Associations between social determinants of health and comorbidity and multimorbidity in people of black ethnicities with HIV

OBJECTIVE

Social determinants of health (SDH) are important determinants of long-term conditions and multimorbidity in the general population. The intersecting relationship between SDH and multimorbidity in people with HIV remains poorly studied.

DESIGN

A cross-sectional study investigating the relationships between eight socio-economic parameters and prevalent comorbidities of clinical significance and multimorbidity in adults of African ancestry with HIV aged 18-65 years in South London, UK.

METHODS

Multivariable logistic regression analysis was used to evaluate associations between SDH and comorbidities and multimorbidity.

RESULTS

Between September 2020 and January 2022, 398 participants (median age 52 years, 55% women) were enrolled; 85% reported at least one SDH and 72% had at least one comorbidity. There were no associations between SDH and diabetes mellitus or kidney disease, few associations between SDH (job and food insecurity) and cardiovascular or lung disease, and multiple associations between SDH (financial, food, housing and job insecurity, low educational level, social isolation, and discrimination) and poor mental health or chronic pain. Associations between SDH and multimorbidity mirrored those for constituent comorbidities.

CONCLUSION

We demonstrate strong associations between SDH and poor mental health, chronic pain and multimorbidity in people of black ethnicities living with HIV in the UK. These findings highlight the likely impact of enduring socioeconomic hardship in these communities and underlines the importance of holistic health and social care for people with HIV to address these adverse psychosocial conditions.

A Framework for Assessing the Impact of Outbreak Response Immunization Programs

The impact of outbreak response immunization (ORI) can be estimated by comparing observed outcomes to modelled counterfactual scenarios without ORI, but the most appropriate metrics depend on stakeholder needs and data availability. This study developed a framework for using mathematical models to assess the impact of ORI for vaccine-preventable diseases. Framework development involved (1) the assessment of impact metrics based on stakeholder interviews and literature reviews determining data availability and capacity to capture as model outcomes; (2) mapping investment in ORI elements to model parameters to define scenarios; (3) developing a system for engaging stakeholders and formulating model questions, performing analyses, and interpreting results; and (4) example applications for different settings and pathogens. The metrics identified as most useful were health impacts, economic impacts, and the risk of severe outbreaks. Scenario categories included investment in the response scale, response speed, and vaccine targeting. The framework defines four phases: (1) problem framing and data sourcing (identification of stakeholder needs, metrics, and scenarios); (2) model choice; (3) model implementation; and (4) interpretation and communication. The use of the framework is demonstrated by application to two outbreaks, measles in Papua New Guinea and Ebola in the Democratic Republic of the Congo. The framework is a systematic way to engage with stakeholders and ensure that an analysis is fit for purpose, makes the best use of available data, and uses suitable modelling methodology.

How the Timing of Annual COVID-19 Vaccination of Nursing Home Residents and Staff Affects Its Value

OBJECTIVES

To evaluate the epidemiologic, clinical, and economic value of an annual nursing home (NH) COVID-19 vaccine campaign and the impact of when vaccination starts.

DESIGN

Agent-based model representing a typical NH.

SETTING AND PARTICIPANTS

NH residents and staff.

METHODS

We used the model representing an NH with 100 residents, its staff, their interactions, COVID-19 spread, and its health and economic outcomes to evaluate the epidemiologic, clinical, and economic value of varying schedules of annual COVID-19 vaccine campaigns.

RESULTS

Across a range of scenarios with a 60% vaccine efficacy that wanes starting 4 months after protection onset, vaccination was cost saving or cost-effective when initiated in the late summer or early fall. Annual vaccination averted 102 to 105 COVID-19 cases when 30-day vaccination campaigns began between July and October (varying with vaccination start), decreasing to 97 and 85 cases when starting in November and December, respectively. Starting vaccination between July and December saved $3340 to $4363 and $64,375 to $77,548 from the Centers for Medicare & Medicaid Services and societal perspectives, respectively (varying with vaccination start). Vaccination's value did not change when varying the COVID-19 peak between December and February. The ideal vaccine campaign timing was not affected by reducing COVID-19 levels in the community, or varying transmission probability, preexisting immunity, or COVID-19 severity. However, if vaccine efficacy wanes more quickly (over 1 month), earlier vaccination in July resulted in more cases compared with vaccinating later in October.

CONCLUSIONS AND IMPLICATIONS

Annual vaccination of NH staff and residents averted the most cases when initiated in the late summer through early fall, at least 2 months before the COVID-19 winter peak but remained cost saving or cost-effective when it starts in the same month as the peak. This supports tethering COVID vaccination to seasonal influenza campaigns (typically in September-October) for providing protection against SARS-CoV-2 winter surges in NHs.

Cost-utility of VISITAG SURPOINT in catheter ablation of atrial fibrillation

BACKGROUND

Clinical studies have demonstrated the safety, efficacy, and efficiency of VISITAG SURPOINT® (VS), which provides important lesion markers during catheter ablation (CA) of atrial fibrillation (AF). The present study evaluated the cost-effectiveness of CA with VS compared to CA without VS in AF from the publicly-funded German and Belgium healthcare perspectives.

METHODS

We constructed a two-stage cost utility model that included a decision tree to simulate clinical events, costs, and utilities during the first year after the index procedure and a Markov model to simulate transitions between health states throughout a patient's lifetime. Model inputs included published literature, a meta-analysis of randomized controlled trials AF outcomes, and publicly available administrative data on costs. Deterministic and probabilistic sensitivity analyses were conducted to determine the robustness of the model.

RESULTS

CA with VS was associated with lower per patient costs vs CA without VS (Germany: €3295 vs. €3936, Belgium: €3194 vs. €3814) and similar quality-adjusted life-years (QALYs) per patient (Germany: 5.35 vs. 5.34, Belgium: 5.68 vs. 5.67). CA with VS was the dominant ablation strategy (incremental cost-effectiveness ratios: Germany: €-52,455/QALY, Belgium: €-50,676/QALY). The model results were robust and not highly sensitive to variation to individual parameters with regard to QALYs or costs. Freedom from AF and procedure time had the greatest impact on model results, highlighting the importance of these outcomes in ablation.

CONCLUSIONS

CA with VS resulted in cost savings and QALY gains compared to CA without VS, supporting the increased adoption of VS in CA in Germany and Belgium.

'My feet cannot stand on their own': podoconiosis patient healthcare expenditures and income impacts in Rwanda

BACKGROUND

Podoconiosis is a progressive and debilitating form of tropical lymphoedema endemic to Rwanda. Although the physical and psychological consequences are well known, few studies have evaluated the financial burden of podoconiosis.

METHODS

This cross-sectional, quantitative study aimed to characterize direct treatment costs and impacts on annual earnings among individuals living with podoconiosis. Participants from two highly endemic districts were invited to complete a survey focused on health-seeking history, insurance status, out-of-pocket costs and income changes. Direct treatment costs included medical expenditures (consultation, diagnostics, medication) and non-medical expenditures (food, transportation, accommodation).

RESULTS

Overall, 226 adults (≥18 y of age) diagnosed with podoconiosis participated. Most had access to community-based health insurance (91.6%) but were unable to work (71.7%). Respondents sought care from health centres/posts (61.9%), hospitals (25.1%), traditional healers (5.8%) and/or community health workers (4.0%). On average, study participants paid US$32.50 (range US$0-779.23) annually, or 11.7% of their household salary, on podoconiosis treatments.

CONCLUSIONS

This study demonstrates the significant financial burden of podoconiosis on individuals and their communities. Increased attention on integrating podoconiosis management into primary care systems and testing cost-effective solutions is needed to protect those who are most vulnerable.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis

BACKGROUND

There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability.

AIMS

To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective.

METHODS

A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations.

RESULTS

The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised.

CONCLUSIONS

The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

Factors and economic burden of non-severe hypoglycemia among insulin-treated type 2 diabetes patients: a cross-sectional study

OBJECTIVE

This cross-sectional survey was performed to assess the prevalence, factors, and economic burden of non-severe hypoglycemia among insulin-treated type 2 diabetes (T2D) patients in northern Thailand.

METHODS

Between April 2021 and August 2022, 600 participants were evaluated via structured questionnaires containing sociodemographic and clinical characteristics, medications, and economic burden. Patients were divided into two groups (having and not having non-severe hypoglycemia). Variables with a p value <.05 in the univariate model were included in the multivariate model.

RESULTS

The percentage of non-severe hypoglycemia was 50.3% (302/600). Of all participants, the average age was 61.4 ± 26.0 years, 55.7% were female, 53.5% used premix insulin, and the average duration of diabetes was 16.1 ± 10.0 years. Multivariate logistic regression analysis indicated that age (OR = .96; p <.001), duration of diabetes (OR = 1.04; p <.001), BMI (OR = .95; p = .002), thiazolidinedione (OR = 1.56; p = .012) and insulin regimens were associated with having non-severe hypoglycemia. Compared to basal insulin, basal bolus (OR = 6.93; p = .001), basal plus (OR = 3.58; p <.001), and premix insulin (OR = 1.83; p =.003) were associated with hypoglycemia. Greater numbers of sick leave were found in the hypoglycemia group (14 vs 4 patients, p = .029).

CONCLUSIONS

These findings help to individuate those patients who are at higher risk of non-severe hypoglycemia in insulin-treated T2D patients. Compared to the non-hypoglycemia group, patients with hypoglycemia were younger, had longer diabetes duration, lower BMI, received thiazolidinedione and insulin regimens such as premix, basal plus, or basal bolus insulins, and more productivity loss.

A Cost Savings Analysis of Topical Estrogen Therapy in Urinary Tract Infection Prevention Among Postmenopausal Women

INTRODUCTION

UTIs are some of the most common infections in geriatric patients, with many women experiencing recurrent infections after menopause. In the US, annual UTI-related costs are $2 billion, with recurrent infections creating a significant economic burden. Given the data published on topical estrogen in reducing the number of infections for postmenopausal women with recurrent UTI, we sought to evaluate how this would translate to cost savings.

METHODS

We performed a systematic literature review of UTI reduction secondary to topical estrogen utilization in postmenopausal female patients. The cost per UTI was determined based on published Medicare spending on UTI per beneficiary, weighted on reported likelihood of complicated and resistant infections. For a patient with recurrent infections, topical estrogen therapy reported on average can reduce infections from 5 to 0.5 to 2 times per person per year.

RESULTS

At a calculated cost per UTI of $1222, the reduction in UTI spending can range between $3670 and $5499 per beneficiary per year. Per-beneficiary spending on topical estrogen therapies was $1013 on average ($578-$1445) in 2020. After including the cost of the therapy, overall cost savings for topical estrogen therapies were $1226 to $4888 annually per patient.

CONCLUSIONS

Topical estrogens are a cost-conscious way to improve the burden of UTI on postmenopausal women with the potential for billions of dollars in Medicare savings. System-wide efforts should be made to have these therapies available as prophylaxis for postmenopausal patients and to ensure they are affordable for patients.

A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study

BACKGROUND

Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia.

OBJECTIVE

The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model.

METHODS

This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes.

RESULTS

As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024).

CONCLUSIONS

This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50146.

A Digital Respiratory Ward in Leicester, Leicestershire, and Rutland, England, for Patients With COVID-19: Economic Evaluation of the Impact on Acute Capacity and Wider National Health Service Resource Use

BACKGROUND

The COVID-19 pandemic stressed global health care systems' acute capacity and caused a diversion of resources from elective care to the treatment of acute respiratory disease. In preparing for a second wave of COVID-19 infections, England's National Health Service (NHS) in Leicester, Leicestershire, and Rutland sought to protect acute capacity in the winter of 2020-2021. Their plans included the introduction of a digital ward where patients were discharged home early and supported remotely by community-based respiratory specialists, who were informed about patient health status by a digital patient monitoring system.

OBJECTIVE

The objective of the digital ward was to maintain acute capacity through safe, early discharge of patients with COVID-19 respiratory disease. The study objective was to establish what impact this digital ward had on overall NHS resource use.

METHODS

There were no expected differences in patient outcomes. A cost minimization was performed to demonstrate the impact on the NHS resource use from discharging patients into a digital COVID-19 respiratory ward, compared to acute care length of stay (LOS). This evaluation included all 310 patients enrolled in the service from November 2020 (service commencement) to November 2021. Two primary methods, along with sensitivity analyses, were used to help overcome the uncertainty associated with the estimated comparators for the observational data on COVID-19 respiratory acute LOS, compared with the actual LOS of the 279 (90%) patients who were not discharged on oxygen nor were in critical care. Historic comparative LOS and an ordinary least squares model based on local monthly COVID-19 respiratory median LOS were used as comparators. Actual comparator data were sourced for the 31 (10%) patients who were discharged home and into the digital ward for oxygen weaning. Resource use associated with delivering care in the digital ward was sourced from the digital system and respiratory specialists.

RESULTS

In the base case, the digital ward delivered estimated health care system savings of 846.5 bed-days and US $504,197 in net financial savings across the 2 key groups of patients-those on oxygen and those not on oxygen at acute discharge (both P<.001). The mean gross and net savings per patient were US $1850 and US $1626 in the base case, respectively, without including any savings associated with a potential reduction in readmissions. The 30-day readmission rate was 2.9%, which was below comparative data. The mean cost of the intervention was US $223.53 per patient, 12.1% of the estimated gross savings. It was not until the costs were increased and the effect reduced simultaneously by 78.4% in the sensitivity analysis that the intervention was no longer cost saving.

CONCLUSIONS

The digital ward delivered increased capacity and substantial financial savings and did so with a high degree of confidence, at a very low absolute and relative cost.

Value of Electronic Health Records Measured Using Financial and Clinical Outcomes: Quantitative Study

BACKGROUND

The Health Information Technology for Economic and Clinical Health Act of 2009 was legislated to reduce health care costs, improve quality, and increase patient safety. Providers and organizations were incentivized to exhibit meaningful use of certified electronic health record (EHR) systems in order to achieve this objective. EHR adoption is an expensive investment, given the resources and capital that are invested. Due to the cost of the investment, a return on the EHR adoption investment is expected.

OBJECTIVE

This study performed a value analysis of EHRs. The objective of this study was to investigate the relationship between EHR adoption levels and financial and clinical outcomes by combining both financial and clinical outcomes into one conceptual model.

METHODS

We examined the multivariate relationships between different levels of EHR adoption and financial and clinical outcomes, along with the time variant control variables, using moderation analysis with a longitudinal fixed effects model. Since it is unknown as to when hospitals begin experiencing improvements in financial outcomes, additional analysis was conducted using a 1- or 2-year lag for profit margin ratios.

RESULTS

A total of 5768 hospital-year observations were analyzed over the course of 4 years. According to the results of the moderation analysis, as the readmission rate increases by 1 unit, the effect of a 1-unit increase in EHR adoption level on the operating margin decreases by 5.38%. Hospitals with higher readmission payment adjustment factors have lower penalties.

CONCLUSIONS

This study fills the gap in the literature by evaluating individual relationships between EHR adoption levels and financial and clinical outcomes, in addition to evaluating the relationship between EHR adoption level and financial outcomes, with clinical outcomes as moderators. This study provided statistically significant evidence (P<.05), indicating that there is a relationship between EHR adoption level and operating margins when this relationship is moderated by readmission rates, meaning hospitals that have adopted EHRs could see a reduction in their readmission rates and an increase in operating margins. This finding could further be supported by evaluating more recent data to analyze whether hospitals increasing their level of EHR adoption would decrease readmission rates, resulting in an increase in operating margins. Hospitals would incur lower penalties as a result of improved readmission rates, which would contribute toward improved operating margins.

Epidemiology of Syphilis in Pregnancy and Congenital Syphilis in Brazil and the Risk or Associated Factors: Protocol for a Systematic Review

BACKGROUND

Syphilis in pregnancy and congenital syphilis are growing public health issues worldwide. Several factors can influence their occurrence in the population. Therefore, understanding the epidemiology of this condition and the factors that influence its occurrence is fundamental for decision-making by clinicians and health managers. However, so far, no systematic review has summarized and analyzed data on the incidence, prevalence, and predictors of these diseases in Brazilian cities, considering different sociocultural, demographic, economic, sanitary, and spatial-temporal characteristics presented across locations.

OBJECTIVE

We propose a systematic review protocol to gather and analyze data on the incidence, prevalence, and risk or associated factors of syphilis in pregnancy and congenital syphilis in Brazil, taking into account different local or regional contexts.

METHODS

Searches will be conducted in CINAHL, MEDLINE, LILACS, Embase, and Web of Science databases. We will include observational studies (ie, cross-sectional, longitudinal, or case-control studies), analyzing the incidence, prevalence, and risk or associated factors of syphilis in pregnancy and congenital syphilis in Brazil from primary data. The diagnosed syphilis will be assessed based on direct pathogen detection tests or through immunological, treponemal or nontreponemal tests, following Brazilian protocols for diagnosing syphilis. The studies are currently undergoing screening in the databases, and after this step, 2 reviewers will perform all identified documents. The Newcastle-Ottawa Scale and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) system will be used to assess methodological quality and quality of evidence of studies, respectively. The Kappa coefficient will assess the agreement between researchers in each study stage. Cochran Q test will assess the heterogeneity among studies. Then, a random-effects meta-analysis will be performed.

RESULTS

Results will be discussed based on subgroup analysis, which is as follows: (1) type of syphilis (in pregnancy or congenital), (2) type of study (case-control and cross-sectional studies for analysis of associated factors and longitudinal studies for risk factors), and (3) contextual factors (ie, region of country, socioeconomic and demographic characteristics, and year of study). This systematic review is expected to be completed by December 2023, and our results will be disseminated through publication in peer-reviewed journals and scientific events.

CONCLUSIONS

This systematic review aims to assist health care managers and professionals in their decision-making to control these diseases in Brazil, considering location heterogeneity. Furthermore, countries with health systems and demographic and socioeconomic contexts similar to those of Brazil may benefit from this information.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50702.

A Narrative Review of Literature Examining Studies Researching the Impact of Law on Health and Economic Outcomes

CONTEXT

Public health policy can play an important role in improving public health outcomes. Accordingly, there has been an increasing emphasis by policy makers on identifying and implementing evidence-informed public health policy interventions.

PROGRAM OR POLICY

Growth and refinement of the field of research assessing the impact of legal interventions on health outcomes, known as legal epidemiology, prompted this review of studies on the relationship between laws and health or economic outcomes.

IMPLEMENTATION

Authors systematically searched 8 major literature databases for all English language journal articles that assessed the effect of a law on health and economic outcomes published between January 1, 2009, and September 18, 2019. This search generated 12 570 unique articles 177 of which met inclusion criteria. The team conducting the systematic review was a multidisciplinary team that included health economists and public health policy researchers, as well as public health lawyers with expertise in legal epidemiological research methods. The authors identified and assessed the types of methods used to measure the laws' health impact.

EVALUATION

In this review, the authors examine how legal epidemiological research methods have been described in the literature as well as trends among the studies. Overall, 3 major themes emerged from this study: (1) limited variability in the sources of the health data across the studies, (2) limited differences in the methodological approaches used to connect law to health outcomes, and (3) lack of transparency surrounding the source and quality of the legal data relied upon.

DISCUSSION

Through highlighting public health law research methodologies, this systematic review may inform researchers, practitioners, and lawmakers on how to better examine and understand the impacts of legal interventions on health and economic outcomes. Findings may serve as a source of suggested practices in conducting legal epidemiological outcomes research and identifying conceptual and method-related gaps in the literature.

Economic evaluations of videoconference and telephone consultations in primary care: A systematic review

INTRODUCTION

Telehealth services using videoconference and telephone modalities have been increasing exponentially in primary care since the coronavirus pandemic. The challenge now is ensuring that these services remain sustainable. This review investigates the cost-effectiveness of videoconference and telephone consultations in primary care settings, by summarizing the available published evidence.

METHODS

A systematic search of PubMed, Embase, Scopus, and CINAHL databases was used to identify articles published from January 2000 to July 2020, using keyword synonyms for telehealth, primary care, and economic evaluation. Databases were searched, and title, abstract, and full-text reviews were conducted. Article reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

Twenty articles were selected for inclusion, with 12 describing telephone triage services, seven describing telehealth substitution services, and one describing another telehealth service in primary care. These services were delivered by nurses, doctors, and allied health clinicians. Of the 20 included studies, 11 used cost analyses, five used cost-minimization analyses, and four used one or more methods, including either a cost-consequence analysis, a cost-utility analysis, or a cost-effectiveness analysis.

CONCLUSIONS

Telephone and videoconference consultations in primary care were cost-effective to the health system when deemed clinically appropriate, clinician when time was used efficiently, and when overall demand on health services was reduced. The societal benefits of telehealth consultations should be considered an important part of telehealth planning and should influence funding reform decisions for telehealth services in primary care.

Prevalence and economic losses associated with foetal wastage in abattoir

BACKGROUND

Both male and female food animals are slaughtered for meat. Some cows, ewes and does  slaughtered are found with viable foetuses resulting in foetal wastage and loss of future replacement stock. Foetal wastage accounts for about 20%-25% of the decline in livestock numbers in sub-Saharan Africa. Slaughter of pregnant cows, ewes and does results in economic losses and threatens food security with consequent decrease in available animal proteins to the fast growing human population. Protein requirement for healthy human development is inadequate in most developing countries including Uganda. The prevalence and economic losses associated with foetal wastage were assessed in an abattoir.

OBJECTIVES

The study was cnducted to assess the prevalence of feotal wastage at the study abattoir and estimate the associated economic losses.

METHODS

The researchers supported by abattoir resident meat inspectors examined all slaughtered female animals during the study period. Gravid uteri obtained from slaughtered animals after dressing of carcasses were eviscerated using a sharp knife across the long axis to recover foetuses. The crown rump lengths (CRLs) of the recovered foetuses were measured using a tape measure, weighed on a scale and categorised into first, second and third trimesters. Prevalence of pregnant animals slaughtered was determined by calculating the percentage of pregnant animals over the total number of female animals slaughtered. Economic losses were estimated based on the monetary losses at birth, weaning, maturity, and carcass loss at weaning and maturity.

RESULTS

The aggregate slaughters were bovine 604 (73.6%), caprine 169 (20.6%) and ovine 48 (5.9%). The overall prevalence of foetal wastage was 21.9%. The aggregate prevalence of foetal wastage by species include 160 (88.9%) cows, 8 (4.4%) heifers, 4 (2.2%) does and 8 (4.4%) ewes. Foetal wastage of cows by trimester included 62 (38.8%), 26 (16.25%) and 72 (45.0%) in first, second and third trimesters, respectively, translating into loss of US$13,055. Foetal wastage was high and the associated economic losses were substantial which undermines sustainability of the national herd. Farmers should be sensitised about the economic losses and long-term impact associated with foetal wastage and dissuaded from this practice. A policy is needed to deter farmers from selling pregnant animals for slaughter.

CONCLUSIONS

A total of 168 bovine, 8 caprine and 12 ovine foetuses were wasted within 60 days study period. These foetal wastages translated to US$ 13,224 monetary losses at birth, US$ 31,849 monetary loss at weaning and US$ 57,0896 monetary loss at maturity.

Development and Pilot Implementation of Neotree, a Digital Quality Improvement Tool Designed to Improve Newborn Care and Survival in 3 Hospitals in Malawi and Zimbabwe: Cost Analysis Study

Background

Two-thirds of the 2.4 million newborn deaths that occurred in 2020 within the first 28 days of life might have been avoided by implementing existing low-cost evidence-based interventions for all sick and small newborns. An open-source digital quality improvement tool (Neotree) combining data capture with education and clinical decision support is a promising solution for this implementation gap.

Objective

We present results from a cost analysis of a pilot implementation of Neotree in 3 hospitals in Malawi and Zimbabwe.

Methods

We combined activity-based costing and expenditure approaches to estimate the development and implementation cost of a Neotree pilot in 1 hospital in Malawi, Kamuzu Central Hospital (KCH), and 2 hospitals in Zimbabwe, Sally Mugabe Central Hospital (SMCH) and Chinhoyi Provincial Hospital (CPH). We estimated the costs from a provider perspective over 12 months. Data were collected through expenditure reports, monthly staff time-use surveys, and project staff interviews. Sensitivity and scenario analyses were conducted to assess the impact of uncertainties on the results or estimate potential costs at scale. A pilot time-motion survey was conducted at KCH and a comparable hospital where Neotree was not implemented.

Results

Total cost of pilot implementation of Neotree at KCH, SMCH, and CPH was US $37,748, US $52,331, and US $41,764, respectively. Average monthly cost per admitted child was US $15, US $15, and US $58, respectively. Staff costs were the main cost component (average 73% of total costs, ranging from 63% to 79%). The results from the sensitivity analysis showed that uncertainty around the number of admissions had a significant impact on the costs in all hospitals. In Malawi, replacing monthly web hosting with a server also had a significant impact on the costs. Under routine (nonresearch) conditions and at scale, total costs are estimated to fall substantially, up to 76%, reducing cost per admitted child to as low as US $5 in KCH, US $4 in SMCH, and US $14 in CPH. Median time to admit a baby was 27 (IQR 20-40) minutes using Neotree (n=250) compared to 26 (IQR 21-30) minutes using paper-based systems (n=34), and the median time to discharge a baby was 9 (IQR 7-13) minutes for Neotree (n=246) compared to 3 (IQR 2-4) minutes for paper-based systems (n=50).

Conclusions

Neotree is a time- and cost-efficient tool, comparable with the results from limited similar mHealth decision-support tools in low- and middle-income countries. Implementation costs of Neotree varied substantially between the hospitals, mainly due to hospital size. The implementation costs could be substantially reduced at scale due to economies of scale because of integration to the health systems and reductions in cost items such as staff and overhead. More studies assessing the impact and cost-effectiveness of large-scale mHealth decision-support tools are needed.

The Role of a Smart Health Ecosystem in Transforming the Management of Chronic Health Conditions

The effective management of chronic conditions requires an approach that promotes a shift in care from the clinic to the home, improves the efficiency of health care systems, and benefits all users irrespective of their needs and preferences. Digital health can provide a solution to this challenge, and in this paper, we provide our vision for a smart health ecosystem. A smart health ecosystem leverages the interoperability of digital health technologies and advancements in big data and artificial intelligence for data collection and analysis and the provision of support. We envisage that this approach will allow a comprehensive picture of health, personalization, and tailoring of behavioral and clinical support; drive theoretical advancements; and empower people to manage their own health with support from health care professionals. We illustrate the concept with 2 use cases and discuss topics for further consideration and research, concluding with a message to encourage people with chronic conditions, their caregivers, health care professionals, policy and decision makers, and technology experts to join their efforts and work toward adopting a smart health ecosystem.

Cost-effectiveness analysis of adult living-donor liver transplantation in Japan

AIM

Living-donor liver transplantation (LDLT) is a highly effective life-saving procedure; however, it requires substantial medical resources, and the cost-effectiveness of LDLT versus conservative management (CM) for adult patients with end-stage liver disease (ESLD) remains unclear in Japan.

METHODS

We performed a cost-effectiveness analysis using the Diagnostic Procedure Combination (DPC) data from the nationwide database of the DPC research group. We selected adult patients (18 years or older) who were admitted or discharged between 2010 and 2021 with a diagnosis of ESLD with Child-Pugh class C or B. A decision tree and Markov model were constructed, and all event probabilities were computed in 3-month cycles over a 10-year period. The willingness-to-pay per quality-adjusted life-year (QALY) was set at 5 million Japanese yen (JPY) (49,801 US dollars [USD]) from the perspective of the public health-care payer.

RESULTS

After propensity score matching, we identified 1297 and 111,849 patients in the LDLT and CM groups, respectively. The incremental cost-effectiveness ratio for LDLT versus CM for Child-Pugh classes C and B was 2.08 million JPY/QALY (20,708 USD/QALY) and 5.24 million JPY/QALY (52,153 USD/QALY), respectively. The cost-effectiveness acceptability curves showed the probabilities of being below the willingness-to-pay of 49,801 USD/QALY as 95.4% in class C and 48.5% in class B. Tornado diagrams revealed all variables in class C were below 49,801 USD/QALY while their ranges included or exceeded 49,801 USD/QALY in class B.

CONCLUSIONS

Living-donor liver transplantation for adult patients with Child-Pugh class C was cost-effective compared with CM, whereas LDLT versus CM for class B patients was not cost-effective in Japan.

Mohs Surgery Price Transparency and Variability at Academic Hospitals After the Implementation of the Federal Price Transparency Final Rule

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Telehealth Diabetes Prevention Program for Adults With Prediabetes in an Academic Medical Center Setting: Protocol for a Hybrid Type III Trial

BACKGROUND

Diabetes is a costly epidemic in the United States associated with both health and economic consequences. These consequences can be mitigated by participation in structured lifestyle change programs such as the National Diabetes Prevention Program (DPP) led by the Centers for Disease Control and Prevention. Mississippi consistently has among the highest rates of diabetes and prediabetes nationally. Implementing the National DPP through large health care systems can increase reach and accessibility for populations at the highest risk for diabetes. Translational research on the National DPP in Mississippi has not been studied.

OBJECTIVE

This study aims to evaluate the implementation and impact of the National DPP delivered using telehealth modalities at the University of Mississippi Medical Center in Jackson, Mississippi.

METHODS

An effectiveness-implementation hybrid type III research design is proposed. The study design is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework and the Practical, Robust Implementation and Sustainability Model. Participants are being recruited via provider referral, and the DPP is being delivered by trained lifestyle coaches. Study participants include adult (≥18 years) patients eligible for the DPP with at least 1 encounter at 1 of 3 ambulatory clinic specialties (lifestyle medicine, family medicine, and internal medicine) between January 2019 and December 2023. The National DPP eligibility criteria include a BMI ≥25 kg/m2 and hemoglobin A1c between 5.7% and 6.4%. The University of Mississippi Medical Center criteria include Medicare or Medicaid beneficiaries. The University of Mississippi Medical Center's a priori implementation plan was developed using the Consolidated Framework for Implementation Research and includes 23 discrete strategies. The primary aim will use an embedded mixed method process analysis to identify and mitigate challenges to implementation. The secondary aim will use a nonrandomized quasi-experimental design to assess the comparative effectiveness of the DPP on health care expenditures. A propensity score matching method will be implemented to compare case subjects to control subjects. The primary outcomes include patient referrals, participant enrollment, retention, engagement, the incidence of diabetes, and health care resource use and costs.

RESULTS

At baseline, of the 26,151 patients across 3 ambulatory clinic specialties, 1010 (3.9%) had prediabetes and were eligible for the National DPP. Of the 1010 patients, more than half (n=562, 55.6%) were aged 65 years or older, 79.5% (n=803) were Medicare beneficiaries, 65.9% (n=666) were female, and 70.8% (n=715) were obese.

CONCLUSIONS

This is the first translational study of the National DPP in Mississippi. The findings will inform implementation strategies impacting the uptake and sustainability of the National DPP delivered in an academic medical setting using distance learning and telehealth modalities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04822480; https://clinicaltrials.gov/study/NCT03622580.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50183.

Cost-effectiveness of telehealth-delivered nutrition interventions: a systematic review of randomized controlled trials

CONTEXT

Telehealth-delivered nutrition interventions are effective in practice; however, limited evidence exists regarding their cost-effectiveness.

OBJECTIVE

To evaluate the cost-effectiveness of telehealth-delivered nutrition interventions for improving health outcomes in adults with chronic disease.

DATA SOURCES

PubMed, CENTRAL, CINAHL, and Embase databases were systematically searched from database inception to November 2021. Included studies were randomized controlled trials delivering a telehealth-delivered diet intervention conducted with adults with a chronic disease and that reported on cost-effectiveness or cost-utility analysis outcomes.

DATA EXTRACTION

All studies were independently screened and extracted, and quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

DATA ANALYSIS

All extracted data were grouped into subcategories according to their telehealth modality and payer perspective, and were analyzed narratively.

RESULTS

Twelve randomized controlled trials comprising 5 phone-only interventions, 3 mobile health (mHealth), 2 online, and 1 each using a combination of phone-online or phone-mHealth interventions, were included in this review. mHealth interventions were the most cost-effective intervention in all studies. Across all telehealth interventions and cost analyses from health service perspectives, 60% of studies were cost-effective. From a societal perspective, however, 33% of studies reported that the interventions were cost-effective. Of the 10 studies using cost-utility analyses, 3 were cost saving and more effective, making the intervention dominant, 1 study reported no difference in costs or effectiveness, and the remaining 6 studies reported increased cost and effectiveness, meaning payers must decide whether this falls within an acceptable willingness-to-pay threshold for them. Quality of study reporting varied with between 63% to 92%, with an average of 77% of CHEERS items reported.

CONCLUSION

Telehealth-delivered nutrition interventions in chronic disease populations appear to be cost-effective from a health perspective, and particularly mHealth modalities. These findings support telehealth-delivered nutrition care as a clinically beneficial, cost-effective intervention delivery modality.

Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation

BACKGROUND

A mobile app that calculates a tuberculosis (TB) risk score based on individual social and pathological characteristics has been shown to be a better predictor of the risk of contracting TB than conventionally used TB signs and symptoms (TBSS) in Myanmar, where the TB burden is high. Its cost-effectiveness, however, has not yet been assessed.

OBJECTIVE

This study aimed to determine the incremental costs of this mobile app and of chest x-rays (CXRs) in averting disability-adjusted life years (DALYs) among missed cases of active TB in the population being screened.

METHODS

Elements of incremental costs and effectiveness of 3 initial TB screening strategies were examined, including TBSS followed by CXR, the mobile app followed by CXR, and universal CXR. The incremental cost-effectiveness ratio (ICER; ie, the additional cost for each additional DALY averted) was compared to TBSS screening. Based on the latest 2020 gross domestic product (GDP) per capita of Myanmar (US $1477.50), the ICER was compared to willingness-to-pay (WTP) thresholds of 1, 2, and 3 times the GDP per capita. Probabilistic sensitivity analysis was conducted with a Monte Carlo simulation to compute the levels of probability that the ICER for each strategy was below each WTP threshold.

RESULTS

For each 100,000 population, the incremental cost compared to TBSS of active TB screening was US $345,942 for the mobile app and US $1,810,712 for universal CXR. The incremental effectiveness was 325 DALYs averted for the mobile app and 576 DALYs averted for universal CXR. For the mobile app, the estimated ICER was US $1064 (72% of GDP per capita) per 1 DALY averted. Furthermore, 100% of the simulated values were below an additional cost of 1 times the GDP per capita for 1 additional DALY averted. The universal CXR strategy has an estimated ICER of US $3143 (2.1 times the GDP per capita) per 1 DALY averted and an additional 77.2% DALYs averted compared to the app (ie, 576 - 325 / 325 DALYs); however, 0.5% of the simulated values were higher than an additional expenditure of 3 times the GDP per capita.

CONCLUSIONS

Based on the status of the economy in 2020, the mobile app strategy is affordable for Myanmar. The universal CXR strategy, although it could prevent an additional 77% of DALYs, is probably unaffordable. Compared to the TBSS strategy, the mobile app system based on social and pathological characteristics of TB has potential as a TB screening tool to identify missing TB cases and to reduce TB morbidity and mortality, thereby helping to achieve the global goal of "End TB" in resource-limited settings with a high TB burden.

Mitigating household psychosocial and economic impact of coronavirus pandemic in Mathare slums, Nairobi, Kenya: an initiative by the German doctors in Kenya

The Psychosocial and Economic Impact of COVID-19 Pandemic in Mathare slums were adverse which necessitated mitigation strategies to be employed to cushion the most vulnerable and help them cope with the new 'state of affairs'. The pandemic was characterized by a surge in the respiratory infections, unemployment, households going hungry, gender-based violence in families, child abuse cases and increased rates of teenage pregnancy. Retrospective case study design was employed; secondary data from hospital departments were extracted for analysis from March 2020 to December 2021. Interventions in focus were health service provision, Gender based and child abuse services, food distribution, wet-feeding program, business grants and house rent grants. The most common burden faced by Mathare residents was food insecurity which was mitigated by giving 9,423 Patients' food baskets while 1,423 patients enrolled to the wet feeding program. Gender Based Violence services provided doubled in the year 2021 with physical and emotional violence being more common than sexual violence which was at 6.2%. Child abuse services were provided more in the year 2020 and 96 teenage mothers were assisted to go back to school. About 158 families received rent grants; which was a 30.4% increase from the year 2020. There was a 75.5% increase in the year 2021 of residents who received business grants. In a pandemic the effects are beyond health hence it is necessary to manage patients comprehensively using a multi-sectorial approach. However it is important to put regulations to avoid overdependence.

Biotechnical Control of Varroa in Honey Bee Colonies: A Trade-Off between Sustainable Beekeeping and Profitability?

Beekeeping faces several challenges, such as the Varroa mite. Few studies have measured the economic performance of farms in relation to the practices used for Varroa control. Our study analyzed various biotechniques (total brood removal, TBR; queen caging, QC; royal cell insertion, CI) and other methods (chemical treatments, CT; thymol use, THY) adopted by Italian beekeepers to show whether the adoption of biotechniques leads to farm profitability or a necessary trade-off between sustainability and profitability. Beekeepers were interviewed about the methods and operations conducted on their farms. The net incomes (NIs) of the farms were calculated and inter- and intrafarm comparisons were performed. A detailed schema of each practice was designed. The net income derived from TBR was the highest in eight out of the nine case studies, followed by CI and then QC. The NI calculated for farms using CT was lower than that for farms using other methods in two of the case studies. We also analyzed different biotechniques applied by the same farm and found that the NI resulting from TBR was higher than that achieved from the use of QC and CI. Our study suggests that use of biotechniques represents a long-term sustainable solution for reducing the level of Varroa infestation, which affects farm net income.

Impact of COVID-19 Infection on Health-Related Quality of Life, Work Productivity and Activity Impairment by Symptom-Based Long COVID Status and Age in the US

COVID-19 infection adversely impacts patients' wellbeing and daily lives. This survey-based study examined differences in patient-reported COVID-19 symptoms, Health-Related Quality of Life (HRQoL) and Work Productivity and Activity Impairment (WPAI) among groups of patients defined based on age and symptom-based long COVID status. Symptomatic, COVID-19-positive US outpatients were recruited from 31 January-30 April 2022. Outcomes were collected via validated instruments at pre-COVID, Day 3, Week 1, Week 4, Month 3 and Month 6 following infection, with changes assessed from pre-COVID and between groups, adjusting for covariates. EQ-5D-5L HRQoL and WPAI scores declined in all groups, especially during the first week. Long COVID patients reported significantly higher symptoms burden and larger drops in HRQoL and WPAI scores than patients without long COVID. Their HRQoL and WPAI scores did not return to levels comparable to pre-COVID through Month 6, except for absenteeism. Patients without long COVID generally recovered between Week 4 and Month 3. Older (>50) and younger adults generally reported comparable symptoms burden and drops in HRQoL and WPAI scores. During the first week of infection, COVID-19-related health issues caused loss of 14 to 26 work hours across the groups. These data further knowledge regarding the differential impacts of COVID-19 on clinically relevant patient groups.

Cost-effectiveness of alginic acid in combination with proton pump inhibitor for the treatment of gastroesophageal reflux disease in systemic sclerosis patients

BACKGROUND

Systemic sclerosis (SSc) patients often become refractory to proton pump inhibitors (PPI)-a standard treatment for gastroesophageal reflux disease (GERD)-and intolerant to PPI in combination with domperidone. PPI with alginic acid is an alternative treatment option, but alginic acid is costly.

OBJECTIVES

We compared the costs and effectiveness of alginic acid plus PPI versus standard treatments (PPI with/without antacids as needed and lifestyle modifications) for GERD in SSc patients unsuitable for, or intolerant to, domperidone.

METHODS

An economic evaluation using the Markov model was conducted among SSc patients aged between 40 and 65 years with GERD, having a partial or non-response to 4 weeks of standard-dose omeprazole (40 mg/day) and being unsuitable for or intolerant to domperidone. Using a societal perspective, we computed the incremental cost-effectiveness ratios (ICERs) in terms of Thai baht (THB) per quality-adjusted life-year (QALY) between a combination of alginic acid plus PPI and standard treatment for GERD. The lifetime time horizon was used.

RESULTS

The ICER for alginic acid plus PPI versus standard treatments was 377 101 THB/QALY. According to the one-way sensitivity analysis, the cost of alginic acid was the most impactful parameter. If the market prices of alginic acid plus PPI were reduced by 61%, this treatment option would become cost-effective at the willingness-to-pay threshold of 160 000 THB/QALY (34.68 THB/USD data on 25 May 2023). Furthermore, if alginic acid were included in the public health insurance program, the national budget would be increased by 66 313 THB per patient, resulting in an overall budget increase of 5 106 101 to 8 885 942 THB compared with the standard treatment.

CONCLUSIONS

Alginic acid plus PPI does not represent good value for money compared with the standard treatment among such SSc patients in Thailand unless its price is reduced significantly.

The True Cost of Antitransgender Legislation

A large body of research finds that sexual and gender minorities experience disparities in health equity that stem from structural discrimination. In particular, transgender and gender diverse (TGD) patients face barriers in access to gender-affirming care (GAC). As of December 2021, 35 state legislatures have introduced >100 bills that categorically deny TGD individuals' human rights and outlaw medically necessary GAC. Importantly, the economic consequences of discriminatory legislation and denial of health care for TGD individuals are void in the literature. This perspective outlines the economic impact of antitransgender policy and calls for federal intervention to protect TGD rights.

Cost-effectiveness of empagliflozin in heart failure patients irrespective of ejection fraction in England

AIMS

Heart failure (HF) is a complex syndrome commonly categorized into two main phenotypes [left ventricular ejection fraction (LVEF) below or above 40%], and although empagliflozin is the first approved medication with proven clinical effectiveness for both phenotypes, its cost-effectiveness of treating the entire HF population remains unknown.

METHODS

The analysis was performed utilizing two preexisting, LVEF phenotype-specific cost-effectiveness models to estimate the cost-effectiveness of empagliflozin in adults for the treatment of symptomatic chronic HF, irrespective of ejection fraction (EF). The results of the phenotype-specific models were combined using a population-weighted approach to estimate the deterministic and probabilistic incremental cost-effectiveness ratios (ICERs).

RESULTS

Based on combined results, empagliflozin + standard of care (SoC) is associated with 6.13 life-years (LYs) and 3.92 quality-adjusted life-years (QALYs) compared with 5.98 LYs and 3.76 QALYs for SoC alone over a lifetime, resulting in an incremental difference of 0.15 LYs and 0.16 QALYs, respectively. Total lifetime healthcare costs per patient are £15 246 for empagliflozin + SoC and £13 982 for SoC giving an incremental difference of £1264. The ICER is £7757/QALY, which is substantially lower than the willingness-to-pay (WTP) of £30 000 per QALY used by NICE. The results of the probabilistic sensitivity analyses are in line with the deterministic results.

CONCLUSION

Empagliflozin is the first efficacious, approved, and cost-effective treatment option for all HF patients, irrespective of EF. The combined ICER was consistently below the WTP threshold. Therefore, empagliflozin offers value for money for the treatment of the full HF population in England.

Benefits, risks, barriers, and facilitators to cycling: a narrative review

There is large potential to increase cycling participation worldwide. Participation in cycling is associated with lower risk of mortality from any cause, and incidence of cardiovascular disease and type 2 diabetes, as well as positive mental health and well-being. The largest potential for health gains likely to come from increasing participation amongst those who do not currently cycle regularly, rather than encouraging those who already cycle regularly to cycle more. Replacing car journeys with cycling can lead to reductions in air pollution emissions and lower pollutant exposure to the general population. Important gaps and uncertainties in the existing evidence base include: the extent to which the health benefits associated with cycling participation are fully causal due to the observational nature of much of the existing evidence base; the real-world economic cost-benefits of pragmatic interventions to increase cycling participation; and the most effective (combination of) approaches to increase cycling participation. To address these uncertainties, large-scale, long-term randomised controlled trials are needed to: evaluate the effectiveness, and cost-effectiveness, of (combinations of) intervention approaches to induce sustained long-term increases in cycling participation in terms of increases in numbers of people cycling regularly and number of cycling journeys undertaken, across a range of population demographic groups; establish the effects of such interventions on relevant outcomes related to health and wellbeing, economic productivity and wider societal impacts; and provide more robust quantification of potential harms of increasing cycling participation, such as collision risks.

Evaluation of the Economic, Environmental, and Social Impact of the Valorization of Grape Pomace from the Wine Industry

The increase in the world population has led to intensive food production systems that are generating increasing amounts of solid waste. In this work, the valorization of the most important waste generated during wine production, grape pomace, is evaluated. Eight processes are proposed to approach different types of valorization (production of energy and value-added products), from economic, environmental, and social points of view. The best process depends on the budget available, the production capacity, and the weight of each impact produced by the factory (economic, environmental, or social). For small (less than 0.1 kg/s) or very large (greater than 10 kg/s) capacities, the production of high-value-added products outperforms the other processes in all three impacts and in profitability. For intermediate capacities, combustion and gasification stand out as having the highest greenhouse emissions and intermediate economic benefits. Anaerobic digestion is remarkable for its low greenhouse gas emissions, while tannin production is the best-balanced process from both economic and environmental points of view. Pyrolysis is the worst process of all three impacts.

Impact of Prenatal and Postnatal Diagnosis on Parents: Psychosocial and Economic Aspects Related to Congenital Heart Defects in Children

Congenital heart defects (CHD) are defects detected both prenatally and after birth. They are the most common congenital defects. Despite advances in diagnosis and treatment, CHD remain an important cause of morbidity and mortality in newborns, which has a great impact on economic aspects. It is crucial to provide a holistic approach to the care of children with CHD, including regular cardiac check-ups, appropriate drug treatment, surgical or cardiac interventions as needed, rehabilitation, psychological support, and education for patients and their families. Parents experience a variety of psychological problems. This article summarizes the influence of CHD in the psychological and economic areas.

Real-World Costs and Cost-Effectiveness Analysis of Rabbit-Antithymocyte Globulin Versus Oxymetholone in Acquired Aplastic Anemia in Thailand

OBJECTIVES

This study aimed to compare rabbit-antithymocyte globulin and cyclosporine (rATG/CsA) with oxymetholone in terms of direct medical expenditures and economic evaluation in severe acquired aplastic anemia (SAA) and very severe acquired aplastic anemia (vSAA) patients.

METHODS

Patients with SAA/vSAA who initiated treatment with rATG/CsA or oxymetholone between 2004 and 2018 were included. Trial-based cost-effectiveness evaluation in healthcare provider perspective was performed. Direct medical costs were retrieved from hospital database, inflated, and converted to 2020 US dollar (30.01 Baht per US dollar). One-way sensitivity analysis and probabilistic sensitivity analysis by nonparametric bootstrap was performed.

RESULTS

After 2-year follow-up, the total mean (SD) direct medical expenditures per patient for oxymetholone and rATG/CsA group were $8 514.48 ($12 595.67) and $41 070.88 ($22 084.04), respectively. Nevertheless, oxymetholone had significant lower survival rate than rATG/CsA (P=.001) but higher in second-year blood transfusion need (71.4% vs 18.2%) and hospitalization (14.3% vs 0%). The incremental cost-effectiveness ratio was $45 854.08 per life-year gained when rATG/CsA was used instead of oxymetholone (95% CI $24 244.03-$143 496.67 per life-year gained). The probabilistic sensitivity analysis indicated that rATG/CsA had no chance of being cost-effective for SAA/vSAA when willingness to pay threshold of one to 3 times of national gross domestic product per capita was applied.

CONCLUSIONS

Oxymetholone remains a viable alternative in resource-limited country. Despite its high cost, the rATG/CsA is a preferred treatment option because of the significant advantages on reducing mortality, treatment complications, and hospitalization.

Updated Estimates of Annual U.S. Health System Spending from a Hypothetical National Naloxone Co-Prescribing Mandate

Background: Naloxone-prescription opioid co-prescribing mandates have increasingly been proposed and adopted in the U.S., at both the national and state levels, as a public health intervention for mitigating the impacts of opioid overdoses. In this study, we assess whether a hypothetical national, naloxone co-prescribing mandate has become less costly for the U.S. health system since 2018. Methods: We expand and update an existing economic model of naloxone co-prescribing to estimate annual health system spending. We refresh the model inputs through 2021 to reflect changes to the opioid and naloxone landscapes, expand the model to account for more types of market responses, and develop additional scenarios around alternate implementation strategies such as bulk purchasing. Results: We estimate annual spending increases across all retail opioid patients of $1.4-$4.0 billion with naloxone nasal sprays and auto-injectors, and $0.6-$0.9 billion with traditional injectable naloxone formulations. We also find that bulk purchasing could lead to higher spending increases in some patient populations absent volume discounts. Conclusions: Our estimates are substantially lower than prior research. Key drivers include lower prices for naloxone, higher current naloxone distribution, a longer approved shelf life for naloxone, and lower estimated sizes for some patient populations. Additional research is needed to estimate the potential benefits of naloxone co-prescribing for mitigating opioid overdoses, and whether they could outweigh spending increases. Steps that could make this policy more beneficial or less costly include targeting higher risk patient populations and promoting large-scale purchasing agreements with volume discounts to help offset potential price increases.

The evolution of economic and political inequality: minding the gap

The extent of economic and political inequality, their change over time, and the forces shaping them have profound implications for the sustainability of a society and the well-being of its members. Here we review the evolution of economic and political inequality broadly, though with particular attention to Europe and the USA. We describe legal/institutional, technological and social forces that have shaped this evolution. We highlight the cumulative effects of inequality across generations as channelled through wealth and inheritance but also through other intergenerational connections. We also review the state of research on the effects of inequality on economic growth, health and societal cohesion. This article is part of the theme issue 'Evolutionary ecology of inequality'.

Nanobiotics and the One Health Approach: Boosting the Fight against Antimicrobial Resistance at the Nanoscale

Antimicrobial resistance (AMR) is a growing public health concern worldwide, and it poses a significant threat to human, animal, and environmental health. The overuse and misuse of antibiotics have contributed significantly and others factors including gene mutation, bacteria living in biofilms, and enzymatic degradation/hydrolyses help in the emergence and spread of AMR, which may lead to significant economic consequences such as reduced productivity and increased health care costs. Nanotechnology offers a promising platform for addressing this challenge. Nanoparticles have unique properties that make them highly effective in combating bacterial infections by inhibiting the growth and survival of multi-drug-resistant bacteria in three areas of health: human, animal, and environmental. To conduct an economic evaluation of surveillance in this context, it is crucial to obtain an understanding of the connections to be addressed by several nations by implementing national action policies based on the One Health strategy. This review provides an overview of the progress made thus far and presents potential future directions to optimize the impact of nanobiotics on AMR.

Nutritional, biochemical, and clinical applications of carob: A review

Carob is botanically called as Ceratonia siliqua and belongs to the Legumes family. The fruit is derived from hermaphrodite trees and hard in shape. The carob contains high sugar contents in pulp, fat in seed and minerals like potassium, calcium, and phosphorus are present in pods. Polyphenols and antioxidants are abundant in leaves and pods. It can be used for enhancing human health due to its high nutritional profile. Carob gum is used in the pharmaceutical industry in the form of pomades, anti-celiac ingredients, pills, and dental paste. The clinical carob can aid as an anti-cancer, anti-reflux, anti-diabetic, anti-diarrheal, anti-hyperlipidemia, anti-bacterial, anti-microbial, and anti-fungal. Nowadays, carob seeds are being used as an alternative to cocoa powder in food items whereas the leaves, pods, and seeds of carob are also historically used as food for animal feed. However, these parts of carob are available in markets with reasonable prices. Carob production, though with a rising contribution, contributes to the local economy. In this sense, we can incorporate knowledge on the chemical properties and the biological effect of carob fruits on human health. In this study, the supportive and health-promoting impacts of carob are discussed along with the clinical testing obtained from natural constituents of carob. In addition, further studies can be performed to extract and separate polyphenols and antioxidant potential for the development of functional that play a valuable role in pharmaceutical and food sectors.

A retrospective review of immunology patients with primary and/or secondary immunodeficiency, demonstrating the benefits of the rapid transitioning from intravenous immunoglobulin to subcutaneous immunoglobulin at the onset of the COVID-19 pandemic

Forty-four of 50 immunology patients with primary or secondary immunodeficiency receiving intravenous immunoglobulin at a hospital in New South Wales, Australia, were rapidly enrolled in the subcutaneous immunoglobulin (SCIg) programme at the onset of the 2020 COVID-19 pandemic. Health and economic outcomes demonstrated that SCIg provides clinical efficacy as evidenced by the number of infections and maintenance of IgG levels, and also facilitates cost reduction in immunoglobulin maintenance programmes.

Economic Impact of a Hospital Cyberattack in a National Health System: Descriptive Case Study

BACKGROUND

Over the last decade, the frequency and size of cyberattacks in the health care industry have increased, ranging from breaches of processes or networks to encryption of files that restrict access to data. These attacks may have multiple consequences for patient safety, as they can, for example, target electronic health records, access to critical information, and support for critical systems, thereby causing delays in hospital activities. The effects of cybersecurity breaches are not only a threat to patients' lives but also have financial consequences due to causing inactivity in health care systems. However, publicly available information on these incidents quantifying their impact is scarce.

OBJECTIVE

We aim, while using public domain data from Portugal, to (1) identify data breaches in the public national health system since 2017 and (2) measure the economic impact using a hypothesized scenario as a case study.

METHODS

We retrieved data from multiple national and local media sources on cybersecurity from 2017 until 2022 and built a timeline of attacks. In the absence of public information on cyberattacks, reported drops in activity were estimated using a hypothesized scenario for affected resources and percentages and duration of inactivity. Only direct costs were considered for estimates. Data for estimates were produced based on planned activity through the hospital contract program. We use sensitivity analysis to illustrate how a midlevel ransomware attack might impact health institutions' daily costs (inferring a potential range of values based on assumptions). Given the heterogeneity of our included parameters, we also provide a tool for users to distinguish such impacts of different attacks on institutions according to different contract programs, served population size, and proportion of inactivity.

RESULTS

From 2017 to 2022, we were able to identify 6 incidents in Portuguese public hospitals using public domain data (there was 1 incident each year and 2 in 2018). Financial impacts were obtained from a cost point of view, where estimated values have a minimum-to-maximum range of €115,882.96 to €2,317,659.11 (a currency exchange rate of €1=US $1.0233 is applicable). Costs of this range and magnitude were inferred assuming different percentages of affected resources and with different numbers of working days while considering the costs of external consultation, hospitalization, and use of in- and outpatient clinics and emergency rooms, for a maximum of 5 working days.

CONCLUSIONS

To enhance cybersecurity capabilities at hospitals, it is important to provide robust information to support decision-making. Our study provides valuable information and preliminary insights that can help health care organizations better understand the costs and risks associated with cyber threats and improve their cybersecurity strategies. Additionally, it demonstrates the importance of adopting effective preventive and reactive strategies, such as contingency plans, as well as enhanced investment in improving cybersecurity capabilities in this critical area while aiming to achieve cyber-resilience.

Economic Evaluation of Digital Therapeutic Care Apps for Unsupervised Treatment of Low Back Pain: Monte Carlo Simulation

BACKGROUND

Digital therapeutic care (DTC) programs are unsupervised app-based treatments that provide video exercises and educational material to patients with nonspecific low back pain during episodes of pain and functional disability. German statutory health insurance can reimburse DTC programs since 2019, but evidence on efficacy and reasonable pricing remains scarce. This paper presents a probabilistic sensitivity analysis (PSA) to evaluate the efficacy and cost-utility of a DTC app against treatment as usual (TAU) in Germany.

OBJECTIVE

The aim of this study was to perform a PSA in the form of a Monte Carlo simulation based on the deterministic base case analysis to account for model assumptions and parameter uncertainty. We also intend to explore to what extent the results in this probabilistic analysis differ from the results in the base case analysis and to what extent a shortage of outcome data concerning quality-of-life (QoL) metrics impacts the overall results.

METHODS

The PSA builds upon a state-transition Markov chain with a 4-week cycle length over a model time horizon of 3 years from a recently published deterministic cost-utility analysis. A Monte Carlo simulation with 10,000 iterations and a cohort size of 10,000 was employed to evaluate the cost-utility from a societal perspective. Quality-adjusted life years (QALYs) were derived from Veterans RAND 6-Dimension (VR-6D) and Short-Form 6-Dimension (SF-6D) single utility scores. Finally, we also simulated reducing the price for a 3-month app prescription to analyze at which price threshold DTC would result in being the dominant strategy over TAU in Germany.

RESULTS

The Monte Carlo simulation yielded on average a €135.97 (a currency exchange rate of EUR €1=US $1.069 is applicable) incremental cost and 0.004 incremental QALYs per person and year for the unsupervised DTC app strategy compared to in-person physiotherapy in Germany. The corresponding incremental cost-utility ratio (ICUR) amounts to an additional €34,315.19 per additional QALY. DTC yielded more QALYs in 54.96% of the iterations. DTC dominates TAU in 24.04% of the iterations for QALYs. Reducing the app price in the simulation from currently €239.96 to €164.61 for a 3-month prescription could yield a negative ICUR and thus make DTC the dominant strategy, even though the estimated probability of DTC being more effective than TAU is only 54.96%.

CONCLUSIONS

Decision-makers should be cautious when considering the reimbursement of DTC apps since no significant treatment effect was found, and the probability of cost-effectiveness remains below 60% even for an infinite willingness-to-pay threshold. More app-based studies involving the utilization of QoL outcome parameters are urgently needed to account for the low and limited precision of the available QoL input parameters, which are crucial to making profound recommendations concerning the cost-utility of novel apps.

Reducing Clinical Trial Monitoring Resources and Costs With Remote Monitoring: Retrospective Study Comparing On-Site Versus Hybrid Monitoring

BACKGROUND

Clinical research associates (CRAs) monitor the progress of a trial, verify the data collected, and ensure that the trial is carried out and reported in accordance with the trial protocol, standard operating procedures, and relevant laws and regulations. In response to monitoring challenges during the COVID-19 pandemic, Peking University Cancer Hospital launched a remote monitoring system and established a monitoring model, combining on-site and remote monitoring of clinical trials. Considering the increasing digitization of clinical trials, it is important to determine the optimal monitoring model for the general benefit of centers conducting clinical trials worldwide.

OBJECTIVE

We sought to summarize our practical experience of a hybrid model of remote and on-site monitoring of clinical trials and provide guidance for clinical trial monitoring management.

METHODS

We evaluated 201 trials conducted by our hospital that used on-site monitoring alone or a hybrid monitoring model, of which 91 trials used on-site monitoring alone (arm A) and 110 used a hybrid model of remote and on-site monitoring (arm B). We reviewed trial monitoring reports from June 20, 2021, to June 20, 2022, and used a customized questionnaire to collect and compare the following information: monitoring cost of trials in the 2 models as a sum of the CRAs' transportation (eg, taxi fare and air fare), accommodation, and meal costs; differences in monitoring frequency; the number of monitored documents; and monitoring duration.

RESULTS

From June 20, 2021, to June 20, 2022, a total of 320 CRAs representing 201 sponsors used the remote monitoring system for source data review and the verification of data from 3299 patients in 320 trials. Arm A trials were monitored 728 times and arm B trials were monitored 849 times. The hybrid model in arm B had 52.9% (449/849) remote visits and 48.1% (409/849) on-site visits. The number of patients' visits that could be reviewed in the hybrid monitoring model increased by 34% (4.70/13.80; P=.004) compared with that in the traditional model, whereas the duration of monitoring decreased by 13.8% (3.96/28.61; P=.03) and the total cost of monitoring decreased by 46.2% (CNY ¥188.74/408.80; P<.001). These differences were shown by nonparametric testing to be statistically significant (P<.05).

CONCLUSIONS

The hybrid monitoring model can ensure timely detection of monitoring issues, improve monitoring efficiency, and reduce the cost of clinical trials and should therefore be applied more broadly in future clinical studies.

Identifying the Relationship Between Economic Prosperity and Quality of Life in Chronic Obstructive Pulmonary Disease Patients

Background Chronic obstructive pulmonary disease (COPD) places a significant economic burden on national healthcare systems, and the economic effects of diseases have long been known. The study aimed to evaluate the association of parental family financial wealth with current economic prosperity and the combined effect of both on health-related quality of life (HRQOL) in a sample of patients with COPD. The moderating effect of birth order is further investigated. Methods The results of the study are based on a purposive sample of 105 COPD patients at the Larisa University Hospital pulmonology clinic (94 males and 11 females), with an average age of 68.9 (SD = 9.2). The data collection was carried out in the spring and summer of 2020. Participants completed the 36-item Short Form Survey (SF-36) and a sociodemographic questionnaire with self-reported parental and current wealth items. A mediation model with the moderation of the indirect effect of parental wealth on current wealth and the direct effect of parental wealth on HRQOL was applied to test the research hypotheses among the variables studied. Results Parental wealth was found to affect current wealth significantly, and both were involved considerably in HRQOL. Birth order had a significant moderating effect on the relationship between parental wealth and HRQOL. Among parental families with lower financial status, patients who grew up as third or later children had significantly lower HRQOL than the first or second children of these families. Neither age nor COPD duration was related to current wealth or HRQOL. Conclusions An intergenerational transmission of poverty was found in our sample. In addition, a birth order effect can provide further insight into the harsher environment that the later children of a low-income family are exposed to and the long-term implications for their HRQOL.

Cost-Effectiveness of the ENJOY Seniors Exercise Park for Older People: A Pre-Post Intervention Study

BACKGROUND

The Exercise interveNtion outdoor proJect in the cOmmunitY (ENJOY) Seniors Exercise Park program uses specialized outdoor equipment and a physical activity program to engage older people in physical activity, with multiple health benefits. We determined the cost-effectiveness of the ENJOY program.

METHODS

The economic evaluation compared health care utilization costs 6 months prior to and 6 months post ENJOY program participation. Incremental cost-utility analysis for the primary aim (quality of life) and incremental cost-effectiveness analysis for the secondary aim (falls) were used. Analyses took a societal perspective inclusive of Australian government-funded health care and pharmaceuticals in addition to hospitalizations, community-based nursing and allied health, and community services. Productivity costs were also calculated.

RESULTS

Fifty participants (average age 72.8 y [SD 7.4] and 78.0% [n = 39/50] women) were included. Participation in the ENJOY program reduced health care costs in the 6 months following the program: preintervention, $9764.49 (SD $26,033.35); postintervention, $5179.30 (SD $3826.64); observed postintervention reduction -$4.585.20 (95% confidence interval, -$12,113.99 to $2943.59; P = .227) without compromising quality of life (mean difference [MD] 0.011; 95% confidence interval, -0.034 to 0.056; P = .631) or increasing the likelihood of a fall (-0.5; 95% confidence interval, 0.00 to -0.50; P = .160). The ENJOY intervention is likely cost-effective.

CONCLUSIONS

Planning for shared community spaces should consider the benefits of a Seniors Exercise Park as part of the built environment.

Regional Differences in Medical Costs of Chronic Kidney Disease in the South Korean Population: Marginalized Two-Part Model

BACKGROUND

There are regional gaps in the access to medical services for patients with chronic kidney disease (CKD), and it is necessary to reduce those gaps, including the gaps involving medical costs.

OBJECTIVE

This study aimed to analyze regional differences in the medical costs associated with CKD in the South Korean population.

METHODS

This longitudinal cohort study included participants randomly sampled from the National Health Insurance Service-National Sample Cohort of South Korea. To select those who were newly diagnosed with CKD, we excluded those who were diagnosed in 2002-2003 and 2018-2019. A total of 5903 patients with CKD were finally included. We used a marginalized two-part longitudinal model to assess total medical costs.

RESULTS

Our cohort included 4775 (59.9%) men and 3191 (40.1%) women. Of these, 971 (12.2%) and 6995 (87.8%) lived in medically vulnerable and nonvulnerable regions, respectively. The postdiagnosis costs showed a significant difference between the regions (estimate: -0.0152, 95% confidence limit: -0.0171 to -0.0133). The difference in medical expenses between the vulnerable and nonvulnerable regions showed an increase each year after the diagnosis.

CONCLUSIONS

Patients with CKD living in medically vulnerable regions are likely to have higher postdiagnostic medical expenses compared to those living in regions that are not medically vulnerable. Efforts to improve early diagnosis of CKD are needed. Relevant policies should be drafted to decrease the medical costs of patients with CKD disease living in medically deprived areas.

The social and economic impacts of cervical cancer on women and children in low- and middle-income countries: A systematic review

BACKGROUND

There is limited knowledge on the social and economic impacts of a diagnosis of cervical cancer on women and children in low- and middle-income countries (LMICs).

OBJECTIVES

To determine the social and economic impacts associated with cervical cancer among women and children living in LMICs.

SEARCH STRATEGY

The MEDLINE, PsychInfo, CINAHL, Pais International, and CAB Global Health databases were systematically searched to retrieve studies up to June 2021.

SELECTION CRITERIA

Studies were included if they reported on either the social or economic impacts of women or children in a LMIC.

DATA COLLECTION AND ANALYSIS

Data was independently extracted by two co-authors. The authors performed a quality assessment on all included articles.

MAIN RESULTS

In all, 53 studies were included in the final review. Social impacts identified included social support, education, and independence. Economic impacts included employment and financial security. No study reported the economic impact on children. Studies that utilized quantitative methods typically reported more positive results than those that utilized qualitative methods.

CONCLUSIONS

Additional mixed-methods research is needed to further understand the social support needs of women with cervical cancer. Furthermore, research is needed on the impact of a mother's diagnosis of cervical cancer on her children.

Tobacco-Derived Nicotine Pouch Brands and Marketing Messages on Internet and Traditional Media: Content Analysis

BACKGROUND

Nicotine pouches and lozenges are increasingly available in the United States, and sales are growing. The brands of nicotine pouch products with the largest market share are produced by tobacco companies.

OBJECTIVE

The aim of this study is to examine the marketing of 5 oral nicotine products sold by tobacco companies.

METHODS

Internet, radio, television, print, and web-based display advertisements between January 2019 and March 2020 for 6 brands of nicotine pouches and lozenges were identified through commercially available marketing surveillance systems supplemented by a manual search of trade press and a review of brand websites. A total of 711 advertisements (122 unique) were analyzed to identify characteristics, themes, marketing strategies, and target audiences, and qualitatively compared by brand. All 5 brand websites were also analyzed. Coders examined the entirety of each advertisement or website for products, marketing claims, and features and recorded the presence or absence of 27 marketing claims and lifestyle elements.

RESULTS

All 6 brands of nicotine pouch products spent a total of US $11.2 million on advertising in 2019, with the most (US $10.7 million) spent by the brand Velo, and 86.1% (n=105) of the unique advertisements were web-based. Of the 711 total nicotine pouch advertisements run in 2019, the 2 brands Velo (n=407, 57%) and ZYN (n=303, 42%) dominated. These brands also made the greatest number of advertising claims in general. These claims focused on novelty, modernity, and use in a variety of contexts, including urban contexts, workplaces, transportation, and leisure activities. Of the 122 unique advertisements, ZYN's most common claims were to be "tobacco-free," featuring many flavors or varieties, and modern. Velo was the only brand to include urban contexts (n=14, 38.9% of advertisements) or freedom (n=8, 22.2%); Velo advertisements portrayed use in the workplace (n=15, 41.7%), bars or clubs (n=5, 13.9%), leisure activities (n=4, 11.1%), transportation (n=4, 11.1%), sports (n=3, 8.3%), cooking (n=2, 5.6%), and with alcohol (n=1, 2.8%). Velo and ZYN also included most of the images of people, including women and people of color. The 36 Velo ads included people in advertising in 77.8% (n=28) of advertisements, and of those advertisements with identifiable people, 40% (n=4) were young adults and 50% (n=5) were middle-aged. About one-third (n=11, 35.5%) of the 31 unique ZYN advertisements included people, and most identifiable models appeared to be young adults. Brands such as Rogue, Revel, Dryft, and on! focused mainly on product features. All nicotine pouch products made either tobacco-free, smoke-free, spit-free, or vape-free claims. The most common claim overall was "tobacco-free," found in advertisements from Rogue (1/1, 100%), ZYN (30/31, 96.8%), Velo (19/36, 52.8%), and Dryft (1/3, 33.3%), but not Revel.

CONCLUSIONS

Nicotine pouches and lozenges may expand the nicotine market as tobacco-free claims alleviate concerns about health harms and advertising features a greater diversity of people and contexts than typical smokeless tobacco advertising. The market leaders and highest-spending brands, ZYN and Velo, included more lifestyle claims. Surveillance of nicotine pouch marketing and uptake, including influence on tobacco use behaviors, is necessary.