Cost-effectiveness of physical activity intervention in children - results based on the Physical Activity and Nutrition in Children (PANIC) study.

BACKGROUND: We assessed the cost-effectiveness of a 2-year physical activity (PA) intervention combining family-based PA counselling and after-school exercise clubs in primary-school children compared to no intervention from an extended service payer's perspective. METHODS: The participants included 506 children (245 girls, 261 boys) allocated to an intervention group (306 children, 60 %) and a control group (200 children, 40 %). The children and their parents in the intervention group had six PA counselling visits, and the children also had the opportunity to participate in after-school exercise clubs. The control group received verbal and written advice on health-improving PA at baseline. A change in total PA over two years was used as the outcome measure. Intervention costs included those related to the family-based PA counselling, the after-school exercise clubs, and the parents' taking time off to travel to and participate in the counselling. The cost-effectiveness analyses were performed using the intention-to-treat principle. The costs per increased PA hour (incremental cost-effectiveness ratio, ICER) were based on net monetary benefit (NMB) regression adjusted for baseline PA and background variables. The results are presented with NMB and cost-effectiveness acceptability curves. RESULTS: Over two years, total PA increased on average by 108 h in the intervention group (95 % confidence interval [CI] from 95 to 121, p < 0.001) and decreased by 65.5 h (95 % CI from 81.7 to 48.3, p < 0.001) in the control group, the difference being 173.7 h. the incremental effectiveness was 87 (173/2) hours. For two years, the intervention costs were €619 without parents' time use costs and €860 with these costs. The costs per increased PA hour were €6.21 without and €8.62 with these costs. The willingness to pay required for 95 % probability of cost-effectiveness was €14 and €19 with these costs. The sensitivity analyses revealed that the ICER without assuming this linear change in PA were €3.10 and €4.31. CONCLUSIONS: The PA intervention would be cost-effective compared to no intervention among children if the service payer's willingness-to-pay for a 1-hour increase in PA is €8.62 with parents' time costs. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01803776. Registered 4 March 2013 - Retrospectively registered, https://clinicaltrials.gov/ct2/results?cond=&term=01803776&cntry=&state=&city=&dist= .

Patient- and health care-related factors associated with initiation of potentially inappropriate medication in community-dwelling older persons.

Potentially inappropriate medications (PIMs) in older persons are defined as medications of which the potential harms outweigh their benefits. The purpose of this study was to determine how initiation of PIMs accumulate in community-dwelling persons aged 65-74 and ≥75 years, and which patient- and health care-related factors are associated with PIM initiation over time. Data of this study were gathered from population-based registers by a 10% random sample of persons (n = 28 497) aged ≥65 years with no prior PIMs within a 2-year period preceding the index date (1 January 2002), and the study individuals were followed until 2013. The Finnish Prescription Register was linked using a personal identity code to register on inpatient care and causes of deaths and socio-economic data. In this study, 10 698 (37.5%) persons initiated PIMs during the study period. Female gender was associated with PIM initiation in 65-74-year-olds, but not in ≥75-year-olds. In 65-74-year-olds, the risk of PIM initiation increased with the higher income, whereas in ≥75-year-olds, the association between PIM initiation and the high income was not significant. The prescribing physician explained 9%-16% of the variation in the probability of PIM initiation. In conclusion, there were age-related differences in the factors associated with PIM initiation in relation to gender and socio-economic status. Overall, patient-related factors explained a large proportion of variation of PIM initiation, but there were also differences in PIM prescribing among physicians. However, physician-related variance of PIM initiations decreased during the 12-year follow-up.

Electrode migration after cochlear implant surgery: more common than expected?

The overall complication rate of cochlear implant surgery is low and so-called electrode failures (electrode migration, misplacement, etc.,) account for only a minority of all complications. The aim of this study was to explore the prevalence of electrode migration as the cause for increased impedance values and non-auditory stimulation in the basal channels. Within the scope of a quality control process, the cochlear implant database of the Kuopio University Hospital (Finland) was reviewed. Patients with gradual elevation of impedance values and/or non-auditory stimulation of the basal electrode channels were re-examined and cone-beam computed tomography was administered. There were 162 cochlear implant recipients and 201 implanted devices registered in the database. A total of 18 patients (18 devices) were identified having significantly increased impedance values or non-auditory stimulation of the basal electrodes. Cone-beam computed tomography revealed extra-cochlear electrodes in 12 of these patients due to the migration of the electrode array. All extruded electrodes were lateral wall electrodes, i.e., straight electrode arrays (Cochlear CI422 and Med-El devices). The most common feature of electrode migration was the gradual increase of the impedance values in the basal electrodes, even though telemetry could also be unsuspicious. Electrode migration after cochlear implant surgery may be more common than previously reported. At surgery, special attention should be paid to the reliable fixation of the electrode array. This study underlines the importance of postoperative imaging after cochlear implant surgery.

Alcohol use among adolescents, aggressive behaviour, and internalizing problems.

Alcohol use is common among adolescents, but its association with behavioural and emotional problems is not well understood. This study aimed to investigate how self-reported psychosocial problems were associated with the use of alcohol in a community sample consisting of 4074 Finnish adolescents aged 13-18 years. Aggressive behaviour associated with alcohol use and a high level of alcohol consumption, while internalizing problems did not associate with alcohol use. Having problems in social relationships associated with abstinence and lower alcohol consumption. Tobacco smoking, early menarche and attention problems also associated with alcohol use.

Cost-minimisation analysis of endometrial thermal ablation in a day case or outpatient setting under different anaesthesia regimens.

OBJECTIVE: To evaluate the cost difference between a daycase endometrial thermal ablation performed under general anaesthesia and an outpatient endometrial ablation using local anaesthetic. STUDY DESIGN: Calculations using real reported resource use in 20 daycase procedures and 16 outpatient procedures. RESULTS: The costs were 1865 euros for daycase procedure versus 1065 euros for outpatient procedure. CONCLUSION: The cost of endometrial thermal ablation can be considerably minimised by taking the procedure out of the theatre and performing it under local anaesthetic instead of general anaesthesia. This setting makes endometrial thermal ablation cost-effective.

Speech recognition and communication outcomes with cochlear implantation in Usher syndrome type 3.

BACKGROUND: Usher syndrome Type 3 (USH3) is an autosomal recessive disorder characterized by variable type and degree of progressive sensorineural hearing loss and retinitis pigmentosa. Cochlear implants are widely used among these patients. OBJECTIVES: To evaluate the results and benefits of cochlear implantation in patients with USH3. STUDY DESIGN: A nationwide multicenter retrospective review. MATERIALS AND METHODS: During the years 1995-2005, in 5 Finnish university hospitals, 19 patients with USH3 received a cochlear implant. Saliva samples were collected to verify the USH3 genotype. Patients answered to 3 questionnaires: Glasgow Benefit Inventory, Glasgow Health Status Inventory, and a self-made questionnaire. Audiological data were collected from patient records. RESULTS: All the patients with USH3 in the study were homozygous for the Finnish major mutation (p.Y176X). Either they had severe sensorineural hearing loss or they were profoundly deaf. The mean preoperative hearing level (pure-tone average, 0.5-4 kHz) was 110 ± 8 dB hearing loss (HL) and the mean aided hearing level was 58 ± 11 dB HL. The postoperative hearing level (34 ± 9 dB HL) and word recognition scores were significantly better than before surgery. According to the Glasgow Benefit Inventory scores and Glasgow Health Status Inventory data related to hearing, the cochlear implantation was beneficial to patients with USH3. CONCLUSION: Cochlear implantation is beneficial to patients with USH3, and patients learn to use the implant without assistance.

A 14-year prospective follow-up study of children treated early in life with tympanostomy tubes: Part 1: Clinical outcomes.

OBJECTIVE: To determine 14-year otological outcomes in young children treated with early insertion of ventilation tubes (VTs) for recurrent acute otitis media or otitis media with effusion (OME). DESIGN: Prospective 14-year follow-up. SETTING: Central Hospital of Central Finland, a tertiary care hospital. Patients Three hundred five consecutive infants and young children aged 5 to 16 months with otitis media were enrolled for early initial tympanostomy tube insertion. The final study group comprised 237 patients (77.7%) attending the 14-year checkup. MAIN OUTCOME MEASURES: At the 14-year checkups, abnormal otological findings were recorded and results compared with those of the 5-year checkups. RESULTS: From 5 to 14 years' follow-up, the number of healed ears increased from 156 (65.8%) to 177 (74.7%), while the number healed of ears with abnormal outcomes decreased from 81 (34.2%) to 60 (25.3%). Of 156 healed ears, 142 (91.0%) remained healed, and 35 (43.2%) of 81 ears with abnormal outcomes healed. The proportion of abnormal outcomes was higher among ears with OME (P = .02) and with 3 or more VT insertions (P<.001). Repeated tympanostomy tube insertion was performed in 141 ears (59.5%), more often in those with OME (P = .003), and ear surgery was performed in 9 ears (3.8%), 8 with OME. CONCLUSIONS: Early VT treatment is recommended for young children with recurrent acute otitis media or persistent OME. Parents should be informed of the long follow-up, of the possible need for repeated VT insertion, and of potential sequelae that sometimes necessitate surgical intervention. Patients healed after 5 years do not need further follow-up.

A 14-year prospective follow-up study of children treated early in life with tympanostomy tubes: Part 2: Hearing outcomes.

OBJECTIVE: To determine hearing outcomes in young children receiving early and repeated tympanostomy tube insertion for recurrent acute otitis media or otitis media with effusion. DESIGN: Prospective 14-year follow-up. SETTING: Central Hospital of Central Finland, a tertiary care hospital. Patients Three hundred five consecutive infants and young children with otitis media received initial tympanostomy tube insertion at the age of 5 to 16 months. The final study group comprised 237 patients (77.7%) attending the 14-year checkups. MAIN OUTCOME MEASURES: At the 14-year checkups, children received clinical examinations and audiometric testing for the determination of bone and air conduction pure-tone thresholds. RESULTS: The mean pure-tone average of 177 healed ears was 4.3 dB. The mean pure-tone average of all ears was 5.8 dB, with significantly poorer results in ears with abnormal outcomes such as grade II or higher pars tensa retraction, otitis media with effusion, and tympanic membrane perforation. Thirteen (5.5%) of 237 ears had a hearing level worse than 15 dB, and the better ear hearing level was poorer than 15 dB in 3 patients. CONCLUSIONS: The hearing level of healed ears was comparable to that of age-matched normal ears. Hearing losses were infrequent, of slight grade, and, when present, almost exclusively conductive and related to unsuccessful otological outcomes. From the hearing point of view, repeated tympanostomy tube insertion for recurrent acute otitis media or otitis media with effusion early in life is a safe treatment.

Patients' preferences for length of stay: valuable in day-case tonsillectomy planning.

Day-case tonsillectomy is becoming more common, but patient satisfaction varies. Before beginning day-case tonsillectomies, we evaluated patients' wishes as to optimal discharge timing. We conducted a prospective study of all 294 patients undergoing elective tonsillectomy or adenotonsillectomy at a tertiary care clinic for 1 year. At discharge, patients received a questionnaire on their preferred length of stay. Of the 236 (80.3%) patients returning the questionnaire, 94 (39.8%) preferred discharge on the 1st, 141 (59.7%) on the 2nd postoperative day or later, and only one patient (0.4%) would have wished day-case tonsillectomy. Patients with postoperative fever, older patients and those discharged on the 2nd postoperative day or later were more likely to prefer a longer postoperative stay. Patients rejected the idea of day-case tonsillectomy after in-patient operation. Day-case tonsillectomies should be begun only after careful preparation of the staff, in children, and preferably in a day-surgery unit.

Patient contact with healthcare professionals after elective tonsillectomy.

OBJECTIVE: To assess the amount and causes of patient contact with healthcare professionals after elective tonsillectomy. MATERIAL AND METHODS: This was a prospective study. All consecutive patients undergoing elective tonsillectomy or adenotonsillectomy in 1997 received a questionnaire concerning the post-discharge period. RESULTS: A total of 276 patients (93.6%) answered questions regarding post-discharge contact. After their discharge, 43.8% of patients contacted healthcare professionals. Pain was the leading indication for telephone contact, and hemorrhage for visits in person. Information given over the telephone was sufficient in 49.5% of cases. Telephone contact was followed by a visit in person in the case of hemorrhage in 88.9% of patients and in the case of pain in 34.1%. Contact was made most frequently in the older age groups. CONCLUSIONS: Although the patients repeatedly received both written and oral information, nearly half of them still contacted healthcare professionals during the recovery period. Frequent post-tonsillectomy contact should be taken into account when the financial and personnel resources of day surgery units are evaluated. In order to reduce the amount of post-tonsillectomy contact with healthcare professionals, careful attention must be paid to the quality of patient counseling prior to discharge.

The costs and effects of laparoscopic appendectomy in children.

BACKGROUND: Laparoscopic procedures are performed commonly in children. In general, the cost containment of laparoscopic surgery in children has not been evaluated. OBJECTIVE: To compare the costs of laparoscopic appendectomy with those of open appendectomy. DESIGN: Prospective clinical trial between November 1, 1997, and April 30, 2000. For analysis, cost of supplies, operation room use, and recovery in the hospital and after discharge was evaluated. Costs common to both groups were not determined. SETTING: Operations performed in a university hospital.Patients Eighty-seven children aged 4 to 15 years who underwent appendectomy for suspected appendicitis. Patients were randomized to laparoscopic or open appendectomy. Intervention Laparoscopic appendectomies performed with the same standard set of reusable equipment. MAIN OUTCOME MEASURES: Cost surplus of the laparoscopic procedure and recovery after surgery were evaluated, to determine the costs and effects of laparoscopic appendectomy compared with those of open appendectomy in children. RESULTS: Excess operating and complication costs per procedure were 96 euros (EUR) in laparoscopic appendectomy. The increased operative expenses were offset by a shorter hospital stay, resulting in a marginal difference of 53 EUR in itemized total costs between the 2 procedures (total cost, 1023 EUR in the laparoscopic appendectomy group and 970 EUR in the open appendectomy group). After laparoscopic appendectomy, children returned to school and sports earlier than those who had had an open appendectomy. CONCLUSION: Laparoscopic appendectomy was marginally more expensive, but it allowed earlier return to normal daily activities than open appendectomy.

Otological and audiological outcomes five years after tympanostomy in early childhood.

OBJECTIVE: Ventilation tubes in the treatment of otitis media in young children remain controversial. Despite abundant research, few prospective long-term follow-up studies have included even a minority of patients under 1 year old. We investigated long-term otological and audiological outcomes in children with recurrent acute otitis media and otitis media with effusion, who were treated early with ventilation tubes. STUDY DESIGN: Prospective follow-up. METHODS: Three hundred five children under 17 months of age received a primary tympanostomy in the Central Hospital of Central Finland (Jyväskylä, Finland), and those 281 (92.1%) who were monitored prospectively for 5 years made up the study group. At the final examination, pneumatic otoscope and otomicroscope were used and pure-tone audiometric thresholds of air and bone conduction were measured to define the hearing levels (mean of 0.5, 1.0, and 2.0 KHz thresholds). RESULTS: Of ears, 67.3% were healed, 7.1% had a retraction of tympanic membrane in pars flaccida and 9.6% in pars tensa, 7.5% had an ongoing otitis media with effusion, 3.9% had a ventilation tube in place, and 4.6% had a tympanic membrane perforation with mean hearing levels of 7.6, 9.0, 16.0, 18.5, 10.5, and 17.7 dB, respectively. CONCLUSIONS: Hearing in general was well preserved, and no ear presented with adhesive otitis media or cholesteatoma. Adverse otological and audiological outcomes of these young children did not exceed those presented by others for older counterparts. Tympanic membrane perforations, ongoing otitis media with effusion, and pars tensa retractions were causes of mild conductive hearing loss. Because one third of ears continued to have middle ear disease or sequelae, we emphasize the proper follow-up and restoration of middle ear ventilation with repeat ventilation tubes if not otherwise achieved.