Prevalence of Age-Related Macular Degeneration in Europe: The Past and the Future

Purpose Age-related macular degeneration (AMD) is a frequent, complex disorder in elderly of European ancestry. Risk profiles and treatment options have changed considerably over the years, which may have affected disease prevalence and outcome. We determined the prevalence of early and late AMD in Europe from 1990 to 2013 using the European Eye Epidemiology (E3) consortium, and made projections for the future. Design Meta-analysis of prevalence data. Participants A total of 42 080 individuals 40 years of age and older participating in 14 population-based cohorts from 10 countries in Europe. Methods AMD was diagnosed based on fundus photographs using the Rotterdam Classification. Prevalence of early and late AMD was calculated using random-effects meta-analysis stratified for age, birth cohort, gender, geographic region, and time period of the study. Best-corrected visual acuity (BCVA) was compared between late AMD subtypes; geographic atrophy (GA) and choroidal neovascularization (CNV). Main Outcome Measures Prevalence of early and late AMD, BCVA, and number of AMD cases. Results Prevalence of early AMD increased from 3.5% (95% confidence interval [CI] 2.1%–5.0%) in those aged 55–59 years to 17.6% (95%

An Economic Examination of Australian Private Psychiatric Services under Medicare: Conceptual and Empirical Studies

The objective of this thesis is to present the results of several conceptual and empirical analyses of the services of private psychiatrists that are provided in Australia on a fee-for-service (FFS) basis. The contributions to knowledge provided by this study are outlined here. Part I of the thesis contains three chapters that contribute separate overviews of some dimensions of private psychiatry, which previously have not been available in the literature. The economic characteristics of FFS psychiatry as an industry are discussed in Chapter One, which also broadly discusses the importance of Medicare in the operation of private psychiatry. Although it has been established medically in the literature that mental illnesses are an important disease category, economists have neglected psychiatry, along with other industries in the mental health sector. The only comprehensive review of the economic literature on Australian mental health issues is provided in Chapter Two, which demonstrates also that numerous lacunae exist. In Chapter Three, the context of this study is given. An innovative conceptual and empirical overview of the mental health sector in Australia is given and various measures of the size and composition of FFS psychiatric services are provided. Part II is entitled Further Conceptual Analyses, the content of which encompasses four new studies. A positive economic analysis of Australias system of health care fi nancing of FFS psychiatric services is provided in Chapter Four. Such an analysis has not been undertaken previously for this industry. The Chapter demonstrates the important economic relationships between the gross prices received by FFS psychiatrists, the net (out-of-pocket) prices that consumers pay and the Medicare rebate, or subsidy. In Chapter Five, there is a conceptual examination of need, which is an asserted basis for the establishment of the Medicare system of funding. This study demonstrates that conventional economic measures of a necessity, such as the income elasticity of demand, are insuffi cient for determining medical need and provides new bases for conceptualising and measuring medical needs. Attention turns in Chapters Six and Seven to another rationale underlying the Medicare funding of private psychiatric services, viz. equality. The importance placed in the economic literature on income inequality measurement is demonstrated in Chapter Six, and this is contrasted with the lack of attention by economists to inequality measurement in the health sector. Some illustrative data are then used in Chapter Seven to demonstrate, in a innovative way, the relevant economic concepts and tools required for measuring inequalities related to the mental health sector. The Further Empirical Analyses of Part III involve a further four new empirical studies. In Chapters Eight and Nine statistical results are provided about the quantity and price outcomes, respectively, of private FFS psychiatry under Medicare. These results are based on quarterly time-series data for six Australian regions. Broadly speaking, these Chapters provide some initial information about a popular word used in respect of Medicare funding, viz. access. The empirical focus turns once again in Chapters Ten and Eleven to distribution. Two major distributional outcomes of this industry are measured in these Chapters, with the inequality measurements of quantities of services and mental health status that are provided, respectively. In Chapter Ten, conventional measures of statistical dispersion and inequality (such as coeffi cients of variation, Gini coeffi cients, Atkinson measures and Lorenz curves) are applied to the quarterly time-series data on quantities of services. The trends on equality of spatial access to psychiatric services since the introduction of Medicare in 1984 are demonstrated. The focus of Chapter Eleven is on mental health per se and its distribution. This focus is appropriate as the ultimate objective of psychiatric services is mental health. In this Chapter is the fi rst economic measure of mental health status, and this is undertaken for the State of Queensland. This measure is based of the period of time lived prior to the onset of serious mental illness. The study demonstrates whether mental health status has increased, decreased or remained constant through time and, by constructing time trends on various inequality measures, including Gini coeffi cients, determines statistically whether inequality in mental health status has increased, decreased or remained constant since 1964. In Chapter Twelve the dissertation is summarised and the main conclusions are presented. The above outline indicates the types of information about the Australian market for psychiatric services that are contributed by this thesis. The contributions are particularly relevant at a time when economic understanding of the industry is like a black hole. Tools and concepts from both Industrial Economics and Public Finance are applied in this study, because the market outcomes of private psychiatric services in Australia, in terms of such variables as prices and quantities, involve the interaction of market and government forces. The role of government is heavily woven into the operations of private FFS psychiatry in Australia, and occurs not only via the control of entry into psychiatry, but also through Commonwealth Government fi nancing of the industry via Medicare. This thesis demonstrates that the institutional forces of Commonwealth Government funding are of fundamental economic relevance to the operation of private psychiatry. However, this is an atypical industry study. Absent are conventional issues in Industrial Economics, such as market structure, collusion, strategic behaviour, mergers and joint ventures, innovation and so forth. Present are contributions to knowledge about the size of the industry, the public-private split in funding private psychiatry, need and access, the quantities of private psychiatric services, and their gross prices, various inequality measures of private psychiatric service provision and, fi nally, an economic measure of mental health and of mental health inequality

An economic classification of “health need”

Purpose – Multiple connotations and conceptions of health need are currently in use. The purpose of this paper is to specify some important distinctions regarding this confusing multiplicity in a taxonomic fashion relevant to the economic problems that arise in addressing health need. Classification is possible with the relevant concepts in conventional economic theory. The classification applies wherever economic considerations bear upon health need. Design/methodology/approach – Initially, some seminal economic ideas about need are presented from Marshall, Pauly, Banfield, Jevons, Deaton and Meullbauer, and Georgescu-Roegen. Recent discussions of basic needs by Sen and Nussbaum concerning “capabilities” and human flourishing are also considered. Ruger's subsequent developments of these concepts specifically for health are noted. The paper then specifies and classifies the current economic connotations of “health need” by applying positive economic analysis and the framework of economic theory. In particular, the conventional theories of consumer demand and production supply are useful. Geometric tools of analysis along with illustrations from the health sector specify various distinctions and classifications. Findings – The uses of the generic term “need” relate to quite different economic problems. The findings show how diverse interpretations of need can be specified. Originality/value – Distinctions over health need are important since, in many Western countries, need is one of the “pillars” of the Welfare State. Effective policy requires sound conceptions and measurements of need. Given the relevance of economics for approaching competing resource uses in the face of health need, measurement of need is improved with taxonomy, and confusion reduced.Classification, Health services, Personal health, Resource management, Social economics

Disabled people's living standards: filling a policy vacuum

Purpose – Government policy can alleviate inequities in living standards. Disabled people often qualify for government assistance which is one way that their living standard can improve, although arbitrary systems for distributing assistance are not likely to serve equity objectives. The purpose of this paper is to indicate the key variables to which government should direct attention, in order to alleviate both horizontal and vertical inequity in grants to disabled people. Design/methodology/approach – There is no literature, either theoretical or empirical, that specifically addresses this problem. This paper invokes important economic concepts associated with the nineteenth century English philosopher/economist, John Stuart Mill, as well as the 1998 Nobel Laureate in Economics, Amartya Sen. Mill's general conception of how government should behave in treating citizens was elaborated subsequently in the public finance literature on principles of taxation. These notions are about “the equal treatment of equals” and “the unequal treatment of unequals”. Sen's recent discussion of the “conversion handicap” from his general framework of capabilities is highly relevant to the question addressed here. Findings – These concepts, applied with some analytical tools of algebra and geometry, show that Mill's principles can combine with Sen's into a relevant conceptual framework. The central principles and concepts for policy formation on the standard of living for disabled people are not random; they can be specified with clarity. Originality/value – This paper contributes the relevant conceptual “yardsticks” by which policy for distributing assistance to disabled people can be evaluated. Steps, towards devising better approaches to the distribution of assistance to disabled people can now be taken.Disabled people, Government policy, Standard of living

Some economic dimensions of the mental health jigsaw in Australia

Purpose – The purpose of this paper is to demonstrate that, although there are some unique features associated with mental illness, such special features do not preclude economic analysis. Design/methodology/approach – As a mechanism for understanding how individual economic studies fit into the mental health sector, a conceptual framework of the components of mental health service provision is outlined. Emphasis is placed on, not simply institutional and market resources, but also on the services provided by relatives, self-help groups, etc. Findings – Australian data on parts of the mental health sector are employed to illustrate that some (and different) economic analyses can be undertaken in mental health. First, time-series data on public psychiatric hospitals are employed to demonstrate trends associated with deinstitutionalisation. Other data (for Queensland alone) indicate that there are state-based differences in the provision of such services. Second, attention is then directed to the analysis of time-series data on private fee-for-service psychiatric services. Various concepts and measures from industrial economics are applied to analyse the relative size of this service industry, the pricing behaviour of the profession, the service-mix of “the psychiatry firms” operating in Australia. In addition, the analysis also sheds some light on the distributional implications of Australia's national (and uniform) system of health funding, Medicare. Originality/value – Apart from demonstrating that economic analyses can be undertaken in the difficult area of mental health, this paper indicates a number of puzzles (e.g. various regional variations within a unified profession and a uniform national funding scheme) that invite further investigationAustralia, Economic sectors, Health services, Mental health services, Psychiatry

Measuring cancer inequality with the cumulative rate

Background: There is widespread interest in comparing populations with respect to cancer incidence and mortality. How does the incidence of cancer one’s own region compare with the incidence in the rest of the state or county? How does the mortality of cancer before an intervention compare with the mortality some years after the intervention? Such questions arise in making decisions about resource allocation. Aim: Usually such comparisons are based on age-standardized rates or cumulative risks. Our aims are (i) to state our reservations about both age standardized rates and cumulative risks, and (ii) to present an alternative approach based on cumulative rates. Methods: In 1976, N. Day introduced the method of cumulative rates into the cancer literature. Cumulative incidence (or mortality) rates can be calculated easily using basic demographic data and incidence (or mortality) data stratified by age groups. The method leads to results that are similar to those that one would obtain by using age-standardized rates or cumulative risks. However, no special assumptions are required to use the method of cumulative rates or to interpret the results. Results: We will illustrate how the method works in practice by measuring inequalities in mortality from colorectal cancer (ICD C18-C20) in Australia. A hard copy of the calculations will be available for delegates at the Congress. Conclusions: The assumptions in age-standardization involve introducing weights from a standard population. However, applying arbitrary weightings is unjustifiable when a better measure is available that obviates that need in the first place. In addition, the key assumption in cumulative risk measurement - namely, that the only cause of death is cancer - can be misleading to the wider public. The cumulative rate does not share these disadvantages of the age-standardized rate and cumulative risk. It can be used to measure inequalities in incidence or mortality between different regions, or between the same region at different times, or between men and women. It leads to confidence intervals and tests of statistical hypotheses. Furthermore, the method is very easy to apply. Based on our experience, we commend the method of cumulative rates for use in impact evaluation studies in cancer care, and as a basis for allocating resources

Accuracy of official suicide mortality data in Queensland

Objective: The purpose is to answer the following research question: are the time-series data published by the Australian Bureau of Statistics for Queensland statistically the same as those of the Queensland Suicide Register? Method: This question was answered by first modelling statistically, for males and females, the time series suicide data from these two sources for the period of data availability, 1994 to 2007 (14 observations). Fitted values were then derived from the ‘best fit’ equations, after rigorous diagnostic testing. The outliers in these data sets were addressed with pulse dummy variables. Finally, by applying the Wald test to determine whether or not the fitted values are the same, we determined whether, for males and females, these two data sets are the same or different. Results: The study showed that the Queensland suicide rate, based on Queensland Suicide Register data, was greater than that based on Australian Bureau of Statistics data. Further statistical testing showed that the differences between the two data sets are statistically significant for 24 of the 28 pair-wise comparisons. Conclusions: The quality of Australia's official suicide data is affected by various practices in data collection. This study provides a unique test of the accuracy of published suicide data by the Australian Bureau of Statistics. The Queensland Suicide Register's definition of suicide applies a more suicidological, or medical/health, conception of suicide, and applies different practices of coding suicide cases, timing of data collection processes, etc. The study shows that ‘difference’ between the two data sets predominates, and is statistically significant; thus the extent of the under-reporting of suicide is not trivial. Given that official suicide data are used for many purposes, including policy evaluation of suicide prevention programmes, it is suggested that the system used in Queensland should be adopted by the rest of Australia too

Immunocompromised patients with acute respiratory distress syndrome : Secondary analysis of the LUNG SAFE database

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods: We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results: Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p < 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions: Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Whole-genome sequencing reveals host factors underlying critical COVID-19

Altres ajuts: Department of Health and Social Care (DHSC); Illumina; LifeArc; Medical Research Council (MRC); UKRI; Sepsis Research (the Fiona Elizabeth Agnew Trust); the Intensive Care Society, Wellcome Trust Senior Research Fellowship (223164/Z/21/Z); BBSRC Institute Program Support Grant to the Roslin Institute (BBS/E/D/20002172, BBS/E/D/10002070, BBS/E/D/30002275); UKRI grants (MC_PC_20004, MC_PC_19025, MC_PC_1905, MRNO2995X/1); UK Research and Innovation (MC_PC_20029); the Wellcome PhD training fellowship for clinicians (204979/Z/16/Z); the Edinburgh Clinical Academic Track (ECAT) programme; the National Institute for Health Research, the Wellcome Trust; the MRC; Cancer Research UK; the DHSC; NHS England; the Smilow family; the National Center for Advancing Translational Sciences of the National Institutes of Health (CTSA award number UL1TR001878); the Perelman School of Medicine at the University of Pennsylvania; National Institute on Aging (NIA U01AG009740); the National Institute on Aging (RC2 AG036495, RC4 AG039029); the Common Fund of the Office of the Director of the National Institutes of Health; NCI; NHGRI; NHLBI; NIDA; NIMH; NINDS.Critical COVID-19 is caused by immune-mediated inflammatory lung injury. Host genetic variation influences the development of illness requiring critical care or hospitalization after infection with SARS-CoV-2. The GenOMICC (Genetics of Mortality in Critical Care) study enables the comparison of genomes from individuals who are critically ill with those of population controls to find underlying disease mechanisms. Here we use whole-genome sequencing in 7,491 critically ill individuals compared with 48,400 controls to discover and replicate 23 independent variants that significantly predispose to critical COVID-19. We identify 16 new independent associations, including variants within genes that are involved in interferon signalling (IL10RB and PLSCR1), leucocyte differentiation (BCL11A) and blood-type antigen secretor status (FUT2). Using transcriptome-wide association and colocalization to infer the effect of gene expression on disease severity, we find evidence that implicates multiple genes-including reduced expression of a membrane flippase (ATP11A), and increased expression of a mucin (MUC1)-in critical disease. Mendelian randomization provides evidence in support of causal roles for myeloid cell adhesion molecules (SELE, ICAM5 and CD209) and the coagulation factor F8, all of which are potentially druggable targets. Our results are broadly consistent with a multi-component model of COVID-19 pathophysiology, in which at least two distinct mechanisms can predispose to life-threatening disease: failure to control viral replication; or an enhanced tendency towards pulmonary inflammation and intravascular coagulation. We show that comparison between cases of critical illness and population controls is highly efficient for the detection of therapeutically relevant mechanisms of disease