Systematic review on the cost-effectiveness of self-management education programme for type 2 diabetes mellitus.

OBJECTIVES: A review of cost-effectiveness studies on self-management education programmes for Type 2 diabetes mellitus. METHODS: Cochrane, PubMed and PsycINFO databases were searched for papers published from January 2003 through September 2015. Further hand searching using the reference lists of included papers was carried out. RESULTS: In total, 777 papers were identified and 12 papers were finally included. We found eight programmes whose effectiveness analyses were based on randomised controlled trials and whose costs were comprehensively estimated from the stated perspective. Among these eight, four studies showed a cost per unit reduction in clinical risk factors (HbA1c or BMI) of US$491 to US$7723 or cost per glycaemic symptom day avoided of US$39. In three studies the cost per QALY gained, as estimated from a life-time model, was less than US$50,000. However, one study found the programme was not cost-effective despite a gain in QALYs at the one-year follow up. CONCLUSION: A small number of cost-effectiveness studies were identified with only eight of sufficiently good quality. The cost of a self-management education programme achieving reduction in clinical risk factors seems to be modest and is likely to be cost-effective in the long-term.

Effectiveness of the multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) for diabetic microvascular complications: A population-based cohort study.

AIM: To evaluate the effectiveness of the multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) in reducing the risks of microvascular complications. METHODS: This prospective cohort study was conducted with 29,670 propensity-score-matched RAMP-DM participants and diabetes patients under the usual primary care (14,835 in each group). Study endpoints were the first occurrence of any diabetic microvascular complications, non-proliferative diabetic retinopathy/preproliferative diabetic retinopathy (NPDR/prePDR), sight-threatening diabetic retinopathy (STDR) or blindness, nephropathy, end-stage renal disease (ESRD), neuropathy and lower-limb ulcers or amputation. Log-rank tests and multivariable Cox proportional-hazards regressions were employed to estimate between-group differences in incidences of study endpoints. RESULTS: After a median follow-up of 36 months with>41,000 person-years in each group, RAMP-DM participants had a lower incidence of microvascular complications (760 vs 935; adjusted hazard ratio [HR]: 0.73; 95% confidence interval [CI]: 0.66-0.81; P<0.001) and lower incidences of all specific microvascular complications except neuropathy (adjusted HR: 0.94; 95% CI: 0.61-1.45; P=0.778). Adjusted HRs for the RAMP-DM vs control group for ESRD, STDR or blindness, and lower-limb ulcers or amputation were 0.40 (95% CI: 0.24-0.69; P<0.001), 0.55 (95% CI: 0.39-0.78; P=0.001) and 0.49 (95% CI: 0.30-0.80; P=0.005), respectively. CONCLUSION: The RAMP-DM intervention was associated with lower incidences of all microvascular complications except neuropathy over a 3-year follow-up. These encouraging results constitute evidence that structured risk assessment and risk-stratified management provided by a multidisciplinary team is effective for reducing microvascular complications in diabetes patients. CLINICAL TRIAL REGISTRY: NCT02034695, www.ClinicalTrials.gov.

Health impact assessment of marine emissions in Pearl River Delta region.

Global marine vessels emissions are adversely affecting human health particularly in southeast Asia. But health burdens from both ocean- and river-going vessels in Pearl River Delta (PRD) regions are not quantified. We estimated the potential health impacts using pooled relative risks of mortality and hospital admissions in China, and the model derived concentrations of sulfur dioxide (SO2), particulate matter (PM10), nitrogen dioxide (NO2) and ozone (O3) due to vessels emissions. SO2 concentrations due to marine emissions in Hong Kong were 13.6 µg m⁻³ compared with 0.7 µg m⁻³ in PRD regions that were far from the marine vessels. In PRD regions, the estimated annual numbers (per million people) of excess deaths from all natural causes and hospital admissions from cardiorespiratory causes attributable to SO2, NO2, O3 and PM10 combined from marine emissions were 45 and 265 respectively. Marine emission control measures could contribute a large reduction in mortality and hospital admissions in PRD regions especially in Hong Kong.

Promoting smoking cessation among the elderly: what are the predictors of intention to quit and successful quitting?

PURPOSE: To assess the predictors of smoking cessation and intention to quit among the Chinese elderly smokers. DESIGN: A cross-sectional survey of elderly smokers. SETTING: Shamsuipo district, Hong Kong. SUBJECT: A total of 1,318 elderly were interviewed (response rate = 83%). MEASURES: A structured questionnaire was used for data collection. The questionnaire sought information on the subject's sociodemographic background and smoking habits. The predictors for successful quitting and intention to quit were assessed by chi-square tests and multiple logistic regression. RESULTS: Of the respondents, 20.2% were current smokers, 25.4% were ex-smokers, and 54.4% were never smokers. Of the smoker (current and ex-smokers) respondents, 55.7% (335/601) had successfully quit at the time of enumeration. The predictors of quitting were living with others, receiving assistance for mobility, being nondrinkers, smoking for shorter duration, and smoking more cigarettes per day. Having health problems in the past, smoking for shorter duration, and smoking fewer cigarettes per day were predictors of intention to quit smoking. CONCLUSION: The study identified several predictors of successful quitting that could help improve the provision of current smoking cessation services. Population-based smoking cessation programs, especially those targeted to elderly, should take these predictors into consideration in the design of interventions.

Cost of tobacco-related diseases, including passive smoking, in Hong Kong.

BACKGROUND: Costs of tobacco-related disease can be useful evidence to support tobacco control. In Hong Kong we now have locally derived data on the risks of smoking, including passive smoking. AIM: To estimate the health-related costs of tobacco from both active and passive smoking. METHODS: Using local data, we estimated active and passive smoking-attributable mortality, hospital admissions, outpatient, emergency and general practitioner visits for adults and children, use of nursing homes and domestic help, time lost from work due to illness and premature mortality in the productive years. Morbidity risk data were used where possible but otherwise estimates based on mortality risks were used. Utilisation was valued at unit costs or from survey data. Work time lost was valued at the median wage and an additional costing included a value of USD 1.3 million for a life lost. RESULTS: In the Hong Kong population of 6.5 million in 1998, the annual value of direct medical costs, long term care and productivity loss was USD 532 million for active smoking and USD 156 million for passive smoking; passive smoking accounted for 23% of the total costs. Adding the value of attributable lives lost brought the annual cost to USD 9.4 billion. CONCLUSION: The health costs of tobacco use are high and represent a net loss to society. Passive smoking increases these costs by at least a quarter. This quantification of the costs of tobacco provides strong motivation for legislative action on smoke-free areas in the Asia Pacific Region and elsewhere.

Passive smoking and its impact on employers and employees in Hong Kong.

AIMS: To estimate the prevalence of passive smoking at work in the whole workforce in Hong Kong (population 6.8 million), the characteristics of the passive smokers, any extra use of health care among passive smokers, and who pays for that health care. METHODS: A random sample of 14,325 households was contacted by telephone; 6,186 responding adults who worked full time were asked about their employment, their most recent use of health care and the cost of that care, their medical benefits, and their exposure to secondhand smoke in the workplace. After weighting the sample for sex, age, household size, and income, 4,739 subjects were included in the analysis. RESULTS: Of 1,961 full time workers who did not smoke, 47.5% were exposed to secondhand smoke in the workplace compared with only 26% exposed at home. Exposure at work was associated with being younger, male, married, less educated, and having a lower income. Those exposed at work were 37% more likely to report having visited a doctor for a respiratory illness in the previous 14 days. Employers were paying 28% of the cost of these visits, the government paid 8%, and the individuals paid 63%. If extrapolated to the 3 million workers in the Hong Kong population, employers would pay just over US$9 million per year, while the affected workers would pay around US$20 million. CONCLUSION: As well as the costs of active smoking, the cost of extra health care utilisation associated with passive smoking is an additional cost being paid by those employers who have not established smoke free workplaces and by their employees.

Public opinion on smoke-free policies in restaurants and predicted effect on patronage in Hong Kong.

BACKGROUND: The Hong Kong government has proposed legislation for smoke-free policies in all restaurants and bars. This is opposed by certain sections of the catering industry. OBJECTIVE: To assess public opinion on smoke-free restaurants and to estimate changes in patronage. DESIGN: A population based, cross sectional random digit dialling telephone survey conducted from November 1999 to January 2000. SETTING AND PARTICIPANTS: 1077 randomly selected subjects age 15 years or over (response fraction of 81.6%). RESULTS: 68.9% (95% confidence interval (CI) 66.2% to 71.7%) supported a totally smoke-free policy in restaurants. Experiences of discomfort or symptoms from second hand smoke in restaurants were common. The majority (77.2%, 95% CI 74.7% to 79.7%) anticipated no change in their frequency of use of restaurants after a smoke-free policy. Increased use was predicted by 19.7% (95% CI 17.3% to 22.1%) of respondents, whereas 3.2% (95% CI 2.2% to 4.4%) stated that they would dine out less often. In multivariate analyses, non-smokers (adjusted odds ratio (OR) 4.9), people who ate three times or less per week in restaurants as compared to those who ate >10 times per week (OR 2.1), those who had previous experience of discomfort from exposure to passive smoking in restaurants (OR 2.8), or who had avoided restaurants in the past because of smoking (OR 1.9), were more likely to support a totally smoke-free policy in restaurants. Smoke-free policies do not appear to have an adverse effect on restaurants, and may increase business by a considerable margin. CONCLUSION: This comprehensive survey-the first in Asia-shows strong community support for smoke-free dining and predicts an overall increase in the patronage of restaurants after the introduction of legislation for totally smoke-free restaurants.

Efficiency is dependent on the control of supply.

At a time when health care systems are undergoing reform, it is useful to review the causes of inefficiency in health care, along with potential solutions. Such solutions can affect suppliers (supply-side measures) or users of care (demand-side measures). This paper argues that to have an efficient health care system, supply-side measures must be implemented. Some examples of supply-side measures, with particular relevance to the Hong Kong situation, are discussed. By their nature, supply-side measures require government intervention. Only then, can allocative efficiency, as well as technical efficiency, be achieved. Once a health care system is operating efficiently, it is an easier task to determine whether the system requires more resources, either currently, or in the future.

Cost-effectiveness study on influenza prevention in Hong Kong.

INTRODUCTION: Recent studies confirm that influenza vaccination confers health benefits and reduces direct and indirect costs associated with the illness. However, these studies did not examine the situation in southern China, a hypothetical influenza epicentre for the emergence of pandemic influenza viruses. METHODS: Surveillance data were collected in Hong Kong in 1993/94 and used economic model was used to estimate the medical and social costs associated with influenza-like illness (ILI) and to predict the cost-effectiveness of implementing an influenza prevention programme. FINDINGS: The estimated ILI incidence was 110/1000. It was highest in those between 1 and 25 years of age while the rate of hospitalization was highest in the elderly. Influenza occurred throughout the study period, which was a mild influenza year. The model predicted more than 660000 ILI cases in a non-epidemic year, in which influenza B virus predominated, with an average ILI-associated cost of HK$283/case (US$36) and vaccination-associated costs of HK$74 (US$9.50) per vaccinated individual. CONCLUSION: The medical, social and monetary costs of ILI in Hong Kong were not observed to be large when compared with those in more developed countries where there is a clearly defined influenza season and recognized disease burden. From the perspective of a susceptible individual, the vaccine was cost-effective but from the perspective of society it was not, even with the most cost-effective strategy of targeting the elderly. However, if the vaccine were effective in controlling newly emerging and highly virulent strains, targeted vaccination programmes might be highly cost-effective.

Cost-effectiveness analysis of applying the Cholesterol and Recurrent Events (CARE) study protocol in Hong Kong.

OBJECTIVE: To determine the cost-effectiveness of secondary prevention with pravastatin in Hong Kong patients with coronary heart disease and average cholesterol levels. DESIGN: Cost-effectiveness analysis based on published results of the CARE study. PATIENTS: Men and women post-myocardial infarction with average cholesterol levels. MAIN OUTCOME MEASURES: Cost-effectiveness analysis: cost per life saved, cost per fatal or non-fatal coronary event prevented, cost per procedure prevented, and cost per fatal or non-fatal stroke prevented. Cost-utility analysis: gross cost and net cost per quality-adjusted life year gained calculated using two alternative models. RESULTS: Cost per life saved or death prevented was HK$4,442,350 (non-discounted); cost per fatal or non-fatal cardiac event prevented HK$1,146,413; cost per procedure prevented HK$732,759; and cost per fatal or non-fatal stroke prevented HK$2,961,566. Net cost per quality adjusted life year gained was HK$73,218 and HK$65,280 non-discounted, respectively using the two alternative models. CONCLUSIONS: The results of this study can assist in prioritising the use of health care resources in Hong Kong but should be considered alongside the benefits and costs of alternative interventions for coronary heart disease.

Contract medicine arrangements in Hong Kong: an example of risk-bearing provider networks in an unregulated environment.

It is increasingly common in Hong Kong and elsewhere for employers to contract directly with physician networks to provide medical services to employees. These contracts are known in Hong Kong as contract medicine arrangements. In other countries and areas, managed care organizations are generally required by regulation or legislation to ensure that services of adequate quality are provided to patients who are locked in to network providers. There are no such requirements in Hong Kong and concerns have been raised about potential quality and cost trade-offs in contract medicine arrangements. Satisfaction surveys were sent to contract medicine enrollees in one large company in Hong Kong. The response rate was 30% and analysis of non-respondent data shows that respondents were representative of their group. Comparison of satisfaction using logistic regression showed that risk-bearing networks paid by capitation had consistently lower satisfaction ratings across all major dimensions including access, interpersonal care, communication with the doctor, choice of doctor, and outcomes. These findings suggest that quality, at least as perceived by the patient, may be lower in these networks. The issue is of concern in Asia where infrastructures and data systems are not well developed to adequately monitor quality of care or protect patient interests. This study highlights the need to structure pre-paid provider networks and managed care organizations so that quality of care is not compromised. At a time when managed care concepts are being applied throughout Asia, we believe attention needs to be drawn to this problem.

Passive smoking at work: the short-term cost.

STUDY OBJECTIVE: To estimate the impact of passive smoking at work on use of health care services and absenteeism. DESIGN: Cross sectional survey. SETTING: A workforce in Hong Kong. PARTICIPANTS: 5142 never-smoking police officers in a total sample of 9926. MAIN RESULTS: A consistently strong association was found among men between length of time exposed to passive smoking at work and self reported consultations with a doctor, use of medicines and time off work. Results for women were similar but most were not statistically significant. CONCLUSIONS: The exposure of healthy adults to passive smoking at work is related to utilisation of health care services and extra time off work. This results in costs to the health services, to employers and to those exposed.