Linguistic Isolation and Mortality in Older Mexican Americans: Findings from the Hispanic Established Populations Epidemiologic Studies of the Elderly.

Purpose: Limited English proficiency and increased language isolation are known to be associated with adverse health outcomes. It is not clear how neighborhood-level linguistic isolation may impact individual health and risk of death among Hispanic older adults. We examined the link between living in a linguistically isolated neighborhood and all-cause mortality among an older Mexican American cohort. Methods: Using a longitudinal sample of older Mexican Americans from the Hispanic Established Populations for the Epidemiologic Studies of the Elderly, we calculated the days from the baseline interview (1993-1994) until observed death through five waves of follow-up (until 2004-2005) using Cox regression. A linguistically isolated neighborhood was defined as a census tract with more than 30% of linguistically isolated households. Results: Our results showed that living in a neighborhood with more than 30% of linguistically isolated households predicted higher mortality (hazard ratio: 1.25; 95% confidence interval: 1.04-1.50), after adjusting for age, sex, nativity, years of education, marital status, self-reported health status, number of chronic conditions, ever smoked, ever drank, and other neighborhood-level contextual factors. Conclusion: Living in a neighborhood with a high proportion of linguistically isolated households predicted higher mortality among older Mexican Americans. Addressing the social capital shortage in linguistically isolated neighborhoods is one way to address health disparities in the United States.

Estimating the government public economic benefits attributed to investing in assisted reproductive technology: a South African case study.

Limited resources and high treatment costs are arguments often used in many public health systems in low- and middle-income countries to justify providing limited treatments for people with infertility. In this analysis, we apply a government public economic perspective to evaluate public subsidy for in-vitro fertilization (IVF) in South Africa. A fiscal model was developed that considered lifetime direct and indirect taxes paid and government transfers received by a child conceived by IVF. The model was constructed from public data sources and was adjusted for mortality, age-specific educational costs, participation in the informal economy, proportions of persons receiving social grants, and health costs. Based on current proportions of individuals receiving social grants and average payments, including education and health costs, we estimate each citizen will receive ZAR513,165 (USD35,587) in transfers over their lifetime. Based on inflated age-specific earnings, we estimate lifetime direct and indirect taxes paid per citizen of ZAR452,869 (USD31,405) and ZAR494,521 (USD34,294), respectively, which also includes adjustments for the proportions of persons participating in the informal economy. The lifetime net tax after deducting transfers was estimated to be ZAR434,225 (USD31,112) per person. Based on the average IVF investment cost needed to achieve one live birth, the fiscal return on investment (ROI) for the South African Government is 5.64. Varying the discount rate from 4% to 7%, the ROI ranged from 9.54 to 1.53, respectively. Positive economic benefits can emanate from public financing of IVF. The fiscal analytic framework described here can be a useful approach for health services to evaluate future public economic benefits.

Costs Analysis of Fibrin Sealant for Prevention of Anastomotic Leakage in Lower Colorectal Surgery.

INTRODUCTION: Postoperative anastomotic leaks remain a common and serious complication of colorectal surgeries and are a major cause of mortality and morbidity of these procedures. Anastomotic leaks (AL) have been extensively studied; however, there has been no significant reduction in their prevalence over time. In addition, there is a significant economic burden from AL attributed to the need for repeat surgery, radiologic intervention and lengthened hospital stay. We conducted a comparative cost analysis of patients undergoing colorectal surgery with anastomosis, with the application of fibrin sealant (FS) to the sutured anastomosis versus not treating the sutured anastomosis with FS. METHODS: The deterministic decision-tree model was populated with clinical data including operating room time, hospitalization days, occurrence of AL, need for revision surgery, blood products and radiologic interventions to treat the AL in lower colorectal surgery. A systematic literature review was conducted to identify appropriate studies with these variables. RESULTS: The average cost per case treated lower colorectal surgery with fibrin sealant glue 10 mL Tisseel® and those not treated with a fibrin sealant after suturing the anastomoses was €3233 and €4130, respectively, for resource expenses paid by the healthcare system. This would suggest potential savings of €897 per surgery, achieved through the application of FS to the sutured anastomosis for preventing AL following colorectal surgery. CONCLUSION: Application of FS to the sutured anastomosis in lower colorectal surgery resulted in a decrease in post-operative AL, and cost savings based on a reduction in hospitalization days, a reduction needing: revision surgery, radiologic intervention and blood products to treat AL.

Evidence-based Clinical Decision Support Systems for the prediction and detection of three disease states in critical care: A systematic literature review.

Background: Clinical decision support (CDS) systems have emerged as tools providing intelligent decision making to address challenges of critical care. CDS systems can be based on existing guidelines or best practices; and can also utilize machine learning to provide a diagnosis, recommendation, or therapy course. Methods: This research aimed to identify evidence-based study designs and outcome measures to determine the clinical effectiveness of clinical decision support systems in the detection and prediction of hemodynamic instability, respiratory distress, and infection within critical care settings. PubMed, ClinicalTrials.gov and Cochrane Database of Systematic Reviews were systematically searched to identify primary research published in English between 2013 and 2018. Studies conducted in the USA, Canada, UK, Germany and France with more than 10 participants per arm were included. Results: In studies on hemodynamic instability, the prediction and management of septic shock were the most researched topics followed by the early prediction of heart failure. For respiratory distress, the most popular topics were pneumonia detection and prediction followed by pulmonary embolisms. Given the importance of imaging and clinical notes, this area combined Machine Learning with image analysis and natural language processing. In studies on infection, the most researched areas were the detection, prediction, and management of sepsis, surgical site infections, as well as acute kidney injury. Overall, a variety of Machine Learning algorithms were utilized frequently, particularly support vector machines, boosting techniques, random forest classifiers and neural networks. Sensitivity, specificity, and ROC AUC were the most frequently reported performance measures. Conclusion: This review showed an increasing use of Machine Learning for CDS in all three areas. Large datasets are required for training these algorithms; making it imperative to appropriately address, challenges such as class imbalance, correct labelling of data and missing data. Recommendations are formulated for the development and successful adoption of CDS systems.

Estimating the Fiscal Costs of Osteoporosis in Korea Applying a Public Economic Perspective.

BACKGROUND: Osteoporosis and attributable fractures are disruptive health events that can cause short and long-term cost consequences for families, health service and government. In this fracture-based scenario analysis we evaluate the broader public economic consequences for the Korean government based on fractures that can occur at 3 different ages. METHODS: We developed a public economic modelling framework based on population averages in Korea for earnings, direct taxes, indirect taxes, disability payments, retirement, pension payments, and osteoporosis health costs. Applying a scenario analysis, we estimated the cumulative average per person fiscal consequences of osteoporotic fractures occurring at different ages 55, 65, and 75 compared to average non-fracture individuals of comparable ages to estimate resulting costs for government in relation to lost tax revenue, disability payments, pension costs, and healthcare costs. All costs are calculated between the ages of 50 to 80 in Korean Won (KRW) and discounted at 0.5%. RESULTS: From the scenarios explored, fractures occurring at age 55 are most costly for government with increased disability and pension payments of KRW 26,048,400 and KRW 41,094,206 per person, respectively, compared to the non-fracture population. A fracture can result in reduction in lifetime direct and indirect taxes resulting in KRW 53,648,886 lost tax revenue per person for government compared to general population. CONCLUSIONS: The fiscal consequences of osteoporotic fractures for government vary depending on the age at which they occur. Fiscal benefits for government are greater when fractures are prevented early due to the potential to prevent early retirement and keeping people in the labor force to the degree that is observed in non-fracture population.

Estimating the fiscal impact of rare diseases using a public economic framework: a case study applied to hereditary transthyretin-mediated (hATTR) amyloidosis.

BACKGROUND: A wide range of rare diseases can have fiscal impacts on government finances that extend beyond expected healthcare costs. Conditions preventing people from achieving national lifetime work averages will influence lifetime taxes paid and increase the likelihood of dependence on public income support. Consequently, interventions that influence projected lifetime work activity, morbidity and mortality can have positive and negative fiscal consequences for government. The aim of this study was to apply a public economic framework to a rare disease that takes into consideration a broad range of costs that are relevant to government in relation to transfers received and taxes paid. As a case study we constructed a simulation model to calculate the fiscal life course of an individual with hereditary transthyretin-mediated (hATTR) amyloidosis in The Netherlands. In this lethal disease different progressive disease scenarios occur, including polyneuropathy and/or cardiomyopathy. RESULTS: Due to progressive disability, health care resource use, and early death, hATTR amyloidosis with polyneuropathy receives more transfers from government compared to the general population. In a scenario where a patient is diagnoses with hATTR at age 45, an individual pays €180,812 less in lifetime taxes and receives incrementally €111,695 in transfers from the government, compared to a person without hATTR. Patients suffering from cardiomyopathy die after median 4 years. The health costs of this scenario are therefore lower than that of the other polyneuropathy-based scenarios. CONCLUSIONS: The fiscal analysis illustrates how health conditions influence not only health costs, but also the cross-sectorial public economic burden attributed to lost tax revenues and public disability allowances. Due to the progressive nature of hATTR amyloidosis used in this study, public costs including disability increase as the disease progresses with reduced lifetime taxes paid. The results indicate that halting disease progression early in the disease course would generate fiscal benefits beyond health benefits for patients. This analysis highlights the fiscal consequences of diseases and the need for broader perspectives applied to evaluate health conditions. Conventional cost-effectiveness framework used by many health technology assessment agencies have well-documented limitations in the field of rare diseases and fiscal modeling should be a complementary approach to consider.

Cost comparison of fibrin sealant versus tack screws for mesh fixation in laparoscopic repair of inguinal hernia.

OBJECTIVES: Inguinal hernias of the abdominal wall are common accounting for 75% of all hernia defects. They can be treated with laparoscopic surgery using a transabdominal preperitoneal (TAPP) approach. However, in surgery there is some contention on how to conclude the hernia repair, as there are alternatives of using fibrin sealant (FS) or tack screws for fixation of a mesh implant over the defect in the abdominal wall. In this study, we evaluate the economic consequences of using FS vs. tacks for mesh fixation in TAPP inguinal hernia repair for the UK from a hospital perspective. METHODS: The model was populated with clinical inputs (theater time, hospitalization days, occurrence of seroma, and neuralgia) from a previously conducted study comparing FS and tack screws in patients who had undergone TAPP hernia repair, and cost inputs from official government sources. One-way sensitivity analyses were also conducted to evaluate key drivers of cost analyses. RESULTS: The average cost per case treated with FS 2 mL Tisseel® and tack screws (ProTackTM) was £1,098 and £1,348, respectively, for resource expenses paid by the healthcare system. This would suggest a potential savings achieved of £249 per surgery using FS for mesh fixation. The sensitivity analysis showed that the key drivers for the cost difference were a variation in time to complete the surgery, followed by hospitalization days, and lower adverse outcomes such as seroma and neuralgia in the two cohorts. CONCLUSION: Using FS resulted in cost savings in hospitals based on reduced time to complete surgery, hospitalization time post-op, and lower adverse outcomes. Indirect cost savings were also found in favor of FS when comparing the two alternatives from a societal perspective, as patients were able to return to work more promptly in the FS group versus the tack screws group.