Managing mental health: why we need to redress the balance between healthcare spending and social spending.

BACKGROUND: Mental health outcomes vary widely among high-income countries, although mental health problems represent an increasing proportion of the burden of disease for all countries. This has led to increased demand for healthcare services, but mental health outcomes may also be particularly sensitive to the availability of social services. This paper examines the variation in the absolute and relative amounts that high-income countries spend on healthcare and social services to determine whether increased expenditure on social services relative to healthcare expenditure might be associated with better mental health outcomes. METHODS: This paper estimates the association between patterns of government spending and population mental health, as measured by the death rate resulting from mental and behavioural disorders, across member countries of the Organisation for Economic Cooperation and Development (OECD). We use country-level repeated measures multivariable modelling for the period from 1995 to 2016 with region and time effects, adjusted for total spending and demographic and economic characteristics. Healthcare spending includes all curative services, long-term care, ancillary services, medical goods, preventative care and administration whilst social spending consists of all transfer payments made to individuals and families as part of the welfare state. RESULTS: We find that a higher ratio of social to healthcare expenditure is associated with significantly better mental health outcomes for OECD populations, as measured by the death rate resulting from mental and behavioural disorders. We also find that there is no statistically significant association between healthcare spending and population mental health when we do not control for social spending. CONCLUSION: This study suggests that OECD countries can have a significant impact on population mental health by investing a greater proportion of total expenditure in social services.

Assessing the influence of conflict on the dynamics of sex work and the HIV and HCV epidemics in Ukraine: protocol for an observational, ethnographic, and mathematical modeling study.

BACKGROUND: Armed conflict erupted in eastern Ukraine in 2014 and still continues. This conflict has resulted in an intensification of poverty, displacement and migration, and has weakened the local health system. Ukraine has some of the highest rates of HIV and Hepatitis C (HCV) in Europe. Whether and how the current conflict, and its consequences, will lead to changes in the HIV and HCV epidemic in Ukraine is unclear. Our study aims to characterize how the armed conflict in eastern Ukraine and its consequences influence the pattern, practice, and experience of sex work and how this affects HIV and HCV rates among female sex workers (FSWs) and their clients. METHODS: We are implementing a 5-year mixed methods study in Dnipro, eastern Ukraine. Serial mapping and size estimation of FSWs and clients will be conducted followed by bio-behavioral cross-sectional surveys among FSWs and their clients. The qualitative component of the study will include in-depth interviews with FSWs and other key stakeholders and participant diaries will be implemented with FSWs. We will also conduct an archival review over the course of the project. Finally, we will use these data to develop and structure a mathematical model with which to estimate the potential influence of changes due to conflict on the trajectory of HIV and HCV epidemics among FSW and clients. DISCUSSION: The limited data that exists on the effect of conflict on disease transmission provides mixed results. Our study will provide rigorous, timely and context-specific data on HIV and HCV transmission in the setting of conflict. This information can be used to inform the design and delivery of HIV and HCV prevention and care services.

Comparison of the accuracy of classification models to estimate healthcare use and costs associated with COPD exacerbations in Saskatchewan, Canada: A retrospective cohort study.

OBJECTIVE: COPD is a high-cost disease and results in frequent contacts with the healthcare system. The study objective was to compare the accuracy of classification models with different covariates for classifying COPD patients into cost groups. METHODS: Linked health administrative databases from Saskatchewan, Canada, were used to identify a cohort of newly diagnosed COPD patients (April 1, 2007 to March 31, 2011) and their episodes of healthcare encounters for disease exacerbations. Total costs of the first and follow-up episodes were computed and patients were categorized as persistently high cost, occasionally high cost, and persistently low cost based on cumulative cost distribution ranking using the 75th percentile cutoff for high-cost status. Classification accuracy was compared for seven multinomial logistic regression models containing socio-demographic characteristics (i.e., base model), and socio-demographic and prior healthcare use characteristics (i.e., comparator models). RESULTS: Of the 1182 patients identified, 8.5% were classified as persistently high cost, 26.1% as occasionally high cost, and the remainder as persistently low cost. The persistently high-cost and occasionally high-cost patients incurred 10 times ($12 449 vs $1263) and seven times ($9334 vs $1263) more costs in their first exacerbation episode than persistently low-cost patients, respectively. Classification accuracy was 0.67 for the base model, whereas the comparator model containing socio-demographic and number of prior hospital admissions had the highest accuracy (0.72). CONCLUSIONS: Costs associated with COPD exacerbation episodes are substantial. Adding prior hospitalization to socio-demographic characteristics produced the highest improvements in classification accuracy. Accurate classification models are important for identifying potential healthcare cost management strategies.

Geographical variation analysis of all-cause hospital readmission cases in Winnipeg, Canada.

BACKGROUND: Hospital readmission is costly and potentially avoidable. The concept of virtual wards as a new model of care is intended to reduce hospital readmissions by providing short-term transitional care to high-risk and complex patients in the community. In order to provide information regarding the development of virtual wards in the Winnipeg Health Region, Canada, this study used spatial statistics to identify geographic variations of hospital readmissions in 25 neighborhood clusters. METHODS: The data were obtained from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. We used a Bayesian Disease Mapping approach which applied Markov chain Monte Carlo (MCMC) for cluster detection. RESULTS: Between 2005/06 and 2008/09, 123,842 patients were hospitalized in all Winnipeg hospitals. Of these, 41,551 (33%) were readmitted to hospital in the year following discharge. Most of these readmitted patients (89.4%) had 1-2 readmissions, while 11.6% of readmitted patients had more than 2 readmissions after initial discharge. The smoothed age- and sex- adjusted relative risk rates of hospital readmission in 25 Winnipeg neighborhood clusters ranged between 0.73 and 1.27. We found that there were spatial cluster variations of hospital readmission across the Winnipeg Health Region. Seven neighborhood clusters are more likely to be significant potential clusters for hospital readmissions (p < .05), while six neighborhood clusters are less likely to be significant potential clusters. CONCLUSIONS: This study provides the foundation and implementation guide for the Winnipeg Regional Health Authority virtual ward program. The findings will also help to improve long-term condition management in community settings and will help program planners to assure the efficient use of healthcare resources.

Expanding Access to High KDPI Kidney Transplant for Recipients Aged 60 y and Older: Cost Utility and Survival.

Background: Modern organ allocation systems are tasked with equitably maximizing the utility of transplanted organs. Increasing the use of deceased donor organs at risk of discard may be a cost-effective strategy to improve overall transplant benefit. We determined the survival implications and cost utility of increasing the use of marginal kidneys in an older adult Canadian population of patients with end-stage kidney disease. Methods: We constructed a cost-utility model with microsimulation from the perspective of the Canadian single-payer health system for incident transplant waitlisted patients aged 60 y and older. A kidney donor profile index score of ≥86 was considered a marginal kidney. Donor- and recipient-level characteristics encompassed in the kidney donor profile index and estimated posttransplant survival scores were used to derive survival posttransplant. Patients were followed up for 10 y from the date of waitlist initiation. Our analysis compared the routine use of marginal kidneys (marginal kidney scenario) with the current practice of limited use (status quo scenario). Results: The 10-y mean cost and quality-adjusted life-years per patient in the marginal kidney scenario were estimated at $379 485.33 (SD: $156 872.49) and 4.77 (SD: 1.87). In the status quo scenario, the mean cost and quality-adjusted life-years per patient were $402 937.68 (SD: $168 508.85) and 4.37 (SD: 1.87); thus, the intervention was considered dominant. At 10 y, 62.8% and 57.0% of the respective cohorts in the marginal kidney and status quo scenarios remained alive. Conclusions: Increasing the use of marginal kidneys in patients with end-stage kidney disease aged 60 y and older may offer cost savings, improved quality of life, and greater patient survival in comparison with usual care.

New questions, new data, old interventions: the health effects of a guaranteed annual income.

OBJECTIVES: This study investigates whether administration data from universal health insurance can yield new insight from an old intervention. Specifically, did a guaranteed annual income experiment from the 1970s, designed to investigate labor market outcomes, reduce hospitalization rates? METHOD: The study re-examined the saturation site of a guaranteed annual income experiment in Dauphin, Manitoba (CANADA) conducted between 1974 and 1979 (MINCOME). We used health administration data generated by the universal government health insurance plan to identify subjects (approximately 12,500 residents of Dauphin and its rural municipality). We used propensity-score matching to select 3 controls for each subject from this database, matched on geography of residence, age, sex, family size and type. Outcome measures were hospital separations and physician claims. RESULTS: Hospital separations declined 8.5% among subjects relative to controls during the experimental period. Accident and injury codes and mental health codes were most responsible for the decline. CONCLUSIONS: Even though MINCOME was designed to measure the impact of a GAI on the number of hours worked, one can re-visit old experiments with new data to determine the health impact of population interventions designed for other purposes. We determined that hospitalization rates declined significantly after the introduction of a guaranteed income.

Exploring the impact of military conflict on sex work in Ukraine: Women's experiences of economic burden.

Little is known about the impact of military conflict on sex work from the perspective of sex workers. We attempt to explore the meaning of conflict on sex work by asking women about the changes that they have experienced in their lives and work since the beginning of the 2014 military conflict in eastern Ukraine. The findings in this article are based on qualitative interviews with 43 cisgender women living and practicing sex work in Dnipro, eastern Ukraine. Our analysis highlights the meanings that sex workers have linked to the conflict, with financial concerns emerging as a dominant theme. The conflict therefore functions as a way of understanding changing economic circumstances with both individual and broader impacts. By better understanding the meaning of conflict as expressed by sex workers, we can begin to adapt our response to address emerging, and unmet, needs of the community.

Exploring the dynamics of workplace typologies for sex workers in Eastern Ukraine.

We examine the typologies of workplaces for sex workers in Dnipro, Ukraine as part of the larger Dynamics Study, which explores the influence of conflict on sex work. We conducted a cross-sectional survey with 560 women from September 2017 to October 2018. The results of our study demonstrate a diverse sex work environment with heterogeneity across workplace typologies in terms of remuneration, workload, and safety. Women working in higher prestige typologies earned a higher hourly wage, however client volume also varied which resulted in comparable monthly earnings from sex work across almost all workplace types. While sex workers in Dnipro earn a higher monthly wage than the city mean, they also report experiencing high rates of violence and a lack of personal safety at work. Sex workers in all workplaces, with the exception of those working in art clubs, experienced physical and sexual violence perpetrated by law enforcement officers and sex partners. By understanding more about sex work workplaces, programmes may be better tailored to meet the needs of sex workers and respond to changing work environments due to ongoing conflict and COVID-19 pandemic.

Exploring dental hygiene decision making: A quantitative study of potential organizational explanations.

BACKGROUND: To improve public access to oral health care, dental hygienists have been identified for practice expansion, and, therefore, they must demonstrate decision-making capacity. This study aimed to identify and test potentially influential factors in dental hygiene decision making. Organizational and gender factors were hypothesized to be most influential and focused the study. METHODS: A 2-phase mixed methods approach was used. In Phase I, a qualitative decision-making model was developed and subsequently published in 2012. Phase II tested aspects of the model through an electronic survey instrument and key informant interviews. This article reports on the statistical results of the quantitative survey. A third article will report on the qualitative thematic analyses and merged interpretation. RESULTS: The Phase I qualitative model guided the development of the survey instrument. The survey had a 38% response rate; moderate to weak correlations between predictor variables (structural and individual) and clinical decision making were shown. The final statistical model demonstrated that individual characteristics and graduating from a 3-year dental hygiene program were together significantly associated with decision-making capacity. DISCUSSION AND CONCLUSIONS: Individual characteristics and longer education were together shown to be associated with increased decision-making capacity. These findings did not show the organization or gender to be important in influencing decision-making capacity. However, the merging of the quantitative survey and qualitative key informant data will potentially inform how the organization influences the individual dental hygienist.

CONTEXTE: Afin d'améliorer l'accès de la population aux soins de santé buccodentaire, les hygiénistes dentaires ont été désignés pour une expansion de la pratique et doivent par conséquent démontrer une capacité décisionnelle. La présente étude visait à cerner et à vérifier les facteurs influents potentiels dans la prise de décision en hygiène dentaire. L'étude était axée sur l'hypothèse que les facteurs organisationnels et de sexe étaient les plus influents. MÉTHODOLOGIE: Une approche méthodologique mixte en 2 phases a été utilisée. Dans la phase I, un modèle décisionnel qualitatif a été conçu et publié par la suite en 2012. La phase II a évalué des aspects du modèle au moyen d'un outil de sondage électronique et des entrevues d'intervenants clés. Cet article présente les résultats statistiques de ce sondage quantitatif. Un troisième article fera part des analyses thématiques qualitatives et des interprétations fusionnées. RÉSULTATS: La phase I du modèle qualitatif a guidé la conception de l'outil de sondage. Le sondage avait un taux de réponse de 38 %, et des corrélations modérées à faibles entre les variables indépendantes (structurelles et individuelles) et la prise de décision clinique étaient démontrées. Le modèle statistique final a démontré que les caractéristiques individuelles, ainsi que l'obtention d'un diplôme d'un programme d'hygiène dentaire de 3 ans étaient fortement associées à la capacité décisionnelle. DISCUSSION ET CONCLUSIONS: Les caractéristiques individuelles et des études plus longues étaient ensemble associées à une meilleure capacité décisionnelle. Ces résultats n'ont pas montré que l'organisation ou le sexe étaient des facteurs d'influence importants dans la capacité décisionnelle. Cependant, la fusion du sondage quantitatif et des données qualitatives des intervenants clés pourrait éclaircir la façon dont l'organisation influence chaque hygiéniste dentaire.

Health-related quality of life and economic burden to smoking behaviour among Canadians.

OBJECTIVES: The objectives of this study were to: (1) examine whether the smoking status of the Canadian population is associated with a reduction in health-related quality of life (HRQoL); (2) calculate the overall economic burden of loss in HRQoL using a commonly accepted $100,000 willingness-to-pay (WTP) threshold to gain one quality-adjusted life year (QALY); and (3) calculate the loss of HRQoL over a lifetime. METHODS: We used the 2015 Canadian Community Health Survey. The variations in HRQoL were estimated using a multivariable generalized linear model. Total expected lifetime QALYs lost due to smoking were calculated by compounding the annual adjusted health utility loss associated with smoking across a respondent's remaining years of life expectancy stratified by age. A discount rate of 1.5% was applied to the analysis based on recent analysis of the costs of borrowing in Canada. RESULTS: Smoking is significantly associated with HRQoL loss. This study demonstrated that smoking is associated with a 0.05 and 0.01 reduction in Health Utilities Index Mark 3 (HUI3) score for current and former smokers, which also corresponds to a loss of 0.66 quality-adjusted life years in average, and also is associated with substantial individual and societal economic cost. The total lifetime economic burden of HUI3 loss per smoker was $65,935, yielding in the aggregate a societal burden of $1068.88 billion in the study population. CONCLUSION: Tobacco control, prevention and intervention not only will improve HRQoL but also will generate social returns on investment.

The effects of cigarette price and the amount of pocket money on youth smoking initiation and intensity in Canada.

OBJECTIVES: To investigate the price and income elasticities of adolescent smoking initiation and intensity to determine the extent to which increased pocket money leads to greater smoking among youth, and whether higher taxes can mitigate this effect. METHODS: We used the 2012/2013 Canadian Youth Smoking Survey including students in grades 7-12. The multivariable logistic regression was used to examine the probability of smoking initiation, and a linear regression to examine the smoking intensity determined by province-level prices of cigarettes, pocket money, and a vector of individual characteristics, including age, sex, race, and school-related and psychosocial factors. RESULTS: Of respondents, 28.8% have tried cigarette smoking. More than 90% of these initiated smoking between age 9 and 17. Male smokers consumed a higher average number of whole cigarettes daily than did females. The price elasticity of smoking initiation and intensity for youth in the full sample were - 1.13 and - 1.02, respectively, which means that a 10% increase in price leads to an 11.3% reduction in initiation and a 10.2% reduction in intensity. The income elasticity of smoking initiation and intensity for youth in the full sample were 0.07 and 0.06, respectively, which means that a 10% increase in income leads to a 0.7% increase in initiation and a 0.6% increase in intensity. CONCLUSION: Economic measures such as taxation that raise the price of cigarettes may be a useful policy tool to limit smoking initiation and intensity.

Enzyme replacement therapy in orphan and ultra-orphan diseases: the limitations of standard economic metrics as exemplified by Fabry-Anderson disease.

BACKGROUND: Fabry-Anderson disease is an x-linked deficiency of lysosomal alpha-galactosidase A (GALA), resulting in chronic renal failure, cardiac arrhythmia, hypertrophy, valvular disease, pain (acro-paraesthesiae) and stroke, together with premature mortality. The disease has a significant impact on quality of life (QOL), as illustrated by studies using the EQ-5D. A specific treatment is available for Fabry-Anderson disease consisting of intravenous enzyme replacement therapy (ERT) of the deficient enzyme. The variable clinical efficacy and cost of ERT has resulted in reluctance by some health providers to approve it. METHODS: We use the limited QOL data available in the Fabry-Anderson disease literature on ERT to derive standard economic metrics. These were derived by bootstrap estimates of the incremental net benefit (INB) statistics together with a cost-effectiveness acceptability curve relating the willingness to pay to the probability that the INB was >0. The estimates were further developed by adoption of a supplementary Bayesian approach utilising a sceptical and enthusiastic prior of the INB of ERT in Fabry-Anderson disease. RESULTS: ERT for Fabry-Anderson disease is not economically viable by standard health programme evaluation metrics. Based on current ERT costs (year 2005 values), derivation of the INB distribution, and a Bayesian analysis using an enthusiastic and sceptical prior of the INB, an upper (350,000 dollars over 1 year) and lower (175,000 dollars over 1 year) economic cost, respectively, of ERT was derived. CONCLUSION: The cost of ERT will always result in a net deficit to society under current costing and ERT efficacy as determined by the QALY metric. The rules of fair cooperation should govern decision making both for ERT in Fabry-Anderson disease and for funding therapeutic advances in other rare diseases belonging to the orphan and ultra-orphan categories.

Cost-effectiveness of alternate strategies for childhood immunization against meningococcal disease with monovalent and quadrivalent conjugate vaccines in Canada.

BACKGROUND: Public health programs to prevent invasive meningococcal disease (IMD) with monovalent serogroup C meningococcal conjugate vaccine (MCV-C) and quadrivalent meningococcal conjugate vaccines (MCV-4) in infancy and adolescence vary across Canadian provinces. This study evaluated the cost-effectiveness of various vaccination strategies against IMD using current and anticipated future pricing and recent epidemiology. METHODS: A cohort model was developed to estimate the clinical burden and costs (CAN$2014) of IMD in the Canadian population over a 100-year time horizon for three strategies: (1) MCV-C in infants and adolescents (MCV-C/C); (2) MCV-C in infants and MCV-4 in adolescents (MCV-C/4); and (3) MCV-4 in infants (2 doses) and adolescents (MCV-4/4). The source for IMD incidence was Canadian surveillance data. The effectiveness of MCV-C was based on published literature. The effectiveness of MCV-4 against all vaccination regimens was assumed to be the same as for MCV-C regimens against serogroup C. Herd effects were estimated by calibration to estimates reported in prior analyses. Costs were from published sources. Vaccines prices were projected to decline over time reflecting historical procurement trends. RESULTS: Over the modeling horizon there are a projected 11,438 IMD cases and 1,195 IMD deaths with MCV-C/C; expected total costs are $597.5 million. MCV-C/4 is projected to reduce cases of IMD by 1,826 (16%) and IMD deaths by 161 (13%). Vaccination costs are increased by $32 million but direct and indirect IMD costs are projected to be reduced by $46 million. MCV-C/4 is therefore dominant vs. MCV-C/C in the base case. Cost-effectiveness of MCV-4/4 was $111,286 per QALY gained versus MCV-C/4 (2575/206 IMD cases/deaths prevented; incremental costs $68 million). CONCLUSIONS: If historical trends in Canadian vaccines prices continue, use of MCV-4 instead of MCV-C in adolescents may be cost-effective. From an economic perspective, switching to MCV-4 as the adolescent booster should be considered.

Identifying Distinct Healthcare Pathways During Episodes of Chronic Obstructive Pulmonary Disease Exacerbations.

Healthcare pathways are important to measure because they are expected to affect outcomes. However, they are challenging to define because patients exhibit heterogeneity in their use of healthcare services. The objective of this study was to identify and describe healthcare pathways during episodes of chronic obstructive pulmonary disease (COPD) exacerbations. Linked administrative databases from Saskatchewan, Canada were used to identify a cohort of newly diagnosed COPD patients and their episodes of healthcare use for disease exacerbations. Latent class analysis (LCA) was used to classify the cohort into homogeneous pathways using indicators of respiratory-related hospitalizations, emergency department (ED) visits, general and specialist physician visits, and outpatient prescription drug dispensations. Multinomial logistic regression models tested patients' demographic and disease characteristics associated with pathway group membership. The most frequent healthcare contact sequences in each pathway were described. Tests of mean costs across groups were conducted using a model-based approach with χ² statistics. LCA identified 3 distinct pathways for patients with hospital- (n = 963) and ED-initiated (n = 364) episodes. For the former, pathway group 1 members followed complex pathways in which multiple healthcare services were repeatedly used and incurred substantially higher costs than patients in the other pathway groups. For patients with an ED-initiated episode, pathway group 1 members also had higher costs than other groups. Pathway groups differed with respect to patient demographic and disease characteristics. A minority of patients were discharged from ED or hospital, but did not have any follow-up care during the remainder of their episode.Patients who followed complex pathways could benefit from case management interventions to streamline their journeys through the healthcare system. The minority of patients whose pathways were not consistent with recommended follow-up care should be further investigated to fully align COPD treatment in the province with recommended care practices.

Surge capacity: analysis of census fluctuations to estimate the number of intensive care unit beds needed.

OBJECTIVE: To compare methods of characterizing intensive care unit (ICU) bed use and estimate the number of beds needed. STUDY SETTING: Three geographic regions in the Canadian province of Manitoba. STUDY DESIGN: Retrospective analysis of population-based data from April 1, 2000, to March 31, 2007. METHODS: We compared three methods to estimate ICU bed requirements. Method 1 analyzed yearly patient-days. Methods 2 and 3 analyzed day-to-day fluctuations in patient census; these differed by whether each hospital needed to independently fulfill its own demand or this resource was shared across hospitals. PRINCIPAL FINDINGS: Three main findings were as follows: (1) estimates based on yearly average usage generally underestimated the number of beds needed compared to analysis of fluctuations in census, especially in the smaller regions where underestimation ranged 25-58 percent; (2) 4-29 percent fewer beds were needed if it was acceptable for demand to exceed supply 18 days/year, versus 4 days/year; and (3) 13-36 percent fewer beds were needed if hospitals within a region could effectively share ICU beds. CONCLUSIONS: Compared to using yearly averages, analyzing day-to-day fluctuations in patient census gives a more accurate picture of ICU bed use. Failing to provide adequate "surge capacity" can lead to demand that frequently and severely exceeds supply.

Development and validation of a predictive model for all-cause hospital readmissions in Winnipeg, Canada.

OBJECTIVE: A number of predictive models have been developed to identify patients at risk of hospital readmission. Most of these have focused on readmission within 30 days of discharge. We used population-based health administrative data to develop a predictive model for hospital readmission within 12 months of discharge in Winnipeg, Canada. METHODS: This was a retrospective cohort study with derivation and validation data sets. Multivariable logistic regression analyses were performed and factors significantly associated with readmission were selected to construct a risk scoring tool. RESULTS: Several variables were identified that predicted readmission (i.e. older age, male, at least one hospital admission in the previous two years, an emergent (index) hospital admission, Charlson comorbidity score >0 and length of stay). Discrimination power was acceptable (C statistic =0.701). At a median risk score threshold, the sensitivity, specificity, positive and negative predictive values were 45.5%, 79%, 68.8% and 58.6%. CONCLUSIONS: This predictive model demonstrated that hospital readmission within 12 months of discharge can be reasonably well predicted based on administrative data. It will help health care providers target interventions to prevent unnecessary hospital readmissions.

Medical savings accounts in a universal system: wishful thinking meets evidence.

Medical savings accounts (MSAs) and similar approaches based on flowing reimbursements through individuals/consumers rather than providers are unsuited for systems with universal coverage. Data from Manitoba, Canada reveal that, because expenditures for physician and hospital services are highly skewed in all age groups, MSAs would substantially increase both public expenditures and out-of-pocket costs for the most ill. The empirical distribution of health expenditures limits the potential impact of many current 'demand-based' approaches to cost control. Because most of the population is relatively healthy and uses few hospital and physician services, inducing the general population to spend less will not yield substantial savings.

Is herpes zoster vaccination likely to be cost-effective in Canada?

OBJECTIVES: To synthesize the current literature detailing the cost-effectiveness of the herpes zoster (HZ) vaccine, and to provide Canadian policy-makers with cost-effectiveness measurements in a Canadian context. METHODS: This article builds on an existing systematic review of the HZ vaccine that offers a quality assessment of 11 recent articles. We first replicated this study, and then two assessors reviewed the articles and extracted information on vaccine effectiveness, cost of HZ, other modelling assumptions and QALY estimates. Then we transformed the results into a format useful for Canadian policy decisions. Results expressed in different currencies from different years were converted into 2012 Canadian dollars using Bank of Canada exchange rates and a Consumer Price Index deflator. Modelling assumptions that varied between studies were synthesized. We tabled the results for comparability. SYNTHESIS: The Szucs systematic review presented a thorough methodological assessment of the relevant literature. However, the various studies presented results in a variety of currencies, and based their analyses on disparate methodological assumptions. Most of the current literature uses Markov chain models to estimate HZ prevalence. Cost assumptions, discount rate assumptions, assumptions about vaccine efficacy and waning and epidemiological assumptions drove variation in the outcomes. This article transforms the results into a table easily understood by policy-makers. CONCLUSION: The majority of the current literature shows that HZ vaccination is cost-effective at the price of $100,000 per QALY. Few studies showed that vaccination cost-effectiveness was higher than this threshold, and only under conservative assumptions. Cost-effectiveness was sensitive to vaccine price and discount rate.

Smoking during pregnancy: findings from the 2009-2010 Canadian Community Health Survey.

OBJECTIVES: Smoking during pregnancy may cause many health problems for pregnant women and their newborns. However, there is a paucity of research that has examined the predictors of smoking during pregnancy in Canada. This study used data from the 2009-2010 Canadian Community Health Survey (CCHS) to estimate the prevalence of smoking during pregnancy and examine the demographic, socioeconomic, health-related and behavioral determinants of this behavior. METHODS AND FINDINGS: The data were obtained from the 2009-2010 CCHS master data file. Weighted estimates of the prevalence were calculated. Multivariable logistic regression was used to determine demographic, socioeconomic, health related and behavioral characteristics associated with smoking behavior during pregnancy. Women living in the Northern Territories had a high rate of smoking during pregnancy (59.3%). The prevalence of smoking during pregnancy was also high among women under 25 years old, of low socioeconomic status, who reported not having a regular medical doctor, being fair to poor in self-perceived health, having at least one chronic disease, having at least one mental illness, being heavy smokers, and being regular alcohol drinkers. Results from multivariable logistic regression revealed that the odds of smoking during pregnancy were decreased with increasing age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.91-0.99), having a regular family doctor [OR, 0.24; 95% CI, 0.11-0.52], having highest level of family income [OR, 0.09; 95% CI, 0.03-0.29]. Mothers who reported poor or fair self-perceived health [OR, 2.13; 95% CI, 0.96-4.71] and those who had at least one mental illness [OR, 1.81; 95% CI, 1.00-3.28] had greater odds of smoking during pregnancy. CONCLUSIONS: There are a number of demographic, socio-economic, health-related and behavioral characteristics that should be considered in developing and implementing effective population health promotional strategies to prevent smoking during pregnancy, promoting health and well-being of pregnant women and their newborns.

Paying people to be healthy.

User Financial Incentives (UFIs) have emerged as a powerful tool for health promotion. Strong evidence suggests that large enough incentives paid to individuals conditional on behaviour they can control encourages more of the desired behaviour. However, such interventions can have unintended consequences for non-targeted behaviours. Implementation difficulties that result in individuals not understanding the nature of the incentive, unintended opportunities to "game" the system and inefficient roll-outs, can dampen results. Moreover, the legitimacy of paternalistic interventions by health planners requires careful consideration if we accept that the families involved will almost certainly be better judges of their own best interests than outsiders.