Cost-utility of bariatric surgery for morbid obesity in Finland.

BACKGROUND: The aim of this study was to evaluate the cost-utility of bariatric surgery (gastric bypass, sleeve gastrectomy and gastric banding) compared with ordinary treatment in the Finnish healthcare system. METHODS: Analysis was done from a healthcare provider's perspective using a combination of a decision tree and a Markov model, with a time horizon of 10 years. Health-related quality of life was estimated from a representative population survey, and other parameter values were based on registers, systematic reviews, controlled studies and expert opinion. RESULTS: In the base-case analysis, bariatric surgery was both more effective and less costly than the ordinary treatment. The mean costs were €33,870 and €50,495, and the mean number of quality-adjusted life-years 7·63 and 7·05, for bariatric surgery and ordinary treatment respectively. Uncertainty around the parameter values was tested comprehensively in sensitivity analyses, and the results were robust. CONCLUSION: Surgery for morbid obesity increases health-related quality of life, and reduces the need for further treatments and total healthcare costs. According to this analysis, non-operative care would be more costly for the Finnish healthcare system on average after 5 years following surgery.

Incidence and outcomes of bulimia nervosa: a nationwide population-based study.

BACKGROUND: Little is known about the epidemiology of bulimia nervosa outside clinical settings. We report the incidence, prevalence and outcomes of bulimia nervosa using for the first time a nationwide study design. METHOD: To assess the incidence and natural course and outcomes of DSM-IV bulimia nervosa among women from the general population, women (n=2881) from the 1975-79 birth cohorts of Finnish twins were screened for lifetime eating disorders using a two-stage procedure consisting of a questionnaire screen and the Structured Clinical Interview for DSM-IV (SCID). Clinical recovery was defined as 1-year abstinence from bingeing and purging combined with a body mass index (BMI) 19 kg/m2. RESULTS: The lifetime prevalence of DSM-IV bulimia nervosa was 2.3%; 76% of the women suffered from its purging subtype and 24% from the non-purging subtype. The incidence rate of bulimia nervosa was 300/100000 person-years at the peak age of incidence, 16-20 years, and 150/100000 at 10-24 years. The 5-year clinical recovery rate was 55.0%. Less than a third of the cases had been detected by health-care professionals; detection did not influence outcome. After clinical recovery from bulimia nervosa, the mean levels of residual psychological symptoms gradually decreased over time but many women continued to experience significantly more body image problems and psychosomatic symptoms than never-ill women. CONCLUSIONS: Few women with bulimia nervosa are recognized in health-care settings. Symptoms of bulimia are relatively long-standing, and recovery is gradual. Many clinically recovered women experience residual psychological symptoms after attaining abstinence from bingeing and purging.

Working hours and produced cellular components as variables to evaluate blood bank efficiency.

SUMMARY: Along with the increasing expenses of the blood system, enhancing efficiency is a necessary task at blood establishments. Labour is the primary expense and is the most likely area for efficiency improvements. The aim of this study was to evaluate and compare the relative efficiency of component production departments from the perspective of labour and cost. The data set was from 13 European blood centres and blood banks for 3 years and was analysed using data envelopment analysis (DEA). Working hours, estimated total costs, produced red blood cells and produced platelets were used in DEA modelling. Comparative analyses included an empirical cost model, in which the costs of working hours were adjusted with purchasing power parities to equalize the costs between countries. Estimated total costs were used to determine the savings potential of production, the unit cost and the economic value of discarded components (waste cost). Results showed a wide variation in labour efficiency (25-100%), in unit cost (fraction of labour costs in component production department) and in cost efficiency (13-100%). Savings potential both in labour and in costs was more than 50% in six departments in all study years. Median waste cost was 9.4% of estimated total costs in the four largest departments and 6.6% in the other departments. Thus, size of department was not a measure of its efficiency. Simple empirical analyses are applicable in efficiency comparisons and can encourage blood establishments to improve their resource management.

Successful weight maintenance preserves lower levels of oxidized LDL achieved by weight reduction in obese men.

OBJECTIVE: We studied the association between weight maintenance, oxidized low-density lipoprotein (ox-LDL) and other lipoproteins in obese men. METHODS: A 2-month weight reduction phase (WRP) with a very-low-energy diet was followed by a 6-month weight maintenance period and an unsupervised 2-year follow-up. Ninety men entered and 68 (76%) completed the study. Subjects were analyzed as one group and after division into two subgroups: 20 most successful men in maintaining the lost weight (subgroup 1) and the remaining (n=48) men (subgroup 2). Ox-LDL was measured by quantifying the amount of conjugated dienes in LDL particles. RESULTS: The mean (+/-s.d.) weight reduction at the end of the WRP (n=68) was 14% (confidence interval (CI) 12.9-14.7%, 14.5+/-4.2 kg, P<0.001). Ox-LDL decreased by 22% (CI 16.9-28.1, 12.3+/-15.4 micromol/l, P<0.001). At the end of the 2-year follow-up, the regain in weight from the end of the WRP was 11% (CI 9.0-12.4, 9.6+/-6.2 kg, P<0.001). The regain in ox-LDL was 30% (CI 18.7-41.2, 8.2+/-15.4 micromol/l, P<0.001). In subgroup 1 vs 2, the respective regains were 3% (CI 0.9-4.2, 2.2+/-3.0 kg, P=0.006) vs 14% (CI 12.7-15.6, 12.9+/-4.0 kg, P<0.001) regarding weight and 9% (2.0+/-6.9 micromol/l, P=NS) vs 39% (CI 23.7-53.9, 11.2+/-17.2 micromol/l, P

Cost-benefit analysis of Helicobacter pylori screening.

BACKGROUND: Helicobacter pylori screening may markedly reduce mortality and morbidity in the decades ahead. AIMS: This study explores the costs and benefits of population-based H. pylori screening in terms of health care cost taking into account all relevant H. pylori-related diseases. MATERIAL AND METHODS: The computer-based decision analysis compared two strategies: (1) screen for H. pylori and treat those individuals who test positive, and (2) do not screen for H. pylori, and test and treat H. pylori only if related clinical symptoms appear. The model estimated the discounted H. pylori-related accumulative health care costs from screening age to death in both strategies. The baseline case estimates cost-benefit for screenees aged 15-45 years. The main outcome measure is the incremental health care cost per case in the screening compared with the no-screening alternative. The probability estimates were obtained from the Finnish Vammala H. pylori screen and treat project, including 5288 subjects in the years 1996-1998, published studies, national statistics and hospitals' internal accounts. RESULTS: The incremental cost per case was 26 US dollars in the screening compared with the no-screening alternative. It was lowest in the group aged 45 years, where H. pylori screening showed cost savings per case. CONCLUSIONS: H. pylori screening is more favourable in the older age cohorts. The estimated cost per screenee can be considered to be very acceptable if the current pathophysiological evidence on the potential effects of H. pylori eradication are confirmed in the future. However, there is uncertainty about the possible negative effect of eradicating H. pylori infection on gastro-esophageal reflux disease and esophageal adenocarcinoma. This could change the balance of benefits against risks of eradicating H. pylori infection.

Perception of melting and flavor release of ice cream containing different types and contents of fat.

Temporal effects of dairy and vegetable fats (0 to 18%) on perception of strawberry flavor release and melting of ice cream were studied using the time intensity sensory method. Also, aroma and flavor attributes of the ice cream samples were evaluated. Only slight effects of fat on the rate of flavor release and flavor intensity were perceived. A slightly faster flavor release from the vegetable fat compared with dairy fat was noticed. Polydextrose and maltodextrin as bodying agents in the fat-free ice cream significantly increased flavor release and melting rate of the ice cream. Increasing fat content slightly retarded melting of ice cream in the mouth. No significant effect of the fat quality on perceived melting was noticed. Significant differences in aroma and flavor attributes of the fat-free and other samples were perceived. Intensity and sharpness of the strawberry aroma and flavor were greater in fat-free samples and they were perceived as nontypical. Fattiness and creaminess were highly correlated. Maltodextrin and polydextrose increased perceived fattiness and creaminess of fat-free ice cream.

Oral symptoms at menopause--the role of hormone replacement therapy.

OBJECTIVE: A questionnaire was used to investigate the prevalence of self-assessed sensations of painful mouth (PM) and dry mouth (DM) in menopause-aged women. Special attention was paid to the association of the use of hormone replacement therapy (HRT) with oral symptoms. Our hypothesis was that women using HRT have fewer oral symptoms than those who do not use HRT. STUDY DESIGN: Patients were selected from among 50- to 58-year-old women attending a communal mammography screening program in Helsinki, Finland. Every fifth woman was offered a structured questionnaire. RESULTS: Completed questionnaires were received from 3173 women (response rate, 65%). Of the total sample, 46.8% (n = 1486) used HRT. The occurrence of PM was 8.2% (n = 259) and DM, 19.9% (n = 631). Climacteric symptoms were reported by 24% (n = 761) of the total sample and by 19.2% (n = 285) of the HRT users. According to logistic regression analyses, climacteric symptoms were found to be predictive of PM (P =.000) and DM (P =.000). The use of HRT also increased the occurrence of PM (P =.03). However, as a single covariate in our statistical model, the use of HRT was not a predictor of PM. The use of HRT also did not correlate with the occurrence of DM. CONCLUSIONS: The occurrence of PM and of DM seemed to be associated with climacteric symptoms in general, and the use of HRT did not prevent the oral symptoms studied.

Measuring efficiency of long-term care units in Finland.

Data Envelopment Analysis (DEA) was used to measure the nursing care efficiency of 64 long-term care units in Finland. New approaches introduced for evaluating efficiency were unit/ward level analysis, and the case-mix classification Resource Utilization Groups (RUG-III). Efficiency determinations were based on four DEA measures: cost, technical, allocative, and scale efficiency. The results indicated considerable variation in efficiency between units, suggesting that efficiency could be improved through better management and allocation of resources. Larger units seemingly operated more efficiently than smaller units. Allocative inefficiency resulted from using too many registered nurses and aides, and too few licensed practical nurses.

Health care financing reform and the productivity change in Finnish hospitals.

The purpose of this study was to analyze productivity and efficiency changes in the production of hospital care in Finland during the period 1988-1994. A special interest was directed to years 1993-1994 because of health care financing reform that took place in 1993. The analysis is based on the Malmquist index approach using linear programming. Positive productivity changes were found particularly towards the end of the observation period, although a few years did not show significant improvements in productivity and efficiency. There was a significantly higher rate of productivity change in 1992-1993 and 1993-1994, suggesting that the state subsidy reform in 1993 may have strengthened hospitals' efforts to improve performance.

Impact of user charges and socio-economic environment on visits to paediatric trauma unit in Finland.

In this report we (i) measure the strength of the association between paediatric trauma visit rates and regional socioeconomic and demographic variables, and (ii) quantify any selective impact of user charges on service demand in socioeconomically and demographically different areas. During the period 1989-94, a total of 30,362 home and leisure injury visits were made to the Aurora City Hospital. The visit rates are analysed using a random effects model. In addition, the areas are ranked into three groups in accordance with a socioeconomic index measure, and the annual visit rates of the three groups are calculated. We found fairly minor differences in children's visit rates between unequal socioeconomic areas, and it is apparent that socioeconomic status cannot explain the change in visit rates as a result of the introduction of user charges. We speculate that these changes in emergency visit rates will not lead to long-term health problems among any segment of the city population.

User charges and the demand for acute paediatric traumatology services.

The city of Helsinki in 1991 introduced moderate patient charges for certain acute paediatric services. This provided the framework for a natural, partially controlled experiment on price elasticity of demand for acute paediatric trauma services. A cross-sectional time-series analysis of a partially controlled natural experiment was done for the period 1989-1994. The findings suggest that moderate user charges may reduce the demand for paediatric trauma services measurably. The effect was diagnosis-specific and, on average, stronger in older than in pre-school children. It probably had a negligible impact on long-term health.

Measuring hospital cost efficiency with panel data models.

This paper investigated the development of hospital cost efficiency and productivity in Finland in 1988-1994 using a comparative application of parametric and non-parametric panel models. Stochastic cost frontier models with a time-varying inefficiency component were used as parametric methods. As non-parametric methods various DEA models were employed to calculate efficiency scores and the Malmquist productivity index. The results revealed a 3-5% annual average increase in productivity, half of which was due to improvement in cost efficiency and half due to technological change. The results by parametric and non-parametric methods compared well with respect to individual efficiency scores, time-varying efficiency and technological change. The state subsidy reform of 1993 did not seem to have any observable effects on the hospital efficiency.

An econometric study of costs of teaching and research in Finnish hospitals.

In this study we used stochastic frontier cost functions to estimate the teaching and research costs of Finnish hospitals. Average and marginal cost estimates were used to evaluate the current reimbursement system as well as to calculate the total expenditure on teaching and research in hospitals. The efficiency adjustment had significant impact on the marginal and average cost estimates of the teaching and research output. The main policy implication of this study is that university teaching hospitals are able to produce both teaching and research output at significantly lower marginal and average incremental costs than other hospitals. According to our results 55% of the total state reimbursement budget for teaching and research (FIM 665 million) should be allocated to teaching and 45% to research.

The socio-economic and demographic context of children's emergency injury visits in Helsinki in 1991-1994.

The aim is to study the association between age- and diagnosis-specific trauma visit rates and socio-economic and demographic variables in the city of Helsinki, Finland. A total of 19,772 home and leisure injury visits were analysed by random effects (REM) and Poisson regression models. Visit rates were calculated for age- and diagnosis-specific groups for each of the city's 33 health districts using the corresponding age-specific census data. In addition, the areas were ranked into three groups according to a socio-economic index measure. The annual visit rates of the three groups were calculated and the effect of distance on visit rates by socio-economic groups was analysed. In the case of pre-school children no correlation was found between explanatory variables and trauma visit rates. In the school-aged children group distance from the hospital (p < 0.001) correlated with childhood ambulatory visit rates. We found a rather modest difference in children's visit rates between unequal socio-economic areas. However, the demand for care was elastic for travelling distance (p < 0.05) in poorer suburbs but not in more affluent areas in the case of school-aged children. The probability of significant inequalities in children's trauma visit rates was small in Helsinki during 1991-94.

PROGNOSTICATION OF BREAST CANCER BY MULTIVARIATE METHODS.

Three multivariate prognostic models based on Cox's regression were tested in terms of how they predicted prognosis in a material of 134 patients with breast cancer. The multivariate models all incorporated tumor size, mitotic activity index (MAI), and axillary lymph node status in their formulas, and were originally produced through studies on different patient materials. The predictive behavior of MAI was also tested separately in the same material. The multivariate models gave roughly parallel predicted percentages of survival at two years (CV=5.2%), but showed clearly greater variation later (12.3% and 24.4% at 5 and 9 years, respectively). The results were more uniform between the multivariate models, than between the prediction by MAI and the multivariate models. The variation between repeated estimates was smaller within multivariate models than within the estimation of one of their components (MAI). We found the use of the multivariate models easy. However, traditional hospital practice does not necessarily favor the use of multivariate models, although they seem to group patients more reliably than single prognostic features.

Carvedilol and atenolol once daily in the treatment of hypertension.

Fifty milligrams of carvedilol and 100 mg atenolol were administered in a random order once a day for 2 months to 43 patients with mild to moderate hypertension, in a double-blind crossover study. Blood pressure, heart rate and peripheral blood flow parameters (n = 11) were recorded 2 and 24 h after the drug administration. Supine blood pressure was the same 2 h after both carvedilol and atenolol administration, but carvedilol caused a greater decrease in standing systolic blood pressure 2 h after the administration (P less than 0.05). The heart rate decreased less with carvedilol (P less than 0.01). There was no difference in the effects exerted by the two therapies on systolic blood pressure and the heart rate 24 h after drug administration, but the diastolic blood pressure was higher in patients given carvedilol (92 versus 88 mmHg; P less than 0.05). Forearm blood flow, forearm vascular resistance and calf blood flow did not change significantly with either of the therapies. In conclusion, 50 mg carvedilol once a day is an effective antihypertensive therapy, though its duration of action did not reach that of 100 mg atenolol once a day. Peripheral vasodilation was similar with both therapies.