Cost-effectiveness of subthalmic nucleus deep brain stimulation for the treatment of advanced Parkinson disease in Hong Kong: a prospective study.

BACKGROUND: Deep brain stimulation (DBS) is an effective but costly treatment for patients with advanced Parkinson disease (PD). This study examined the cost-effectiveness of DBS in relation to its improved effectiveness to help funding decision makers decide whether the treatment should be adopted. The incremental cost-effective ratio (ICER) per quality-adjusted life year has been benchmarked as being between US$50,000 and US$100,000 by US agencies, whereas it is less than €30,000 per quality-adjusted life year in Europe. OBJECTIVE: To provide cost-effectiveness information of subthalamic nucleus DBS for patients with advanced PD. MATERIALS: Direct medical expenses during the year before the DBS treatment were used to measure the baseline cost. Cost-effectiveness was measured by the ICER for the Unified Parkinson's Disease Rating Scale Part III and the ICER for the EuroQol Group's Health-Related Quality of Life measurement. RESULTS: Thirteen patients with advanced PD were recruited between January 2009 and January 2011. A 1-point improvement in the Unified Parkinson's Disease Rating Scale Part III score was associated with an ICER of US$926 in the first year and US$421 in the second year. A 1-point improvement on the EuroQol Group's Health-Related Quality of Life measurement was associated with an ICER of US$123,110 in the first year and US$62,846 in the second year. CONCLUSION: Cost-effectiveness of subthalamic nucleus DBS for treatment of advanced PD is greater during a 2-year period than 1 year only. These results can be used as a reference for the use of DBS for PD in a region with public health financing.

The rising tide of diabetes mellitus in a Chinese population: a population-based household survey on 121,895 persons.

OBJECTIVES: We studied the prevalence of self-reported diabetes mellitus in selected years from 2001 to 2008, and evaluated the factors associated with diabetes. METHODS: From territory-wide household interviews in a Chinese population in the years 2001, 2002, 2005 and 2008, we evaluated the trend of self-reported diabetes with respect to age, sex and household income. Binary logistic regression analyses were conducted to study the independent factors associated with diabetes. RESULTS: From 121,895 respondents in the household surveys, 103,367 were adults aged 15 years or older. Among male respondents, the age- and sex-adjusted prevalence of diabetes in 2001, 2002, 2005 and 2008 was 2.80, 2.87, 3.32 and 4.66 %, respectively; while among female respondents the respective prevalence was 3.25, 3.37, 3.77 and 4.31 %. In all the years, the prevalence escalated with age and increased sharply among the poor. From binary logistic regression analyses, advanced age and low monthly household income were significantly associated with self-report of diabetes. CONCLUSIONS: This study showed a rising trend of diabetes mellitus in a large Chinese population and found a strong association between population demography and diabetes.

Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) accounts for around 4% of all public hospital annual admissions in Hong Kong. By year 2020, COPD will be ranked fifth among the conditions with the highest burden to the society. This study identifies admission and unplanned readmission of COPD patients, factors affecting unplanned readmission, and estimates its cost burden on the public healthcare system in Hong Kong. METHODS: This is a retrospective study analyzing COPD admissions to all public hospitals in Hong Kong. All admission episodes to acute medical wards with the principal diagnosis of COPD (ICD-9:490-492, 494-496) from January 2006 to December 2007 were captured. Unplanned readmission was defined as an admission which followed a previous admission within 30 days. RESULTS: In 2006 and 2007, 65497 (8.0%) of episodes from medical wards were identified as COPD admissions, and among these, 15882 (24.2%) were unplanned readmissions. The mean age of COPD patients was 76.81 ± 9.59 years and 77% were male. Unplanned readmission was significantly associated with male gender, receiving public assistance and living in nursing homes while no association was found with the Charlson comorbidity index. Patients who were readmitted unplanned had a significant longer acute length of stay (ß = 0.3894, P < 0.001) after adjustment for other covariates. CONCLUSIONS: Unplanned readmission of COPD patients has a huge impact on the public healthcare system. A systematic approach in programme provision and a good discharge planning process targeting on COPD patients who are at high risk of unplanned readmission are essential.

A population-based survey using PPE-15: relationship of care aspects to patient satisfaction in Hong Kong.

OBJECTIVE: Satisfaction with hospitalization may lead to both better health outcomes for patients and create better working environment and relationship between staff and patients. The objective of this study is to explore the relationship between the experiences of inpatients with specific aspects of care and satisfaction with the hospitalization experience. DESIGN: A secondary data analysis based on the Thematic Household Survey which was regularly conducted by the Census and Statistic Department. SETTING: This survey covered the land-based non-institutional population of the Hong Kong Special Administrative Region (HKSAR), China, and representing 99% of the total population of HKSAR of 6.8 million. PARTICIPANTS: Totally 1264 respondents aged ≥15 who had ever been admitted to local hospital in 12 months prior enumeration were recruited. MAIN OUTCOME MEASURES: The Picker Patient Experience Questionnaire-15 (PPE-15) was adopted for measuring patient-perceived quality of hospitalization; and one global rating of the overall quality of hospital service was included. RESULTS: The mean global satisfaction scores for public and private hospital care were 7.3/10 and 7.8/10, respectively. By adjusting patient demographics, the regression models show that 'want to be more involved in decision made about the care and treatment', 'respect for patient's dignity', 'patients' family have enough opportunity to talk to doctor' and 'tell about danger signals regarding illness/treatment after went home' are major determinants of the global satisfaction scores. CONCLUSION: Communication, respect and patient engagement in provider-patient relationship are important in determining patient's satisfaction. Training and healthcare education curriculum could take this into account for ensuring the quality of patient-centered care.

Unplanned readmission rates, length of hospital stay, mortality, and medical costs of ten common medical conditions: a retrospective analysis of Hong Kong hospital data.

BACKGROUND: Studies on readmissions attributed to particular medical conditions, especially heart failure, have generally not addressed the factors associated with readmissions and the implications for health outcomes and costs. This study aimed to investigate the factors associated with 30-day unplanned readmission for 10 common conditions and to determine the cost implications. METHODS: This population-based retrospective cohort study included patients admitted to all public hospitals in Hong Kong in 2007. The sample consisted of 337,694 hospitalizations in Internal Medicine. The disease-specific risk-adjusted odd ratio (OR), length of stay (LOS), mortality and attributable medical costs for the year were examined for unplanned readmissions for 10 medical conditions, namely malignant neoplasms, heart diseases, cerebrovascular diseases, pneumonia, injury and poisoning, nephritis and nephrosis, diabetes mellitus, chronic liver disease and cirrhosis, septicaemia, and aortic aneurysm. RESULTS: The overall unplanned readmission rate was 16.7%. Chronic liver disease and cirrhosis had the highest OR (1.62, 95% confidence interval (CI) 1.39-1.87). Patients with cerebrovascular disease had the longest LOS, with mean acute and rehabilitation stays of 6.9 and 3.0 days, respectively. Malignant neoplasms had the highest mortality rate (30.8%) followed by aortic aneurysm and pneumonia. The attributed medical cost of readmission was highest for heart disease (US$3 199 418, 95% CI US$2 579 443-803 393). CONCLUSIONS: Our findings showed variations in readmission rates and mortality for different medical conditions which may suggest differences in the quality of care provided for various medical conditions. In-hospital care, comprehensive discharge planning, and post-discharge community support for patients need to be reviewed to improve the quality of care and patient health outcomes.

Avoidable readmission in Hong Kong--system, clinician, patient or social factor?

BACKGROUND: Studies that identify reasons for readmissions are gaining importance in the light of the changing demographics worldwide which has led to greater demand for hospital beds. It is essential to profile the prevalence of avoidable readmissions and understand its drivers so as to develop possible interventions for reducing readmissions that are preventable. The aim of this study is to identify the magnitude of avoidable readmissions, its contributing factors and costs in Hong Kong. METHODS: This was a retrospective analysis of 332,453 inpatient admissions in the Medical specialty in public hospital system in Hong Kong in year 2007. A stratified random sample of patients with unplanned readmission within 30 days after discharge was selected for medical record reviews. Eight physicians reviewed patients' medical records and classified whether a readmission was avoidable according to an assessment checklist. The results were correlated with hospital inpatient data. RESULTS: It was found that 40.8% of the 603 unplanned readmissions were judged avoidable by the reviewers. Avoidable readmissions were due to: clinician factor (42.3%) including low threshold for admission and premature discharge etc.; patient factor (including medical and health factor) (41.9%) such as relapse or progress of previous complaint, and compliance problems etc., followed by system factor (14.6%) including inadequate discharge planning, inadequate palliative care/terminal care, etc., and social factor (1.2%) such as carer system, lack of support and community services. After adjusting for patients' age, gender, principal diagnosis at previous discharge and readmission hospitals, the risk factors for avoidable readmissions in the total population i.e. all acute care admissions irrespective of whether there was a readmission or not, included patients with a longer length of stay, and with higher number of hospitalizations and attendance in public outpatient clinics and Accident and Emergency departments in the past 12 months. In the analysis of only unplanned readmissions, it was found that the concordance of the principal diagnosis for admission and readmission, and shorter time period between discharge and readmission were associated with avoidable readmissions. CONCLUSIONS: Our study found that almost half of the readmissions could have been prevented. They had been mainly due to clinician and patient factors, in particular, both of which were intimately related to clinical management and patient care. These readmissions could be prevented by a system of ongoing clinical review to examine the clinical practice/decision for discharge, and improving clinical care and enhancing patient knowledge of the early warning signs for relapse. The importance of adequate and appropriate ambulatory care to support the patients in the community was also a key finding to reduce avoidable readmissions. Education on patient self-management should also be enhanced to minimize the patient factors with regard to avoidable readmission. Our findings thus provide important insights into the development of an effective discharge planning system which should place patients and carers as the primacy focus of care by engaging them along with the healthcare professionals in the whole discharge planning process.

Measuring and preventing potentially avoidable hospital readmissions: a review of the literature.

OBJECTIVE: To review literature identifying key components for measuring avoidable readmissions, their prevalence, risk factors, and interventions that can reduce potentially avoidable readmissions. DATA SOURCES AND EXTRACTION: Literature search using Medline, PubMed and the Cochrane Library up to June 2010, using the terms "avoidable", "preventable", "unplanned", "unnecessary", "readmission", and "rehospitalization". STUDY SELECTION: A total of 48 original papers and review articles were selected for inclusion in this review. DATA SYNTHESIS: Although hospital readmission seemed to be a term commonly used as an outcome indicator in many studies, it is difficult to make valid comparison of results from different studies. This is because the definitions of terms, methods of data collection, and approaches to data analysis differ greatly. The following criteria for studying hospital readmissions have been recommended: (a) identify hospital admissions and define relevant terms, (b) establish a clinical diagnosis for a readmission; (c) establish the purpose for a readmission, (d) set a discharge-to-readmission timeframe, and (e) identify the sources of information for assessing readmissions. Studies to identify avoidable readmissions usually involve medical records and chart reviews by clinicians using the classification scheme developed by the authors. The proportion of all readmissions assessed as preventable varies from 9 to 59% depending on the population of patients studied, duration of follow-up, type and methodology of the study and case-mix-related factors. A number of studies classified risk factors for readmission into four categories: patient, social, clinical, and system factors. Home-based interventions, intensive education/counselling, multidisciplinary care approaches, and telephone follow-up were the main types of interventions to address potentially avoidable readmissions. CONCLUSIONS: A standard instrument to identify avoidable readmission is important in enabling valid comparisons within the system and at different timelines, so as to permit robust evaluation of interventions. The assessment of preventable risk factors for readmissions also provides a basis for designing and implementing intervention programmes.

Primary care delivery, risk pooling and economic efficiency.

The consequences of consumer-driven health care under different health insurance plans are studied by means of a game theoretic approach. Suitable demand-side cost-sharing can induce consumer behavior that avoids over-treatment when there are information asymmetries between providers and consumers, leading to the efficient recommendations and provision of treatment by providers. If under-treatment can be penalized, then a full insurance model that pays providers a fixed salary and fee-for-service or one that requires patients to present a referral letter before specialist care is delivered also achieves provision efficiency. The two models, however, yield higher welfare for consumers. Hence, the findings in this paper favor some amount of regulation in health-care markets.

An economic analysis of life expectancy by gender with application to the United States.

This paper presents an economic model to explain the behavior of life expectancy of both sexes. It explicitly examines the relationship between the gender gap in life expectancy and the gender gap in pay. It shows that as the latter narrows over the course of economic development, the former may initially expand but will eventually shrink. Simulation results from our model accord with the behavior of life expectancy for both sexes since the 1940s in the United States.