Detecting and describing heterogeneity in health care cost trajectories among asylum seekers.

The mechanism underlying the health care cost trajectories among asylum seekers is not well understood. In the canton of Vaud in Switzerland, a nurse-led health care and medical Network for Migrant Health ("Réseau santé et migration" RESAMI) has established a health care model focusing on the first year after arrival of asylum seekers, called the "community health phase". This model aims to provide tailored care and facilitate integration into the Swiss health care system. The aim of this study is to explore different health care cost trajectories among asylum seekers during this phase and identify the associated factors. We detected different patterns of health care cost trajectories using time-series clustering of longitudinal data of asylum seekers in the canton of Vaud in Switzerland. These data included all adult asylum seekers and recipients of emergency aid who entered the canton between 2012 and 2015 and were followed until 2018. The different clusters of health care cost trajectories were then described using a multinomial logistic regression model. We identified a concave, an upward trending, and a downward trending cluster of health care cost trajectories with different characteristics being associated with each cluster. The likelihood of being in the concave cluster is positively associated with coming from the Eastern Mediterranean region or Africa rather than Europe and with a higher share of consultations with an interpreter. The likelihood of being in the upward trending cluster, which accrued the highest costs, is positively associated with 20-24-year-olds rather than older individuals, coming from Europe than any other region and having a mental disorder. In contrast to the other two clusters, the likelihood of being in the downward trending cluster is positively associated with having contacted the RESAMI network within the first month after arrival, which might indicate the potential of early intervention. It is also positively associated with older age and living in a group lodge. Asylum seekers are heterogeneous in terms of health care cost trajectories. Exploring these differences can help point to possible ways to improve the care and supporting services provided to asylum seekers. Our findings could indicate that early and patient-centered interventions might be well-suited to this aim

The prevalence and contextual correlates of non-communicable diseases among inter-provincial migrants and non-migrants in South Africa

BACKGROUND: The socioeconomic conditions of different environments manifest in varying experiences of illnesses. Even as migrants do transit across these different environments for various reasons, including settlement, they are bound to have peculiar experiences of diseases, which could be traced to lifestyle, gender, adaptation, and reactions to specific social, economic, psychological and climatic conditions. Paying attention to such unique scenarios, our study examines the prevalence and contextual correlates of non-communicable diseases among inter-provincial migrants and non-migrants in South Africa. METHODS: Data was from the National Income Dynamics Study (NIDS), waves 5 of 2017, which comprised of 28,055 respondents aged 15–64 years made up of 22,849 inter-provincial non-migrants and 5206 inter-provincial migrants. A composite dependent/outcome variable of non-communicable diseases (NCDs) was generated for the study and data analysis involved descriptive statistics, chi Square analysis and multilevel logistic regression analysis. RESULTS: More migrants (19.81%) than non-migrants (16.69%) reported prevalence of NCDs. With the exception of household size for migrants and smoking for non-migrants, the prevalence of NCDs showed significant differences in all the community, behavioral, and individual variables. The factors in the full model, which significantly increased odds of NCDs among the migrants and the non-migrants, were older populations, the non-Blacks, and those with higher education levels. On the one hand, being married, having a household with 4–6 persons, and being residents of urban areas significantly increased odds of NCDs among the migrant population. While on the other, living in coastal provinces, being a female, and belonging to the category of those who earn more than 10,000 Rands were significantly associated with increased odds of NCDs among the non-migrants. CONCLUSIONS: These findings, therefore, among other things underscore the need for increased education and awareness campaigns, especially among the older populations on the preventive and mitigative strategies for NCDs. In addition, changes in lifestyles with regard to smoking and physical exercises should be more emphasized in specific contextual situations for the migrant and non-migrant populations, as highlighted by the results of this study

Pediatric consultations and health status among children and adolescents in Switzerland

Background and status of (inter)national research: Regular pediatric consultations in primary health care are important to detect physical, psychological, cognitive, and motoric problems and development disorders in children. One immediate effect on children, who lack adequate preventive care, are unplanned hospital admissions (Cecil et a.l 2018). In addition, untreated health problems in childhood may have long lasting negative effects in adulthood. The Swiss society of pediatricians recommends 15 preventive health screenings from birth until the age of 14, with more frequent screenings in the first two years of life. Eight of these screenings are done on the parents’ initiative and reimbursed by the compulsory health insurance. Further three are mandatory school health screenings. International literature shows that the uptake of recommended preventive care is lower and not complete among some population groups and progressively declines with age (Schmidke et al. 2018 & Wood et al. 2012). Question and objective: The current data and knowledge about frequency of pediatric consultations, health status and associated factors among children and adolescents remains limited in Switzerland. The aim of our study is to shed light on this knowledge gap by addressing the following research questions using two different data sources: 1. Are there differences in health status between socioeconomic groups of school-aged children and adolescents? 2. Are there children between 0 and 6 years with fewer than recommended pediatric consultations, and are there differences between socioeconomic groups in this regard? Method or hypothesis: 1. To investigate differences in health status, we use data of children between 4 and 14-years from the school medical services in a big Swiss city and compare health status indicators between subgroups. 2.To investigate frequency of pediatric consultations, we draw claims data from children between 0 and 6 years from a large Swiss health insurer from 2012 to 2019 and analyze differences between subgroups. For both analyses we expect to find differences between socioeconomic groups such as children from native vs. from non-native parents, as well as regional differences. Results: This is a still ongoing project and final results will be available for the conference. Discussion: This study provides insight into the frequency and potential under-use of pediatric health consultations, what the health status of school-aged children are and if there are systematic differences between subgroups. Practical implications: Identifying differences in primary care consultations and health status at an early age could be key for establishing measures to improve the integration of vulnerable groups in the Swiss health care system. Appeal for practice (science and/or care) in one sentence: Identifying health differences and barriers to health care in early life might help to reduce life-long health inequalities

Determinants of inadequate use of pediatric health care services in Switzerland

Background and current state of (inter)national research: Exposure to unfavorable circumstances in childhood has been shown to have negative implications on physical, cognitive and psychological health in adulthood. Health problems in childhood should, therefore, be detected and treated at an early stage. Adequate pediatric health care, particularly preventive pediatric health screenings, play a key role in this context. In Switzerland, children and adolescents from 0-14 years are recommended to go through ten preventive health screenings. These screenings are performed at the parents’ initiative by the pediatrician or family doctor, except for two to three compulsory screenings at around the age of 6, 10 and 14 years, which are typically performed by the school medical services. However, little is known about the extent to which these screenings are performed and about potential barriers limiting the utilization of health care services. Research questions and objectives: The aim of our study is to evaluate children’s access to adequate health care in Switzerland. Specifically, we aim to identify potential inequalities in the use of pediatric health care between socioeconomic groups. Methods or hypothesis: We employ the following two strategies using a quantitative descriptive research design: - Using panel data from the school medical services in the city of Bern, we assess the extent of foregone pediatric health care in different socioeconomic groups by evaluating the incidence of untreated or inadequately treated health problems. - Using claims data from a large Swiss health insurance company, we assess the health care utilization patterns throughout childhood and the extent to which preventive health screenings are performed. Results/Discussion/Practical implications: The identification of groups at risk of inadequate health care and a better understanding of the underlying mechanisms can contribute to improving access to preventive health care services and, hence, to reducing health inequalities in childhood

Health technology assessment (HTA) : medicines for dementia due to Alzheimer's and Parkinson's disease

Background: Currently, no disease-modifying treatment is available for Alzheimer disease (AD) or Parkinson’s disease dementia (PD). Professional societies in Switzerland generally recommend symptomatic treatment using non-pharmacological therapies, and to add antidementia drugs when needed. However, scientific literature is inconclusive about the clinical benefit of antidementia drugs. A health technology assessment (HTA) was requested to compare the available evidence on Acetylcholinesterase (AChE) inhibitors and memantine for the symptomatic treatment of AD and PD. Objective: This HTA examines the efficacy, effectiveness, safety and cost-effectiveness of antidementia drugs compared to treatment without antidementia drugs or placebo in AD and PD and presents the health economic impact of a potential removal of these drugs from the list of pharmaceutical specialties in Switzerland. Furthermore, ethical, legal, social and organizational aspects are considered. Research questions: Is it efficacious, effective, safe and cost-effective 1) to treat mild to moderately severe AD patients with donepezil, galantamine or rivastigmine compared to not treating them with antidementia drugs? 2) to treat moderate to severe AD patients with memantine compared to not treating them with memantine? 3) to treat mild to moderately severe PD patients with rivastigmine compared to not treating them with rivastigmine? What is the budget impact of donepezil, rivastigmine, galantamine and memantine? Are there ethical, legal, social, or organizational issues related to antidementia drugs? Methods: We conducted systematic literature reviews of evidence on the efficacy, effectiveness and safety and of health economic evaluations regarding the treatment with antidementia drugs compared to treatment without antidementia drugs or placebo in AD and PD. For the clinical evidence meta-analysis was performed for outcomes with sufficient available evidence. The certainty of evidence for relevant outcomes was assessed by applying the GRADE approach. The cost-effectiveness and cost-utility were assessed by transferring the results from international studies to Switzerland, while a budget impact model was built for the Swiss setting. Furthermore, a targeted search for evidence on the ethical, legal, social and organizational aspects of antidementia drugs was conducted and findings were qualitatively summarized and discussed. Results: Regarding treatment with donepezil, galantamine or rivastigmine in mild to moderately severe AD patients, 24 RCTs were included in the analysis. 15 trials investigated donepezil, 6 trials rivastigmine and 3 trials galantamine. The certainty of evidence for the critical outcomes was judged as low to high, with evidence pointing at better results on cognition, function and global outcomes for AChE inhibitors compared to placebo in patients with mild to moderate dementia due to AD. Serious adverse events were higher for AChE inhibitors at one year of follow-up. Regarding treatment with memantine in moderate to severe AD patients, only two RCTs were identified. We found better results for memantine compared to placebo in patients with moderate to severe dementia due to AD on the domains of function and global outcomes with moderate certainty. With low certainty, there were no statistically significant differences with respect to mortality and serious adverse events. Regarding treatment with rivastigmine in mild to moderately severe PD patients, only one RCT was identified. This trial was rated with a high risk of bias and showed statistically significant better results on cognition, function, neuropsychiatric symptoms and global outcomes for rivastigmine compared to placebo in patients with mild to moderate dementia due to PD. Regarding safety, no statistically significant differences were identified. Based on a systematic review of health economic evaluations we retrieved 30 studies, 17 of which were considered transferable and were adapted for Switzerland. Seven studies investigated donepezil, galantamine or rivastigmine in mild to moderately severe AD patients and ten studies memantine in moderate to severe AD patients. Only one study was identified regarding rivastigmine in mild to moderately severe PD patients but was not considered transferable. Of the seven studies investigating donepezil, galantamine or rivastigmine in mild to moderately severe AD patients, four were regarding donepezil, three galantamine and no study was considered transferable regarding rivastigmine. Although these studies were considered transferable there is uncertainty related to their input parameters and assumptions. Regarding donepezil, galantamine or rivastigmine in mild to moderately severe AD patients, the results suggest that donepezil is not cost-effective over a time-horizon of up to 1.5 years. Over a time-horizon of 10 years, donepezil becomes dominant. Similarly, treatment with galantamine seems to be cost-effective over a time-horizon of 5 years. Regarding memantine in moderate to severe AD patients, four out of the seven adapted studies indicate memantine to be dominant. The other three studies indicate that memantine is cost-effective below a hypothetical threshold of CHF 100,000 per QALY. Regarding budget impact, a total removal of the AChE inhibitors or memantine would lead to additional costs ranging from CHF 1.01 million for galantamine to CHF 12.42 million for rivastigmine for the healthcare payers, attributable mostly to higher rates of institutionalization. In the extreme assumption that there is no treatment effect on institutionalization, stopping AD treatment with one of the AChE inhibitors or memantine would lead to savings that vary from CHF 0.80 million for galantamine to CHF 7.87 million for rivastigmine. Several ethical, legal, social, and organizational issues were identified concerning the use of antidementia drugs. A decision that would affect the use of these medications should respect patient autonomy and consider the consequences for the proxies. Another crucial ethical issue is the focus on cognitive and global outcomes in the trials that might leave out many much more relevant signs and symptoms, such as alterations of mood, anxiety, psychotic symptoms, and insomnia. From a legal perspective, a decision by the competent authorities must guarantee the protection of people with disabilities and elderly persons and consider the capacity of judgment. On the social domain, a high level of burden was noted in caregivers of dementia patients, and problems with access to antidementia drugs for some patients. A variety of organizational issues were discussed in the literature, from national dementia strategies to variations in antidementia treatment between different regions. Conclusion: Our results are consistent with previous findings from Cochrane reviews and other systematic reviews including meta analysis. Despite statistically significant differences for many outcomes investigated, we come to the conclusion that the clinical relevance of the differences between the treatment with and without antidementia drugs is questionable based on published cut-off values for Minimal Clinically Important Difference (MCID). There is also no strong evidence in support of a difference on the safety outcomes between the two groups. All antidementia drugs can be cost-effective except for rivastigmine when used for the treatment of PD due to lack of published transferrable health economic studies. The budget impact caused by total removal of the AChE inhibitors or memantine could range between additional costs of up to CHF 12.42 million to savings of up to CHF 7.87 million in 2021. This remarkable range is related to the uncertainty of evidence regarding the delay of need of being transferred to institutionalized care