A claims-based Markov model for Crohn's disease.

BACKGROUND: Crohn's disease is a chronic condition that often presents in early adulthood. AIM: To evaluate health care costs and costs per quality-adjusted life year (QALY) for Crohn's disease. METHODS: A Markov model was developed using administrative claims data for patients aged > or = 18 years with > or = 3 years of continuous enrolment from 2000 to 2008 and > or =2 Crohn's disease claims. Disease states (remission, mild-moderate, moderate-severe, and severe-fulminant) were defined using the American College of Gastroenterology treatment guidelines criteria. Transition probabilities were calculated from consecutive 6-month periods. Costs were determined from paid claims and QALY utilities were obtained from the literature. The model assumed a 30-year-old patient at the time of entry into the model. RESULTS: There were 40 063 patients identified, with a total of 420 773 cycles [remission (197 111; 46.8%), mild-moderate (44 024; 10.5%), moderate-severe (132 695; 31.5%), severe-fulminant (46 925; 11.2%)]. The costs/QALY for remission, mild-moderate, moderate-severe, and severe-fulminant disease states respectively were $2896, $8428, $11 518 and $69 277 for males and $2896, $8426, $22 633 and $69 412 for females. CONCLUSIONS: Overall, health care costs for patients with Crohn's disease increased with disease severity. Although the probabilities of transitioning from other health states to the severe-fulminant disease state were low, the cost/QALY was high.

Clinical and economic outcomes in a population-based European cohort of 948 ulcerative colitis and Crohn's disease patients by Markov analysis.

BACKGROUND: Forecasting clinical and economic outcomes in ulcerative colitis (UC) and Crohn's disease (CD) patients is complex, but necessary. AIMS: To determine: the frequency of treatment-classified clinical states; the probability of transition between states; and the economic outcomes. METHODS: Newly diagnosed UC and CD patients, allocated into seven clinical states by medical and surgical treatments recorded in serial 3-month cycles, underwent Markov analysis. RESULTS: Over 10 years, 630 UC and 318 CD patients had 22,823 and 11,871 cycles. The most frequent clinical outcomes were medical/surgical remission (medication-free) and mild disease (on 5-aminosalicylates, antibiotics, topical corticosteroids), comprising 28% and 62% of UC cycles and 24% and 51% of CD cycles respectively. The probability of drug-response in patients receiving systemic corticosteroids/immunomodulators was 0.74 in UC, 0.66 in CD. Both diseases had similar likelihood of persistent drug-dependency or drug-refractoriness. Surgery was more probable in CD, 0.20, than UC, 0.08. In terms of economic outcomes, surgery was costlier in UC per cycle, but the outlay over 10 years was greater in CD. Drug-refractory UC and CD cases engendered high costs in the cohort. CONCLUSIONS: Most patients on 5-aminosalicylates, corticosteroids and immunomodulators had favourable clinical and economic outcomes over 10 years. Drug-refractory and surgical patients exhibited greater long-term expenses.

User fees and health service utilization in Vietnam: how to protect the poor?

OBJECTIVES: Vietnam started its health reform process two decades ago, initiated by economic reform in 1986. Economic reform has rapidly changed the socio-economic environment with the transition from a centrally planned economy to a market-oriented economy. Health reform in Vietnam has been associated with the introduction of user fees, the legalization of private medical practices, and the commercialization of the pharmaceutical industry. This paper presents the user fees and health service utilization in Vietnam during a critical period of economic transition in the 1990s. STUDY DESIGN: The study is based on two national household surveys: the Vietnam Living Standard Survey 1992-1993 and 1997-1998. METHODS: The concentration index and related concentration curve were used to measure differences in health service utilization as indicators of health outcomes of income quintiles, ranking from the poorest to the richest. RESULTS: User fees contribute to health resources and have helped to relieve the financial burden on the Government. However, comparisons of concentration indices for hospital stays and community health centre visits show that user fees can drive people deeper into poverty, widen the gap between the rich and the poor, and increase inequality in health outcomes. CONCLUSIONS: An effective social protection and targeting system is proposed to protect the poor from the impact of user fees, to increase equity and improve the quality of healthcare services. This cannot be done without taking measures to improve the quality of care and promote ethical standards in health care, including the elimination of unofficial payments.

The impact of taxation on tobacco consumption in Mexico.

BACKGROUND: The price of cigarettes to consumers in Mexico, and Latin America in general, remains low in comparison with other regions of the world. In Mexico, taxes represented 59% of the total price of cigarettes in 2006, compared to 75% or more in many high-income countries. The feasibility of raising taxes on cigarettes in Mexico--to both discourage consumption and increase revenues--is an important policy question. METHODS: Using household survey data, we undertake a pooled cross-sectional analysis of the demand for cigarettes in Mexico. We use a two-part model to estimate the price elasticity of cigarettes. This model controls for the selection effect that arises from the fact that the impact of price on the decision to smoke or not is estimated using all households in the dataset. RESULTS: The results indicate that price is a significant factor in household decisions concerning smoking and the number of cigarettes smoked. Holding other factors constant, our simulations show that a 10% increase in the cigarette tax in Mexico--calculated as a percentage of the price--yields a 12.4% increase in the price to the consumer, a 6.4% decrease in consumption of cigarettes and a 15.7% increase in the revenue yielded by the tax. CONCLUSION: In Mexico, there are strong arguments for increasing cigarette taxes. Revenue raised could be used to further prevent tobacco consumption and to finance current funding shortages for the treatment of diseases related to smoking.

Exploring the economics of motorcycle helmet laws--implications for low and middle-income countries.

This paper reviews economic evaluations of motorcycle helmet interventions in preventing injuries. A comprehensive literature review focusing on the effectiveness of motorcycle helmet use, and on mandatory helmet laws and their enforcement was done. When helmet laws were lifted between 1976-80, 48 states within the U.S.A. experienced a cost of $342,047 per excess fatality of annual net savings. Helmet laws in the USA had a benefit-cost ratio of 1.33 to 5.07. Taiwan witnessed a 14% decline in motorcycle fatalities and a 22% reduction of head injury fatalities with the introduction of a helmet law. In Thailand, where 70-90% of all crashes involve motorcycle, after enforcement of a helmet law, helmet-use increased five-fold, the number of injured motorcyclists decreased by 33.5%, head injuries decreased by 41.4%, and deaths decreased by 20.8%. There is considerable evidence that mandatory helmet laws with enforcement alleviate the burden of traffic injuries greatly. For low and middle-income countries with high rates of motorcycle injuries, enforced, mandatory motorcycle helmet laws are potentially one of the most cost-effective interventions available.

The economic dimensions of interpersonal violence

It strengthens the case for investing in prevention even further by highlighting the enormous economic costs of the consequences of interpersonal violence, and reviewing the limited but nonetheless striking evidence for the cost-effectiveness of preventionprogrammes. Document in pdf format; Acrobat Reader required.

Economic evaluation of Mectizan distribution.

The distribution of ivermectin has dramatically altered the nature of onchocerciasis control. Existing economic analyses of ivermectin distribution programmes show that these programmes have a highly beneficial impact. Most analyses have estimated the economic benefits in terms of increased labour productivity as a result of reductions in blindness, and in terms of additional land-availability because of a reduced transmission of the parasite. Economic evaluations of the Onchocerciasis Control Program (OPC) in West Africa have calculated a net present value - equivalent discounted benefits minus discounted costs - of $485 million for the programme over a 39-year period, using a conservative 10% rate to discount future health and productivity gains. The net present value for the African Program for Onchocerciasis Control (APOC) is calculated at 88 million US dollars over a 21-year time period, also using a 10% discount rate. Cost-effectiveness analyses of ivermectin distribution have found a cost of 14-30 US dollars per disability-adjusted life-year prevented - estimates comparable with other priority disease control programmes. However, the economic success of ivermectin distribution is sensitive to the fact that the drug itself has been donated free of charge. The market value of Merck's donations to the APOC for just 1 year considerably outweighs the benefits calculated for both the OPC and the APOC over the life of these projects. Pending the development of an effective macrofilaricide, the distribution of ivermectin will remain a public health priority into the foreseeable future.

Economic evaluation of interventions to reduce road traffic injuries--a review of the literature with applications to low and middle-income countries.

Road Traffic Injuries (RTIs) kill over one million people worldwide annually. This article takes the perspective of economic costs and benefits to review the impact of available road safety interventions in industrialized countries--and the potential effect of these interventions in low and middle-income countries, where RTIs pose an increasingly large public health problem. A comprehensive review of the literature on cost-benefits and cost-effectiveness studies related to road traffic injuries internationally, with comparisons of costs adjusted for inflation and exchange differentials was conducted. In the United States (U.S.), motor vehicle inspection laws resulted in annual savings of US $1.7 to $2.3 billion. The installation of seatbelts results in net savings of $162 per vehicle; with benefits outweighing costs by a factor ranging from 240 to 1727. Other cost effective interventions include mandatory seatbelt use, lowering speed limits, motorcycle helmet laws, and traffic calming devices such as speed bumps and road deviations. The dearth of similar economic evaluations of interventions for road traffic injuries in low and middle-income countries represents a serious research gap and hinders the implementation of effective strategies in those countries.

A systematic approach to the assessment of erythropoiesis.

The pathogenesis of anaemia may be simple or complex and the differential diagnosis can be difficult. An appreciation of the erythropoietic processes is required, together with regular review of investigations, to ensure that appropriate protocols are adopted. The application of tests, which define different facets of erythropoiesis, should be appropriate to the clinical circumstances. In some situations, such as the anaemia of chronic disorders, pregnancy and chronic renal failure, a detailed analysis of erythropoiesis is often required. Guidelines for investigating anaemia due to megaloblastosis or haemoglobinopathy are well established, whereas disturbances of iron metabolism are often difficult to classify. These require a clear distinction between storage and functional iron to differentiate whether the defect is due to readily treatable simple iron deficiency or more complex mechanisms, which do not respond to iron supplementation. Determination of red cell haemoglobin content, reticulocyte analysis and the assay of serum transferrin receptors are new generation parameters developed to address this. Practice pressures and new treatment options have contributed to investigations becoming more complex, especially those of the secondary anaemias, as new tests have become more readily available and often automated. This has resulted in reduced turnaround times and clinical demand has driven request patterns. Initiatives to develop evidence-based anaemia management protocols are welcomed but, wherever possible, should be developed through collaboration between the haematology department and the user unit, and based on available guidelines.

Application of activity-based costing (ABC) for a Peruvian NGO healthcare provider.

This article describes the application of activity-based costing (ABC) to calculate the unit costs of the services for a health care provider in Peru. While traditional costing allocates overhead and indirect costs in proportion to production volume or to direct costs, ABC assigns costs through activities within an organization. ABC uses personnel interviews to determine principal activities and the distribution of individual's time among these activities. Indirect costs are linked to services through time allocation and other tracing methods, and the result is a more accurate estimate of unit costs. The study concludes that applying ABC in a developing country setting is feasible, yielding results that are directly applicable to pricing and management. ABC determines costs for individual clinics, departments and services according to the activities that originate these costs, showing where an organization spends its money. With this information, it is possible to identify services that are generating extra revenue and those operating at a loss, and to calculate cross subsidies across services. ABC also highlights areas in the health care process where efficiency improvements are possible. Conclusions about the ultimate impact of the methodology are not drawn here, since the study was not repeated and changes in utilization patterns and the addition of new clinics affected applicability of the results. A potential constraint to implementing ABC is the availability and organization of cost information. Applying ABC efficiently requires information to be readily available, by cost category and department, since the greatest benefits of ABC come from frequent, systematic application of the methodology in order to monitor efficiency and provide feedback for management. The article concludes with a discussion of the potential applications of ABC in the health sector in developing countries.

Impact of critical care physician workforce for intensive care unit physician staffing.

The Society for Critical Care Medicine has advocated for intensivist lead multi-disciplinary critical care for our 30 years; growing evidence supports their assertion. It is estimated that if intensive care unit (ICU) physician staffing (IPS) was implemented in non-rural United States hospitals, 53,000 lives and $5.4 billion would be saved annually. Despite the benefits of hiring physicians specialized in the treatment of critically ill patients, many hospitals worry about their ability to hire critical care physicians to staff their ICUs. In this essay, we discuss issues regarding the future supply of and demand for critical care physicians beginning with an overview of how to evaluate physician supply and demand in general. We then discuss supply and demand for critical care physicians considering emerging issues such as the Leapfrog standard that may impact estimates of the supply and demand for critical care physicians.

COPD: focus on prevention: recommendations of the National Lung Health Education Program. Chronic obstructive pulmonary disease.

The purpose of this article is to provide the nurse in primary care with an overview of the National Lung Health Education Program guidelines. We outline the components of the guidelines for spirometry testing in persons at risk for chronic obstructive pulmonary disease. The role of spirometry testing in identifying those persons for whom smoking cessation is crucial is emphasized.

Memory strategy development: do we need yet another deficiency?

Recent discussions of strategy development have included the introduction of the concept of utilization deficiency. The present analysis examines the definition of utilization deficiency vis-à-vis the older contrasts between mediation and production deficiency and assesses the logical clarity of the current definition. Further, because utilization deficiency focuses on the transition from initial to proficient strategy use, the present analysis considers all of the possible types of strategy inefficiencies and evaluates whether the current definition of utilization deficiency precludes consideration of important strategy inefficiencies that have been documented in the existing literature and are likely to form the bulk of yet-to-be discovered inefficiencies. Although the emphasis on strategy inefficiencies is welcomed, the current analysis concludes that there are serious problems with the current definition of utilization deficiency, problems that both obscure important theoretical distinctions of the past and limit the investigation of strategy inefficiencies that are likely to play an important role in our understanding of the development of strategy use. Furthermore, the linear developmental model that frames utilization deficiencies from no benefit to sophisticated strategy use ignores the heterogeneity in strategy development that has been recently documented.

Measuring equity in access to health care.

This article develops and uses methodologies to: (1) measure equity in the distribution of access to health services; and (2) measure the impact of health insurance programs on equity. The article proposes two egalitarian-based indicators for measuring equity in terms of access to health care--a concentration coefficient derived from the Gini coefficient, and the Atkinson distributional measure and also employs a weighted Utilitarian social welfare function to measure overall levels of access. The article defines access as the use of health care by individuals with a need for care; need is measured as self-reported morbidity. The setting for the empirical application is the country of Ecuador. The Ecuador Social Security Institute runs a General Health Insurance (GHI) program, whose affiliates are primarily workers in the formal sector of the economy. The principal data source is the 1995 Ecuador Living Standards Measurement Survey. The study uses a microeconomic health care demand model and bivariate probit estimation techniques to measure the impact of insurance on health service use for each quintile of adjusted per-capita household expenditure. The study also predicts health care use and program impact for each quintile under a series of simulation scenarios corresponding to proposed expansion of eligibility for the GHI program. The GHI program increases overall access to health care, but has a negative impact on equity in the distribution of health services. The benefits of the program, calculated as its marginal impact on the probability of using of health care, have a strongly regressive distribution. Expanding eligibility to the self-employed makes the benefit more equitably distributed (but still inequitable), and increases overall social welfare considerably. Expanding eligibility to the dependents of the insured person has similar effects, although less important in magnitude.

Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition.

This paper summarizes eight country studies of inequality in the health sector. The analyses use household data to examine the distribution of service use and health expenditures. Each study divides the population into "income" quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are found to have a higher probability of obtaining care when sick, to be more likely to be seen by a doctor, and to have a higher probability of receiving medicines when they are ill, than the poorer groups. The richer also spend more in absolute terms on care. In several instances there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions. It would thus be worthwhile to measure inequality to inform policy-making. Additional research could be performed using a common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes on inequality.

PIP: This paper summarizes results from eight country studies of inequality in the health sector. The analyses included household data to examine the distribution of service use and health expenditures. In each case, the results were presented by income quintiles, estimated using consumption expenditures. Results revealed that the rich groups have a higher probability of obtaining care when sick, to be more likely to be seen by physicians, and have a higher probability of receiving medicines, than the poor groups. The rich also spend more in absolute terms on care. There was no consistent pattern in the use of private providers. Wealthier households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicated that intuition concerning inequalities could result in misguided decisions. Thus, it would be worthwhile to measure the direction and extent of inequality in order to identify problems and to gauge the success of policy-making. Implications for further research are discussed.

Measuring the impact of health insurance with a correction for selection bias--a case study of Ecuador.

This article develops and uses methodologies to evaluate the impact of publicly-financed health insurance programmes on the use of health care. Using univariate and bivariate probit estimation techniques, the study tests and corrects for endogeneity resulting from selection bias. Potential endogeneity arises from the choice to be insured, eligibility for insurance, and differences in individuals' health status. The setting for the study is the country of Ecuador. The General Health Insurance (GHI) programme, which primarily covers workers in the formal sector of the economy, is found to have a strong positive association with the use of curative health care after correcting for selection bias, but no significant effect on the use of preventive care. Individuals with severe illnesses who are eligible for GHI have a preference for private health care, and self-select out of the GHI programme. The Seguro Campesino Social (SSC) programme, directed at farming populations, has positive but insignificant associations with both curative and preventive care.

Cortical sulcal enlargement in catatonic schizophrenia: a planimetric CT study.

To determine whether patients with catatonic schizophrenia have specific alterations in brain morphology, internal (ventricles) and external (frontal, temporal, parieto-occipital) components of the cerebrospinal fluid (CSF) spaces were examined morphometrically. Planimetric measurements of computed tomographic (CT) scans from 37 patients with catatonic schizophrenia, 28 patients with hebephrenic schizophrenia, and 39 patients with paranoid schizophrenia, all diagnosed according to DSM-III-R criteria, were compared with separate age- and sex-matched non-psychiatric control groups, respectively. The areas of the frontal sulci, the parieto-occipital sulci, the inter-hemispheric fissure, and the lateral and third ventricles were measured separately for the right and left hemispheres. Catatonic patients showed significant enlargements in almost all CSF spaces, especially in the left fronto-temporal area which, in addition, correlated significantly with illness duration. Hebephrenic patients showed selective enlargements in left temporal and left/right lower frontal cortical sulci, whereas paranoid schizophrenic patients showed no enlargements but significant correlations between left temporal cortical sulcal volume and illness duration. Alterations in temporal cortical areas were present in all three sub-types of schizophrenia. In addition to temporal alterations, hebephrenic schizophrenia was characterised by lower frontal (i.e. orbitofrontal) enlargement. Catatonic schizophrenia, the most severe sub-type with regard to clinical symptomatology and brain pathology, showed fronto-parietal cortical alterations.

An enzyme immunoassay for intrinsic factor in urine.

An enzyme immunoassay for intrinsic factor has been used on urine. The assay can measure intrinsic factor in native urine from healthy people and from patients with pernicious anaemia with no antibodies. The urinary intrinsic factor concentration in healthy individuals ranged from 40 to 54 pmol/l. Intrinsic factor antibodies, demonstrated by testing the recovery of added intrinsic factor, interfered with the assay. Cobalamin at high concentrations also affected the assay result. A low intrinsic factor concentration or the presence of antibodies to intrinsic factor was found in the urine of individuals with pernicious anaemia.