Cost-effectiveness analysis of influenza and pneumococcal vaccination for Hong Kong elderly in long-term care facilities.

BACKGROUND: To compare cost and quality-adjusted life-years (QALYs) gained by influenza vaccination with or without pneumococcal vaccination in the elderly living in long-term care facilities (LTCFs). METHODS: Cost-effectiveness analysis based on Markov modelling over 5 years, from a Hong Kong public health provider's perspective, on a hypothetical cohort of LTCF residents aged > or = 65 years. Benefit-cost ratio (BCR) and net present value (NPV) of two vaccination strategies versus no vaccination were estimated. The cost and QALYs gained by two vaccination strategies were compared by Student's t-test in probabilistic sensitivity analysis (10,000 Monte Carlo simulations). RESULTS: Both vaccination strategies had high BCRs and NPVs (6.39 and US$334 for influenza vaccination; 5.10 and US$332 for influenza plus pneumococcal vaccination). In base case analysis, the two vaccination strategies were expected to cost less and gain higher QALYs than no vaccination. In probabilistic sensitivity analysis, the cost of combined vaccination and influenza vaccination was significantly lower (p<0.001) than the cost of no vaccination. Both vaccination strategies gained significantly higher (p<0.001) QALYs than no vaccination. The QALYs gained by combined vaccination were significantly higher (p = 0.030) than those gained by influenza vaccination alone. The total cost of combined vaccination was significantly lower (p = 0.011) than that of influenza vaccination. CONCLUSION: Influenza vaccination with or without pneumococcal vaccination appears to be less costly with higher QALYs gained than no vaccination, over a 5-year period, for elderly people living in LTCFs from the perspective of a Hong Kong public health organisation. Combined vaccination was more likely to gain higher QALYs with lower total cost than influenza vaccination alone.

Social determinants of frailty.

BACKGROUND: Frailty represents a body-wide set of a linked deterioration that occurs with ageing, but is susceptible to active intervention and is reversible. The concept of frailty should include broader environmental factors. A quantitative measure of frailty, the frailty index (FI), developed for elderly Canadians and shown to be valid for an elderly Chinese population, was examined for its association with socioeconomic, lifestyle, and social support network factors in an elderly Chinese cohort. OBJECTIVE: 2,032 people aged 70 years and over recruited by stratified random sampling of the population were surveyed in 1990-1991, and information obtained regarding physical and functional health, psychological factors, lifestyle, socioeconomic and social support factors. The FI was constructed from 62 variables covering cognitive, psychological and physical health, and tested for association with socioeconomic, lifestyle and social support factors using ANOVA and t test. RESULTS: The mean FI for women was higher than for men (0.16 +/- 0.08, n = 1,033 vs. 0.13 +/- 0.08, n = 999, p < 0.001, t test). For men, increasing frailty was observed with non-white collar occupations, inadequate expenses, no or little exercise, abstinence from alcohol, few relatives or neighbours and no or infrequent participation in helping others. For women, little contact with relatives (rather than number of relatives), and absence of participation in community/religious activities were additional factors. CONCLUSION: FI is influenced by social and environmental factors in keeping with the concept of frailty being multi-dimensional. Such a quantitative measure may be a useful indicator of the health of elderly populations as well as for public health measures to combat frailty.

Depression is the predominant factor contributing to morale as measured by the Philadelphia Geriatric Morale Scale in elderly Chinese aged 70 years and over.

OBJECTIVE: To examine factors contributing to the total Philadelphia Geriatric Morale Scale (PGMS) and its two subscales: reconciled ageing and unstrained affect. METHOD: The PGMS was administered to 759 community-living subjects aged 70 years and over. Information regarding socioeconomic status, health conditions, sensory impairment, physical symptoms, social support, activities of daily living as measured by the Barthel Index, life satisfaction, and the Geriatric Depression Score, was collected. Associations between these factors and PGMS and its subscale were examined using univariate analysis (Mann-Whitney; Kruskal-Wallis tests), and multivariate analysis using the classification and regression tree (CART) method. RESULTS: Gender, old age, physical, socioeconomic and social factors were significantly associated with PGMS. There was a strong correlation with GDS (r = 0.77, p < 0.001). In the CART analysis, for both subscales and the total score, GDS was the predominant factor contributing to the score. Other factors include self perception of health, enough expenses, overall satisfaction with life, gender, and constipation. DISCUSSION: The PGMS and GDS are closely related. In addition to the GDS, health perception, life satisfaction, and adequate finance were factors contributing to quality of life in elderly Hong Kong Chinese.

An estimate of long-term care needs and identification of risk factors for institutionalization among Hong Kong Chinese aged 70 years and over.

BACKGROUND: The goal of this study is to estimate the long-term care needs of the Hong Kong Chinese population age 70 years and older, and to identify risk factors for institutionalization. METHODS: A three-year prospective follow-up study was carried out in Hong Kong Special Administrative Region, China. 2,032 subjects aged 70 years and older were recruited territory-wide by stratified random sampling of the Old Age and Disability Allowance register, covering over 90% of the elderly population. A questionnaire was administered at baseline to obtain information on social, functional, physical, and mental health status, and place of residence. A repeat interview was carried out at 36 months. The number of subjects moving from home to institution or vice versa, and the number who had died, were noted. Univariate analysis was performed to determine risk factors for institutionalization, and backward stepwise multiple logistic regression was used to identify independent factors predisposing to institutionalization. RESULTS: The institutionalization rate per year is estimated to be 0.7% for the 70-79 age group, and 1.5% for the 80+ age group. Using population figures projected by the Hong Kong Census, the corresponding number of places required will be 24,150 and 42,000, respectively, for the two age groups by 2005, whereas the number of government subvented places projected to be available is unlikely to be more than 40,000 for the whole population. Age, being a woman, being single, not having a formal education, cognitive impairment, physical dependency, and the presence of depressive symptoms were factors predisposing to institutionalization. In multivariate analysis, age, marital status, and dependency were identified as independent factors. CONCLUSION: The requirement for institutional places is unlikely to be met by government, the shortfall likely to be met by the private sector. Maintenance of functional independence, good social support network, engagement in social activities, and good informal carer support may reduce demand for institutional care.

Epidemiology of health changes in older women in Hong Kong.

This paper aims to present the baseline social, mental and functional characteristics, the changes of these characteristics over a 36-month follow-up period, and the issues and implications related to these changes, particularly in older women. The cohort comprising 2030 subjects aged 70 and above has been assembled by stratified disproportional random sampling. Registrants with the Old Age Allowance Scheme, which has over 90 percent coverage of the Hong Kong elderly population, was used to define the accessible population. Face-to-face interviews were conducted at the respondents' place of residence. A number of social and health variables were collected at baseline. The surviving subjects had been followed up at 36 months and repeated measurements of the baseline variables were obtained. Older women were over-represented by low level education, financial dependency, as well as residence in institutions. Women had higher prevalence as well as incidence of musculoskeletal problems. While there was a general decline in health and social support in the elderly cohort, we observed a preponderance of older female subjects with mental and functional decline over the follow-up period. An overrepresentation of female subjects with depressive symptoms at baseline and follow-up was also noted. The descriptive data have revealed a host of social and health changes over a three-year follow-up period. Women aged 80 years and above formed a particularly disadvantaged group. The results will have direct implications for the shaping of social and health policy for strategic planning of priorities in social and health care services.

An estimate of chronic disease burden and some economic consequences among the elderly Hong Kong population.

OBJECTIVES: To estimate the burden of chronic disease for an elderly Chinese population aged 70 years and over, and to illustrate the use of this information in estimating the economic consequences of disease burden using stroke as an example. PARTICIPANTS: A total of 1902 subjects recruited by random sampling of the old age and disability allowance schemes, which cover over 90% of the Hong Kong elderly population, stratified by sex and five year age groups from age 70 years onwards. METHOD: Information was collected on 10 medical conditions at baseline: arthritis, hypertension, cardiac disease, stroke, chronic obstructive airways disease, peptic ulcer, diabetes mellitus, osteoporotic fracture, malignancy, and dementia. A follow up survey was carried out after 18 months to determine the occurrence of new disease and the number with disease who had died. Disease burden is calculated as the number with disease at baseline plus the number developing new disease minus the number who had died. RESULTS: Disease burden figures were highest for arthritis, hypertension, cardiac disease, and peptic ulcer, and were higher in the 70-79 age group than the 80+ age group for some diseases. For stroke, the economic cost based on a population projection for 2001 was estimated to be around HK$1,900,000,000, or US$250 million. CONCLUSION: Information on the burden of chronic disease is important. It enables the economic consequences to be estimated so that strategies can be developed to prevent diseases with high costs and known effective preventive methods.

Life satisfaction and associated factors in older Hong Kong Chinese.

OBJECTIVE: To determine life satisfaction and its association with physical, functional, socioeconomic, psychological, and social support characteristics in Hong Kong Chinese aged 70 years and older. DESIGN: Cross-sectional study. SETTING: Territory-wide random sample of persons aged 70 years and older. SUBJECTS: A total of 843 men and 714 women were selected by random sampling, stratified by age and sex, from the Old age and Disability Allowance Register, after exclusion of subjects with cognitive impairment. MEASUREMENTS: Life satisfaction was assessed by the subjects' response to the question "Are you satisfied with life", using a 0 to 10-point linear scale. They were also asked to name the most important factor contributing to life satisfaction. Information was also obtained regarding physical health, functional ability, depressive symptoms, and socioeconomic factors. RESULTS: There was a weak association between score and age. Health, adequate income to meet living expenses, and caring relatives were rated the most important factors (> 65%). Some of these factors were also those associated with a high life satisfaction score. Factors associated with a life satisfaction score greater than 6 points were higher social class and educational attainment, adequate income to meet living expenses, satisfactory living arrangement, Christianity, good social support, participation in social activities, functional independence, good self-perceived health, good hearing and vision, daily exercise, absence of recurrent falls, and low depressive symptom score. Multiple logistic regression identified having two or more relatives and tertiary education as positive associated factors, whereas inadequate income to meet expenses, dissatisfaction with living arrangement, nonparticipation in religious group activities, and a high depressive symptom score were negative associated factors. CONCLUSION: In older Chinese, social factors such as the support provided by family members, as well as adequate income to meet living expenses, play a role equal to that of physical factors in contributing to life satisfaction.

Drug use in an elderly Chinese population: prevalence and associated factors.

This study examined the pattern of drug use in an elderly population aged 70 years and over, and the factors associated with drug use. The study population was selected by stratified random sampling of all registered recipients of Old Age and Disability Allowance in Hong Kong. 997 men and 1,035 women were interviewed as part of a survey on physical, functional, mental health and social status of the elderly in Hong Kong. 71% of the sample took drugs, the prevalence being higher in women. The most common drugs taken were antihypertensives, skin preparations, vitamins and minerals, other cardiovascular drugs, antacids or H2 antagonists, and non-steroidal anti-inflammatory analgesics (all over 10%). Overall, 66% were using medications that were unlabelled. Factors associated with drug use that were examined included socioeconomic factors, educational level, physical health, cognitive function, depressive symptoms, functional ability, life satisfaction, and living arrangements. Multivariate analysis using forward stepwise logistic regression showed that the use of prescription drugs was associated with the presence of chronic disease, poor self-perceived health and being female. Use of > 5 drugs was associated with similar factors: presence of chronic disease, being female, and residence in institutions. The factors for use of non-prescription drugs were different: living in the community, presence of joint pain restricting activities, dissatisfaction with living arrangements, and age. Reducing the number of unlabelled drugs, restricting access to non-prescription drugs, improving access to doctors and patient education all might well be important measures in improving the therapeutic needs of this elderly population.

Age and marital status are major factors associated with institutionalisation in elderly Hong Kong Chinese.

STUDY OBJECTIVE: To determine the need for long term institutional care for elderly Chinese living in Hong Kong and factors associated with institutional living. DESIGN: Survey by interviewer administered questionnaire of a stratified random sample of all recipients of old age or disability allowance covering 90% of the population. SETTING: Survey performed in Hong Kong, a city on the south coast of China with an area of 1070 km2 and approximately six million people. PARTICIPANTS: A total of 2032 subjects aged 70 years and over (999 men, 1033 women) participated. MAIN RESULTS: Overall, 16% of the elderly live in institutions. The percentage is higher in women and in the older age group (81% for those aged 80 years and over). After adjusting for age and sex, the following factors were positively associated with institutionalisation: poor cognitive function, measures of functional disability, poor vision, Parkinson's disease, stroke, and past fractures. Multivariate analysis identified age and marital status as associated factors with the highest odds ratio (13.6 and 7.1 respectively), followed by various disability indicators. CONCLUSION: The survey shows that requirements for long term care places are unlikely to be much affected by preventive measures, and would need to increase by about 30% by 2000 to cope with the projected increase in the number of elderly aged 70 years and over. Measures to provide sufficient trained personnel and policy for regulation of standards should be made.

Health and social predictors of mortality in an elderly Chinese cohort.

A total of 1,054 Hong Kong Chinese subjects aged 70 years or over were recruited into a cohort study to investigate the relation between social support and health outcomes. More than 30 social, health, and behavioral characteristics were recorded as baseline information when the study began in 1985. Mortality data were obtained during a 2-year follow-up. Logistic regression analyses were used to determine the roles of these variables in predicting mortality. The mortality patterns of Hong Kong and of the studied cohort closely resemble that of Western developed countries with cancer, heart disease, and cerebrovascular diseases as the leading causes of death. Besides sex and place of residence (whether living in the community or in homes for the elderly), the independent predictors of mortality included five baseline variables: being single or widowed, limited ability in activities of daily living, smoking habit, low body mass index, and poor self-evaluated health status. Subjects with at least three of these predictors had a relative risk of 3.9 (95% confidence interval 2.4-6.2) compared with those with zero to two of these characteristics.

The role of Chinese traditional medical practice as a form of health care in Singapore--III. Conditions, illness behaviour and medical preferences of patients of institutional clinics.

Both the modern scientific and the Chinese traditional forms of health care are within easy geographical, economical and quantitative accessibility to the people in Singapore. The fourth component of accessibility, socio-cultural component encompasses the social milieu surrounding the individual, and the values and beliefs attached to diseases and health care services. This paper reveals the findings of a survey of a quota sample of patients in institutional clinics providing Chinese traditional medical consultations. The survey aimed to look at the types of illness conditions presented in these clinics, the multi-usage of both modern and traditional health care by these patients, and the inter-relationship between illness behaviour and differential preferences of treatment methods for various disease conditions.

Factors influencing the outcome of health campaigns: a case study in Singapore.

Singapore, located in South-east Asia, enjoys a high standard of health care. However, certain diseases are still of major concern to the health authorities, who feel these could be more easily controlled if the public were more aware of their modes of transmission. A "Combat infectious diseases" campaign was therefore launched to educate the public on food-borne diseases (cholera, enteric fever), malaria, dengue/dengue haemmorrhagic fever, leprosy, tuberculosis, and sexually transmitted diseases (syphilis, gonorrhoea). Educational activities in the form of talks, film shows and exhibitions in schools, community centres and other institutions were carried out over a 15-month period. This paper analyzes some of the factors which affected the results of the campaign, as revealed by a health survey conducted in a selected lower-middle income urban community, where sub-groups of the adult population (aged above 15) were tested to assess their health knowledge. Findings indicate that educational level, age of respondents and language proficiency--four languages are used in Singapore--seem to be the three variables that affect the likelihood of the respondents' receptivity to campaign information.