Applying economic evaluation to public health interventions: The case of interventions to promote physical activity

Copyright @ 2012 The Authors. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been made available through the Brunel Open Access Publishing Fund.BACKGROUND: This paper explores the application of alternative approaches to economic evaluation of public health interventions, using a worked example of exercise referral schemes (ERSs). METHODS: Cost-utility (CUA) and cost-consequence analyses (CCA) were used to assess the cost-effectiveness of ERSs. For the CUA, evidence was synthesized using a decision analytic model that adopts a lifetime horizon and NHS/Personal Social Services perspective. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). CCA was conducted from a partial-societal perspective, including health and non-healthcare costs and benefits. Outcomes were reported in natural units, such as cases of strokes or CHD avoided. RESULTS: Compared with usual care, the incremental cost per QALY of ERS is £20 876. Based on a cohort of 100 000 individuals, CCA estimates cost of ERS at £22 million to the healthcare provider and £12 million to participants. The benefits of ERS include additional 3900 people becoming physically active, 51 cases of CHD avoided, 16 cases of stroke avoided, 86 cases of diabetes avoided and a gain of ∼800 QALYs. CONCLUSIONS: CCA might provide greater transparency than CUA in reporting the outcomes of public health interventions and have greater resonance with stakeholders involved in commissioning these interventions.This work was supported by the NIHR Health Technology Assessment programme (project number 08/72/01). This article is made available through the Brunel Open Access Publishing Fund

Snca and Bdnf gene expression in the VTA and raphe nuclei of midbrain in chronically victorious and defeated male mice

The study aimed to analyze the mRNA levels of Snca and Bdnf genes in the ventral tegmental area (VTA) and raphe nuclei of the midbrain in male mice that had each won or defeated 20 encounters in daily agonistic interactions. Groups of animals that had the same winning and losing track record followed by a no-fight period for 14 days were also studied. Snca mRNA levels were increased in the raphe nuclei in the losers and in the VTA of the winners. After fighting deprivation Snca mRNA levels were decreased to the control level in both groups. Snca mRNA levels were similar to the control level in the VTA of the losers and in the raphe nuclei of the winners. However Snca gene expression was increased in these areas after no-fight period in the winners and losers in comparison with respective mRNA levels in the undeprived animals. Significant positive correlations were found between the mRNA levels of Snca and Bdnf genes in the raphe nuclei. It was concluded, that social experience affects Snca gene expression depending on brain areas and functional activity of monoaminergic systems in chronically victorious or defeated mice

Interprofessional Communication of Clinicians Using a Mobile Phone App: A Randomized Crossover Trial Using Simulated Patients

Background: Most hospitals use paging systems as the principal communication system, despite general dissatisfaction by end users. To this end, we developed an app-based communication system (called Hark) to facilitate and improve the quality of interpersonal communication. Objective: The objectives of our study were (1) to assess the quality of information transfer using pager- and app-based (Hark) communication systems, (2) to determine whether using mobile phone apps for escalation of care results in additional delays in communication, and (3) to determine how end users perceive mobile phone apps as an alternative to pagers. Methods: We recruited junior (postgraduate year 1 and 2) doctors and nurses from a range of specialties and randomly assigned them to 2 groups who used either a pager device or the mobile phone-based Hark app. We asked nurses to hand off simulated patients while doctors were asked to receive handoff information using these devices. The quality of information transfer, time taken to respond to messages, and users’ satisfaction with each device was recorded. Each participant used both devices with a 2-week washout period in between uses. Results: We recruited 22 participants (13 nurses, 9 doctors). The quality of the referrals made by nurses was significantly better when using Hark (Hark median 118, range 100–121 versus pager median 77, range 39–104; P=.001). Doctors responded to messages using Hark more quickly than when responding to pagers, although this difference was not statistically significant (Hark mean 86.6 seconds, SD 96.2 versus pager mean 136.5 seconds, SD 201.0; P=.12). Users rated Hark as significantly better on 11 of the 18 criteria of an information transfer device (P<.05) These included “enhances interprofessional efficiency,” “results in less disturbance,” “performed desired functions reliably,” and “allows me to clearly transfer information.” Conclusions: Hark improved the quality of transfer of information about simulated patients and was rated by users as more effective and efficient, and less distracting than pagers. Using this device did not result in delay in patient care

Influence of shear-thinning blood rheology on the laminar-turbulent transition over a backward facing step

Cardiovascular diseases are the leading cause of death globally and there is an unmet need for effective, safer blood-contacting devices, including valves, stents and artificial hearts. In these, recirculation regions promote thrombosis, triggering mechanical failure, neurological dysfunction and infarctions. Transitional flow over a backward facing step is an idealised model of these flow conditions; the aim was to understand the impact of non-Newtonian blood rheology on modelling this flow. Flow simulations of shear-thinning and Newtonian fluids were compared for Reynolds numbers ( R e ) covering the comprehensive range of laminar, transitional and turbulent flow for the first time. Both unsteady Reynolds Averaged Navier&ndash;Stokes ( k &minus; &omega; SST) and Smagorinsky Large Eddy Simulations (LES) were assessed; only LES correctly predicted trends in the recirculation zone length for all R e . Turbulent-transition was assessed by several criteria, revealing a complex picture. Instantaneous turbulent parameters, such as velocity, indicated delayed transition: R e = 1600 versus R e = 2000, for Newtonian and shear-thinning transitions, respectively. Conversely, when using a Re defined on spatially averaged viscosity, the shear-thinning model transitioned below the Newtonian. However, recirculation zone length, a mean flow parameter, did not indicate any difference in the transitional Re between the two. This work shows a shear-thinning rheology can explain the delayed transition for whole blood seen in published experimental data, but this delay is not the full story. The results show that, to accurately model transitional blood flow, and so enable the design of advanced cardiovascular devices, it is essential to incorporate the shear-thinning rheology, and to explicitly model the turbulent eddies

Visualization and chemical characterization of the cathode electrolyte interphase using He-ion microscopy and in situ time-of-flight secondary ion mass spectrometry

Unstable cathode electrolyte interphase (CEI) formation increases degradation in high voltage Li-ion battery materials. Few techniques couple characterization of nano-scale CEI layers on the macroscale with in situ chemical characterization, and thus, information on how the underlying microstructure affects CEI formation is lost. Here, the process of CEI formation in a high voltage cathode material, LiCoPO4, has been investigated for the first time using helium ion microscopy (HIM) and in situ time-of-flight (ToF) secondary ion mass spectrometry (SIMS). The combination of HIM and Ne-ion ToF-SIMS has been used to correlate the cycle-dependent morphology of the CEI layer on LiCoPO4 with a local cathode microstructure, including position, thickness, and chemistry. HIM imaging identified partial dissolution of the CEI layer on discharge resulting in in-homogenous CEI coverage on larger LiCoPO4 agglomerates. Ne-ion ToF-SIMS characterization identified oxyfluorophosphates from HF attack by the electrolyte and a Li-rich surface region. Variable thickness of the CEI layer coupled with inactive Li on the surface of LiCoPO4 electrodes contributes to severe degradation over the course of 10 cycles. The HIM–SIMS technique has potential to further investigate the effect of microstructures on CEI formation in cathode materials or solid electrolyte interphase formation in anodes, thus aiding future electrode development

Effects of atmospheric pressure plasma on dye uptake by the surface of wool

A woven pure wool fabric has been exposed to atmospheric pressure plasma for 30 seconds using a pilot-scale. commercial machine. X-ray photoelectron spectral data revealed large increases in oxygen and nitrogen. and a large reduction in carbon. on the surfaces of the plasma-treated fibres. A CIN ratio of 3.55 for plasma-treated wool was consistent with removal of the covalently-bound fatty acids from the surface of the cuticle cells. resulting in exposure of the proteinaceous epicuticle. Dye staining experiments revealed that the back of the fabric had received the same, uniform level of treatment as the face, despite the fact that only the face had been directly exposed to the plasma. Dyes (1 % oww) were applied to fabric at 50&deg;C (liquor ratio =40: 1) and pH values from 3 to 6. The relatively low temperature of 50&deg;C was selected in order to accentuate the effects of plasma on the rate of dye uptake. Under these conditions, dye was adsOibed onto the fibre surfaces, with very little penetration into the fibres. Effects of the plasma treatment on the rate of dyes adsorption were dyespecific. No significant effects of plasma on the rate of dye uptake were observed with relatively hydrophobic dyes, but hydrophilic dyes were adsorbed more rapidly by the plasmatreated fabric. It would appear that for more hydrophobic dyes, hydrophobic effects are more important for the adsorption of dyes by the plasma-treated fibres, even though these fibres were quite hydrophilic. On the other hand. it is concluded that for more hydrophilic dyes, electrostatic effects are more important for adsorption by the plasma-treated fibre.<br /

Excess length of stay and mortality due to Clostridium difficile infection: a multi-state modelling approach.

BACKGROUND: The burden of healthcare-associated infections, such as healthcare-acquired Clostridium difficile (HA-CDI), can be expressed in terms of additional length of stay (LOS) and mortality. However, previous estimates have varied widely. Although some have considered time of infection onset (time-dependent bias), none considered the impact of severity of HA-CDI; this was the primary aim of this study. METHODS: The daily risk of in-hospital death or discharge was modelled using a Cox proportional hazards model, fitted to data on patients discharged in 2012 from a large English teaching hospital. We treated HA-CDI status as a time-dependent variable and adjusted for confounders. In addition, a multi-state model was developed to provide a clinically intuitive metric of delayed discharge associated with non-severe and severe HA-CDI respectively. FINDINGS: Data comprised 157 (including 48 severe) HA-CDI cases among 42,618 patients. HA-CDI reduced the daily discharge rate by nearly one-quarter [hazard ratio (HR): 0.72; 95% confidence interval (CI): 0.61-0.84] and increased the in-hospital death rate by 75% compared with non-HA-CDI patients (HR: 1.75; 95% CI: 1.16-2.62). Whereas overall HA-CDI resulted in a mean excess LOS of about seven days (95% CI: 3.5-10.9), severe cases had an average excess LOS which was twice (∼11.6 days; 95% CI: 3.6-19.6) that of the non-severe cases (about five days; 95% CI: 1.1-9.5). CONCLUSION: HA-CDI contributes to patients' expected LOS and risk of mortality. However, when quantifying the health and economic burden of hospital-onset of HA-CDI, the heterogeneity in the impact of HA-CDI should be accounted for

Application of a policy framework for the public funding of drugs for rare diseases

BACKGROUND: In many countries, decisions about the public funding of drugs are preferentially based on the results of randomized trials. For truly rare diseases, such trials are not typically available, and approaches by public payers are highly variable. In view of this, a policy framework intended to fairly evaluate these drugs was developed by the Drugs for Rare Diseases Working Group (DRDWG) at the request of the Ontario Public Drug Programs. OBJECTIVE: To report the initial experience of applying a novel evaluation framework to funding applications for drugs for rare diseases. METHODS: Retrospective observational cohort study. MEASURES: Clinical effectiveness, costs, funding recommendations, funding approval. KEY RESULTS: Between March 2008 and February 2013, eight drugs were evaluated using the DRDWG framework. The estimated average annual drug cost per patient ranged from 28,000 to 1,200,000 Canadian dollars (CAD). For five drugs, full evaluations were completed, specific funding recommendations were made by the DRDWG, and funding was approved after risk-sharing agreements with the manufacturers were negotiated. For two drugs, the disease indications were determined to be ineligible for consideration. For one drug, there was insufficient natural history data for the disease to provide a basis for recommendation. For the five drugs fully evaluated, 32 patients met the predefined eligibility criteria for funding, and five were denied based on predefined exclusion criteria. CONCLUSIONS: The framework improved transparency and consistency for evaluation and public funding of drugs for rare diseases in Ontario. The evaluation process will continue to be iteratively refined as feedback on actual versus expected clinical and economic outcomes is incorporated. © 2014 Society of General Internal Medicine