after pancreatectomy may be impaired. The extent of the problem and the effect on intake of specific nutrients is unknown.

METHODS

A 1-week weighed dietary food intake (using digital scales and a food diary) was studied in 15 patients, a median of 4 (range 1-30) months after pancreatectomy. Results were expressed as a percentage of estimated average requirement (EAR), reference nutrient intake (RNI) or lower RNI (LRNI) values.

RESULTS

The median energy intake was 1914 (range 1154-2804) kcal/day, representing a median of 88 (56-154) per cent of EAR. Fat intake was low (72 (60-123) g/day); protein intake was adequate (139 (99-219) per cent of RNI). Deficiencies were observed in the intake of vitamin D (17 (6-56) per cent of LRNI) and, in some patients, selenium (107 (19-203) per cent of LRNI).

CONCLUSION

Nutritional intake in the months after pancreatectomy could be improved by increasing fat intake (with enzyme supplements as appropriate). This 7-day study also suggests that these patients may require vitamin D and possibly selenium supplementation.

Improving ambulatory surgery reimbursement

As outpatient services become the new focal point for managed care, ambulatory surgery reimbursement structures are coming under increasing scrutiny. Operating room managers play a key role in developing ambulatory surgery payment mechanisms that are competitive, clinically meaningful and profitable. Operating room managers must understand the market forces that are redefining outpatient surgery reimbursement as well as the reimbursement mechanisms involved. Payment methodologies in ambulatory surgery are explored.

Reliability of a knowledge of AIDS scale a replication

Zimet's knowledge of AIDS scale was completed anonymously by 2,209 university students to assess whether a split-half approach in which items in each half were matched for content would provide better estimates of reliability than other method. Analysis indicates that the odd even Spearman Brown split-half reliability coefficient was lower than both the alpha coefficient and the content-based split-half coefficient. The Cronbach alpha was similar to the content-based Spearman-Brown reliability coefficient.

Heartburn, oesophagitis and Barrett's oesophagus in self-medicating patients in general practice

A postal questionnaire on heartburn sent to 6760 randomly selected subjects yielded 3971 replies suitable for analysis. Heartburn had never been experienced by 1665 (42%) respondents. Significant symptoms of more than three months' duration that had occurred at least once a month in the preceding 12 months were reported by 1337 (34%) respondents. Of these, 875 had not consulted their general practitioner and were invited to attend for a structured interview with questionnaire and upper gastrointestinal endoscopy. A total of 177 were interviewed, and 143 underwent upper gastrointestinal endoscopy. Of those endoscoped, 106 (74%) experienced symptoms at least once a week. These were relieved by alginate consumption in 97 (68% of) cases. Just nine (6%) patients had been taking H2-receptor antagonists. Macroscopic appearances of oesophagitis were seen in 46 cases [13 (6%) grade 1, 24 (11%) grade 2, five (2%) grade 3, two (1%) grade 4, and two (1%) grade 5]. Three patients had mild strictures and six patients had Barrett's oesophagus. There were no appearances suggestive of malignancy. Biopsies were taken in 122 cases, including all those in which abnormalities had been seen. Histological evidence of oesophagitis was seen in 47 cases. Gastric metaplasia was found in six cases and dysplasia seen in three. Patients who self-medicate for reflux symptoms have a low prevalence of pre-neoplastic and neoplastic pathology. A substantial proportion, however, have histological evidence of oesophagitis and a small number have metaplasia.

Nurse caring behaviors: comparing five tools to define perceptions

We asked which of five tools that measure perceptions of caring attributes (Larson's Care Q, Larson's Care/Sat, Nyberg's CAS, Duffy's CAT, Wolf's CBI) have the greatest usefulness in studies with patients and nurses. A convenience sample of 26 nurse administrators completed all five tools. Data was collected on completion time, demographic characteristics, and how results compared with earlier research using the same instruments. Larson's Care Q had similar results as previously described in the literature but problems included a forced choice format, difficulty with instructions, and it took the longest time to complete. Larson's Care/Sat was difficult to analyze, contained negatively worded items, but took the least time to complete. Nyberg's CAS was designed for use with nurses and would be difficult to use with patients. Duffy's CAT had negatively worded items. Similar results were obtained with Wolf's CBI as previously described in the literature and it had consistent language, short completion time, easy to understand instructions, and easy to analyze results which could be used in a correlational design study. We conclude that Larson's Care Q (using a simpler method of administration) or Wolf's CBI could be valuable in determining perceptions of caring in patients and nurses.

Prognostic criteria in Clostridium difficile colitis

OBJECTIVE

To determine the prognostic factors in Clostridium difficile (CD) colitis.

METHODS

We conducted a retrospective study of proven cases of CD colitis in l8 months. Seventy six patients (from a 605-bed community hospital in the Bronx, NY) with proven CD colitis were studied. Mortality in patients with CD colitis was also examined.

RESULTS

Seventy six patients with proven CD colitis were admitted between January 1993 and June 1994. Eighteen patients died during the same admission. Upon admission, serum albumin was less than 25 g/L in 12 (20.6%) of the survivors and in eight (44%) of the deceased patients (p <0.05). A fall in serum albumin levels was noted with the onset of symptoms of CD colitis in those who survived as well as in those who died, with a greater fall of 11.2 g/L (range 10-20 g/L) in patients who died compared with a fall of 6 g/L (range 5-10 g/L)in those who survived (p <0.05). Use of more than three antibiotics was noted in 13 (72%) of those who died and in 18 (31%) of those who survived (p <0.05). Persistence of CD cytotoxin 7 or more days after initiation of treatment was present in 14 (77%) of those who died and in eight (13%) of the survivors (p <0.01). Duration of hospitalization correlated with the development of CD colitis (35.89 vs 11.7 days) with no significant difference between survivors and deceased patients with CD colitis. Factors such as age, sex, residence, past medical history score, mean score of presenting complaints of CD colitis, history of prior episodes CD colitis, and mean number of recurrent episodes showed no difference in mortality.

CONCLUSION

Factors predictive of an increased mortality in patients with CD colitis include a serum albumin of less than 25 g/L on admission, a fall in serum albumin level of greater than 11 g/L at the onset of symptoms of CD colitis, use of three or more antibiotics, and persistence of positive CD cytotoxin in the stool after completion of 7 or more days of treatment.

AIDS knowledge and attitudes towards homosexuals of black first-year university students: 1990-1992

Using an anonymous structured questionnaire to obtain baseline data on knowledge and attitudes of first-year black university students about the Acquired Immunodeficiency Syndrome (AIDS) and their attitudes towards homosexuals during 1990, 1991, and 1992 (ns = 1902, 2113, and 1558), the following information was obtained. Students' knowledge of AIDS was inadequate and misconceptions about AIDS transmission prevalent as were prejudiced and exclusionary beliefs about people with AIDS. Little difference was evident on any of the scales over the three-year period.

PCR detection of ovine herpesvirus-2 DNA in Indonesian ruminants--normal sheep and clinical cases of malignant catarrhal fever

Malignant catarrhal fever (MCF), a fatal viral disease of cattle and other large ruminants, has a worldwide distribution. There are two forms of the disease, one of which, is caused by Alcelaphine herpesvirus-1 (AHV-1) and is derived from wildebeest. The other form is associated with domestic sheep and is caused by ovine herpesvirus-2 (OHV-2). The disease in Indonesia is sheep-associated with the preferred livestock of this area, Balinese cattle (Bos javanicus) and water buffalo (Bubalus bubalis), both highly susceptible to SA-MCF. The incidence in these species is thought to be high but the prevalence and economic losses attributable to SA-MCF have been difficult to assess. a polymerase chain reaction (PCR) test, based on a cloned OHV-2 gene sequence, was successfully applied to the detection of OHV-2 DNA in normal sheep and animals affected with SA-MCF. OHV-2 DNA was detected in eleven confirmed cases of SA-MCF and in the peripheral blood leucocyte (PBL) fraction of six latently infected sheep. These findings have confirmed that the PCR can be of value in establishing a diagnosis of MCF and that the aetiological agent of MCF in Indonesia is OHV-2. The amplification of DNA from the PBL of goats suggests that they are infected with a similar or identical herpesvirus.

MDA-image: an environment of networked desktop computers for teleradiology/pathology

MDA-Image, a project of The University of Texas M. D. Anderson Cancer Center, is an environment of networked desktop computers for teleradiology/pathology. Radiographic film is digitized with a film scanner and histopathologic slides are digitized using a red, green, and blue (RGB) video camera connected to a microscope. Digitized images are stored on a data server connected to the institution's computer communication network (Ethernet) and can be displayed from authorized desktop computers connected to Ethernet. Images are digitized for cases presented at the Bone Tumor Management Conference, a multidisciplinary conference in which treatment options are discussed among clinicians, surgeons, radiologists, pathologists, radiotherapists, and medical oncologists. These radiographic and histologic images are shown on a large screen computer monitor during the conference. They are available for later review for follow-up or representation.

The prevalence of schizophrenia in a refuge for homeless men

The prevalence of schizophrenia in a large hostel for homeless men in an inner city area was found to be in the order of 15%. Concern is expressed that this figure represents a recent increase in the number of mentally ill among homeless men and may be related to changes in the management of chronic mental illness. Literature relating mental illness and homelessness is reviewed.