Inequality in socio-emotional skills: A cross-cohort comparison.

We examine changes in inequality in socio-emotional skills very early in life in two British cohorts born 30 years apart. We construct comparable scales using two validated instruments for the measurement of child behaviour and identify two dimensions of socio-emotional skills: 'internalising' and 'externalising'. Using recent methodological advances in factor analysis, we establish comparability in the inequality of these early skills across cohorts, but not in their average level. We document for the first time that inequality in socio-emotional skills has increased across cohorts, especially for boys and at the bottom of the distribution. We also formally decompose the sources of the increase in inequality and find that compositional changes explain half of the rise in inequality in externalising skills. On the other hand, the increase in inequality in internalising skills seems entirely driven by changes in returns to background characteristics. Lastly, we document that socio-emotional skills measured at an earlier age than in most of the existing literature are significant predictors of health and health behaviours. Our results show the importance of formally testing comparability of measurements to study skills differences across groups, and in general point to the role of inequalities in the early years for the accumulation of health and human capital across the life course.

The role of economies of scale in the cost of dialysis across the world: a macroeconomic perspective.

BACKGROUND: The treatment of chronic kidney disease through dialysis is a considerable expense in most health systems. The two chief methods of providing dialysis, haemodialysis (HD) and peritoneal dialysis (PD) have significant differences in cost composition and factors of production. The aim of this article is to identify and quantify the macroeconomic variables that influence the relative cost of such modalities across different countries. METHODS: From previously published literature, we extracted the estimates of HD/PD cost ratios in a total of 46 countries. We conducted a multivariate regression analysis using the estimated HD/PD cost ratio in each country, with several country level indicators as explanatory variables. We found a strong statistical effect of the following variables on the HD/PD cost ratio: country's level of development, economies of scale and percentage of private health-care expenditure. RESULTS: The statistical effects on HD/PD ratio by local manufacturing and relaxed import regulation of PD equipment were calculated and were found to be very significant. CONCLUSIONS: it is possible for a country to still reap the benefits of economies of scale in provision of PD, even in the absence of a large enough market to make local production of PD equipment feasible in that country.

Healthcare systems and chronic kidney disease: putting the patient in control.

Today, health policy seems to be on the top of governments' agendas around the world. Healthcare systems are challenged by a number of phenomena happening on a global scale; these trends include demographic change in terms of an ageing population, an increase in chronic disease, patients having higher expectations on healthcare delivery and above all a major pressure on public finances to slow increasing healthcare expenditures. Such developments are forcing policy-makers to reform healthcare systems. First, there is a tendency towards decentralization of responsibilities. Second, governments are moving towards reimbursement schemes rewarding good outcomes and performance. Third, great importance is being attributed to transparency and accountability, and to introduce competition in healthcare. Fourth, attention is being shifted from simple treatment of a disease towards preventive initiatives, in a more holistic approach to health. Finally, healthcare policy-makers are recognizing the importance of empowering patients to give them control over decisions regarding their own health. These dynamics can be observed in chronic kidney disease, the management of which is a huge economic burden to healthcare systems globally, and which represents a good example of a field where important changes can be witnessed in therapy, technology, delivery and financing.

Cost of peritoneal dialysis and haemodialysis across the world.

Peritoneal dialysis (PD) as a modality is underutilized in most parts of the world today despite several advantages including the possibility of it being offered in the remotest of locations and being significantly more affordable than haemodialysis (HD) in most cases. In this article, we will compare the cost of HD and PD in several countries to demonstrate that PD is less than, or at least as expensive as, HD. A thorough literature survey of EMBASE and PUBMED was conducted; 78 articles which compared the annual PD and annual HD costs were finally selected. Careful attention was paid to the methodology followed by each study and the year it was published in. Our final calculations included 46 countries (20 developed and 26 developing). We found that the cost of HD was between 1.25 and 2.35 times the cost of PD in 22 countries (17 developed and 5 developing), between 0.90 and 1.25 times the cost of PD in 15 countries (2 developed and 13 developing), and between 0.22 and 0.90 times the cost of PD in 9 countries (1 developed and 8 developing). From our analysis, it is evident that most developed countries can provide PD at a lesser expense to the healthcare system than HD. The evidence on developing countries is more mixed, but in most cases PD can be provided at a similar cost where economies of scale have been achieved, either by local production or by low import duties on PD equipment.

Fluid management in the intensive care unit: bioelectrical impedance vector analysis as a tool to assess hydration status and optimal fluid balance in critically ill patients.

BACKGROUND: Fluid balance disorders are a relevant risk factor for morbidity and mortality in critically ill patients. Volume assessment in the intensive care unit (ICU) is thus of great importance, but there are currently few methods to obtain an accurate and timely assessment of hydration status. Our aim was to evaluate the hydration status of ICU patients via bioelectric impedance vector analysis (BIVA) and to investigate the relationship between hydration and mortality. METHODS: We evaluated 280 BIVA measurements of 64 patients performed daily in the 5 days following their ICU admission. The observation period ranged from a minimum of 72 h up to a maximum of 120 h. We observed the evolution of the hydration status during the ICU stay in this population, and analyzed the relationship between mean and maximum hydration reached and mortality--both in the ICU and at 60 days--using logistic regression. RESULTS: A state of overhydration was observed in the majority of patients (70%) on admission, which persisted during the ICU stay. Patients who required continuous renal replacement therapy (CRRT) were more likely to be overhydrated starting from the 2nd day of observation. Logistic regression showed a strong and significant correlation between mean/maximum hydration reached and mortality, both independently and correcting for severity of prognosis. CONCLUSIONS: Fluid overload measured by BIVA is a frequent condition in critically ill patients--whether or not they undergo CRRT--and a significant predictor of mortality. Hence, hydration status should be considered as an additional prognosticator in the clinical management of the critically ill patient. KEY MESSAGES: (i) On the day of ICU admittance, patients showed a marked tendency to overhydration (>70% of total). This tendency was more pronounced in patients on CRRT. (ii) Hyperhydration persisted during the ICU stay. Patients who underwent CRRT showed significantly higher hyperhydration from the 2nd day of hospitalization. (iii) Nonsurvivors showed worse hyperhydration patterns in comparison to survivors in logistic univariate analysis (p < 0.05). This relationship between hydration and mortality is confirmed even when controlling for the effect of a worse prognosis approximated by any of three ICU scoring systems (APACHE II, SAPS II and SOFA). Mean and maximum hydration levels present a stronger correlation with mortality than with mean and maximum cumulative fluid balance reached during the observation period.

Cost-effectiveness analysis of online hemodiafiltration versus high-flux hemodialysis.

BACKGROUND: Clinical studies suggest that hemodiafiltration (HDF) may lead to better clinical outcomes than high-flux hemodialysis (HF-HD), but concerns have been raised about the cost-effectiveness of HDF versus HF-HD. Aim of this study was to investigate whether clinical benefits, in terms of longer survival and better health-related quality of life, are worth the possibly higher costs of HDF compared to HF-HD. METHODS: The analysis comprised a simulation based on the combined results of previous published studies, with the following steps: 1) estimation of the survival function of HF-HD patients from a clinical trial and of HDF patients using the risk reduction estimated in a meta-analysis; 2) simulation of the survival of the same sample of patients as if allocated to HF-HD or HDF using three-state Markov models; and 3) application of state-specific health-related quality of life coefficients and differential costs derived from the literature. Several Monte Carlo simulations were performed, including simulations for patients with different risk profiles, for example, by age (patients aged 40, 50, and 60 years), sex, and diabetic status. Scatter plots of simulations in the cost-effectiveness plane were produced, incremental cost-effectiveness ratios were estimated, and cost-effectiveness acceptability curves were computed. RESULTS: An incremental cost-effectiveness ratio of €6,982/quality-adjusted life years (QALY) was estimated for the baseline cohort of 50-year-old male patients. Given the commonly accepted threshold of €40,000/QALY, HDF is cost-effective. The probabilistic sensitivity analysis showed that HDF is cost-effective with a probability of ~81% at a threshold of €40,000/QALY. It is fundamental to measure the outcome also in terms of quality of life. HDF is more cost-effective for younger patients. CONCLUSION: HDF can be considered cost-effective compared to HF-HD.