An Assessment of the Economic Feasibility of Selected Surgeries in the Obstetrics and Gynaecology Department under Community-Based Health Insurance (CBHI) in a Tertiary Care Hospital in South India.

Community-Based Health Insurance (CBHI) is a form of micro health insurance targeted at low-income groups that permits for grouping of assets to tackle the expenses of future, uncertain, health-related circumstances. According to the International Labour Organisation, more than 80% of India's employed nonagricultural population is in the informal sector, implying that they are possibly excluded from receiving health insurance benefits. This is where CBHI comes into play, wherein groups of people belonging to a community define the demand and benefits and pool their resources to provide financial protection to all their members. This study aims to scrutinize the package prices sanctioned by these schemes and compare them with the cost incurred by the hospital. The expense pattern of three surgeries in the Department of Obstetrics and Gynaecology was analysed under three insurance schemes: Arogya Bhagya Yojana, Arogya Karnataka, and Employees' State Insurance Scheme. Methodology. A retrospective study was conducted in a 2,032-bedded tertiary care hospital in South India. Patients of abdominal hysterectomy, vaginal hysterectomy, and caesarean section surgeries covered by any of the insurance schemes mentioned above were a part of the inclusion criteria. The patient records were examined from the hospital's Medical Records Department (MRD). The patients' bills were assembled from the inpatient billing department to scrutinize all the expenses associated with each surgery. The variable costs include consumables, medicine, electricity and AC, diagnostics, blood bank materials, doctor's fee, package differences, and others. In contrast, fixed costs include bed cost, equipment cost (purchase + annual maintenance cost), manpower cost-OT, manpower cost-nursing, and allocated indirect costs associated with the medical treatment. These were computed and compared with the package price of respective insurance schemes to determine if the schemes are profit-yielding schemes or loss-yielding schemes, using the data from the finance department. Results and Conclusion. It has been observed that the operating loss of the hospital for abdominal hysterectomy, vaginal hysterectomy, and caesarean section under CBHI schemes ranges between 7% and 36%. The highest loss was observed in Arogya Karnataka Scheme for caesarean section surgery (BPL patients). The amount received through these schemes is insufficient to cover the costs acquired by the hospital, let alone make a profit. However, under Arogya Bhagya and ESI Schemes, the hospital has made a profit in covering the variable costs for these surgeries. The study concludes that the hospital is running under loss due to the three Community-Based Health Insurance (CBHI) schemes.

Dietary assessment in Whitehall II: comparison of 7 d diet diary and food-frequency questionnaire and validity against biomarkers.

The aim of the present cross-sectional study was to examine the agreement and disagreement between a 7 d diet diary (7DD) and a self-administered machine-readable food-frequency questionnaire (FFQ) asking about diet in the previous year, and to validate both methods with biomarkers of nutrient intake. The subjects were an age- and employment-grade-stratified random subsample of London-based civil servants (457 men and 403 women), aged 39-61 years, who completed both a 7DD and a FFQ at phase 3 follow-up (1991-1993) of the Whitehall II study. Mean daily intakes of dietary energy, total fat, saturated, monounsaturated and polyunsaturated fatty acids, linoleic acid, total carbohydrate excluding fibre, sugars, starch, dietary fibre, protein, vitamin C, vitamin E (as alpha-tocopherol equivalents), folate, carotenes (as total beta-carotene activity), Fe, Ca, Mg, K and alcohol were measured. Serum cholesteryl ester fatty acids (CEFA), plasma alpha-tocopherol and beta-carotene were also measured as biomarkers. Estimates of mean energy intake from the two methods were similar in men, and some 10 % higher according to the FFQ in women. Compared with the 7DD, the FFQ tended to overestimate plant-derived micronutrient intakes (carotenes from FFQ v. 7DD men 2713 (SD 1455) v. 2180 (SD 1188) microg/d, women 3100 (SD 1656) v. 2221 (SD 1180) microg/d, both differences P<0.0001) and to underestimate fat intake. Against plasma beta-carotene/cholesterol, carotene intake was as well estimated by the FFQ as the 7DD (Spearman rank correlations, men 0.32 v. 0.30, women 0.27 v. 0.22, all P< or =0.0001, energy-adjusted data). Ranking of participants by other nutrient intakes tended to be of the same order according to the two dietary methods, e.g. rank correlations for CEFA linoleic acid against FFQ and 7DD estimates respectively, men 0.38 v. 0.41, women 0.53 v. 0.62, all P< or =0.0001, energy-adjusted % fat). For alpha-tocopherol there were no correlations between plasma level and estimated intakes by either dietary method. Quartile agreement for energy-adjusted nutrient intakes between the two self-report methods was in the range 37-50 % for men and 32-44 % for women, and for alcohol, 57 % in both sexes. Disagreement (misclassification into extreme quartiles of intake) was in the range 0-6 % for both sexes. The dietary methods yielded similar prevalences (about 34 %) of low energy reporters. The two methods show satisfactory agreement, together with an expected level of systematic differences, in their estimates of nutrient intake. Against the available biomarkers, the machine-readable FFQ performed well in comparison with the manually coded 7DD in this study population. For both methods, regression-based adjustment of nutrient intake to mean dietary energy intake by gender appears on balance to be the optimal approach to data presentation and analysis, in view of the complex problem of low energy reporting.

Dietary assessment in Whitehall II: the influence of reporting bias on apparent socioeconomic variation in nutrient intakes.

OBJECTIVE: To assess socio-economic differences in nutrient intake, giving particular consideration to the influence of reporting bias. DESIGN: Cross-sectional study. Three methods of data analysis (inclusion of all subjects, exclusion of low energy reporters, and regression-based energy adjustment) were evaluated against biomarkers of fatty acid and antioxidant intakes. SETTING: London-based Civil Servants. SUBJECTS: Age and employment grade stratified random sub-sample of 459 men and 406 women aged 39-61 y who completed 7 d diet diaries at Phase 3 follow-up (1991-93) of the Whitehall II Study. DIETARY MEASURES: Mean daily intakes by employment grade (6 levels) of dietary energy, total fat, saturated fatty acids, polyunsaturated fatty acids (PUFA), linoleic acid, carbohydrate excluding fibre, dietary fibre, protein, alcohol, vitamin C, vitamin E, carotenes, potassium and calcium. Biomarkers: serum cholesterol ester fatty acids (CEFA), total cholesterol, plasma alpha-tocopherol and beta-carotene. RESULTS: Low energy reporting (LER), defined as a reported energy intake below 1.2 times calculated basal metabolic rate, was strongly associated with employment grade (top grade: men 17.3%, women 19.3%, bottom grade: men 45.7%, women 49.2% trend P < 0.0001 both sexes). This association is only to a small extent accounted for by the relative weight distribution across grades. The direct associations with grade--high status, high intakes--of total fat, saturated and polyunsaturated fatty acids seen in the results overall were greatly reduced or abolished when LER were excluded or when energy adjustment was used. Direct associations between grade and intakes of vitamin C and potassium in both sexes were evident regardless of data presentation method. Spearman correlations between biomarkers and reported intakes, for example CEFA and dietary linoleate (men 0.46, women 0.61), plasma beta-carotene/cholesterol ratio and dietary carotenes (men 0.16, women 0.21) together with theoretical considerations indicate that energy adjustment may be the preferred method for reducing the influence of reporting bias. CONCLUSIONS: Low energy reporting is a major source of bias in dietary surveys and its prevalence shows a marked inverse association with socio-economic status. The energy adjustment method provides an approach which reduces this bias without exclusion of low energy reporters. Intakes of micronutrients including vitamin C, rather than fatty acids, showed associations with socio-economic status consistent with a dietary explanation for social inequalities in cardiovascular disease.

Correlates of leukocyte counts in men.

Because of previously reported associations between a high leukocyte count and risk of ischemic heart disease (IHD), we examined the relation of leukocyte counts to various characteristics among 3591 white and 506 black 31- to 45-year-old men. The mean leukocyte count was approximately 1000 cells/microL higher among whites than among blacks, and approximately 1900 cells/microL higher among current smokers than among nonsmokers. The leukocyte count was also higher among men who had recently stopped smoking and among men who reported their general health as poor or fair. Independent of these relations, the leukocyte count was associated positively with the platelet count (r = 0.29), triglyceride level (r = 0.21), heart rate (r = 0.15), and use of corticosteroids and beta-blockers; and inversely with alcohol consumption and prothrombin time (r = -0.10). The examined characteristics could together account for 37% of the variability in leukocyte counts. These relatively strong associations indicate that it may be difficult to disentangle the relation of the leukocyte count to IHD from that of other risk factors.

Chronic fenfluramine treatment: effects on body weight, food intake and energy expenditure.

Fenfluramine suppressess the body weight of experimental animals during chronic treatment by a mechanism that is not yet clear. The present research investigated the contributions of fenfluramine-induced alterations in food intake and two components of energy expenditure, resting energy expenditure (REE) and the thermic effect of food (TEF), to maintenance of a lowered body weight in male Long Evans rats. DI-Fenfluramine (20 mg/kg) produced an initial severe anorexia and weight loss. Food intake then increased steadily, reaching control levels by the fourth day of treatment. Tolerance to the anorectic effects of fenfluramine was not complete however -- food intake of fenfluramine-treated rats fell below control levels on 7 of the remaining 20 days of treatment. The body weight of fenfluramine treated rats remained significantly below control levels throughout the entire treatment period, but rose rapidly to control levels following fenfluramine withdrawal. REE was unaffected by fenfluramine treatment. By contrast, fenfluramine treatment significantly altered the TEF. Twenty-four hours after initiation of treatment the TEF of fenfluramine treated animals was higher than that of controls. On the 15th day of drug administration and the first day of fenfluramine withdrawal, however, the TEF of control and treated animals no longer differed. By contrast, on the second day of fenfluramine withdrawal the TEF of fenfluramine treated rats was suppressed to 17% of control levels. These findings suggest that the effect of fenfluramine on body weight involves modulation of both food intake and energy expenditure.

Decline in delayed-type hypersensitivity response in obese women following weight reduction.

The effect of weight loss on immuno function was evaluated in 14 middle-aged obese women. Cutaneous delayed-type hypersensitivity to five recall antigens was measured before a weight loss of 21 kg and again after weight had been stabilized. Weight loss was associated with a decrease in both number and magnitude of delayed-type hypersensitivity responses. The number of positive skin tests decreased from 3.1 +/- 0.2 to 2.4 +/- 0.3 per subject, and the mean cutaneous induration size decreased by 38%. The decrease in induration size was positively correlated with the decrease in body mass index (r = 0.63), weight (r = 0.59), and fat mass (r = 0.52). These preliminary findings suggest that large weight losses may result in decreased expression of immune function.

The influence of obesity and its treatment on the immune system.

Obesity and weight reduction are significant public health concerns in the United States and other developed countries. Although much research has examined the adverse health consequences of overweight and the benefits of weight loss, the effects on immunologic function of either excess adiposity or weight reduction treatments for obesity have received relatively little attention. In general, studies of immunologic function in obese humans and experimental animals indicate that excess adiposity is associated with impairments in host defense mechanisms. Definitive studies of immune function in human obesity are, however, still needed. Preliminary investigations suggest that certain types of weight reduction strategies produce further alterations in immune responsiveness. More research is needed to confirm or refute these initial findings and to assess the long term consequences of weight loss for overweight individuals. Nutritional and neuroendocrine status are among the factors likely to be involved in modulation of immune responses in obesity and as a consequence of dieting and weight reduction.

Weight loss and body fat distribution: a feasibility study using computed tomography.

Computerized tomography (CT) was used to assess the effect of a loss of body weight (18.8 kg) on the size of five fat depots in 11 obese postmenopausal women: the abdominal subcutaneous and visceral depots, the pelvic subcutaneous and intrapelvic depots, and the thigh subcutaneous depot. The mean decrease in total body fat was 34 percent, with comparable decreases in total abdominal fat (33 percent) and total pelvic fat (32 percent). In the abdomen, visceral fat was reduced by 35 percent and subcutaneous fat by 33 percent. In the pelvic region, intrapelvic fat decreased by 51 percent and subcutaneous fat by 25 percent. The decrease in the size of the abdominal visceral fat depot was highly correlated with fat loss during treatment (r = 0.68). By contrast, the decrease in the size of the subcutaneous abdominal fat depot correlated less highly with fat loss. These preliminary findings suggest that obese postmenopausal women with large visceral fat depots will decrease the size of their visceral fat depots by weight reduction. This is good news since the adverse health effects of obesity are believed to be associated with visceral fat.

Increased food intake and carbohydrate preference in the rat following treatment with the serotonin antagonist metergoline.

The effect on feeding of antagonism of the serotonergic system was studied. Intraperitoneal injection of one of 8 doses of the serotonin antagonist metergoline (MET) (0.06-1.5 mg.kg-1) given prior to a 3 h food deprivation produced a significant dose-related increase in intake of a standard laboratory diet throughout a 2 h measurement period. A 1 mg/kg dose of MET administered prior to one of 3 isocaloric powdered diets a medium carbohydrate, a high carbohydrate, and a non-carbohydrate diet - produced a significant increase in the intake by rats of all 3 diets in the first hour after food presentation. However, in the second hour MET continued to increase consumption of the high carbohydrate diet, whereas intakes of the medium carbohydrate and non-carbohydrate diets were no longer affected by MET treatment. These data suggest that the serotonergic system is a tonic inhibitor of food intake and of carbohydrate preference.

Cholecystokinin-induced anorexia depends on serotoninergic function.

The existence of a relationship between cholecystokinin (CCK)-induced satiety and the serotoninergic system was evaluated. The food intake of 3-h-fasted male rats was studied after treatment with the COOH-terminal octapeptide of CCK (CCK-8) alone or in combination with one of two blockers of serotonin (5-HT) receptors, metergoline (MET; 1.0 or 0.06 mg/kg), active in both the periphery and brain, or xylamidine tosylate (XYL; 1.5 mg/kg), active only in the periphery. CCK-8 reduced food intake in the 30 min after food presentation by 37% at 2 micrograms/kg, 68% at 4 micrograms/kg, and 80% at 8 micrograms/kg compared with controls. Both doses of MET attenuated CCK-8-induced satiety, increasing food intake of rats treated with all doses of CCK-8 to control values. Food intake was significantly increased over base line by the 1.0-mg/kg dose of MET alone but unaffected by the 0.06-mg/kg dose of MET alone. XYL had no effect either given alone or in combination with CCK-8. These results indicate that the inhibitory action of CCK-8 on food intake is dependent on intact functioning of the serotoninergic system, probably at central sites.

Enhancement of the thermic effect of food by d-fenfluramine.

Following approximately a week of daily ingestion of fenfluramine, the body weight of female rats is reduced and remains chronically suppressed for as long as treatment is continued. This chronic suppression of body weight by fenfluramine cannot be explained by the anorectic effects of fenfluramine, since food intake returns to normal after about a week. Part of this chronic suppression of body weight lies in the ability of fenfluramine to enhance the thermic effect of food. Fenfluramine ingested by a fasted rat causes no change in metabolic rate. However, following the ingestion of the meal consisting of mixed nutrients or only carbohydrates, the thermic effect of the food is significantly greater than that of the meal without fenfluramine. A similar observation was observed in humans. These observations when combined with the negligible effects of dieting as a means of controlling body weight, argue for the chronic use of fenfluramine as a therapeutic technique to produce sustained weight loss in humans.

Modulation of the thermic effect of food by fenfluramine.

The thermogenic effect of fenfluramine was examined in rats following either fasting or the ingestion of a large meal. Fenfluramine did not produce a thermogenic effect in the fasting animal, but significantly potentiated the thermogenic effect of the meal. Furthermore, fenfluramine was found to produce a significant thermogenic effect when accompanied with a glucose meal, but not with one consisting of fat. These data demonstrate the importance of drug and nutrient interactions in the analysis of thermogenesis and suggest that substrate cycling may play a role in the thermogenic effect of fenfluramine.