Canadian Men's Health Literacy: A Nationally Representative Study.

Though men's health promotion has attracted increased research attention, conspicuously absent have been empirical insights to health literacy levels within and across male subgroups. Recent advancements in the measurement of health literacy have made available avenues for evaluating individual and social determinants of health literacy. Important insights can be drawn to detail patterns and diversity among men as a means to informing the design, implementation, and evaluation of tailored health promotion programs. Drawing on 2000 Canada-based men's responses to the Health Literacy Questionnaire, correlations between demographic variables and six health literacy scales are described. Low income, low education, and living alone were associated with men's low health literacy, with the strongest effect sizes for the "Social support for health" and "Actively engaged with health care professionals" scales. Multiple linear regressions confirmed low income as the strongest predictor of men's low health literacy in all the scales except "Appraisal of health information." Low income, self-identifying as gay, bisexual, or other, and living alone were strongly predictive of low scores on the "Social support for health" scale. The findings affirm the importance of considering men's health literacy and inequities to advance effective men's health promotion programs.

Caregiver burden and quality of life 2 years after attendance at a memory clinic.

OBJECTIVES: We aimed to describe (1) the burden and health-related quality of life (HRQL) of informal caregivers of new patients attending a memory assessment service (MAS), (2) changes in these outcomes over 2 years, and (3) satisfaction with services. METHODS: Informal caregivers of patients attending one of 73 MASs throughout England completed questionnaires at the patient's first appointment, and 6 and 12 months later. Participants from 30 of these MASs were also followed up at 24 months. Questionnaires covered caregivers' sociodemographic characteristics, Zarit Burden Interview, EQ-5D-3L, and satisfaction with services. We used multivariable linear regression to assess relationships between burden, HRQL, and caregiver and patient characteristics. RESULTS: Of 1020 caregivers at baseline, 569 were followed up at 6 months, 452 at 12 months, and 187 at 24 months. There was a small increase in caregiver burden over 2 years (effect size 0.30 SD). These changes were not associated with most caregiver or patient characteristics, except socio-economic deprivation, which was associated with larger increases in burden at 2 years. Caregivers' HRQL was weakly associated with burden and showed a small reduction over time (0.2 SD). Most caregivers were satisfied with services, but caregivers who were not satisfied with the services they received reported greater increases in burden. CONCLUSIONS: Increases in caregiver burden and reductions in HRQL appear to be small over the first 2 years after attending a MAS. However, the longer term impact on caregivers and those they care for needs investigating, as do strategies to reduce their burden.

Cost-effectiveness analysis of English memory assessment services 2 years after first consultation for patients with dementia.

OBJECTIVES: This paper aims to compare changes over 2 years in patients' health-related quality of life (HRQL) with the health and social care costs of diagnosis and treatment of people newly referred to memory assessment services (MAS). METHODS: We analysed observational data from 1318 patients referred to 69 MAS who completed resource use and HRQL questionnaires at baseline 3, 6, 12, and 24 months. We reported mean differences in HRQL (disease-specific DEMQOL and generic EQ-5D-3 L), quality-adjusted life years (QALYs), costs and cost-effectiveness between baseline, and 2-year follow-up. RESULTS: Two years after referral to MAS, patients reported a higher DEMQOL score (mean gain 4.47, 95% confidence interval, 3.08-5.90) and EQ-5D-3 L (0.014, -0.011 to 0.039). Mean total costs and QALYs over 24 months was £2411 (£1721-£2873) and 0.027 (0.003-0.051), respectively. Assuming that patients' HRQL would not have altered over the 2 years had they not attended MAS, these outcomes suggest an incremental cost-effectiveness ratio of £89 546 (£38 123-£145 864) based on changes in EQ-5D-3 L. If we assumed that patients' HRQL would have declined by about 10% over this period had they not attended MAS, the cost-effectiveness ratio would be £25 056. The largest MAS (N = 32; 46%) with over 50 new patients a month were more likely to be cost-effective than smaller ones (P < 0.01). CONCLUSIONS: MAS are effective and can be cost-effective for diagnosing and treating people with suspected dementia. Large variations in costs between clinics suggest that many MAS could improve their cost-effectiveness.

Composite health behaviour classifier as the basis for targeted interventions and global comparisons in men's health.

INTRODUCTION: Lifestyle-related diseases are the leading cause of death among North American men. We evaluated health behaviours and their predictors that contribute to morbidity and mortality among Canadian men as a means to making recommendations for targeted interventions. METHODS: A cross-sectional analysis of Canadian men drawn from 5362 visitors to our online survey page was conducted. The current study sample of 2000 men (inclusion: male and >18 years; exclusion: incomplete surveys) were stratified to the 2016 Canadian census. The primary outcome was the number of unhealthy men classified using our Canadian Composite Classification of Health Behaviour (CCCHB) score. Secondary outcomes included the number of men with unhealthy exercise, diet, smoking, sleep, and alcohol intake, as well as socioeconomic and demographic factors associated with unhealthy behaviours to be used for targeting future interventions. RESULTS: Only 118/2000 (5.9%) men demonstrated 5/5 healthy behaviours, and 829 (41.5%) had 3/5 unhealthy behaviours; 391 (19.6%) men currently smoked, 773 (38.7%) demonstrated alcohol overuse, 1077 (53.9%) did not get optimal sleep (<7 or >9 hours per night), 977 (48.9%) failed to exercise >150 minutes/week, and 1235 (61.8%) had an unhealthy diet. Multivariate analysis indicated that men with high school education were at increased risk of unhealthy behaviours (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.15-2.18; p=0.005), as were men living with relatives (OR 2.10; 95% CI1.04-4.26; p=0.039), or with their partner and children (OR 1.34; 95% CI 1.02-1.76; p=0.034). CONCLUSIONS: An overwhelming 41.5% of Canadian men had 3/5 unhealthy behaviours, affirming the need for targeted lifestyle interventions. Significant health inequities within vulnerable subgroups of Canadian men were identified and may guide the content and delivery of future interventions.

Memory assessment services and health-related quality of life: 1-year follow-up.

OBJECTIVES: Our group has already demonstrated that patients' health-related quality of life (HRQL) improves in the first 6 months after their first appointment at memory assessment services (MASs), but the sustainability of such gains is unknown. We aimed to describe changes in patients' HRQL at 12 months after their first MAS appointment and to examine associations with patient and MAS characteristics. METHODS: We collected data from 702 patients and 452 lay caregivers at the first appointment and 12 months later. Multivariable linear regression was used to examine the relationships of change in HRQL (self-reported and proxy-reported) with patients' characteristics and use of post-diagnostic interventions, and multilevel models were used to analyse the relationships of HRQL with MAS characteristics. RESULTS: In the whole group, self-reported HRQL improved over 12 months (+3.5 points, 95% CI 2.7 to 4.2). Among people diagnosed with dementia, improvement in HRQL was more than double that among those with mild cognitive impairment or no diagnosis. Proxy-reported HRQL improved only in those diagnosed with dementia (+1.2 points, 95% CI 0.2 to 2.2). Changes in HRQL were not associated with any patient characteristics. The only feature of MASs associated with larger improvements in HRQL was the presence of advisory and support staff. CONCLUSIONS: Improvements in HRQL observed at 6 months are maintained up to 1 year after the first MAS appointment, more so among those who receive a diagnosis of dementia. Continued follow-up will determine if the improvement is even longer lasting.

The cost of diagnosis and early support in patients with cognitive decline.

OBJECTIVE: Recent research indicates considerable heterogeneity in the provision of memory assessment services (MAS). However, little is known on the extent of variation in the costs of the services MAS provide. We investigated the costs of supporting patients with suspected dementia, including assessment and support over the following 6 months. METHODS: Clinic costs were estimated on the basis of an organisational survey reporting staff roll, grade and activities. Costs of primary health and social care were estimated from questionnaire data reported by carers of patients at baseline, 3 and 6 months after referral. RESULTS: Mean monthly staff costs at MAS were £73 000. Imaging at assessment costs an additional £3500 per month. Monthly clinic cost per new patient assessed varied from £320 to £5400 across clinics. Additional primary health and social care costs of £130-220 a month between baseline and 6 months were reported by carers. Costs of pharmacological and non-pharmacological treatments reported by carers were small. Informal care costs dwarfed health and social care costs when valued at a modest unit cost. The overall mean cost of supporting a patient for 6 months varied from £1600 to £2500 dependent on assumptions regarding the proportion of MAS intervention and review costs accrued at 6 months. CONCLUSIONS: There is considerable variation in the intensity and associated costs of services provided by MAS. Further research should ascertain to what extent such variation is associated with differences in patient outcomes. Copyright © 2016 John Wiley & Sons, Ltd.

Is the effectiveness of memory assessment services associated with their structural and process characteristics?

OBJECTIVES: The aim of this study was to investigate whether structural and process characteristics of memory assessment services (MASs) are associated with outcomes (changes in patients' health-related quality of life (HRQL), carers' HRQL and carers' burden) over the first 6 months following the first appointment. METHODS: Data from 785 patients referred to 69 MASs and 511 of their lay carers, collected at the first appointment and 6 months later. Data on MAS characteristics were collected using a questionnaire at baseline. We used multilevel linear regression models to explore the associations of patients' HRQL and carers' outcomes with structural and process characteristics of MASs. Analyses were conducted on the full sample of patients and carers, and separately on those patients diagnosed with dementia. RESULTS: None of the structural (skill mix, workload, volume, provision of clinical assessments and provision of psychosocial support) or process (waiting time, length and number of appointments, anti-dementia drug use and psychosocial interventions use) characteristics included in the analyses were associated with patients' or carers' outcomes at 6 months, apart from the presence of allied health professionals (AHPs), which was associated with a DEMQOL score 2.7 points higher. When only those with a diagnosis of dementia were considered, the association with presence of AHPs was no longer observed. CONCLUSIONS: Apart from involving AHPs, alterations to the way MASs are structured or function appear unlikely to improve their effectiveness in improving patients' and carers' HRQL. It is possible that the characteristics of MASs may influence patients' and carers' experience, but this was not studied. Copyright © 2017 John Wiley & Sons, Ltd.

Cost-effectiveness of Memory Assessment Services for the diagnosis and early support of patients with dementia in England.

Background Policy makers in England advocate referral of patients with suspected dementia to Memory Assessment Services (MAS), but it is unclear how any improvement in patients' health-related quality of life (HRQL) compares with the associated costs. Aims To evaluate the cost-effectiveness of MAS for the diagnosis and follow-up care of patients with suspected dementia. Method We analysed observational data from 1318 patients referred to 69 MAS, and their lay carers (n = 944), who completed resource use and HRQL questionnaires at baseline, three and six months. We reported mean differences in HRQL (disease-specific DEMQOL and generic EQ-5D-3L), quality-adjusted life years (QALYs) and costs between baseline and six months after referral to MAS. We also assessed the cost-effectiveness of MAS across different patient subgroups and clinic characteristics. Results Referral to MAS was associated with gains in DEMQOL (mean gain: 3.48, 95% confidence interval: 2.84 to 4.12), EQ-5D-3L (0.023, 0.008 to 0.038) and QALYs (0.006, 0.002 to 0.01). Mean total cost over six months, assuming a societal perspective, was £1899 (£1277 to £2539). This yielded a negative incremental net monetary benefit of -£1724 (-£2388 to -£1085), assuming NICE's recommended willingness-to-pay threshold (£30,000 per QALY). These base case results were relatively robust to alternative assumptions about costs and HRQL. There was some evidence that patients aged 80 or older benefitted more from referral to MAS (p < 0.01 from adjusted mean differences in net benefits) compared to younger patients. MAS with over 75 new patients a month or cost per patient less than £2500 over six months were relatively more cost-effective (p < 0.01) than MAS with fewer new monthly patients or higher cost per patient. Conclusions Diagnosis, treatment and follow-up care provided by MAS to patients with suspected dementia appears to be effective, but not cost-effective, in the six months after diagnosis. Longer term evidence is required before drawing conclusions about the cost-effectiveness of MAS.

Change in Health-related Quality of Life After Referral to Memory Assessment Services.

Despite strong support for the provision of memory assessment services (MASs) in England and other countries, their effectiveness in improving patient outcomes is uncertain. We aimed to describe change in patients' health-related quality of life (HRQL) 6 months after referral to MASs and to examine associations with patient characteristics and use of postdiagnostic interventions. Data from 883 patients referred to 69 MASs and their informal caregivers (n=569) were collected at referral and 6 months later. Multivariable linear regression was used to examine associations of change in HRQL (DEMQOL, DEMQOL-Proxy) with patient characteristics (age, sex, ethnicity, socioeconomic deprivation, and comorbidity) and use of postdiagnostic interventions (antidementia medications and nonpharmacological therapies). Mean HRQL improved, irrespective of diagnosis: self-reported HRQL increased 3.4 points (95% CI, 2.7-4.1) and proxy-reported HRQL 1.3 points (95% CI, 0.5-2.1). HRQL change was not associated with any of the patient characteristics studied. Patients with dementia (54%) receiving antidementia drugs reported greater improvement in their HRQL but those using nonpharmacological therapies reported less improvement compared with those note receiving therapy. HRQL improved in the first 6 months after referral to MASs. Research is needed to determine longer term sustainability of the benefits and the cost-effectiveness of MASs.

Sociodemographic Characteristics, Cognitive Function, and Health-related Quality of Life of Patients Referred to Memory Assessment Services in England.

National policy in England is to encourage referral of people with suspected dementia to Memory Assessment Services (MAS). However, little is known about the characteristics of new referrals, which limits our capacity to evaluate these services. The objectives were to: describe the characteristics (age, sex, ethnicity, socioeconomic deprivation, and comorbidity) of referred patients, and examine the relationships between these characteristics and cognitive function (tertiles of Mini-Mental State Examination score) and health-related quality of life (HRQL) (DEMQOL, DEMQOL-Proxy). We used multivariable regression methods to analyze data from 1420 patients from 73 MAS, and their lay carers (n=1020). The mean age of patients was 78 years; 42% had cognitive function equivalent to Mini-Mental State Examination <24. Characteristics associated with lower function were: older age, being female, deprivation, and nonwhite ethnicity. Deprivation and nonwhite ethnicity were also associated with lower self-reported HRQL, as was having multiple comorbidities; older age was associated with better self-reported HRQL. Lower proxy-reported HRQL was associated with being female, deprivation and comorbidities, but not age and ethnicity. A large proportion of study participants had moderate or high cognitive function scores, suggesting that these patients were referred early to MAS. Research is needed to identify why apparent sociodemographic inequalities in use of MAS exist.

Cost-Effectiveness of Five Commonly Used Prosthesis Brands for Total Knee Replacement in the UK: A Study Using the NJR Dataset.

BACKGROUND: There is a lack of evidence on the effectiveness or cost-effectiveness of alternative brands of prosthesis for total knee replacement (TKR). We compared patient-reported outcomes, revision rates, and costs, and estimated the relative cost-effectiveness of five frequently used cemented brands of unconstrained prostheses with fixed bearings (PFC Sigma, AGC Biomet, Nexgen, Genesis 2, and Triathlon). METHODS: We used data from three national databases for patients who had a TKR between 2003 and 2012, to estimate the effect of prosthesis brand on post-operative quality of life (QOL) (EQ-5D-3L) in 53 126 patients at six months. We compared TKR revision rates by brand over 10 years for 239 945 patients. We used a fully probabilistic Markov model to estimate lifetime costs and quality-adjusted life years (QALYs), incremental cost effectiveness ratios (ICERs), and the probability that each prosthesis brand is the most cost effective at alternative thresholds of willingness-to-pay for a QALY gain. FINDINGS: Revision rates were lowest with the Nexgen and PFC Sigma (2.5% after 10 years in 70-year-old women). Average lifetime costs were lowest with the AGC Biomet (£9 538); mean post-operative QOL was highest with the Nexgen, which was the most cost-effective brand across all patient subgroups. For example, for 70-year-old men and women, the ICERs for the Nexgen compared to the AGC Biomet were £2 300 per QALY. At realistic cost per QALY thresholds (£10 000 to £30 000), the probabilities that the Nexgen is the most cost-effective brand are about 98%. These results were robust to alternative modelling assumptions. CONCLUSIONS: AGC Biomet prostheses are the least costly cemented unconstrained fixed brand for TKR but Nexgen prostheses lead to improved patient outcomes, at low additional cost. These results suggest that Nexgen should be considered as a first choice prosthesis for patients with osteoarthritis who require a TKR.

Using patient-reported outcomes (PROs) to compare the providers of surgery: does the choice of measure matter?

BACKGROUND: Patient-reported outcomes (PROs) are being used to compare health care providers with little knowledge of how the choice of measure affects such comparisons. OBJECTIVES: To assess how much difference the choice of PRO makes to a provider's adjusted outcome and whether the choice affects a provider's rating. RESEARCH DESIGN: PROs collected in England from patients undergoing: hip replacement (243 providers; 52,692 patients); knee replacement (244; 60,118); varicose vein surgery (100; 11,163); and groin hernia repair (201; 31,714). Four case-mix-adjusted outcomes (mean postoperative disease-specific and generic PRO; proportion achieving a minimally important difference in disease-specific PRO; proportion reporting improvement on single transitional item). We calculated the associations between measures and for each measure, the proportion of providers rated as statistically above or below average and the level of agreement in ratings. RESULTS: For major surgery, disease-specific PROs were strongly correlated with the generic PRO (hip 0.90; knee 0.88), they rated high proportions of providers as above or below average (hip 25.1%; knee 19.3%) and there was agreement in ratings with the generic PRO. Even so, for a large proportion of providers (hip 30%; knee 16%) their rating depended on the choice of measure. For minor surgery, correlations between measures were mostly weak. The single transitional item identified the most outliers (varicose vein 20%, hernia 10%). CONCLUSIONS: Choice of outcome measure can determine a provider's rating. Measure selection depends on whether the priority is to avoid missing "poor" providers or avoid mislabeling average providers as "poor."

Cemented, cementless, and hybrid prostheses for total hip replacement: cost effectiveness analysis.

OBJECTIVE: To compare the cost effectiveness of the three most commonly chosen types of prosthesis for total hip replacement. DESIGN: Lifetime cost effectiveness model with parameters estimated from individual patient data obtained from three large national databases. SETTING: English National Health Service. PARTICIPANTS: Adults aged 55 to 84 undergoing primary total hip replacement for osteoarthritis. INTERVENTIONS: Total hip replacement using either cemented, cementless, or hybrid prostheses. MAIN OUTCOME MEASURES: Cost (£), quality of life (EQ-5D-3L, where 0 represents death and 1 perfect health), quality adjusted life years (QALYs), incremental cost effectiveness ratios, and the probability that each prosthesis type is the most cost effective at alternative thresholds of willingness to pay for a QALY gain. RESULTS: Lifetime costs were generally lowest with cemented prostheses, and postoperative quality of life and lifetime QALYs were highest with hybrid prostheses. For example, in women aged 70 mean costs were £6900 ($11 000; €8200) for cemented prostheses, £7800 for cementless prostheses, and £7500 for hybrid prostheses; mean postoperative EQ-5D scores were 0.78, 0.80, and 0.81, and the corresponding lifetime QALYs were 9.0, 9.2, and 9.3 years. The incremental cost per QALY for hybrid compared with cemented prostheses was £2500. If the threshold willingness to pay for a QALY gain exceeded £10 000, the probability that hybrid prostheses were most cost effective was about 70%. Hybrid prostheses have the highest probability of being the most cost effective in all subgroups, except in women aged 80, where cemented prostheses were most cost effective. CONCLUSIONS: Cemented prostheses were the least costly type for total hip replacement, but for most patient groups hybrid prostheses were the most cost effective. Cementless prostheses did not provide sufficient improvement in health outcomes to justify their additional costs.

Factors associated with non-response in routine use of patient reported outcome measures after elective surgery in England.

BACKGROUND: Patient-reported outcome measures are increasingly being used to compare providers. We studied whether non-response rates to post-operative questionnaires are associated with patients' characteristics and organisational features of providers. METHODS: 131,447 patients who underwent a hip or knee replacement, hernia repair or varicose vein surgery in 2009-10 in England. Multivariable logistic regression to calculate adjusted odds ratios of non-response for characteristics of the patients and organisational characteristics of providers. Multiple imputation was used for missing patient characteristics. Providers were included as random effects. RESULTS: Response rates to the post-operative questionnaire were 85.1% for hip replacement (n = 37 961), 85.3% for knee replacements (n = 44 422), 72.9% for hernia repair (n = 34 964), and 64.8% for varicose vein surgery (n = 14 100). Across the four procedures, there were higher levels of non-response in men (odds ratios 1.03 [95% CI 0.95-1.11] - 1.35 [1.25-1.46]), younger patients (those under 55 years 3.01 [2.72-3.32] - 6.05 [5.49-6.67]), non-white patients (1.24 [1.11-1.38] - 2.08 [1.89-2.31]), patients in the most deprived quintile of socio-economic status (1.47 [1.34-1,62] - 1.86 [1.71-2.03]), those who lived alone (1.11 [0.99-1.23] - 1.27 [1.18-1.36]) and those who had been assisted when completing their pre-operative questionnaire (1.26 [1.10-1.46] -1.67 [1.56-1.79]). Non-response rates were also higher in patients who had poorer pre-operative health (three or more comorbidities: 1.14 [0.96-1.35] - 1.45 [1.30-1.63]). Providers' patient recruitment rates before surgery and the timing of pre-operative questionnaire administration did not affect the rates of response to post-operative questionnaires. CONCLUSION: If non-response can be shown to be associated with outcome, then rates of non-response to post-operative questionnaires would need to be taken into account when these measures are being used to compare the performance of providers or to evaluate surgical procedures.