Moving Beyond the QALY: Economic Evaluation in Health and Social Care for Elderly Populations

__Abstract__ The growing number of elderly consumes an increasing amount of health and social care services, straining public budgets. Economic evaluations have traditionally focused on curative care using health-related quality of life as outcomes, and gave answers which interventions to fund or not to fund. However in order to evaluate long-term care as well, broader outcomes are necessary. The aim of this thesis is to address a number of issues related to outcome measurement in economic evaluations in elderly populations consuming health and social care. After performing a traditional economic evaluation in long-term care and identifying the limitations, a systematic review was performed in order to search for more appropriate outcomes. The review identified the ICECAP-O instrument, and this has been validated in Dutch and German Nursing homes, as well as in a population of post-hospitalized older people. Finally, we have performed an economic evaluation using the ICECAP-O. The ICECAP-O in general measures broader than health outcomes. It was related to measures of health-related and dementia-specific quality of life, physical, mental and social health, and to wellbeing instruments. It also differentiates between elderly below and above 75 years, multimorbidity, dementia severity, living alone or together and elderly with nursing homes with or without physical restraints. In

Cost-effectiveness of a pressure ulcer quality collaborative

ABSTRACT. BACKGROUND: A quality improvement collaborative (QIC) in the Dutch long-term care sector (nursing homes, assisted living facilities, home care) used evidence-based prevention methods to reduce the incidence and prevalence of pressure ulcers (PUs). The collaborative consisted of a core team of experts and 25 organizational project teams. Our aim was to determine its cost-effectiveness from a healthcare perspective. METHODS: We used a non-controlled pre-post design to establish the change in incidence and prevalence of PUs in 88 patients over the course of a year. Staff indexed data and prevention methods (activities, materials). Quality of life (Qol) weights were assigned to the PU states. We assessed the costs of activities and materials in the project. A Markov model was built based on effectiveness and cost data, complemented with a probabilistic sensitivity analysis. To illustrate the results of longer term, three scenarios were created in which change in incidence and prevalence measures were (1) not sust

ASCA Observation of the Dipping X-Ray Source X1916-053

We present the results of timing and spectral studies of the dipping X-ray source X1916-053, observed by ASCA during its Performance Verification phase. The detected dipping activity is consistent with previous observations, with a period of 3008s and an intermittent secondary dip observed roughly 0.4 out of phase with the primary dip. The energy spectra of different intensity states are fitted with a power law with partial covering fraction absorption and interstellar absorption. The increase in the hardness ratio during the primary and secondary dips, and the increase in the covering fraction and column density with decreasing X-ray intensity, all imply that the dipping is caused by the photo-absorbing materials which have been suggested to be where the accreted flow hits the outer edge of the disk materials. The spectra at all intensity levels show no apparent evidence for Fe or Ne emission lines. This may be due to the low metal abundance in the accretion flow. Alternatively, the X-ray luminosity of the central source may be too weak to excite emission lines, which are assumed to be produced by X-ray photoionization of the disk materials

Quality of life of nursing home residents with dementia: Validation of the German version of the ICECAP-O

Objectives: To validate the ICECAP-O capability wellbeing measure's German translation in older people with dementia living in a nursing home, and to investigate the influence of proxy characteristics on responses. Method: Cross-sectional study. For 95 residents living in a German nursing home, questionnaires were completed by nursing professionals serving as proxy respondents. We investigated the convergent validity of the ICECAP-O with other Quality of Life (Qol) measures, the EQ-5D extended with a cognitive dimension (EQ-5D+C), the Alzheimer's Disease Related Quality of Life (ADRQL) measures, and the Barthel-index measure of Activities of Daily Living (ADL). Discriminant validity was investigated using bivaria

Risks and risk mitigation in waste-work: A qualitative study of informal waste workers in Nepal

Objectives To explore how informal waste workers (IWWs) working in Kathmandu Valley perceive risks associated with waste work and what they do to mitigate them. Study design Qualitative Study Design. Methods A mix of one-to-one semi-structured interviews (n ​= ​18) and focus group discussions (n ​= ​4) with IWWs were undertaken. Participants were recruited purposively using snowball sampling. All interviews and discussions were audio-recorded, transcribed verbatim, translated and subsequently analysed thematically. Results The IWWs perceived discrimination and health risks as the main risks associated with waste work. IWWs reported considerable stigma and discrimination not only from the wider society but also from family members and within their own profession. Similarly, the occupational risks most frequently recognized were physical injuries and cuts from working with waste. However, the potential risks from hazardous chemicals present in or generated from waste were not articulated by participants. Mitigation strategies to combat the risks included avoidance, greater care and the use of informal means of “protection”. Awareness of the importance of personal protective equipment (PPE) was limited. The key barriers to the use of PPE identified included costs, the lack of easy availability of PPE and the inconvenience of working with PPE. Conclusions The vulnerability of informal waste workers in Nepal is multifaceted. A range of policy and regulatory measures, along with interventions that promote greater social inclusion and occupational support are needed to promote IWW’s health and safety

Upper bounds for the eigenvalues of Hessian equations

We prove some upper bounds for the Dirichlet eigenvalues of a class of fully nonlinear elliptic equations, namely the Hessian equationsComment: 15 pages, 1 figur

Development and testing of an online community care platform for frail older adults in the Netherlands: a user-centred design

Background Recent transitions in long-term care in the Netherlands have major consequences for community-dwelling older adults. A new paradigm expects them to manage and arrange their own care and support as much as possible. Technology can support this shift. A study has been conducted to explore the needs of community-dwelling frail older adults with regard to an online platform. An existing platform was subsequently modified, based upon these needs, resulting in an online community care platform (OCC-platform) comprising of care, health, and communication functions. The purpose of this platform was to support frail older adults in their independence and functioning, by stimulating self-care and providing reliable information, products and services. Methods The study used a User-Centred Design. The development processes involved the following steps: Step 1) Identification of the User Requirements. To assess the user requirements, direct observations (N = 3) and interviews (N = 14) were performed. Step 2) Modification of an Existing Online Platform. Based upon Step 1, available online platforms were explored to determine whether an existing useful product was available. Two companies collaborated in modifying such a platform; Step 3) Testing the Modified Platform. A total of 73 older adults were invited to test a prototype of the OCC-platform during 6 months, which comprised of two phases: (1) a training phase; and (2) a testing phase. Results An iterative process of modifications resulted in an interactive software concept on a Standard PC, containing 11 Functions. The Functions of ‘contacts’, ‘services’ and ‘messaging’, were by far, the most frequently used. The use was at its highest during the first 2 weeks of the testing and then its use steadily declined. The vast majority of the subjects (94%) were positive about the usability of the platform. Only a minority of the subjects (27%) indicated that the platform had added value for them. Conclusion The overall prospect was that an OCC-platform can contribute to the social participation and the self-management competencies of frail older adults, together with their social cohesion in the community. In order to validate these prospects, further research is needed on the characteristics and the impact of online platforms

Geometric characterization of nodal domains: the area-to-perimeter ratio

In an attempt to characterize the distribution of forms and shapes of nodal domains in wave functions, we define a geometric parameter - the ratio $\rho$ between the area of a domain and its perimeter, measured in units of the wavelength $1/\sqrt{E}$. We show that the distribution function $P(\rho)$ can distinguish between domains in which the classical dynamics is regular or chaotic. For separable surfaces, we compute the limiting distribution, and show that it is supported by an interval, which is independent of the properties of the surface. In systems which are chaotic, or in random-waves, the area-to-perimeter distribution has substantially different features which we study numerically. We compare the features of the distribution for chaotic wave functions with the predictions of the percolation model to find agreement, but only for nodal domains which are big with respect to the wavelength scale. This work is also closely related to, and provides a new point of view on isoperimetric inequalities.Comment: 22 pages, 11 figure