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2.

Public health impact and economic evaluation of vitamin D-fortified dairy products for fracture prevention in France.

Hiligsmann, M; Burlet, N; Fardellone, P; Al-Daghri, N; Reginster, J-Y
| Idioma(s): Inglés
The recommended intake of vitamin D-fortified dairy products can substantially decrease the burden of osteoporotic fractures and seems an economically beneficial strategy in the general French population aged over 60 years. INTRODUCTION: This study aims to assess the public health and economic impact of vitamin D-fortified dairy products in the general French population aged over 60 years. METHODS: We estimated the lifetime health impacts expressed in number of fractures prevented, life years gained, and quality-adjusted life years (QALY) gained of the recommended intake of dairy products in the general French population over 60 years for 1 year (2015). A validated microsimulation model was used to simulate three age cohorts for both women and men (60-69, 70-79, and >80 years). The incremental cost per QALY gained of vitamin D-fortified dairy products compared to the absence of appropriate intake was estimated in different populations, assuming the cost of two dairy products per day in base case. RESULTS: The total lifetime number of fractures decreased by 64,932 for the recommended intake of dairy products in the general population over 60 years, of which 46,472 and 18,460 occurred in women and men, respectively. In particular, 15,087 and 4413 hip fractures could be prevented in women and men. Vitamin D-fortified dairy products also resulted in 32,569 QALYs and 29,169 life years gained. The cost per QALY gained of appropriate dairy intake was estimated at €58,244 and fall below a threshold of €30,000 per QALY gained in women over 70 years and in men over 80 years. CONCLUSION: Vitamin D-fortified dairy products have the potential to substantially reduce the burden of osteoporotic fractures in France and seem an economically beneficial strategy, especially in the general population aged above 70 years.
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3.

Contamination from organochlorine pesticides (OCPs) in agricultural soils of Kuttanad agroecosystem in India and related potential health risk.

Sruthi, S N; Shyleshchandran, M S; Mathew, Sunil Paul; Ramasamy, E V
| Idioma(s): Inglés
The presence and distribution of a few organochlorine pesticides (OCPs) in the paddy fields of the Kuttanad agroecosystem (KAE) was examined in the present study. Kuttanad forms a part of the Vembanad wetland system which is a Ramsar site of international importance in the state of Kerala. This study, to the best of our knowledge, is the first report on the occurrence of OCP residues in KAE. Pesticide residue analysis was done with gas chromatograph (GC-ECD). Twenty-one soil samples were collected for the multiresidual analysis of OCPs. Sixteen OCP residues with a notable concentration were observed from the study area. α-BHC; ß-BHC; γ-BHC; δ-BHC; α-chlordane; γ-chlordane; heptachlor; 4,4-DDT; 4,4-DDE; 4,4-DDD; α-endosulfan; ß-endosulfan; aldrin; dieldrin; endrin aldehyde; and endrin ketone were the residues observed. The percentage-wise occurrence of OCP residues in the soil samples analysed (total of 63 samples from 21 sites, three samples per site) exhibits the following order: Σ BHC˃ Σ chlordane ˃ Σ dieldrin ˃ Σ aldrin ˃ Σ endrin˃ Σ heptachlor = endosulfan˃ Σ DDT. All pesticides detected from KAE are in the list of priority pollutants of US Environmental Protection Agency (USEPA). The distribution pattern of OCPs in the KAE soils revealed their origin as both historical and recent application of pesticides. Health risk assessment of OCP residues on human population was also conducted. The findings indicated that the concentrations of OCPs were within the permissible limits of USEPA, thus, the human population in the study area was safe.
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4.

Association of a Bundled-Payment Program With Cost and Outcomes in Full-Cycle Breast Cancer Care.

Wang, C Jason; Cheng, Skye H; Wu, Jen-You; Lin, Yi-Ping; Kao, Wen-Hsin; Lin, Chia-Li; Chen, Yin-Jou; Tsai, Shu-Ling; Kao, Feng-Yu; Huang, Andrew T
| Idioma(s): Inglés
Importance: Value-driven payment system reform is a potential tool for aligning economic incentives with the improvement of quality and efficiency of health care and containment of cost. Such a payment system has not been researched satisfactorily in full-cycle cancer care. Objective: To examine the association of outcomes and medical expenditures with a bundled-payment pay-for-performance program for breast cancer in Taiwan compared with a fee-for-service (FFS) program. Design, Setting, and Participants: Data were obtained from the Taiwan Cancer Database, National Health Insurance Claims Data, the National Death Registry, and the bundled-payment enrollment file. Women with newly diagnosed breast cancer and a documented first cancer treatment from January 1, 2004, to December 31, 2008, were selected from the Taiwan Cancer Database and followed up for 5 years, with the last follow-up data available on December 31, 2013. Patients in the bundled-payment program were matched at a ratio of 1:3 with control individuals in an FFS program using a propensity score method. The final sample of 17 940 patients included 4485 (25%) in the bundled-payment group and 13 455 (75%) in the FFS group. Main Outcomes and Measures: Rates of adherence to quality indicators, survival rates, and medical payments (excluding bonuses paid in the bundled-payment group). The Kaplan-Meier method was used to calculate 5-year overall and event-free survival rates by cancer stage, and the Cox proportional hazards regression model was used to examine the effect of the bundled-payment program on overall and event-free survival. Sensitivity analysis for bonus payments in the bundled-payment group was also performed. Results: The study population included 17 940 women (mean [SD] age, 52.2 [10.3] years). In the bundled-payment group, 1473 of 4215 patients (34.9%) with applicable quality indicators had full (100%) adherence to quality indicators compared with 3438 of 12 506 patients (27.5%) with applicable quality indicators in the FFS group (P < .001). The 5-year event-free survival rates for patients with stages 0 to III breast cancer were 84.48% for the bundled-payment group and 80.88% for the FFS group (P < .01). Although the 5-year medical payments of the bundled-payment group remained stable, the cumulative medical payments for the FFS group steadily increased from $16 000 to $19 230 and exceeded pay-for-performance bundled payments starting in 2008. Conclusions and Relevance: In Taiwan, compared with the regular FFS program, bundled payment may lead to better adherence to quality indicators, better outcomes, and more effective cost-control over time.
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5.

Bundling of Reimbursement for Inferior Vena Cava Filter Placement Resulted in Significantly Decreased Utilization between 2012 and 2014.

Glocker, Roan J; TerBush, Matthew J; Hill, Elaine L; Guido, Joseph J; Doyle, Adam; Ellis, Jennifer L; Raman, Kathleen; Morrow, Gary R; Stoner, Michael C
| Idioma(s): Inglés
BACKGROUND: On January 1, 2012, reimbursement for inferior vena cava filters (IVCFs) became bundled by the Centers for Medicare and Medicaid Services. This resulted in ICVF placement (CPT code 37191) now yielding 4.71 relative value units (RVUs), a decrease from 15.6 RVUs for placement and associated procedures (CPT codes 37620, 36010, 75825-26, 75940-26). Our hypothesis was that IVCF utilization would decrease in response to this change as other procedures had done once they had become bundled. METHODS: Including data from 2010 to 2011 (before bundling) and 2012 to 2014 (after bundling), we utilized 5% inpatient, outpatient, and carrier files of Medicare limited data sets and analyzed IVCF utilization before and after bundling across specialty types, controlling for total diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) (ICD-9 codes 453.xx and 415.xx, respectively) and placement location. RESULTS: In 2010 and 2011, the rates/10,000 DVT/PE diagnoses were 918 and 1,052, respectively (average 985). In 2012, 2013, and 2014, rates were 987, 877, and 605, respectively (average 823). Comparing each year individually, there is a significant difference (P < 0.0001) with 2012, 2013, and 2014 having lower rates of ICVF utilization. Comparing averages in the 2010-2011 and 2012-2014 groups, there is also a significant decrease in utilization after bundling (P < 0.0001). CONCLUSIONS: Following the bundling of reimbursement for IVCF placement, procedural utilization decreased significantly. More data from subsequent years will be needed to show if this decrease utilization continues to persist.
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6.

Surgery for degenerative cervical myelopathy: a patient-centered quality of life and health economic evaluation.

Witiw, Christopher D; Tetreault, Lindsay A; Smieliauskas, Fabrice; Kopjar, Branko; Massicotte, Eric M; Fehlings, Michael G
| Idioma(s): Inglés
BACKGROUND CONTEXT: Degenerative cervical myelopathy (DCM) represents the most common cause of non-traumatic spinal cord impairment in adults. Surgery has been shown to improve neurologic symptoms and functional status, but it is costly. As sustainability concerns in the field of health care rise, the value of care has come to the forefront of policy decision-making. Evidence for both health-related quality of life outcomes and financial expenditures is needed to inform resource allocation decisions. PURPOSE: This study aimed to estimate the lifetime incremental cost-utility of surgical treatment for DCM. DESIGN/SETTING: This is a prospective observational cohort study at a Canadian tertiary care facility. PATIENT SAMPLE: We recruited all patients undergoing surgery for DCM at a single center between 2005 and 2011 who were enrolled in either the AOSpine Cervical Spondylotic Myelopathy (CSM)-North America study or the AOSpine CSM-International study. OUTCOME MEASURES: Health utility was measured at baseline and at 6, 12, and 24 months following surgery using the Short Form-6D (SF-6D) health utility score. Resource expenditures were calculated on an individual level, from the hospital payer perspective over the 24-month follow-up period. All costs were obtained from a micro-cost database maintained by the institutional finance department and reported in Canadian dollars, inflated to January 2015 values. METHODS: Quality-adjusted life year (QALY) gains for the study period were determined using an area under the curve calculation with a linear interpolation estimate. Lifetime incremental cost-to-utility ratios (ICUR) for surgery were estimated using a Markov state transition model. Structural uncertainty arising from lifetime extrapolation and the single-arm cohort design of the study were accounted for by constructing two models. The first included a highly conservative assumption that individuals undergoing nonoperative management would not experience any lifetime neurologic decline. This constraint was relaxed in the second model to permit more general parameters based on the established natural history. Deterministic and probabilistic sensitivity analyses were employed to account for parameter uncertainty. All QALY gains and costs were discounted at a base of 3% per annum. Statistical significance was set at the .05 level. RESULTS: The analysis included 171 patients; follow-up was 96.5%. Mean age was 58.2±12.0 years and baseline health utility was 0.56±0.14. Mean QALY gained over the 24-month study period was 0.139 (95% confidence interval: 0.109-0.170, p<.001) and the mean 2-year cost of treatment was $19,217.82±12,404.23. Cost associated with the operation comprised 65.7% of the total. The remainder was apportioned over presurgical preparation and postsurgical recovery. Three patients required a reoperation over the 2-year follow-up period. The costs of revision surgery represented 1.85% of the total costs. Using the conservative model structure, the estimated lifetime ICUR of surgical intervention was $20,547.84/QALY gained, with 94.7% of estimates falling within the World Health Organization definition of "very cost-effective" ($54,000 CAD). Using the more general model structure, the estimated lifetime ICUR of surgical intervention was $11,496.02/QALY gained, with 97.9% of estimates meeting the criteria to be considered "very cost-effective." CONCLUSIONS: Surgery for DCM is associated with a significant quality of life improvement. The intervention is cost-effective and, from the perspective of the hospital payer, should be supported.
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8.

Metal bioaccumulation in two edible cephalopods in the Gulf of Gabes, South-Eastern Tunisia: environmental and human health risk assessment.

Rabaoui, Lotfi; El Zrelli, Radhouan; Balti, Rafik; Mansour, Lamjed; Courjault-Radé, Pierre; Daghbouj, Nabil; Tlig-Zouari, Sabiha
| Idioma(s): Inglés
Samples of Octopus vulgaris and Sepia officinalis were collected from four areas in the Gulf of Gabes, south-eastern Tunisia, and their edible tissues (mantle and arms) were analyzed for cadmium, copper, mercury, and zinc. While the concentrations of metals showed significant differences between the sampling sites, no differences were revealed between the tissues of the two species. The spatial distribution of metals analyzed showed similar pattern for both tissues of the two species, with the highest concentrations found in the central area of Gabes Gulf, and the lowest in the northern and/or southern areas. From a human health risk point of view, the highest values of estimated daily intake, target hazard quotient, and hazard index were found in the central area of Gabes Gulf. Although the results of these indices were, in general, not alarming, the health risks posed by the consumption of cephalopods on local consumers cannot be excluded.
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9.

The Economic Impact of Levothyroxine Dose Adjustments: the CONTROL HE Study.

Ernst, Frank R; Barr, Peri; Elmor, Riad; Sandulli, Walter; Thevathasan, Lionel; Sterman, Arnold B; Goldenberg, Jessica; Vora, Kevin
| Idioma(s): Inglés
BACKGROUND: In general, hypothyroidism can be adequately treated with a consistent daily dose of levothyroxine. However, the need for levothyroxine dose adjustments is frequent in clinical practice. The extent to which levothyroxine dose adjustments increase the utilization of healthcare resources has not previously been described in the clinical literature. OBJECTIVE: The primary objective of our study was to measure the effect of levothyroxine dose adjustments in terms of their utilization of healthcare resources including direct and indirect costs. A secondary goal was to identify any differences in patient characteristics that may be responsible for levothyroxine dose adjustments. METHODS: A retrospective medical chart review was conducted among patients of selected healthcare providers in the USA. Patients who were recently started on levothyroxine therapy (<6 months) were excluded to avoid situations that were more likely attributable to treatment initiation than inadequate therapeutic effect. Trained nurses extracted data from patient charts and electronic medical record systems for review. We analyzed the cost of resources consumed by the frequency of levothyroxine dose changes over 24 months: 0 dose changes (no dose adjustment group); one dose change, two dose changes, three or more dose changes (≥1 dose adjustment group). RESULTS: The study included 454 patients. Overall estimated resource utilization was higher per patient in the ≥1 dose adjustment group (US$5824) vs. the no dose adjustment group (US$3166) during the 24-month study period. When direct and indirect costs were combined, overall costs of care were greatest in patients requiring three or more dose adjustments (US$8220/patient). Patients in this cohort incurred 2.5-fold greater total costs compared with patients requiring no dose adjustments (US$8220 vs. US$3166). Among the 58 patients in the group requiring three or more dose adjustments, mean direct medical costs were significantly higher than in the patients requiring no dose adjustments (US$6387 vs. US$2182). Patients with at least one dose adjustment experienced a 40.3% increase in lost productivity vs. patients who had no dose adjustments (US$1381 vs. US$984). Loss of productivity was highest among patients with three or more levothyroxine dose adjustments. Among this cohort, there was an 86.4% increase in lost productivity vs. patients who had no levothyroxine dose adjustments (US$1833 vs. US$984). CONCLUSIONS: Patients experiencing multiple levothyroxine dose adjustments were shown to consume more healthcare resources, resulting in higher costs than those who required no dose adjustments. Each care episode contributed to lost time and wages with total estimated lost productivity escalating with increasing levothyroxine dose adjustments over a 24-month period.
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10.

Australia's economic transition, unemployment, suicide and mental health needs.

Myles, Nicholas; Large, Matthew; Myles, Hannah; Adams, Robert; Liu, Dennis; Galletly, Cherrie
| Idioma(s): Inglés
OBJECTIVE: There have been substantial changes in workforce and employment patterns in Australia over the past 50 years as a result of economic globalisation. This has resulted in substantial reduction in employment in the manufacturing industry often with large-scale job losses in concentrated sectors and communities. Large-scale job loss events receive significant community attention. To what extent these mass unemployment events contribute to increased psychological distress, mental illness and suicide in affected individuals warrants further consideration. METHODS: Here we undertake a narrative review of published job loss literature. We discuss the impact that large-scale job loss events in the manufacturing sector may have on population mental health, with particular reference to contemporary trends in the Australian economy. We also provide a commentary on the expected outcomes of future job loss events in this context and the implications for Australian public mental health care services. RESULTS AND CONCLUSION: Job loss due to plant closure results in a doubling of psychological distress that peaks 9 months following the unemployment event. The link between job loss and increased rates of mental illness and suicide is less clear. The threat of impending job loss and the social context in which job loss occurs has a significant bearing on psychological outcomes. The implications for Australian public mental health services are discussed.
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