Terveyteen liittyvä elämänlaatu erikoissairaanhoidon kustannusvaikuttavuuden arvioinnissa

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.Järjestelmällisesti kerätty tieto hoidon vaikuttavuudesta ja kustannusvaikuttavuudesta on keskeisessä asemassa, kun erikoissairaanhoidon palveluja järjestetään tulevaisuudessa. Rajalliset resurssit ja terveysteknologioiden nopea kehittyminen edellyttävät toimintojen arviointia ja priorisointia. Päätösten tulee olla läpinäkyviä ja perustua tutkittuun tietoon, mutta ennen kaikkea myös siihen, miten potilaat itse kokevat hyötyvänsä erikoissairaanhoidon toiminnoista. Tämän väitöskirjan tavoitteena oli kartoittaa tutkimukset, joissa hoidon lopputulosta arvioitiin laatupainotteisina elinvuosina siten, että hoidon arvioijana oli potilas itse. Lisäksi väitöskirjan tavoitteena oli tutkia, miten erikoissairaanhoidon kustannusvaikuttavuuden arviointia voitaisiin toteuttaa Helsingin ja Uudenmaan sairaanhoitopiirissä. Erikoissairaanhoidon kustannusvaikuttavuuden arvioimiseksi tutkimukseen valittiin kolme lääketieteen erikoisalaa, jotka edustavat volyymiltaan suuria erikoissairaanhoidon ryhmiä, ja joilla siten on vaikutusta sekä kansantalouteen että kansanterveyteen. Taloudellisten arviointien määrä terveydenhuollossa on kasvanut viimeisen kahden vuosikymmenen ajan. Tästä huolimatta kirjallisuuskatsauksemme perusteella löytyi vain vähän tutkimuksia, joissa hoidon lopputulosmittarina ovat laatupainotteiset elinvuodet, QALYt (Quality-adjusted life years) siten, että arvio hoidon vaikuttavuudesta on kysytty validilla menetelmällä potilaalta itseltään. Hoidon vaikuttavuutta mitattiin 712 kirurgisesti hoidetun potilaan antamalla arviolla terveyteen liittyvästä elämänladusta ennen hoitoa ja noin 3 12 kuukauden kuluttua hoidosta. Terveyteen liittyvän elämänlaadun mittarina oli Suomessa kehitetty geneerinen, potilaan itsensä täyttämä 15D- kyselylomake. Kaikki potilaat saivat erikoissairaanhoidon normaalikäytännön mukaista hoitoa. Vaikuttavuustieto yhdistettiin hoidon kustannuksia ja järjestämistä koskevaan tietoon hoidon kustannusvaikuttavuuden arvioimiseksi. Vaikuttavuustiedon rutiininomainen kerääminen erikoissairaanhoitoon tulevilta potilaita osoittautui kohtuullisen helpoksi eikä vaatinut esimerkiksi lisähenkilöstön palkkaamista osastoille, joilla tutkimus toteutettiin. Vastusprosentti oli keskimäärin yli 70 %, mikä osoittaa sen, että potilaat osallistuvat mielellään tutkimukseen ja arvostavat sitä, että heidän voinnistaan ollaan kiinnostuneita vielä hoidon päättymisen jälkeenkin. Tutkimustulosten mukaan sekä polvi- ja lonkkaproteesipotilaiden että lanne- ja kaularangan ahtaumapotilaiden terveyteen liittyvä elämänlaatu paranee seuranta-aikana merkitsevästi. Lonkan uusintaleikkausten ja kaihileikkauspotilaiden elämänlaadussa paranemista tapahtuu vain vähän. Erikoissairaanhoidolle aiheutuneet kustannukset potilasta kohden vaihtelivat 1 640 (kaihikirurgia) ja 11 240 (lonkan uusintaproteesileikkaus) välillä. Kustannukset laatupainotteista elinvuotta kohden olivat halvimmat lannerangan ahtaumapotilailla, 1 740 , ja kalleimmat lonkan uusintaproteesileikkauksessa, 52 270 . Johtopäätöksenä voidaan todeta että järjestelmällinen ja rutiininomaisesti toteutettu vaikuttavuustiedon kerääminen ja yhdistäminen kustannustietoihin on mahdollista melko vähäisin ponnistuksin. Tutkimus osoitti, että eri potilasryhmien kustannus laatupainotteista elinvuotta kohden vaihtelee suuresti, mutta on kaikissa muissa ryhmissä paitsi lonkan uusintaproteesileikkauksessa alle 50 000 , jota alan kirjallisuudessa pidetään eräänlaisena kustannusvaikuttavan hoidon kattohintana. Laatupainotteiset elinvuodet ovat tärkeä terveydenhuollon vaikuttavuuden mittari. Arviointien, joissa laatupainotteiset elinvuodet perustuvat potilaiden itsensä antamaan arvioon saamastaan hoidosta ennen jälkeen-asetelmassa, tulisi olla yksi keskeinen menetelmä pyrittäessä kustannusvaikuttavaan erikoissairaanhoitoon

Reliability and validity evidence of the early numeracy test for identifying children at risk for mathematical learning difficulties

This study investigated reliability and validity evidence regarding the Early Numeracy WA (EN-test) in a sample of 1139 Swedish-speaking children (587 girls) in kindergarten (n = 361), first grade (n = 321), and second grade (n = 457). Structural validity evidence was established through confirmatory factor analysis (CFA), which showed that a four-factor model fit the data significantly better than a one-factor or two-factor model. The known-group and cross-cultural validity were established through multigroup CFAs, finding that the four-factor model fit the gender, age and language groups equally well. Internal consistency for the WA and sub-skills varied from good to excellent. The EN-test can be considered as an appropriate assessment to identify children at risk for mathematical learning difficulties.Peer reviewe

Plant residue mulch increases measured and modelled soil moisture content in the effective root zone of maize in semi-arid Kenya

Difficulties in efficient utilization of seasonal precipitation cause limitations in yields and even total crop failure on rainfed farms in semi-arid East Africa. The objective of the present study was to find out if covering the soil with plant residue mulch at a semi-arid site could retain water in the soil between precipitation events and build dry spell resilience by reducing soil water evaporation and increasing infiltration to deeper soil. Covering soil with plant residue mulch was studied at a smallholder farm in semi-arid Kenya by continuously measuring volumetric soil moisture content with soil sensors at multiple depths in bare soil and in maize (Zea mays L.) plant residue mulched soil. A physically based one-dimensional soil moisture model was calibrated and used to estimate the effect of plant residue mulch on soil moisture over a two-year period (multiple growing seasons). The modelled multiyear time series provides an estimate of the effect residue mulches of different thicknesses have on soil moisture over time. The simple soil moisture model was able to estimate soil moisture in the effective root zone of maize. By comparing measured data from mulched and uncovered soil and by model prediction, it was demonstrated that maize residue mulch conserved soil moisture over time in the effective root zone of maize compared to bare soil. During the two-year period mulching increased the total amount of days when measured relative soil moisture (s) exceeded water stress limit of maize (s*) by 24%-46%. Moisture accumulated in the mulched profile, especially in the deeper layers of the effective root zone. Calculations indicated that further increasing mulch thickness (delta(m)) from 1 to 3 cm would have increased the total days when s > s* 59%. Furthermore, increasing delta(m) from 3 to 5 cm would have resulted in 25% increase in total days when s > s*. According to our calculations mulching (delta(m) > 1 cm) could have maintained s > s* throughout a 19 days dry spell that occurred during the measurement period. The demonstrated moisture conserving effect of mulch increases with delta(m), but availability of plant residue may set limits on mulch application rates. The results suggest that maize residue mulching is as an accessible and feasible method for conserving soil moisture in the effective root zone in dryland smallholder systems in East Africa.Peer reviewe

Effects of Gender on Basic Numerical and Arithmetic Skills : Pilot Data From Third to Ninth Grade for a Large-Scale Online Dyscalculia Screener

In this study, we analyzed the development and effects of gender on basic number skills from third to ninth grade in Finland. Because the international comparison studies have shown slightly different developmental trends in mathematical attainment for different language groups in Finland, we added the language of education as a variable in our analysis. Participants were 4,265 students from third to ninth grade in Finland, representing students in two national languages (Finnish, n = 2,833, and Swedish, n = 1,432). Confirmatory factor analyses showed that the subtasks in the dyscalculia screener formed two separate factors, namely, number-processing skills and arithmetic fluency. We found a linear development trend across age cohorts in both the factors. Reliability and validity evidence of the measures supported the use of these tasks in the whole age group from 9 to15 years. In this sample, there was an increasing gender difference in favor of girls and Swedish-speaking students by grade levels in number-processing skills. At the same time, boys showed a better performance and a larger variance in tasks measuring arithmetic fluency. The results indicate that the gender ratio within the group with mathematical learning disabilities depends directly on tasks used to measure their basic number skills.Peer reviewe

Työttömien terveyspalvelujen kehittäminen – verkosto mahdollisuutena

Artikkelin tavoitteena on kuvata ja ymmärtää terveydenhuollon sisäisiä verkostoja työttömien terveyspalvelujen toteuttamisessa ja kehittämisessä. Artikkeli perustuu Kuopiossa toteutetun Työterveysneuvontahankkeen loppuarviointiin vuonna 2011. Hankkeen keskeisin toiminta pohjautui terveystapaamisiin työterveyshoitajan kanssa. Asiakaskunta hankkeessa oli 15–25 vuotiaita työttömiä sekä keski-ikäisiä, työvoimapoliittisessa koulutuksessa olevia henkilöitä. Aineisto kerättiin Kuopion terveydenhuollon ja sidosryhmien sekä seurantapaikkakuntien (Joensuu, Jyväskylä, Oulu, Vammala) edustajien teemahaastatteluilla sekä Kuopiossa toteutetulla verkostokyselyllä. Työttömien terveyspalvelujen toimintaympäristö ja työttömien terveyden erityispiirteet sekä verkostotutkimus muodostavat teoreettisen viitekehyksen tutkimukselle. Tulosten mukaan työttömien terveyspalveluissa lähtökohtana on asiakaskeskeisyys ja organisaation rajapinnoilla toimiminen. Terveydenhuollon mahdollisuudet arvioida työ- ja toimintakykyä ovat rajalliset, sillä terveydenhuollon keinoin ei kaikkia asiakkaan asioita voida ratkaista. Työ- ja elinkeinotoimiston ja terveydenhuollon yhteistyötä pitää lisätä, sillä prosessivastuu työttömän asioissa kuuluu työ- ja elinkeinotoimistolle. Työterveyshuollon ja muun perusterveydenhuollon roolijakoa pitää selkeyttää. Työttömäksi jäävän terveydenhuollon kehittäminen tulee tapahtua työterveyshuollosta käsin yhteistyössä muun perusterveydenhuollon kanssa. Palvelun kehittäminen vaatii organisaation rajojen madaltamista, koordinointia pysyviä toimintamalleja sekä sopimuksia

Health-related quality of life and costs of switching originator infliximab to biosimilar one in treatment of inflammatory bowel disease

Effectiveness, efficacy and safety of biosimilar infliximab (CT-P13) in inflammatory bowel disease (IBD) patients has been shown in previous studies. Limited data exist on health-related quality of life (HRQoL) of switching originator to biosimilar infliximab (IFX) in IBD patients. The objective of this study was to evaluate impact of switching originator to biosimilar IFX on HRQoL, disease activity, and health care costs in IBD maintenance treatment. In this single-center prospective observational study, all IBD patients receiving maintenance IFX therapy were switched to biosimilar IFX. HRQoL was measured using the generic 15D health-related quality of life instrument (15D) utility measurement and the disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ). Crohn Disease Activity Index (CDAI) or Partial Mayo Score (pMayo), and fecal calprotectin (FC) served for evaluation of disease activity. Data were collected at time of switching and 3 and 12 months after switching. Patients' characteristics, clinical background information and costs were collected from patient records and the hospital's electronic database. Fifty-four patients were included in the analysis. No statistically significant changes were observed in 15D, CDAI, pMayo, and FC during 1-year follow-up. IBDQ scores were higher (P = .018) in Crohn disease 3 months after switching than at time of switching. Costs of biosimilar IFX were one-third of costs of originator one. Total costs related to secondary health care (excluding costs of IFX), were similar before and after the onset of biosimilar IFX. HRQoL and disease activity were after switching from originator to biosimilar IFX comparable, but the costs of biosimilar IFX were only one-third of those of the originator one.Peer reviewe