Changes in Inequality in Use of Maternal Health Care Services: Evidence from Skilled Birth Attendance in Mauritania for the Period 2007-2015.

Skilled birth attendance is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the use of skilled birth attendance services in Mauritania. The study identifies the inequality determinants and explores its changes over the period 2007−2015. The concentration curve, concentration index, decomposition of the concentration index, and Oaxaca-type decomposition technique were performed to measure socioeconomically-based inequalities in skilled birth attendance services utilization, and to identify the contribution of different determinants to such inequality as well as the changes in inequality overtime using data from Mauritania Multiple Indicator Cluster Surveys (MICS) 2007 and 2015. The concentration index for skilled birth attendance services use dropped from 0.6324 (p < 0.001) in 2007 to 0.5852 (p < 0.001) in 2015. Prenatal care, household wealth level, and rural−urban residence contributed most to socioeconomic inequality. The concentration index decomposition and the Oaxaca-type decomposition revealed that changes in prenatal care and rural−urban residence contributed positively to lower inequality, but household economic status had an opposite contribution. Clearly, the pro-rich inequality in skilled birth attendance is high in Mauritania, despite a slight decrease during the study period. Policy actions on eliminating geographical and socioeconomic inequalities should target increased access to skilled birth attendance. Multisectoral policy action is needed to improve social determinants of health and to remove health system bottlenecks. This will include the socioeconomic empowerment of women and girls, while enhancing the availability and affordability of reproductive and maternal health commodities. This policy action can be achieved through improving the availability of obstetric service providers in rural areas; ensuring better distribution and quality of health infrastructure, particularly health posts and health centers; and, ensuring user fees removal for equitable, efficient, and sustainable financial protection in line with the universal health coverage objectives.

Socio-demographic indicators of self-reported health based on EQ-5D-3L: A cross-country analysis of population surveys from 18 countries.

Background: Generic health-related quality of life instruments, such as the EQ-5D, are increasingly used by countries to monitor population health via general population health surveys. Our aim was to demonstrate analytic options to measure socio-demographic differences in self-reported health using the EuroQol Group's archive of EQ-5D-3L population surveys that accumulated over the past two decades. Methods: Analyses captured self-reported EQ-5D-3L data on over 100,000 individuals from 18 countries with nationally representative population surveys. Socio-demographic indicators employed were age, sex, educational level and income. Logistic regression odds ratios and the health concentration index methodology were used in the socio-demographic analysis of EQ-5D-3L data. Results: Statistically significant socio-demographic differences existed in all countries (p < 0.01) with the EQ VAS based health concentration index varying from 0.090 to 0.157 across countries. Age had generally the largest contributing share, while educational level also had a consistent role in explaining lower levels of self-reported health. Further analysis in a subset of 7 countries with income data showed that, beyond educational level, income itself had an additional significant impact on self-reported health. Among the 5 dimensions of the EQ-5D-3L descriptive system, problems with usual activities and pain/discomfort had the largest contribution to the concentration of overall self-assessed health measured on the EQ VAS in most countries. Conclusion: The EQ-5D-3L was shown to be a powerful multi-dimensional instrument in the analyses of socio-demographic differences in self-reported health using various analytic methods. It offered a unique insight of inequalities by health dimensions.

Real-World Budget Impact of the Adoption of Insulin Glargine Biosimilars in Primary Care in England (2015-2018).

BACKGROUND: Lantus, the reference insulin glargine used for the treatment of diabetes, lost its patent protection in 2014, opening the market to biosimilar competitors. OBJECTIVE: First, to analyze the adoption rates of insulin glargine biosimilars in primary care in England and estimate the savings realized and missed, since an insulin glargine biosimilar was first used, and second, to assess potential variations in adoption rates across Clinical Commissioning Groups (CCGs). RESEARCH DESIGN AND METHODS: Data sets capturing information on all insulin glargine items prescribed by all general practitioners up to December 2018 were used. Total costs of insulin glargine and uptake rates of biosimilars were calculated. The real-world budget impact was estimated assuming the cost of reference insulin glargine for all items and comparing the total costs in this scenario with the total costs in the real world. The missed savings were estimated assuming the cost of biosimilars for all insulin glargine items. Choropleth maps were generated to assess potential variations in uptake across CCGs. RESULTS: Insulin glargine biosimilars generated savings of £900,000 between October 2015 (time of first prescription) and December 2018. The missed savings amounted to £25.6 million in this period, indicating that only 3.42% of the potential savings were achieved. The analyses demonstrated a large level of variation in the uptake of insulin glargine biosimilars across CCGs, with market shares ranging from 0 to 53.3% (December 2018). CONCLUSIONS: These results may encourage decision makers in England to promote the use of best-value treatments in primary care and to reevaluate variation across CCGs.

Inequalities in prescription rates of anti-osteoporosis drugs in primary care in England: A practice-level prescribing data analysis in 2013-2018.

OBJECTIVE: To investigate potential variations in prescription rates of anti-osteoporosis drugs at the general practitioner (GP) practice level in England, analysing associations of prescription rates with key demographic and socio-economic variables, and its evolution over time. METHODS: A retrospective database analysis was conducted using prescription data from all GP practices in England between April 2013 and September 2018. Potential associations between prescription rates and other variables (sex, age, ethnicity, rural-urban classification and income deprivation) were analysed using mixed-effects Poisson regressions and concentration indices. RESULTS: Alendronic acid was the most frequently prescribed anti-osteoporosis drug. Exploratory and regression analyses showed the association between GP prescriptions and the characteristics of the population they serve. Income deprivation had a statistically significant and negative effect on prescription levels of alendronic acid, denosumab, ibandronic acid and risedronate sodium. Since 2013, denosumab prescriptions exhibited a steep surge in the least income-deprived areas, compared with a modest rise in the most income-deprived areas. Concentration indices indicated a disproportionate concentration of denosumab and, to a lesser extent, ibandronic acid prescriptions among the least income-deprived. The analyses demonstrated that different prescribing behaviours may exist across GPs according to the Clinical Commissioning Group (CCG) to which they belong. CONCLUSIONS: Variation in the prescription of anti-osteoporosis drugs exists across GPs and CCGs in England, this being more prominent for certain drugs (e.g. denosumab) compared with others (e.g. alendronic acid). Inequalities exist in English primary healthcare and we advocate our findings could support the efforts of decision-makers towards a more equitable system.

The Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) questionnaire. A validation study with Spanish schizophrenia spectrum outpatients.

INTRODUCTION: The Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) is a disease-specific subjective Quality of Life (QL) questionnaire for patients with schizophrenia. This study assesses the psychometric properties of the SQLS-R4 when applied to a sample of Spanish schizophrenia spectrum outpatients with stable disease. METHODS: The SQLS-R4 and EUROQOL-5D-5L were completed once by 168 schizophrenia and schizoaffective disorder patients. Of these, 61 also completed the WHOQOL-BREF and 50 completed the SQLS-R4 one week later. Psychometric evaluation of structure, reliability and validity was conducted. RESULTS: Multi-trait scaling confirmed the two multiitem scales. Internal consistency for the two scales (Cronbach’s coefficients>0.89) and the whole questionnaire (0.96) was adequate, as was test–retest reliability (intraclass correlation coefficients>0.79). Correlations with related areas of EUROQOL-5D-5L and WHOQOL-BREF (Spearman’s Rho>0.60) supported convergent validity. Divergent validity was confirmed through low correlations with less-related areas of these two questionnaires (Spearman’s Rho<0.30). Patients with higher levels of depression, more acute episodes and schizoaffective disorder had higher QL limitations. CONCLUSIONS: The SQLS-R4 is a reliable and valid instrument when applied to Spanish outpatients with stable disease. The results of our validation study concur with those of other psychometric studies performed in Europe and other cultural areas.

How the relationship between physical activity and health changes with age.

In the context of age-related declines in physical activity (PA) and the dramatic increase in ageing populations in many countries, this paper sheds further light on the link between PA and self-perceived health (SPH) by examining whether the magnitude of this relationship is age specific. With a sample of 14,456 Spanish individuals aged 18-69, we estimated three levels of intensity in PA using the International Physical Activity Questionnaire. Individuals who did more PA per week showed higher levels of SPH (ß = 0.28; 95% CI 0.24-0.32), and age moderated this relationship, with a positive effect over age 49. People aged 50-59 and 60-69 who practiced PA had higher probabilities of better SPH compared with those aged 40-49 (ß = 0.14; 95% CI 0.04-0.24) and (ß = 0.32; 95% CI 0.21-0.43), respectively. This association between PA and SPH also depended on the intensity of PA, especially for walking (ß = 0.14; 95% CI 0.04-0.24). In particular, in comparison with people age 40-49, a statistically significant relationship with SPH was found among people age 50-59 who walked (ß = 0.22; 95% CI 0.07-0.36) and people age 60-69 who did moderate PA (ß = 0.38; 95% CI 0.23-0.54). This paper provides a major rationale for the design, organisation and implementation of public policies promoting PA and healthy ageing for different age groups.

Impact of successful treatment with direct-acting antiviral agents on health-related quality of life in chronic hepatitis C patients.

BACKGROUND: Direct-acting antivirals (DAA) have demonstrated high efficacy to achieve sustained virological response (SVR) in chronic hepatitis C patients. We aim to assess the change in health-related quality of life (HRQoL) among patients successfully treated, and to identify predictors of this variation. METHODS: In a prospective observational study, patients with chronic hepatitis C who started DAA therapy between May 2016 and April 2017 completed the EQ-5D-5L questionnaire at baseline and 12 weeks after the end of therapy before knowing the virological result. Analysis included all patients with SVR. RESULTS: Median baseline EQ-5D-5L scores of the 206 enrolled patients were 0.857 utility and 70.0 visual analogue scale (VAS). Following SVR, a reduction occurred in the proportion of patients with mobility problems (35% vs 24%, p = 0.012), pain/discomfort (60% vs 42%, p<0.001) and anxiety/depression (57% vs 44%, p = 0.012), with an increase in utility (+0.053, p<0.001) and VAS (+10, p<0.001). Score improvements were also observed in cirrhotic (+0.048 utility, p = 0.027; +15 VAS, p<0.001) and HIV co-infected patients (+0.039 utility, p = 0.036; +5 VAS, p = 0.002). In multivariate analyses, middle age (45-64 years) and baseline anxiety/depression were associated to greater improvement in utility after SVR, and moderate-advanced liver fibrosis and cirrhosis to greater increase in VAS score. Low baseline values were associated to greater improvements in utility value and VAS score. CONCLUSIONS: The cure of chronic hepatitis C infection with DAA has a short term positive impact on HRQoL with improvement in mobility, pain/discomfort, anxiety/depression, utility value and VAS score. Patients with poor baseline HRQoL were the most beneficed.

Head-to-head comparison between the EQ-5D-5L and the EQ-5D-3L in general population health surveys.

BACKGROUND: The EQ-5D has been frequently used in national health surveys. This study is a head-to-head comparison to assess how expanding the number of levels from three (EQ-5D-3L) to five in the new EQ-5D-5L version has improved its distribution, discriminatory power, and validity in the general population. METHODS: A representative sample (N = 7554) from the Catalan Health Interview Survey 2011-2012, aged ≥18, answered both EQ-5D versions, and we evaluated the response redistribution and inconsistencies between them. To assess validity of this redistribution, we calculated the mean of the Visual Analogue Scale (VAS), which measures perceived health. The discriminatory power was examined with Shannon Indices, calculated for each dimension separately. Spanish preference value sets were applied to obtain utility indices, examining their distribution with statistics of central tendency and dispersion. We estimated the proportion of individuals reporting the best health state in EQ-5D-5L and EQ-5D-3L within groups of specific chronic conditions and their VAS mean. RESULTS: A very small reduction in the percentage of individuals with the best health state was observed, from 61.8% in EQ-5D-3L to 60.8% in EQ-5D-5L. In contrast, a large proportion of individuals reporting extreme problems in the 3 L version moved to severe problems (level 4) in the 5 L version, particularly for pain/discomfort (75.5%) and anxiety/depression (66.4%). The average proportion of inconsistencies was 0.9%. The pattern of the perceived health VAS mean confirmed the hypothesis established a priori, supporting the validity of the observed redistribution. Shannon index showed that absolute informativity was higher in the 5 L version for all dimensions. The means (SD) of the Spanish EQ-5D-3L and EQ-5D-5L indices were 0.87 (0.25) and 0.89 (0.22). The proportion of individuals with the best health state within each specific chronic condition was very similar, regardless of the EQ-5D version (≤ 30% in half of the 28 chronic conditions). CONCLUSION: Although the proportion of individuals with the best possible health state is still very high, our findings support that the increase of levels provided by the EQ-5D-5L contributed to the validity and discriminatory power of this new version to measure health in general population, as in the national health surveys.

Validity of the EQ-5D-5L and reference norms for the Spanish population.

BACKGROUND AND OBJECTIVE: The EuroQol 5 dimensions 5 levels (EQ-5D-5L) is the new version of EQ-5D, developed to improve its discriminatory capacity. This study aims to evaluate the construct validity of the Spanish version and provide index and dimension population-based reference norms for the new EQ-5D-5L. METHODS: Data were obtained from the 2011/2012 Spanish National Health Survey, with a representative sample (n = 20,587) of non-institutionalized Spanish adults (≥ 18 years). The EQ-5D-5L index was calculated by using the Spanish value set. Construct validity was evaluated by comparing known groups with estimators obtained through regression models, adjusted by age and gender. Sampling weights were applied to restore the representativeness of the sample and to calculate the norms stratified by gender and age groups. We calculated the percentages and standard errors of dimensions, and the deciles, percentiles 5 and 95, means, and 95% confidence intervals of the health index. RESULTS: All the hypotheses established a priori for known groups were confirmed (P < 0.001). The EQ-5D-5L index indicated worse health in groups with lower education level (from 0.94 to 0.87), higher number of chronic conditions (0.96-0.79), probable psychiatric disorder (0.94 vs 0.80), strong limitations (0.96-0.46), higher number of days of restriction (0.93-0.64) or confinement to bed (0.92-0.49), and hospitalized in the previous 12 months (0.92 vs 0.81). CONCLUSIONS: The EQ-5D-5L is a valid instrument to measure perceived health in the Spanish-speaking population. The representative population-based norms provided here will help improve the interpretation of results obtained with the new EQ-5D-5L.

Cost analysis and cost-benefit analysis of a medication review with follow-up service in aged polypharmacy patients.

BACKGROUND: Drug related problems have a significant clinical and economic burden on patients and the healthcare system. Medication review with follow-up (MRF) is a professional pharmacy service aimed at improving patient's health outcomes through an optimization of the medication. OBJECTIVE: To ascertain the economic impact of the MRF service provided in community pharmacies to aged polypharmacy patients comparing MRF with usual care, by undertaking a cost analysis and a cost-benefit analysis. METHODS: The economic evaluation was based on a cluster randomized controlled trial. Patients in the intervention group (IG) received the MRF service and the comparison group (CG) received usual care. The analysis was conducted from the national health system (NHS) perspective over 6 months. Direct medical costs were included and expressed in euros at 2014 prices. Health benefits were estimated by assigning a monetary value to the quality-adjusted life years. One-way deterministic sensitivity analysis was undertaken in order to analyse the uncertainty. RESULTS: The analysis included 1403 patients (IG: n = 688 vs CG: n = 715). The cost analysis showed that the MRF saved 97 € per patient in 6 months. Extrapolating data to 1 year and assuming a fee for service of 22 € per patient-month, the estimated savings were 273 € per patient-year. The cost-benefit ratio revealed that for every 1 € invested in MRF, a benefit of 3.3 € to 6.2 € was obtained. CONCLUSION: The MRF provided health benefits to patients and substantial cost savings to the NHS. Investment in this service would represent an efficient use of healthcare resources.

Valuation and Modeling of EQ-5D-5L Health States Using a Hybrid Approach.

BACKGROUND: The EQ-5D instrument is the most widely used preference-based health-related quality of life questionnaire in cost-effectiveness analysis of health care technologies. Recently, a version called EQ-5D-5L with 5 levels on each dimension was developed. This manuscript explores the performance of a hybrid approach for the modeling of EQ-5D-5L valuation data. METHODS: Two elicitation techniques, the composite time trade-off, and discrete choice experiments, were applied to a sample of the Spanish population (n=1000) using a computer-based questionnaire. The sampling process consisted of 2 stages: stratified sampling of geographic area, followed by systematic sampling in each area. A hybrid regression model combining composite time trade-off and discrete choice data was used to estimate the potential value sets using main effects as starting point. The comparison between the models was performed using the criteria of logical consistency, goodness of fit, and parsimony. RESULTS: Twenty-seven participants from the 1000 were removed following the exclusion criteria. The best-fitted model included 2 significant interaction terms but resulted in marginal improvements in model fit compared to the main effects model. We therefore selected the model results with main effects as a potential value set for this methodological study, based on the parsimony criteria. The results showed that the main effects hybrid model was consistent, with a range of utility values between 1 and -0.224. CONCLUSION: This paper shows the feasibility of using a hybrid approach to estimate a value set for EQ-5D-5L valuation data.

Incentives and intrinsic motivation in healthcare.

OBJECTIVE: It has been established in the literature that workers within public organisations are intrinsically motivated. This paper is an empirical study of the healthcare sector using methods of qualitative analysis research, which aims to answer the following hypotheses: 1) doctors are intrinsically motivated; 2) economic incentives and control policies may undermine doctors' intrinsic motivation; and 3) well-designed incentives may encourage doctors' intrinsic motivation. METHOD: We conducted semi-structured interviews à-la-Bewley with 16 doctors from Navarre's Healthcare Service (Servicio Navarro de Salud-Osasunbidea), Spain. The questions were based on current theories of intrinsic motivation and incentives to test the hypotheses. Interviewees were allowed to respond openly without time constraints. Relevant information was selected, quantified and analysed by using the qualitative concepts of saturation and codification. RESULTS: The results seem to confirm the hypotheses. Evidence supporting hypotheses 1 and 2 was gathered from all interviewees, as well as indications of the validity of hypothesis 3 based on interviewees' proposals of incentives. CONCLUSIONS: The conclusions could act as a guide to support the optimal design of incentive policies and schemes within health organisations when healthcare professionals are intrinsically motivated.

Cost-effectiveness analysis of a collaborative care programme for depression in primary care.

BACKGROUND: Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care. METHODS: A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007-2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs). RESULTS: Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane. LIMITATIONS: The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression. CONCLUSIONS: The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation.

Cost-effectiveness analysis of the surgical treatment of female urinary incontinence using slings and meshes.

OBJECTIVE: To determine the cost-utility and cost-effectiveness of the surgical treatment of female urinary incontinence using suburethral slings and prolapse meshes compared with therapeutic abstention. STUDY DESIGN: An economic analysis was performed on 69 women receiving surgical treatment for urinary incontinence using suburethral slings and prolapse meshes. To calculate the procedure's cost-effectiveness, an incremental analysis up to one year was performed using the incremental cost-effectiveness ratio (ICER). The costs were calculated using a cost-by-process model. Answers to the health-related quality of life questionnaires EQ-5D (generic) and International Consultation Incontinence Questionnaire Short-form (specific) were collected before the operation and as well as one month and one year post-operation to calculate the utility, using quality-adjusted life years (QALY), and the effectiveness, respectively. To complete the economic evaluation, we derived confidence ellipses and acceptability curves. The analysis was conducted for the entire sample and also for each type of urinary incontinence. RESULTS: In total, 45 women presented with stress incontinence, 15 with mixed incontinence and 9 with incontinence associated with prolapse. The average cost per patient at one year post-operation was 1220 €. The QALY achieved at one year was 0.046. The results reveal an ICER at one year of 26,288 €/QALY, which is below the cost-effectiveness threshold considered acceptable, and this value was lower for stress incontinence (21,191 €/QALY). The cost-effectiveness was 106.5 €/International Consultation Incontinence Questionnaire Short-form unit. CONCLUSION: Surgery for female urinary incontinence using slings is cost-effective compared with abstention in our public health environment.

Dealing with the health state 'dead' when using discrete choice experiments to obtain values for EQ-5D-5L heath states.

OBJECTIVE: To evaluate two different methods to obtain a dead (0)--full health (1) scale for EQ-5D-5L valuation studies when using discrete choice (DC) modeling. METHOD: The study was carried out among 400 respondents from Barcelona who were representative of the Spanish population in terms of age, sex, and level of education. The DC design included 50 pairs of health states in five blocks. Participants were forced to choose between two EQ-5D-5L states (A and B). Two extra questions concerned whether A and B were considered worse than dead. Each participant performed ten choice exercises. In addition, values were collected using lead-time trade-off (lead-time TTO), for which 100 states in ten blocks were selected. Each participant performed five lead-time TTO exercises. These consisted of DC models offering the health state 'dead' as one of the choices--for which all participants' responses were used (DCdead)--and a model that included only the responses of participants who chose at least one state as worse than dead (WTD) (DCWTD). The study also estimated DC models rescaled with lead-time TTO data and a lead-time TTO linear model. RESULTS: The DC(dead) and DCWTD models produced relatively similar results, although the coefficients in the DCdead model were slightly lower. The DC model rescaled with lead-time TTO data produced higher utility decrements. Lead-time TTO produced the highest utility decrements. CONCLUSIONS: The incorporation of the state 'dead' in the DC models produces results in concordance with DC models that do not include 'dead'.

The cost of generalized anxiety disorder in primary care settings: results of the ANCORA study.

To assess the cost of illness of generalized anxiety disorder (GAD) in a primary healthcare setting in Spain. A cross-sectional, retrospective study was conducted. The sample comprised patients diagnosed with GAD according to ICD-10 criteria and a control group. Healthcare/non-healthcare resource utilization was recorded retrospectively for the 12 months prior to the study visit. Costs were estimated from a societal perspective. Two models have been produced to study the variables that influence the cost of the illness both, without and with controls. The study enrolled 456 patients [76.8 % women, 49.2 (17.0) years] with GAD and 74 controls without GAD [42.5 % women, 47.9 (16.7) years]. 67.8 % of subjects were on combination therapy (antidepressant + anxiolytic); 6 % were using 2 or more drugs to treat anxiety; and 23.4 % were on monotherapy. Total annual average costs were higher in the GAD group (€7,739 vs. €2,609), with mean costs attributable to GAD of €5,139 (healthcare costs: €1,329, indirect costs: 75 % of total cost, approximately). Age and health status measured by Hamilton Anxiety Rating Scale and clinical global impression were related to costs. The improvements in quality of life measured by EQ-5D index are associated to lower cost. GAD treated in Spanish primary healthcare settings generated considerable healthcare costs and, particularly, loss-of-productivity costs.