Health mobility: implications for efficiency and equity in priority setting

Adverse Health mobility is a statistical measure of inter-temporal fluctuations in health of a group of individuals. Increased availability of panel data has led to a number of studies which analyse and compare health mobility across subgroups. Mobility can differ systematically across patient subgroups, even if prevalence measured at one point in time is the same. There is a lack of discussion regarding whether health mobility is a relevant concept for resource allocation decisions. In this think piece, we explore whether and how health mobility is incorporated in cost-effectiveness analysis (CEA). CEA takes health mobility into account where it matters in terms of efficiency and -depending on treatment programs- either favours groups with low mobility or gives equal priority to groups of differing levels of mobility. However, CEA fails to take into account the equity dimension of mobility. There is qualitative research to suggest that some members of the public find that patient groups with low health mobility should be given priority even if some efficiency was sacrificed. Results also indicate that this may depend on the nature of the condition, the actual lengths involved and the magnitude of the efficiency sacrifice. Health mobility may also have political implications which affect resource allocation decisions, possibly in opposing directions. Further research is required to investigate the extent to which the public is concerned with health mobility, to determine conditions for which health mobility matters most, and to explore ways of how the equity dimension of health mobility can be incorporated into CEA.Health mobility, health dynamics, panel data, resource allocation, cost effectiveness analysis, equity

A structural equation model of adverse events and length of stay in hospitals

Adverse events in hospitals cause significant morbidity and mortality, and considerable effort has been invested into analysing their incidence and preventability. An unresolved issue in models of medical adverse events is potential endogeneity of length of stay (LOS): whilst the probability of suffering a medical adverse event during the episode is likely to increase as a patient stays longer, there are a range of unobservable patient and hospital factors affecting both the occurrence of adverse events and LOS, such as unobserved patient complexity and hospital management. Therefore, statistical models of adverse events which do not account for the potential endogeneity of LOS may generate biased estimates. Our objective is to examine the effects of risk factors on the incidence of adverse events using structural equation models and accounting for endogeneity of LOS. We estimate separate models for three of the most common and serious types of medical adverse events: adverse drug reactions, hospital acquired infections, and pressure ulcers. We use episode level administrative hospital data from public hospitals in the state of Victoria, Australia, for the years 2004/05 and 2005/06 with detailed information on patients, in particular medical complexity and adverse events suffered during admission. We use days and months of discharge as instruments for LOS. Our research helps assessing the costs and benefits of additional days spent in hospital. For example, it can contribute to identifying the ideal time of discharge of patients, or inform whether 'hospital at home' programs reduce rates of hospital acquired infections.Medical errors, complications of care, adverse drug reactions, infections, ulcers, hospital quality

Health Dynamics: Implications for Efficiency and Equity in Priority Setting

AbstractHealth dynamics are intertemporal fluctuations in health status of an individual or a group of individuals. It has been found in empirical studies of health inequalities that health dynamics can differ systematically across subgroups, even if prevalence measured at one point in time is the same. We explore the relevance of the concept of health dynamics in the context of cost-effectiveness analysis. Although economic evaluation takes health dynamics into account where they matter in terms of efficiency, we find that it fails to take into account the equity dimensions of health dynamics. In addition, the political implications of health dynamics may influence resource allocation decisions, possibly in opposing directions

Do obese patients stay longer in hospital? Estimating the health care costs of obesity

Increasing obesity rates are a major public health concern in many countries, as the obese have significantly higher risks of developing serious illnesses such as type II diabetes, cardiovascular disease, osteoarthritis, and various cancers. While it might be assumed that higher levels of obesity in the community must therefore translate to longer and more expensive hospital stays, this study shows that obese patients stay longer in some specialties, but shorter in others. This means it cannot simply be assumed that it is more costly to treat obese patients on average

Richer, wiser and in better health? The socioeconomic gradient in hypertension prevalence, unawareness and control in South Africa

The socioeconomic gradient in chronic conditions is clear in the poorest and wealthiest of countries, but extant evidence on this relationship in low- and middle-income countries is inconclusive. We use data gathered between 2008 and 2012 from a nationally representative sample of over 10,000 South African adults, and objective health measures to analyse the differential effects of education, income and other factors on the prevalence of hypertension, individuals' awareness and control of hypertensive status. Prevalence of hypertension is high at 38% among women and 34% among men. 59% of hypertensive individuals are unaware of their status. We find prevalence and unawareness of hypertension are a public health concern across all income groups in South Africa. Higher income is however associated with effective control amongst men. Completing secondary education is associated with 7 mmHg lower blood pressure only in a small sub-group of women but is associated with 22 percentage point higher likelihood of effective hypertension control amongst women. We conclude that poorer and less educated individuals are particularly at high risk of cardiovascular disease in South Africa

Neisseria meningitidis Has Two Independent Modes of Recognizing Its Human Receptor CEACAM1

BACKGROUND: Several human-restricted gram-negative bacteria exploit carcinoembryonic antigen-related cell adhesion molecules (CEACAMs) for host colonization. For example, Neisseria meningitidis engages these human receptors via outer membrane proteins of the colony opacity-associated (Opa) protein family triggering internalization into non-phagocytic cells. PRINCIPAL FINDINGS: We report that a non-opaque strain of N. meningitidis selectively interacts with CEACAM1, but not other CEACAM family members. Using functional assays of bacterial adhesion and internalisation, microscopic analysis, and a panel of CEACAM1 deletion mutants we demonstrate that the engagement of CEACAM1 by non-opaque meningococci occurs in a manner distinct from Opa protein-mediated association. In particular, the amino-terminal domain of CEACAM1 is necessary, but not sufficient for Opa protein-independent binding, which requires multiple extracellular domains of the human receptor in a cellular context. Knock-down of CEACAM1 interferes with binding to lung epithelial cells, whereas chemical or pharmacological disruption of host protein glycosylation does not abrogate CEACAM1 recognition by non-opaque meningococci. The previously characterized meningococcal invasins NadA or Opc do not operate in a CEACAM1-dependent manner. CONCLUSIONS: The results demonstrate a mechanistically distinct, Opa protein-independent interaction between N. meningitidis and human CEACAM1. Our functional investigations suggest the presence of a second CEACAM1-binding invasin on the meningococcal surface that associates with the protein backbone and not the carbohydrate structures of CEACAM1. The redundancy in meningococcal CEACAM1-binding factors further highlights the important role of CEACAM recognition in the biology of this human-adapted pathogen

Herausforderungen der Öko-Weinbranche - eine Analyse der Wertschöpfungskette von Öko-Wein in Deutschland

In der vorliegenden Studie wurde die komplette Wertschöpfungskette von Öko-Wein mit einer Kombination von qualitativen und quantitativen Methoden systematisch untersucht. Die Analyse erfolgte unter Einbeziehung von Verbänden, Produzenten, Händlern und Endkonsumenten, um die jeweiligen Bedürfnisse und Erwartungen der unterschiedlichen Interessengruppen zu erfassen. Zunächst wurden Bio und konventionelle Winzer in Deutschland interviewt, um die Gründe für oder gegen eine Umstellung auf Bio zu analysieren. Im nächsten Schritt wurden Händler nach ihrer Einschätzung und Einstellung zum Bioweinmarkt in Deutschland befragt, um bereits einen Eindruck von der Biowein-Nachfrage zu erhalten. Anschließend wurden zunächst Gruppendiskussionen durchgeführt und die Datenerhebung mit einer repräsentativen Befragung von Weinkonsumenten abgeschlossen. Die Endverbraucher wurden zu ihrer Wahrnehmung, Einstellung und Erwartung von bzw. an Bio-Wein befragt. Somit wurden alle Stakeholder entlang der Wertschöpfungskette von Bio-Wein in Deutschland involviert. Die Ergebnisse der Analyse helfen zu verstehen, warum 1) Weingüter auf Bio umstellen und warum nicht; 2) Händler Bio-Wein im Sortiment anbieten und wie kommunizieren; 3) die Mehrheit der deutschen Weinkonsumenten Bio-Wein nicht aktiv nachfragt. Darüber hinaus würden die Bio-Weinkonsumenten segmentiert und mithilfe von Marketingund Kommunikationsexperten Handlungsempfehlungen zur Steigerung der Bio-Wein-Nachfrage erarbeitet

Social norms and free-riding in influenza vaccine decisions in the UK: an online experiment

Nudge-based social norm messages conveying high influenza vaccination coverage levels signal a strong social norm, encouraging vaccination, but also a low risk of infection, discouraging vaccination and promoting free-riding. The complex interplay between these two signals can result in ambiguous vaccination decision-making at varying coverage levels. We aimed to measure different vaccination coverage levels’ (VCLs) effect on influenza vaccination intention through an online experiment

Bandwagoning, free-riding and heterogeneity in influenza vaccine decisions: an online experiment

‘Nudge’-based social norms messages conveying high population influenza vaccination coverage levels can encourage vaccination due to bandwagoning effects but also discourage vaccination due to free-riding effects on low risk of infection, making their impact on vaccination uptake ambiguous. We develop a theoretical framework to capture heterogeneity around vaccination behaviors, and empirically measure the causal effects of different messages about vaccination coverage rates on four self-reported and behavioral vaccination intention measures. In an online experiment, N = 1365 UK adults are randomly assigned to one of seven treatment groups with different messages about their social environment's coverage rate (varied between 10% and 95%), or a control group with no message. We find that treated groups have significantly greater vaccination intention than the control. Treatment effects increase with the coverage rate up to a 75% level, consistent with a bandwagoning effect. For coverage rates above 75%, the treatment effects, albeit still positive, stop increasing and remain flat (or even decline). Our results suggest that, at higher coverage rates, free-riding behavior may partially crowd out bandwagoning effects of coverage rate messages. We also find significant heterogeneity of these effects depending on the individual perceptions of risks of infection and of the coverage rates

Centralisation of acute stroke services in London: impact evaluation using two treatment groups

The bundling of clinical expertise in centralised treatment centres is considered an effective intervention to improve quality and efficiency of acute stroke care. In 2010, 8 London Trusts were converted into Hyper Acute Stroke Units. The intention was to discontinue acute stroke services in 22 London hospitals. However, in reality, provision of services declined only gradually, and 2 years later, 15% of all patients were still treated in Trusts without a Hyper Acute Stroke Unit. This study evaluates the impact of centralising London's stroke care on 7 process and outcome indicators using a difference-in-difference analysis with two treatment groups, Hyper Acute and discontinued London Trusts, and data on all stroke patients recorded in the hospital episode statistics database from April 2006 to April 2014. The policy resulted in improved thrombolysis treatment and lower rates of pneumonia in acute units. However, 6 indicators worsened in the Trusts that were meant to discontinue services, including deaths within 7 and 30 days, readmissions, brain scan rates, and thrombolysis treatment. The reasons for these results are difficult to uncover and could be related to differences in patient complexity, data recording, or quality of care. The findings highlight that actual implementation of centralisation policies needs careful monitoring and evaluation