RESUMO
OBJECTIVE: Postoperative delirium (POD) has a high prevalence among vascular surgery patients, increasing morbidity, mortality, and length of stay. We prospectively studied preoperative risk factors for delirium that can be assessed by the surgical team to identify high-risk patients and assessed its impact on hospital costs. METHODS: There were 173 elective vascular surgery patients assessed preoperatively for cognitive function using the Montreal Cognitive Assessment (MoCA) and the Confusion Assessment Method for POD, which was verified by chart and clinical review. Demographic information, medications, and a history of substance abuse, psychiatric disorders, and previous delirium were prospectively recorded. An accompanying retrospective chart review of an additional 434 (elective and emergency) vascular surgery patients provided supplemental cost information related to sitter use and prolonged hospitalization secondary to three factors: delirium alone, dementia alone, and delirium and dementia. RESULTS: Prospective screening of 173 patients (73.4% male; age, 69.9 ± 10.97 years) identified that 119 (68.8%) had MoCA scores <24, indicating cognitive impairment, with 7.5% having severe impairment (dementia). Patients who underwent amputation had significantly (P < .000) lower MoCA scores (17 of 30) compared with open surgery and endovascular aneurysm repair patients (23.7 of 30). The incidence of delirium was 11.6% in the elective cohort. Regression analysis identified predictors of delirium to be type of surgical procedure, including lower limb amputation (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.41-71.54; P < .000) and open aortic repair (OR, 5.33; 95% CI, 1.91-14.89; P < .000); cognitive variables (dementia: OR, 5.63; 95% CI, 2.08-15.01; P < .001); MoCA scores ≤15, indicating moderate to severe impairment (OR, 6.13; 95% CI, 1.56-24.02; P = .02); and previous delirium (OR, 2.98; 95% CI, 1.11-7.96; P = .03). Retrospective review (N = 434) identified differences in sitter needs for patients with both delirium and dementia (mean, 13.6 days), delirium alone (mean, 3.9 days), or dementia alone (mean, <1 day [17.7 hours]). Fifteen patients required >200 hours (8.3 days), accounting for 69.7% of sitter costs for the surgical unit; 43.7% of costs were accounted for by patients with pre-existing cognitive impairment. CONCLUSIONS: POD is predicted by type of vascular surgery procedure, impaired cognition (MoCA), and previous delirium. Costs and morbidity related to delirium are greatest for those with impaired cognitive burden. Preoperative MoCA screening can identify those at highest risk, allowing procedure modification and informed care.
Assuntos
Transtornos Cognitivos/complicações , Transtornos Cognitivos/economia , Cognição , Delírio/economia , Delírio/etiologia , Custos Hospitalares , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/economia , Idoso , Idoso de 80 Anos ou mais , Transtornos Cognitivos/psicologia , Transtornos Cognitivos/terapia , Delírio/psicologia , Delírio/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
As patients lose cognitive function, they lose autonomy and increasingly use fiscal, social, and medical resources. Healthcare costs for Americans older than age 65 years are three to five times higher than for the remaining population, and dementia is the third most costly disease in the United States. Interventions that promote successful aging can help patients and reduce the financial, workforce, and treatment resource burdens on the population. Because a relationship between physical activity, particularly aerobic exercise, and cognitive decline has been established, physical activity interventions may prove practical, affordable, and effective. Attention to empiric research and knowledge of evidence-based strategies for prescribing physical activity are critical for PAs to embrace.
Assuntos
Transtornos Cognitivos/prevenção & controle , Envelhecimento Cognitivo , Terapia por Exercício/métodos , Exercício Físico/psicologia , Idoso , Idoso de 80 Anos ou mais , Cognição , Transtornos Cognitivos/economia , Demência/economia , Demência/prevenção & controle , Feminino , Humanos , Masculino , Estados UnidosRESUMO
BACKGROUND: Although it is well recognized that people with multiple sclerosis (MS) may experience impairments in addition to limited mobility, there has been little effort to study their relative importance to patients with the condition. The objective of this study was to assess patient preferences for addressing various MS symptoms. METHODS: This study was conducted at Tufts Medical Center, Boston, Massachusetts. We developed a national online survey of MS patients and neurologists to estimate the value each group places on treating specific MS symptoms. Each respondent was presented with two randomly selected scenarios with different symptoms and treatments. MS patients were asked about their own preferences, whereas neurologists were asked to consider what a patient of theirs would do or think in each scenario. We used a bidding game approach to elicit respondents' willingness to pay (WTP) for the treatments. RESULTS: To treat mobility alone, WTP for MS patients averaged US$410-US$520 per month, depending on the scenario. For paired symptoms, MS patients would pay most to treat mobility and upper limb function (US$525/month) or mobility and cognition (US$514/month), somewhat less to treat mobility and eyesight (US$445/month), and least to treat mobility and fatigue (US$371/month). Patient WTP values increased with income and education. Neurologists believed their patients would be willing to pay US$216-US$249 per month to treat mobility alone, depending on the scenario. For paired symptoms, neurologists believed patients would pay most to treat mobility and fatigue (US$263/month) and least to treat mobility and upper limb function (US$177/month). CONCLUSION: Our findings suggest MS patients may value one outcome (e.g., improved arm and hand coordination) over another (e.g., less fatigue). Further, MS patients and neurologists may rank the importance of treating various symptoms differently. Given this potential mismatch, it is crucial for MS patients and their clinicians to discuss treatment priorities that take into account patient preferences.
Assuntos
Financiamento Pessoal/estatística & dados numéricos , Esclerose Múltipla/terapia , Preferência do Paciente/estatística & dados numéricos , Adolescente , Adulto , Idoso , Transtornos Cognitivos/economia , Transtornos Cognitivos/etiologia , Transtornos Cognitivos/terapia , Escolaridade , Fadiga/economia , Fadiga/etiologia , Fadiga/terapia , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Esclerose Múltipla/economia , Esclerose Múltipla/fisiopatologia , Preferência do Paciente/economia , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Few longitudinal studies have analyzed how socioeconomic status (SES) influences both depressive and cognitive development over an individual's life course. This study investigates the change trajectories of both depressive symptomatology and general cognitive status, as well as their associations over time, focusing on the effects of mid-life SES. METHODS: Data were obtained from the Taiwan Longitudinal Study on Aging (1993-2007), a nationally representative cohort study of older adults in Taiwan. The short form of the Center of Epidemiological Studies-Depression (CES-D) scale that measures depressive symptomatology in two domains (negative affect and lack of positive affect) was used. General cognitive status was assessed using the brief Short Portable Mental Status Questionnaire scale. Assessments of the subjects' mid-life SES included measurement of the participant's education and occupation. Analyses were conducted by the parallel latent growth curve modeling. RESULTS: The participants' initial levels of depressive symptomatology and general cognitive status were significantly and negatively correlated; furthermore, any changes in these two outcomes were also correlated over time. The initial assessment of general cognitive status significantly contributed to any advancement towards more severe depressive symptomatology over time, particularly when this occurred in a negative manner. Furthermore, a mid-life SES advantage resulted in a significant reduction in late-life depressive symptomatology and also produced a slower decline in general cognitive status during later life. In contrast, lower mid-life SES exacerbated depressive symptomatology during old age, both at the initial assessment and in terms of the change over time. In addition, female gender was significantly associated with lower general cognitive status and more severe depressive symptomatology in negative affect. CONCLUSIONS: These findings suggest a complex and longitudinal association between depressive symptomatology and general cognitive status in later life and this complicated relationship seems to be affected by mid-life SES over time.
Assuntos
Transtornos Cognitivos/economia , Transtornos Cognitivos/psicologia , Depressão/economia , Depressão/psicologia , Relações Interpessoais , Classe Social , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Envelhecimento/psicologia , Cognição/fisiologia , Transtornos Cognitivos/epidemiologia , Envelhecimento Cognitivo/fisiologia , Envelhecimento Cognitivo/psicologia , Estudos de Coortes , Depressão/epidemiologia , Feminino , Seguimentos , Humanos , Aprendizagem/fisiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Taiwan/epidemiologia , Fatores de TempoRESUMO
OBJECTIVES: Dementia draws on a variety of public and private resources. There is increasing pressure to define the cost components in this area to improve resource allocation and accountability. The aim of this study was to characterize frailty in a group of cognitively impaired community-dwelling elders and evaluate its relationship with cost and resource utilization. METHODS: We assessed a cross-sectional, convenient sample of 115 cognitively impaired patients of age >55 years who attended the National Memory Clinic in St James' University Hospital, a Trinity College-affiliated hospital in Dublin, Ireland. Participants had a clinical diagnosis of possible Alzheimer's disease or mild cognitive impairment. Frailty was measured using the biological syndrome model. Formal health and social care costs and daily informal caregiving costs were collected and the total costs of care estimated by applying the appropriate unit cost estimate for each resource activity. Stepwise regression models were constructed to establish the factors associated with increased care costs. RESULTS: Patient dependence, frailty and number of co-morbid illnesses explained 43.3% of the variance in observed daily informal care costs in dementia and cognitively impaired patients. Dependence was the sole factor retained in an optimal model explaining 19% of the variance in formal health and social care costs. CONCLUSION: Frailty retained a strong association with daily informal care costs even in the context of other known risk factors for increasing care costs. Interventions that reduce frailty as well as patient dependence on others may be associated with cost savings.
Assuntos
Transtornos Cognitivos/economia , Idoso Fragilizado/estatística & dados numéricos , Custos de Cuidados de Saúde , Idoso , Análise de Variância , Cuidadores/economia , Efeitos Psicossociais da Doença , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Irlanda do NorteRESUMO
BACKGROUND: Major depressive disorder is one of the most common and disabling mental health disorders and is associated with substantial costs in terms of direct health care utilization and workplace productivity. Cognitive dysfunction, which alone substantially increases health care costs, is commonly associated with major depressive disorder. However, the health care costs of cognitive dysfunction in the context of depressive disorder are unknown. Recovery from mood symptoms is not always associated with resolution of cognitive dysfunction. Thus, cognitive dysfunction may contribute to health care burden even with successful antidepressant therapy. OBJECTIVE: To compare health care utilization and costs for patients with a depressive disorder with and without cognitive dysfunction, at 3 and 6 months after initiation of antidepressant medication. METHODS: This was an observational study, combining a cross-sectional patient survey, administered during a telephone interview, with health care claims data from a large, geographically diverse U.S. health plan. Included patients had at least 1 pharmacy claim for an antidepressant medication between August 1 and September 30, 2012, and no claim for any antidepressant during the 6 months prior to the index date. In addition to other criteria assessed in the claims data, patients confirmed a diagnosis of depression or major depressive disorder and the absence of any exclusionary neurological diagnoses possibly associated with cognitive impairment. Eligible patients were administered validated cognitive function assessments of verbal episodic memory (Hopkins Verbal Learning Test-Revised, Delayed and Total); attention (Digit Span Forward Maximum Sequence Length); working memory (Digit Span Backward Maximum Sequence Length); and executive function (D-KEFS-Letter Fluency Test). Based on comparison of scores with normative data, patients were assigned to cognitive dysfunction or cognitive normal cohorts. All-cause (all diagnoses) and depressive disorder-related health care utilization and costs (all from a payer perspective) were assessed 6 months prior (baseline) to antidepressant initiation and 3 months and 6 months after (follow-up) initiation of antidepressant medication. Health care utilization and costs included ambulatory (office and hospital outpatient), emergency room, inpatient hospital, pharmacy, other medical (e.g., laboratory and diagnostics), and total (all categories combined). All-cause and depressive disorder-related total costs during the 3- and 6-month follow-up periods were modeled with generalized linear modeling with gamma distribution and log link, while adjusting for potential confounders (age, race, gender, education, employment, and comorbidities). RESULTS: Of the 13,537 patients who were mailed an invitation, 824 (6%) were eligible and agreed to participate. Of these, 563 patients provided informed consent, completed the interview, maintained eligibility, and were included in the 3-month calculations. Among these, 255 (45%) were classified as having cognitive dysfunction. Mean patient age was 41.3 (± 12.5) years; 80% were female. Most patients were white and employed. More patients in the cognitive normal cohort were white (P less than 0.001) and employed full time (P = 0.029), had higher education attainment (P less than 0.001), and had fewer comorbidities (P = 0.007) than those in the cognitive dysfunction cohort. Over the first 3 months, patients with cognitive dysfunction had higher adjusted all-cause costs ($3,309 vs. $2,157, P = 0.002) and higher adjusted depressive disorder-related costs ($718 vs. $406, P less than 0.001) than patients without cognitive dysfunction. At 6 months, data from 4 patients were removed from the analysis because of exclusionary diagnoses. Over 6 months, patients with cognitive dysfunction had higher adjusted all-cause costs ($4,793) than patients without cognitive dysfunction ($3,683, P = 0.034). Over 6 months, depressive disorder-related costs did not significantly differ between patients with ($771) and without cognitive dysfunction ($594, P = 0.071). The main drivers of all-cause costs were office visits, outpatient hospital visits, and inpatient costs, and the main driver of depressive disorder-related costs was inpatient costs. CONCLUSIONS: Cognitive dysfunction was associated with higher adjusted all-cause and depressive disorder-related costs 3 months after initiation of an antidepressant medication. This difference persisted for all-cause costs through 6 months. Identification and treatment of cognitive dysfunction in patients with depressive disorder might reduce health care costs.
Assuntos
Antidepressivos/uso terapêutico , Cognição/efeitos dos fármacos , Transtorno Depressivo Maior/tratamento farmacológico , Custos de Cuidados de Saúde , Adulto , Antidepressivos/administração & dosagem , Antidepressivos/economia , Transtornos Cognitivos/tratamento farmacológico , Transtornos Cognitivos/economia , Estudos Transversais , Transtorno Depressivo Maior/economia , Transtorno Depressivo Maior/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: Post-stroke cognitive impairment (PSCI) lessens quality of life, restricts the rehabilitation of stroke, and increases the social and economic burden stroke imposes on patients and their families. Therefore effective treatment is of paramount importance. However, the treatment of PSCI is very limited. The primary aim of this protocol is to propose a lower cost and more effective therapy, and to confirm the long-term effectiveness of a therapeutic regimen of Traditional Chinese Medicine (TCM) rehabilitation for PSCI. METHODS/DESIGN: A prospective, multicenter, large sample, randomized controlled trial will be conducted. A total of 416 eligible patients will be recruited from seven inpatient and outpatient stroke rehabilitation units and randomly allocated into a therapeutic regimen of TCM rehabilitation group or cognitive training (CT) control group. The intervention period of both groups will last 12 weeks (30 minutes per day, five days per week). Primary and secondary outcomes will be measured at baseline, 12 weeks (at the end of the intervention), and 36 weeks (after the 24-week follow-up period). DISCUSSION: This protocol presents an objective design of a multicenter, large sample, randomized controlled trial that aims to put forward a lower cost and more effective therapy, and confirm the long-term effectiveness of a therapeutic regimen of TCM rehabilitation for PSCI through subjective and objective assessments, as well as highlight its economic advantages. TRIAL REGISTRATION: This trial was registered with the Chinese Clinical Trial Registry (identifier: ChiCTR-TRC-14004872 ) on 23 June 2014.
Assuntos
Terapia por Acupuntura , Transtornos Cognitivos/reabilitação , Cognição , Terapia Cognitivo-Comportamental , Reabilitação do Acidente Vascular Cerebral , Terapia por Acupuntura/efeitos adversos , Terapia por Acupuntura/economia , China , Protocolos Clínicos , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/economia , Transtornos Cognitivos/psicologia , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Estudos Prospectivos , Projetos de Pesquisa , Método Simples-Cego , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/psicologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The influence of the sociodemographic context of one's environment on cognitive ageing is not well understood. METHODS: We examined differences in cognitive trajectories according to the racial/ethnic characteristics of the residential environment. On the basis of 63â 996 person-years of data from a nationally representative cohort of 6150 adults over the age of 50â years from the Health and Retirement Study, we used multivariate linear mixed models to determine the effect of neighbourhood racial/ethnic composition and county-level segregation on cognitive function and cognitive decline over a 10-year period. RESULTS: In models adjusting for individual demographic and health characteristics, Hispanic composition had a significant positive association with cognitive function (standardised ß=0.136, p<0.05) and moderate evidence of an association with greater cognitive decline (standardised ß=-0.014, p=0.09). Greater Hispanic-white segregation was associated with statistically significant higher cognitive function at baseline (standardised ß=0.099, p<0.001) and greater cognitive decline (standardised ß=-0.011, p<0.01). For a 20 percentage-point increase in Hispanic composition and segregation, the observed associations implied 1 and 1.25 additional years of cognitive ageing over 10â years, respectively. These effects did not differ by individual race/ethnicity and were not explained by neighbourhood socioeconomic status or neighbourhood selection. Black composition and black-white segregation did not have a significant influence on cognitive ageing. DISCUSSION: This study demonstrates disparities in the progression of cognitive ageing according to racial/ethnic characteristics of the neighbourhood environment.
Assuntos
Envelhecimento , Transtornos Cognitivos/etnologia , Disparidades nos Níveis de Saúde , Racismo/psicologia , Características de Residência/classificação , Meio Social , Negro ou Afro-Americano/psicologia , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Censos , Transtornos Cognitivos/economia , Transtornos Cognitivos/etiologia , Feminino , Comportamentos Relacionados com a Saúde , Inquéritos Epidemiológicos , Hispânico ou Latino/psicologia , Hispânico ou Latino/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Racismo/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Fatores Socioeconômicos , Estados Unidos/epidemiologia , População Branca/psicologia , População Branca/estatística & dados numéricosRESUMO
BACKGROUND: The assessment of neurodevelopmental effects in children associated with prenatal methylmercury exposure, from contaminated fish and seafood in the maternal diet, has recently been strengthened by adjustment for the negative confounding resulting from co-exposure to beneficial polyunsaturated fatty acids (PUFAs). OBJECTIVES: We aimed to determine the cost-effectiveness of a periconceptional screening program of blood mercury concentration for women planning to become pregnant in Ontario, Canada. Fish intake recommendations would be provided for those found to have blood mercury levels above the intervention threshold. METHODS: Analysis was conducted using a combined decision tree/Markov model to compare the proposed screening intervention with standard care from a societal perspective over a lifetime horizon. We used the national blood mercury distributions of women 20-49 years of age reported in the Canadian Health Measures Survey from 2009 through 2011 to determine the cognitive deficits associated with prenatal methylmercury exposure for successful planned pregnancies. Outcomes modeled included the loss in quality of life and the remedial education costs. Value of information analysis was conducted to assess the underlying uncertainty around the model results and to identify which parameters contribute most to this uncertainty. RESULTS: The incremental cost per quality-adjusted life year (QALY) gained for the proposed screening intervention was estimated to be Can$18,051, and the expected value for a willingness to pay of Can$50,000/QALY to be Can$0.61. CONCLUSIONS: Our findings suggest that the proposed periconceptional blood mercury screening program for women planning a pregnancy would be highly cost-effective from a societal perspective. The results of a value of information analysis confirm the robustness of the study's conclusions.
Assuntos
Programas de Rastreamento/economia , Exposição Materna/economia , Compostos de Metilmercúrio/sangue , Efeitos Tardios da Exposição Pré-Natal/economia , Adulto , Transtornos Cognitivos/economia , Análise Custo-Benefício , Feminino , Humanos , Cadeias de Markov , Troca Materno-Fetal , Compostos de Metilmercúrio/toxicidade , Pessoa de Meia-Idade , Ontário , Gravidez , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Ensino de Recuperação/economia , IncertezaRESUMO
BACKGROUND: Objective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild cognitive impairment (MCI), newly discovered dementia, and prevalent dementia. METHODS: Subjects were a subset of the Mayo Clinic Study of Aging stratified-random sampling of Olmsted County, MN, residents aged 70 to 89 years. A neurologist reviewed provider-linked medical records to identify prevalent dementia (review date = index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly discovered dementia (assessment date = index). Costs for medical services/procedures 1-year pre-index (excluding indirect and long-term care costs) were estimated using line-item provider-linked administrative data. We estimated contributions of care-delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between-category cost differences. RESULTS: Annual mean medical costs for CN, MCI, newly discovered dementia, and prevalent dementia were $6042, $6784, $9431, $11,678, respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age-, sex-, education-adjusted differences reached significance for CN versus newly discovered and prevalent dementia and for MCI versus prevalent dementia. After considering all comorbid diagnoses, between-category differences were reduced (e.g., prevalent dementia minus MCI (from $4842 to $3575); newly discovered dementia minus CN (from $3578 to $711)). Following the exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between-category differences tended to revert to greater differences. CONCLUSIONS: Cost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co-occurring mental disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost-effective.
Assuntos
Transtornos Cognitivos/economia , Transtornos Cognitivos/terapia , Custos de Cuidados de Saúde , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Envelhecimento , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/epidemiologia , Planejamento em Saúde Comunitária , Estudos Transversais , Bases de Dados Factuais/estatística & dados numéricos , Demência/economia , Demência/epidemiologia , Demência/terapia , Progressão da Doença , Feminino , Humanos , Masculino , Testes NeuropsicológicosRESUMO
Arsenicosis is believed to have debilitating effects on social relations, but with arsenic poisoning previously associated directly with economic and cognitive impacts, the degree to which stigmatisation is influenced by socio-economic or health status has not been established in the literature. Based on face-to-face interviews with 100 arsenic outpatients from specialist arsenic clinics in rural Bangladesh, this study represents an early quantitative analysis of factors predicting social impacts of arsenicosis. Physical health status, average years of schooling, family size and the presence of non-government organisation (NGO) and government-run arsenic-awareness campaigns significantly predicted social impacts. We found that the presence of awareness-raising activities was by far the most significant predictor of social impacts after other key variables, including gender and income, thus underscoring the importance of public health interventions in mitigating the impact of stigmatised diseases. The study confirms previous qualitative findings that ostracism is a pervasive problem for arsenicosis patients, and that public health interventions can be a valuable counter to such social problems.
Assuntos
Intoxicação por Arsênico/complicações , Transtornos Cognitivos/induzido quimicamente , Educação em Saúde/métodos , Dermatopatias/induzido quimicamente , Estigma Social , Poluição Química da Água/efeitos adversos , Adulto , Intoxicação por Arsênico/economia , Intoxicação por Arsênico/etiologia , Atitude Frente a Saúde , Bangladesh , Transtornos Cognitivos/economia , Estudos Transversais , Feminino , Humanos , Entrevistas como Assunto , Modelos Logísticos , Masculino , Organizações , Dermatopatias/economia , Classe SocialAssuntos
Envelhecimento/psicologia , Transtornos Cognitivos/psicologia , Cognição , Internação Compulsória de Doente Mental/legislação & jurisprudência , Liberdade , Hospitalização/legislação & jurisprudência , Consentimento Livre e Esclarecido/legislação & jurisprudência , Competência Mental/legislação & jurisprudência , Fatores Etários , Idoso , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/economia , Internação Compulsória de Doente Mental/economia , Compreensão , Inglaterra , Custos de Cuidados de Saúde/legislação & jurisprudência , Hospitalização/economia , Humanos , Defesa do Paciente/legislação & jurisprudência , Populações Vulneráveis/legislação & jurisprudênciaRESUMO
BACKGROUND: Lead time tradeoff (L-TTO) is a variant of the time tradeoff (TTO). L-TTO introduces a lead period in full health before illness onset, avoiding the need to use 2 different procedures for states better and worse than dead. To estimate utilities, additive separability is assumed. We tested to what extent violations of this assumption can bias utilities estimated with L-TTO. METHODS: A sample of 500 members of the Spanish general population evaluated 24 health states, using face-to-face interviews. A total of 188 subjects were interviewed with L-TTO and the rest with TTO. Both samples evaluated the same set of 24 health states, divided into 4 groups with 6 health states per set. Each subject evaluated 1 of the sets. A random effects regression model was fitted to our data. Only health states better than dead were included in the regression since it is in this subset where additive separability can be tested clearly. RESULTS: Utilities were higher in L-TTO in relation to TTO (on average L-TTO adds about 0.2 points to the utility of health states), suggesting that additive separability is violated. The difference between methods increased with the severity of the health state. Thus, L-TTO adds about 0.14 points to the average utility of the less severe states, 0.23 to the intermediate states, and 0.28 points to the more severe estates. CONCLUSIONS: L-TTO produced higher utilities than TTO. Health problems are perceived as less severe if a lead period in full health is added upfront, implying that there are interactions between disjointed time periods. The advantages of this method have to be compared with the cost of modeling the interaction between periods.
Assuntos
Comportamento de Escolha , Morte , Nível de Saúde , Qualidade de Vida , Atividades Cotidianas , Adulto , Atitude Frente a Saúde , Transtornos Cognitivos/economia , Transtornos Cognitivos/psicologia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Avaliação de Resultados em Cuidados de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Índice de Gravidade de Doença , Espanha , Fatores de TempoRESUMO
Cognitive rehabilitation aims to remediate or alleviate the cognitive deficits appearing after an episode of acquired brain injury (ABI). The purpose of this work is to describe the telerehabilitation platform called Guttmann Neuropersonal Trainer (GNPT) which provides new strategies for cognitive rehabilitation, improving efficiency and access to treatments, and to increase knowledge generation from the process. A cognitive rehabilitation process has been modeled to design and develop the system, which allows neuropsychologists to configure and schedule rehabilitation sessions, consisting of set of personalized computerized cognitive exercises grounded on neuroscience and plasticity principles. It provides remote continuous monitoring of patient's performance, by an asynchronous communication strategy. An automatic knowledge extraction method has been used to implement a decision support system, improving treatment customization. GNPT has been implemented in 27 rehabilitation centers and in 83 patients' homes, facilitating the access to the treatment. In total, 1660 patients have been treated. Usability and cost analysis methodologies have been applied to measure the efficiency in real clinical environments. The usability evaluation reveals a system usability score higher than 70 for all target users. The cost efficiency study results show a relation of 1-20 compared to face-to-face rehabilitation. GNPT enables brain-damaged patients to continue and further extend rehabilitation beyond the hospital, improving the efficiency of the rehabilitation process. It allows customized therapeutic plans, providing information to further development of clinical practice guidelines.
Assuntos
Lesões Encefálicas/reabilitação , Transtornos Cognitivos/reabilitação , Terapia Cognitivo-Comportamental/métodos , Sistemas de Apoio a Decisões Clínicas/organização & administração , Assistência Centrada no Paciente/métodos , Telemedicina/métodos , Adolescente , Adulto , Lesões Encefálicas/diagnóstico , Lesões Encefálicas/economia , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/economia , Terapia Cognitivo-Comportamental/economia , Sistemas de Apoio a Decisões Clínicas/economia , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Assistência Centrada no Paciente/economia , Espanha , Telemedicina/economia , Terapia Assistida por Computador , Resultado do Tratamento , Interface Usuário-Computador , Adulto JovemRESUMO
BACKGROUND: Cognitive decline is one of the most prominent healthcare issues of the 21st century. Within the context of combating cognitive decline through behavioural interventions, physical activity is a promising approach. There is a dearth of health economic data in the area of behavioural interventions for dementia prevention. Yet, economic evaluations are essential for providing information to policy makers for resource allocation. It is essential we first address population and intervention-specific methodological challenges prior to building a larger evidence base. We use a cost-utility analysis conducted alongside the exercise for cognition and everyday living (EXCEL) study to illustrate methodological challenges specific to assessing the cost-effectiveness of behavioural interventions aimed at older adults at risk of cognitive decline. METHODS: A cost-utility analysis conducted concurrently with a 6-month, three-arm randomised controlled trial (ie, the EXCEL study) was used as an example to identify and discuss methodological challenges. RESULTS: Both the aerobic training and resistance training interventions were less costly than twice weekly balance and tone classes. In critically evaluating the economic evaluation of the EXCEL study we identified four category-specific challenges: (1) analysing costs; (2) assessing quality-adjusted life-years; (3) Incomplete data; and (4) 'Intervention' activities of the control group. CONCLUSIONS: Resistance training and aerobic training resulted in healthcare cost saving and were equally effective to balance and tone classes after only 6â months of intervention. To ensure this population is treated fairly in terms of claims on resources, we first need to identify areas for methodological improvement.
Assuntos
Terapia Comportamental/economia , Demência/economia , Idoso , Idoso de 80 Anos ou mais , Terapia Comportamental/métodos , Transtornos Cognitivos/economia , Transtornos Cognitivos/terapia , Análise Custo-Benefício , Demência/terapia , Terapia por Exercício/economia , Terapia por Exercício/métodos , Feminino , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study is to examine the relative contribution of functional impairment and cognitive deficits on risk of hospitalization and costs. METHODS: A prospective cohort of Medicare beneficiaries aged 65 and older who participated in the Washington Heights-Inwood Columbia Aging Project (WHICAP) were followed approximately every 18 months for over 10 years (1805 never diagnosed with dementia during study period, 221 diagnosed with dementia at enrollment). Hospitalization and Medicare expenditures data (1999-2010) were obtained from Medicare claims. Multivariate analyses were conducted to examine (1) risk of all-cause hospitalizations, (2) hospitalizations from ambulatory care sensitive (ACSs) conditions, (3) hospital length of stay (LOS), and (4) Medicare expenditures. Propensity score matching methods were used to reduce observed differences between demented and non-demented groups at study enrollment. Analyses took into account repeated observations within each individual. RESULTS: Compared to propensity-matched individuals without dementia, individuals with dementia had significantly higher risk for all-cause hospitalization, longer LOS, and higher Medicare expenditures. Functional and cognitive deficits were significantly associated with higher risks for hospitalizations, hospital LOS, and Medicare expenditures. Functional and cognitive deficits were associated with higher risks of for some ACS but not all admissions. CONCLUSIONS: These results allow us to differentiate the impact of functional and cognitive deficits on hospitalizations. To develop strategies to reduce hospitalizations and expenditures, better understanding of which types of hospitalizations and which disease characteristics impact these outcomes will be critical.
Assuntos
Demência/economia , Gastos em Saúde/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Hospitalização/economia , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Transtornos Cognitivos/economia , Comorbidade , Demência/epidemiologia , Feminino , Custos de Cuidados de Saúde , Nível de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Estudos Prospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: We aimed to determine the timing and size of the cognitive deficit associated with poverty in the first 5 years of life and to examine the role of parental characteristics, pre- and postnatal growth, and stimulation in the home in Bangladeshi children. We hypothesized that the effect of poverty on cognition begins in infancy and is mainly mediated by these factors. METHODS: We enrolled 2853 singletons, a subsample from a pregnancy supplementation trial in a poor rural area. We assessed mental development at 7, 18, and 64 months; anthropometry at birth, 12, 24, and 64 months; home stimulation at 18 and 64 months; and family's socioeconomic background. In multiple regression analyses, we examined the effect of poverty at birth on IQ at 64 months and the extent that other factors mediated the effect. RESULTS: A mean cognitive deficit of 0.2 (95% confidence interval -0.4 to -0.02) z scores between the first and fifth wealth quintiles was apparent at 7 months and increased to 1.2 (95% confidence interval -1.3 to -1.0) z scores of IQ by 64 months. Parental education, pre- and postnatal growth in length, and home stimulation mediated 86% of the effects of poverty on IQ and had independent effects. Growth in the first 2 years had larger effects than later growth. Home stimulation had effects throughout the period. CONCLUSIONS: Effects of poverty on children's cognition are mostly mediated through parental education, birth size, growth in the first 24 months, and home stimulation in the first 5 years.
Assuntos
Desenvolvimento Infantil , Transtornos Cognitivos/economia , Transtornos Cognitivos/epidemiologia , Pobreza/economia , Pobreza/tendências , Adulto , Antropometria/métodos , Bangladesh/epidemiologia , Desenvolvimento Infantil/fisiologia , Pré-Escolar , Transtornos Cognitivos/psicologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Lactente , Estudos Longitudinais , Masculino , Pobreza/psicologia , Gravidez , Fatores Socioeconômicos , Adulto JovemRESUMO
BACKGROUND: The management of children with special needs can be very challenging and expensive. OBJECTIVE: To examine direct and indirect cost drivers of home care expenditures for this vulnerable and expensive population. METHODS: We retrospectively assessed secondary data on children, ages 4-20, receiving Medicaid Personal Care Services (PCS) (n = 2760). A structural equation model assessed direct and indirect effects of several child characteristics, clinical conditions and functional measures on Medicaid home care payments. RESULTS: The mean age of children was 12.1 years and approximately 60% were female. Almost half of all subjects reported mild, moderate or severe ID diagnosis. The mean ADL score was 5.27 and about 60% of subjects received some type of rehabilitation services. Caseworkers authorized an average of 25.5 h of PCS support per week. The SEM revealed three groups of costs drivers: indirect, direct and direct + indirect. Cognitive problems, health impairments, and age affect expenditures, but they operate completely through other variables. Other elements accumulate effects (externalizing behaviors, PCS hours, and rehabilitation) and send them on a single path to the dependent variable. A few elements exhibit a relatively complex position in the model by having both significant direct and indirect effects on home care expenditures - medical conditions, intellectual disability, region, and ADL function. CONCLUSIONS: The most important drivers of home care expenditures are variables that have both meaningful direct and indirect effects. The only one of these factors that may be within the sphere of policy change is the difference among costs in different regions.