Hepatocellular carcinoma surveillance based on the Australian Consensus Guidelines: a health economic modelling study.

BACKGROUND: Hepatocellular carcinoma (HCC) is the fastest increasing cause of cancer death in Australia. A recent Australian consensus guidelines recommended HCC surveillance for cirrhotic patients and non-cirrhotic chronic hepatitis B (CHB) patients at gender and age specific cut-offs. A cost-effectiveness model was then developed to assess surveillance strategies in Australia. METHODS: A microsimulation model was used to evaluate three strategies: biannual ultrasound, biannual ultrasound with alpha-fetoprotein (AFP) and no formal surveillance for patients having one of the conditions: non-cirrhotic CHB, compensated cirrhosis or decompensated cirrhosis. One-way and probabilistic sensitivity analyses as well as scenario and threshold analyses were conducted to account for uncertainties: including exclusive surveillance of CHB, compensated cirrhosis or decompensated cirrhosis populations; impact of obesity on ultrasound sensitivity; real-world adherence rate; and different cohort's ranges of ages. RESULTS: Sixty HCC surveillance scenarios were considered for the baseline population. The ultrasound + AFP strategy was the most cost-effective with incremental cost-effectiveness ratios (ICER) compared to no surveillance falling below the willingness-to-pay threshold of A$50,000 per quality-adjusted life year (QALY) at all age ranges. Ultrasound alone was also cost-effective, but the strategy was dominated by ultrasound + AFP. Surveillance was cost-effective in the compensated and decompensated cirrhosis populations alone (ICERs < $30,000), but not cost-effective in the CHB population (ICERs > $100,000). Obesity could decrease the diagnostic performance of ultrasound, which in turn, reduce the cost-effectiveness of ultrasound ± AFP, but the strategies remained cost-effective. CONCLUSIONS: HCC surveillance based on Australian recommendations using biannual ultrasound ± AFP was cost-effective.

Survival of primary liver cancer for people from culturally and linguistically diverse backgrounds in Australia.

BACKGROUND: Survival for Primary Liver Cancer (PLC) has been investigated in Australia, but limited work has been conducted on the burden for people with different socioeconomic status, region of residence, causes of PLC, and culturally and linguistically diverse (CALD) backgrounds. This study aimed to cover this gap in the literature by investigating PLC survival with the aforementioned factors. METHODS: This study linked four administrative datasets: Victorian Cancer Registry, Admitted Episodes Dataset, Emergency Minimum Dataset, and Death Index. The cohort was all cases with a PLC notification within the Victorian Cancer Registry between 01/01/2008 and 01/01/2016. The Kaplan-Meier method was used to estimate survival probabilities and the log-rank test was used to compare the difference in survival between subgroups. The Cox proportional hazard model was used to explore factors associated with PLC survival. RESULTS: The 1-, 3- and 5-year survival rates were 50.0%, 28.1% and 20.6%, respectively, with a median survival of 12.0 months (95% confidence interval (CI): 11.0 - 12.9 months). Higher survival was associated with younger age, hepatocellular carcinoma, and higher socio-economic status. People born in Asian, African, and American regions had higher survival than those born in Australia and New Zealand. Cases with viral hepatitis as an identified aetiology had higher survival than those whose PLC was related to alcohol consumption (hazard ratio=1.52, 95% CI: 1.19 - 1.96), diabetes and fatty liver disease (hazard ratio=1.35, 95% CI: 1.08 - 1.68). CONCLUSION: Survival outcomes for people diagnosed with PLC were still poor and affected by many factors. Asian and African cases had better survival than Australian and New Zealand patients as PLC in Asian and African cases was mostly caused by viral hepatitis. Metropolitan areas were associated with a higher survival than rural areas, not only due to accessibility to surveillance and healthcare services but also because the majority of overseas-born patients reside in metropolitan areas.

Hospitalisation costs of primary liver cancer in Australia: evidence from a data-linkage study.

Objective This study aimed to estimate the public hospital costs associated with primary liver cancer (PLC) in the first and second years following the cancer diagnosis. Methods This study linked administrative datasets of patients diagnosed with PLC in Victoria, Australia, from January 2008 to December 2015. The health system perspective was adopted to estimate the direct healthcare costs associated with PLC, based on inpatient and emergency costs. Costs were estimated for the first 12 months and 12-24 months after the PLC diagnosis and expressed in 2017 Australian dollars (A$). The cost estimated was then extrapolated nationally. The linear mixed model with a Box-Cox transformation of the costs was used to explore the relationship between costs and patients' sociodemographic and clinical characteristics. Results For the first 12 months, the total and annual per-patient cost was A$211.4 million and A$63 664, respectively. Costs for the subsequent year were A$49.7 million and A$46 751, respectively. Regarding the cost extrapolation to Australia, the total cost was A$137 million for the first 12 months after notification and A$42.6 million for the period from 12 to 24 months. Higher costs per episode of care were mostly associated with older age, hepatocellular carcinoma type of PLC, metropolitan hospitals, and Asian birth region. Conclusion This study showed the public hospital admission and emergency costs associated with PLC and the substantial economic burden this cancer has placed on the Australian health system.

Trauma Care Training in Vietnam: Narrative Scoping Review.

BACKGROUND: The model of trauma in Vietnam has changed significantly over the last decade and requires reforming medical education to deal with new circumstances. Our aim is to evaluate this transition regarding the new target by analyzing trauma and the medical training system as a whole. OBJECTIVE: This study aimed to establish if medical training in the developing country of Vietnam has adapted to the new disease pattern of road trauma emerging in its economy. METHODS: A review was performed of Vietnamese medical school, Ministry of Health, and Ministry of Education and Training literature on trauma education. The review process and final review paper were prepared following the guidelines on scoping reviews and using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. RESULTS: The current trauma training at the undergraduate level is minimal and involves less than 5% of the total credit. At the postgraduate level, only the specialties of surgery and anesthesia have a significant and increasing trauma training component ranging from 8% to 22% in the content. Trauma training, which focuses on practical skills, accounts for 31% and 32% of the training time of orientation courses for young doctors in "basic surgery" and "basic anesthesia," respectively. Other relevant short course trainings, such as continuing medical education, in trauma are available, but they vary in topics, facilitators, participants, and formats. CONCLUSIONS: Medical training in Vietnam has not adapted to the new emerging disease pattern of road trauma. In the interim, the implementation of short courses, such as basic trauma life support and primary trauma care, can be considered as an appropriate method to compensate for the insufficient competency-related trauma care among health care workers while waiting for the effectiveness of medical training reformation.

A Systematic Review and Narrative Synthesis of Health Economic Evaluations of Hepatocellular Carcinoma Screening Strategies.

OBJECTIVES: Many economic evaluations of hepatocellular carcinoma (HCC) screenings have been conducted; however, these vary substantially with regards to screening strategies, patient group, and setting. This review aims to report the current knowledge of the cost-effectiveness of screening and describe the published data. METHODS: We conducted a search of biomedical and health economic databases up to July 2020. We included full and partial health economic studies if they evaluated the costs or outcomes of HCC screening strategies. RESULTS: The review included 43 studies. Due to significant heterogeneity in key aspects across the studies, a narrative synthesis was conducted. Most studies reported using ultrasound or alpha fetoprotein as screening strategies. Screening intervals were mostly annual or biannual. Incidence, diagnostic performance, and health state utility values were the most critical parameters affecting the cost-effectiveness of screening. The majority of studies reported HCC screening to be cost-effective, with the biannual ultrasound + alpha fetoprotein standing out as the most cost-effective strategy. However, few studies considered the utilization rate, and none considered the diagnostic performance of ultrasound in the context of central adiposity. Computed tomography and magnetic resonance imaging were also evaluated, but its cost-effectiveness was still controversial. CONCLUSIONS: Although many studies suggested HCC screening was cost-effective, substantial limitations of the quality of these studies means the results should be interpreted with caution. Future modeling studies should consider the impact of central adiposity on the precision of ultrasound, real-world utilization rates and projections of increased HCC incidence.

The Interdependence of Blood Pressure and Glucose in Vietnam.

INTRODUCTION: Modelling of associations of systolic blood pressure (BP) and blood glucose (BG) with their explanatory factors in separate regressions treats them as having independent biological mechanisms. This can lead to statistical inferences that are unreliable because the substantial overlap in their etiologic and disease mechanisms is ignored. AIM: This study aimed to examine the relationship of systolic blood pressure (BP) and blood glucose (BG) with measures of obesity and central fat distribution and other factors whilst taking account of the inter-dependence between them. METHODS: Participants (n = 14706, 53.5 % females) aged 25-64 years were selected by multi-stage stratified cluster sampling from eight provinces each representing one of the eight geographical regions of Vietnam. Measurements were made using the World Health Organization STEPS protocols. RESULTS: Structural modelling identified direct effects for BG (men P = 0.000, women P = 0.029), age (men P = 0.000, women P = 0.000) and body mass index (BMI) (men P = 0.000, women P = 0.000) in the estimation of systolic BP, and for systolic BP (men P = 0.036, women P = 0.000) and waist circumference (WC) (men P = 0.032, women P = 0.009) in the estimation of BG. There were indirect effects of age, cholesterol, physical activity and tobacco smoking via their influence on WC and BMI. The errors in estimation of systolic BP and BG were correlated (men P = 0.000, women P = 0.004), the stability indices (men 0.466, women 0.495) showed the non-recursive models were stable, and the proportion of variance explained was mid-range (men 0.553, women 0.579). CONCLUSION: This study provided statistical evidence of a feedback loop between systolic BP and BG. BMI and WC were confirmed to be their primary explanatory factors. Saturated fat intake and physical activity were identified as possible targets of intervention for overweight and obesity, and indirectly for reducing systolic BP and BG. Harmful/hazardous alcohol intake was identified as a target of intervention for systolic BP.

Sex Differences in Causes of Death After Stroke: Evidence from a National, Prospective Registry.

Background: We examined sex differences in cause of death and cause-specific excess mortality after stroke. Materials and Methods: First-ever strokes (2010-2013; 35 hospitals) participating in the Australian Stroke Clinical Registry were linked to national death registrations and other administrative datasets. One-year cause-specific mortality was categorized as stroke, ischemic heart disease, other cardiovascular disease (CVD; e.g., hypertension), cancer, and other. Specific hazard ratios (sHRs) of death for women compared to men were estimated using competing risk models, with adjustment for factors differing by sex (e.g., age and stroke severity). Age- and sex-specific mortality rates expected in the general population were derived from national data. Standardized mortality ratios (SMRs; observed/expected deaths) were estimated for cause-specific mortality by sex after age standardization. Results: Among 9,441 cases (46% women), women were 7 years older than men, had more severe strokes, and received similar patterns of suboptimal secondary prevention medications at discharge. Women had greater mortality associated with stroke (sHRunadjusted 1.65) and other CVD (sHRunadjusted 1.65), which was related to age and stroke severity rather than other factors. Compared to population norms, those surviving to 30 days had eight-fold increased mortality from stroke (primary/recurrent) events irrespective of sex (SMRage-standardised women 8.8; men 8.3). Excess mortality from other CVD was greater in women (SMRage-standardised 3.6 vs. men 2.8; p = 0.026). Conclusions: Cause-specific mortality after first-ever stroke differs by sex. The greater death rate attributed to stroke/other CVD in women was mostly explained by age and stroke severity. Greater implementation of secondary stroke prevention is relevant to both sexes.

Rationale and design of a trial to personalize risk assessment in familial coronary artery disease.

BACKGROUND: The lifetime risk of coronary artery disease (CAD) is doubled in people with a family history of premature disease, yet this risk is not captured in most 5- or 10-year risk assessment algorithms. Coronary artery calcium scoring (CCS) is a marker of subclinical CAD risk, which has been shown in observational studies to provide prognostic information that is incremental to clinical assessment; is relatively inexpensive; and is performed with a small radiation dose. However, the use of CCS in guiding prevention is not strongly supported by guidelines. Showing definitive evidence of the efficacy and cost-effectiveness of CCS is therefore of importance. STUDY DESIGN: The proposed randomized controlled trial of the use of CCS will be targeted to 40- to 70-year-old first-degree relatives of patients with CAD onset <60 years old or second-degree relatives of patients with onset <50 years old. Control patients will undergo standard risk scoring and be blinded to CCS results. In the intervention group, primary prevention in patients undergoing CCS will be informed by this score. At 3 years, effectiveness will be assessed on change in plaque volume at computed tomography coronary angiography, the extent of which has been strongly linked to outcome. SUMMARY: The CAUGHT-CAD trial will provide evidence to inform the guidelines regarding the place of CCS in decision making regarding primary prevention of patients with a family history of premature disease.

National survey of risk factors for non-communicable disease in Vietnam: prevalence estimates and an assessment of their validity.

BACKGROUND: To estimate the prevalence of non-communicable disease (NCD) risk factors at a provincial level in Vietnam, and to assess whether the summary estimates allow reliable inferences to be drawn regarding regional differences in risk factors and associations between them. METHODS: Participants (n = 14706, 53.5 % females) aged 25-64 years were selected by multi-stage stratified cluster sampling from eight provinces each representing one of the eight geographical regions of Vietnam. Measurements were made using the World Health Organization STEPS protocols. Data were analysed using complex survey methods. RESULTS: Differences by sex in mean years of schooling (males 8.26 ± 0.20, females 7.00 ± 0.18), proportions of current smokers (males 57.70 %, females 1.73 %), and binge-drinkers (males 25.11 %, females 0.63 %), and regional differences in diet, reflected the geographical and socio-cultural characteristics of the country. Provinces with a higher proportion of urban population had greater mean levels of BMI (r = 0.82), and lesser proportions of active people (r = -0.89). The associations between the summary estimates were generally plausible (e.g. physical activity and BMI, r = -0.80) but overstated, and with some anomalous findings due to characterisation of smoking and hypertension by STEPS protocols. CONCLUSIONS: This report provides an extensive description of the sex-specific and regional distribution of NCD risk factors in Vietnam and an account of some health-related consequences of industrialisation in its early stages. The STEPS protocols can be utilized to provide aggregate data for valid between-population comparisons, but with important caveats identified.

The cross-sectional association of sitting time with carotid artery stiffness in young adults.

OBJECTIVES: Physical activity is negatively associated with arterial stiffness. However, the relationship between sedentary behaviour and arterial stiffness is poorly understood. In this study, we aimed to investigate the association of sedentary behaviour with arterial stiffness among young adults. DESIGN: Cross-sectional. SETTING: 34 study clinics across Australia during 2004-2006. PARTICIPANTS: 2328 participants (49.4% male) aged 26-36 years who were followed up from a nationally representative sample of Australian schoolchildren in 1985. MEASUREMENTS: Arterial stiffness was measured by carotid ultrasound. Sitting time per weekday and weekend day, and physical activity were self-reported by questionnaire. Cardiorespiratory fitness was estimated as physical work capacity at a heart rate of 170 bpm. Anthropometry, blood pressure, resting heart rate and blood biochemistry were measured. Potential confounders, including strength training, education, smoking, diet, alcohol consumption and parity, were self-reported. Rank correlation was used for analysis. RESULTS: Sitting time per weekend day, but not per weekday, was correlated with arterial stiffness (males r=0.11 p<0.01, females r=0.08, p<0.05) and cardiorespiratory fitness (males r = -0.14, females r = -0.08, p<0.05), and also with fatness and resting heart rate. One additional hour of sitting per weekend day was associated with 5.6% (males p=0.046) and 8.6% (females p=0.05) higher risk of having metabolic syndrome. These associations were independent of physical activity and other potential confounders. The association of sitting time per weekend day with arterial stiffness was not mediated by resting heart rate, fatness or metabolic syndrome. CONCLUSIONS: Our study demonstrates a positive association of sitting time with arterial stiffness. The greater role of sitting time per weekend day in prediction of arterial stiffness and cardiometabolic risk than that of sitting time per weekday may be due to better reflection of discretionary sitting behaviour.

Resting heart rate and the association of physical fitness with carotid artery stiffness.

BACKGROUND: Physical fitness is known to influence arterial stiffness. Resting heart rate is reduced by exercise and positively associated with arterial stiffness. This study aimed to investigate the role of resting heart rate in the relationship of physical fitness with arterial stiffness. METHODS: Subjects were 2,328 young adults from the Childhood Determinants of Adult Health study. Cardiorespiratory fitness was estimated as physical work capacity at a heart rate of 170 bpm. Muscular strength was estimated by hand-grip (both sides), shoulder (pull and push), and leg strength. Arterial stiffness was measured using carotid ultrasound. RESULTS: Arterial stiffness was negatively associated with cardiorespiratory fitness (men P < 0.001; women P = 0.002), and positively associated with muscular strength in women (P = 0.002) but not in men. Resting heart rate was positively associated with arterial stiffness (P < 0.001 both men and women). Adjustment for resting heart rate reduced the inverse association of arterial stiffness with cardiorespiratory fitness by 93.7% (men) and 67.6% (women) but substantially increased the positive association of arterial stiffness with muscular strength among women and revealed a positive association of arterial stiffness with muscular strength among men. These findings were independent of body size, blood pressure, biochemical markers, socioeconomic status, smoking, and alcohol consumption. CONCLUSIONS: Our findings attribute a key intermediary role for resting heart rate in the relationship between fitness and arterial stiffness, whereby higher cardiorespiratory fitness may reduce arterial stiffness mainly through resting heart rate, and higher muscular strength might have deleterious effects on arterial stiffness that are partially offset by lower resting heart rate.