Social gradients in health and social care costs: analysis of linked electronic health records in Kent, UK

Objectives: Research into the socio-economic patterning of health and social care costs in the UK has so far been limited to examining only particular aspects of healthcare. In this study, we explore the social gradients in overall healthcare and social care costs, as well as in the disaggregated costs by cost category. Study design: We calculated the social gradient in health and social care costs by cost category using a linked electronic health record data set for Kent, a county in South East England. We performed a cross-sectional analysis on a sample of 323,401 residents in Kent older than 55 years to assess the impact of neighbourhood deprivation on mean annual per capita costs in 2016/17. Methods: Patient-level costs were estimated from activity data for the financial year 2016/17 and were extracted alongside key patient characteristics. Mean costs were calculated for each area deprivation quintile based on the index of multiple deprivation of the neighbourhood (lower super output area) in which the patient lived. Cost subcategories were analysed across primary care, secondary care, social care, community care and mental health. Results: The mean annual per capita cost increased with deprivation across each deprivation quintile, with a cost of £1205 in the most affluent quintile, compared with £1623 in the most deprived quintile, a 35% cost increase. Social gradients were found across all cost subcategories. Conclusions: Health inequalities in the population older than 55 years in Kent are associated with health and social care costs of £109m, equivalent to 15% of the estimated total expenditure in this age group. Such significant costs suggest that appropriate interventions to reduce socio-economic inequalities have the potential to substantially improve population health and, depending on how much investment they require, may even result in cost savings

Cost-Effectiveness of Genetic Testing for All Women Diagnosed with Breast Cancer in China

Unselected multigene testing for all women with breast cancer (BC) identifies more cancer susceptibility gene (CSG) carriers who can benefit from precision prevention compared with family history (FH)/clinical-criteria-based guidelines. Very little CSG testing is undertaken in middle-income countries such as China, and its cost-effectiveness remains unaddressed. We aimed to estimate cost-effectiveness and population impact of multigene testing for all Chinese BC patients. Data from 8085 unselected BC patients recruited to a Peking University Cancer Hospital study were used for microsimulation modeling, comparing three strategies in the Chinese setting: all BC women undergo BRCA1/BRCA2/PALB2 genetic testing, only BC women fulfilling FH/clinical criteria undergo BRCA testing, and no genetic testing. Prophylactic mastectomy and salpingo-oophorectomy would be adopted where appropriate. Societal and payer perspectives with a lifetime horizon along with sensitivity analyses were presented. Incremental cost-effectiveness ratio (ICER): incremental cost per quality-adjusted life-year (QALY) gained is compared to the USD 10,260/QALY (one-times GDP per capita) willingness-to-pay threshold. BC incidence, ovarian cancer (OC) incidence, and related deaths were also estimated. FH/clinical-criteria-based BRCA testing was ruled out on the principle of extensive dominance. Compared with no genetic testing, multigene testing for all BC patients had an ICER = USD 4506/QALY (societal perspective) and USD 7266/QALY (payer perspective), well below our threshold. Probabilistic sensitivity analysis showed unselected multigene testing remained cost-effective for 94.2%/86.6% of simulations from the societal and payer perspectives. One year's unselected multigene testing could prevent 7868 BC/OC cases and 5164 BC/OC deaths in China. Therefore, unselected multigene testing is extremely cost-effective and should be offered to all Chinese women with BC

EQ-5D-5L versus 3L: the impact on cost-effectiveness

Objectives To model the relationship between EQ-5D-3L and EQ-5D-5L and examine how differences impact on cost-effectiveness in case studies. Methods We used two datasets that included both EQ-5D-3L and EQ-5D-3L from the same respondents. The EuroQoL dataset (n=3551) included patients with different diseases and a healthy cohort. The National Databank (NDB) dataset included patients with rheumatoid disease (n=5205). We estimated a system of ordinal regressions in each dataset using copula models, to link responses to the 3L instrument to 5L and its tariff, and vice versa. Results were applied to nine cost-effectiveness studies. Results Best-fitting models differed between EuroQoL and NDB datasets in terms of the explanatory variables, copulas and coefficients. In both cases the coefficients of the covariates and latent factor between -3L and -5L were significantly different, indicating that the two instruments are not a uniform realignment of the response levels for most dimensions. In the case studies, moving from 3L to 5L caused a decrease of up to 87% in incremental QALYs gained from effective technologies in almost all cases. ICERs increased, often substantially. Conversely, one technology with a significant mortality gain saw increased incremental QALYs. Conclusion 5L shifts mean utility scores up the utility scale towards full health and compresses them into a smaller range, compared to -3L. Improvements in quality of life are valued less using 5L than with 3L. 3L and 5L can produce substantially different estimates of cost effectiveness. There is no simple proportional adjustment that can be made to reconcile these differences

Health-related quality of life associated with bullying and aggression: a cross-sectional study in English secondary schools.

Associations between adolescent health-related quality of life (HRQoL), bullying, and aggression are not well understood. We used baseline data from a large-cluster randomized school trial to study the relationship between HRQoL, bullying experience, and other demographic factors. Cross-sectional self-reported questionnaires collected pre-randomization from the on-going INCLUSIVE trial. The questionnaires were completed in the classroom. The Gatehouse Bullying Scale measured bullying victimization and the Edinburgh Study of Youth Transitions and Crime school misbehavior subscale (ESYTC) measured aggressive behaviors. HRQoL was assessed using the Child Health Utility 9 Dimensions (CHU-9D) and general quality of life using the Pediatric Quality of Life Inventory (PedsQL). Participants were a cohort of year 7 students (age 11-12 years) from 40 state secondary schools in England. Descriptive statistics for the CHU-9D and PedsQL were calculated using standard methods with tests for differences in median scores by sex assessed using quantile regression. Correlation between HRQoL measures was conducted using Spearman's rank correlation coefficients. Predictors of HRQoL were identified using univariate and multiple regressions. A total of 6667 students filled out the questionnaire. The CHU-9D was correlated with the PedsQL (0.63, p < 0.001). The multivariable regression results suggest that if students were bullied frequently and upset it resulted in a decrement in CHU-9D scores of (-0.108) and fall in PedsQL score of (-16.2). The impact of the antisocial/aggressive behavior on the ESYTC scale resulted in a utility decrement of -0.004 and fall of -.5 on the PedsQL. Adolescents' involvement in bullying and aggression is a strong correlate of HRQoL. These data have important implications for the potential cost-effectiveness of reducing bullying and aggression in schools

The Impact of Molar Proportion of Sodium Hydroxide and Water Amount on the Compressive Strength of Slag/Metakaolin (Waste Materials) Geopolymer Mortar

This investigation aimed to improve great early geopolymer mortar strengths under various parameters with various binder proportions to reduce the use of cement since the OPC production process leads to high emissions of CO2. Hence, to solve this problem, alternative materials were used. In this research, metakaolin (MK) and ground-granulated blast-furnace slag (GGBFS) waste materials were utilized and mixed together with the sodium hydroxide and alkaline activator sodium silicate (NaOH and Na2SiO3). The performance of the various mixtures was assessed via compressive strength testing based on British standards. The compressive strength was found to be highly affected by molar proportion and water amount. The optimum strength was 77.8 MPa for a mix design of 95% GGBFS +5% MK and a 2.5 mass proportion between Na2SiO3 and NaOH (12 Molar), together with a 0.2 water/binder proportion

An evaluation of the clinical and cost-effectiveness of alternative care locations for critically ill adult patients with acute traumatic brain injury.

BACKGROUND: For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre. METHODS: The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses. FINDINGS: Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000. CONCLUSIONS: For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced mortality, improvement in QOL and is cost-effective

Economic Evaluation of Population-Based BRCA1/BRCA2 Mutation Testing across Multiple Countries and Health Systems

Clinical criteria/Family history-based BRCA testing misses a large proportion of BRCA carriers who can benefit from screening/prevention. We estimate the cost-effectiveness of population-based BRCA testing in general population women across different countries/health systems. A Markov model comparing the lifetime costs and effects of BRCA1/BRCA2 testing all general population women ≥30 years compared with clinical criteria/FH-based testing. Separate analyses are undertaken for the UK/USA/Netherlands (high-income countries/HIC), China/Brazil (upper–middle income countries/UMIC) and India (low–middle income countries/LMIC) using both health system/payer and societal perspectives. BRCA carriers undergo appropriate screening/prevention interventions to reduce breast cancer (BC) and ovarian cancer (OC) risk. Outcomes include OC, BC, and additional heart disease deaths and incremental cost-effectiveness ratio (ICER)/quality-adjusted life year (QALY). Probabilistic/one-way sensitivity analyses evaluate model uncertainty. For the base case, from a societal perspective, we found that population-based BRCA testing is cost-saving in HIC (UK-ICER = $−5639/QALY; USA-ICER =$−4018/QALY; Netherlands-ICER = $−11,433/QALY), and it appears cost-effective in UMIC (China-ICER =$18,066/QALY; Brazil-ICER = $13,579/QALY), but it is not cost-effective in LMIC (India-ICER =$23,031/QALY). From a payer perspective, population-based BRCA testing is highly cost-effective in HIC (UK-ICER = $21,191/QALY, USA-ICER =$16,552/QALY, Netherlands-ICER = $25,215/QALY), and it is cost-effective in UMIC (China-ICER =$23,485/QALY, Brazil−ICER = $20,995/QALY), but it is not cost-effective in LMIC (India-ICER =$32,217/QALY). BRCA testing costs below $172/test (ICER =$19,685/QALY), which makes it cost-effective (from a societal perspective) for LMIC/India. Population-based BRCA testing can prevent an additional 2319 to 2666 BC and 327 to 449 OC cases per million women than the current clinical strategy. Findings suggest that population-based BRCA testing for countries evaluated is extremely cost-effective across HIC/UMIC health systems, is cost-saving for HIC health systems from a societal perspective, and can prevent tens of thousands more BC/OC cases

Evaluation of biochemical effects of diclofenac sodium in goats

ABSTRACT Diclofenac sodium is one of the most commonly using Non steroidal anti -inflammatory drugs (NSAID) worldwide in medical as well as veterinary practices. Use of anti-inflammatory drugs may affect liver function which may or may not be reversible in various livestock breeds. In this study effect of diclofenac sodium on Alanin transaminase (ALT), Aspartate transaminase (AST), Alkaline phosphatase (ALK), serum creatinine, serum uric acid, blood urea and total protein of liver and kidney of local dairy goats has been evaluated at Sindh Agriculture University, Tandojam since 2007. The drug was administered in six goats in two phases with adequate wash out period of 21 days between each phase. Dose rates, 2.5mg/kg (b.w) and 1 mg/kg (b.w), of diclofenac was administered in Phase-1 and Phase-2 respectively. For biochemical analysis the blood samples were collected at different intervals up to 96 hrs post drug administration. Significant change (p<0.05) with high dose was documented at 2, 3, 6, 12, 24 48 hrs in blood serum level of ALT, AST, ALK.PO4, creatinine, uric acid, and blood urea respectively. Where as highly significant change (p<0.01) was monitored at 6, 12, 24, 48 hrs in ALT and AST, ALK.PO4, and blood urea respectively. Significant increase in serum level of Alanin transaminase, Aspartate transaminase and Alkaline phosphatase was noticed at 12 and 24 hrs with low dose of diclofenac respectively. No significant change in serum creatinine and uric acid was observed but blood urea significantly increased at 48 hrs with low dose. No change was examined in total serum protein with both the doses. The effect of diclofenac was short-lived and most of the parameters went back to normal after 72hrs of drug administration