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1.
Health Place ; 80: 102975, 2023 03.
Artigo em Inglês | MEDLINE | ID: mdl-36774810

RESUMO

The planning and delivery of infrastructure influences how places create health equity. The scholarship on place and health has recently been developed into 'levelling up' principles for equity focussed policy and planning. We conducted a scoping review of the literature on infrastructure through urban regeneration and placemaking interventions. We interrogated the 15 final selected articles for their use of one or more of the five 'levelling' up principles. No article encompassed all five principles. It was most common to find two or three principles in action. Reviewing the articles against the principles allows a deeper explanation of how infrastructure planning practice can positively impact on health equity. We conclude that applying all the principles in standard infrastructure planning practice has great potential for creating places that are positive for health equity.


Assuntos
Meio Ambiente , Equidade em Saúde , Humanos
2.
Subst Abuse Treat Prev Policy ; 9: 31, 2014 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-25091704

RESUMO

BACKGROUND: Supervised injection facilities (SIFs) are venues where people who inject drugs (PWID) have access to a clean and medically supervised environment in which they can safely inject their own illicit drugs. There is currently only one legal SIF in North America: Insite in Vancouver, British Columbia, Canada. The responses and feedback generated by the evaluations of Insite in Vancouver have been overwhelmingly positive. This study assesses whether the above mentioned facility in the Downtown Eastside of Vancouver needs to be expanded to other locations, more specifically that of Canada's capital city, Ottawa. METHODS: The current study is aimed at contributing to the existing literature on health policy by conducting cost-benefit and cost-effective analyses for the opening of SIFs in Ottawa, Ontario. In particular, the costs of operating numerous SIFs in Ottawa was compared to the savings incurred; this was done after accounting for the prevention of new HIV and Hepatitis C (HCV) infections. To ensure accuracy, two distinct mathematical models and a sensitivity analysis were employed. RESULTS: The sensitivity analyses conducted with the models reveals the potential for SIFs in Ottawa to be a fiscally responsible harm reduction strategy for the prevention of HCV cases--when considered independently. With a baseline sharing rate of 19%, the cumulative annual cost model supported the establishment of two SIFs and the marginal annual cost model supported the establishment of a single SIF. More often, the prevention of HIV or HCV alone were not sufficient to justify the establishment cost-effectiveness; rather, only when both HIV and HCV are considered does sufficient economic support became apparent. CONCLUSIONS: Funded supervised injection facilities in Ottawa appear to be an efficient and effective use of financial resources in the public health domain.


Assuntos
Programas de Troca de Agulhas/economia , Abuso de Substâncias por Via Intravenosa/reabilitação , Análise Custo-Benefício , Infecções por HIV/prevenção & controle , Redução do Dano , Hepatite C/prevenção & controle , Humanos , Modelos Estatísticos , Ontário , Abuso de Substâncias por Via Intravenosa/economia
3.
N Engl J Med ; 371(3): 234-47, 2014 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-25014688

RESUMO

BACKGROUND: The efficacy and toxic effects of nucleoside reverse-transcriptase inhibitors (NRTIs) are uncertain when these agents are used with a protease inhibitor in second-line therapy for human immunodeficiency virus (HIV) infection in resource-limited settings. Removing the NRTIs or replacing them with raltegravir may provide a benefit. METHODS: In this open-label trial in sub-Saharan Africa, we randomly assigned 1277 adults and adolescents with HIV infection and first-line treatment failure to receive a ritonavir-boosted protease inhibitor (lopinavir-ritonavir) plus clinician-selected NRTIs (NRTI group, 426 patients), a protease inhibitor plus raltegravir in a superiority comparison (raltegravir group, 433 patients), or protease-inhibitor monotherapy after 12 weeks of induction therapy with raltegravir in a noninferiority comparison (monotherapy group, 418 patients). The primary composite end point, good HIV disease control, was defined as survival with no new World Health Organization stage 4 events, a CD4+ count of more than 250 cells per cubic millimeter, and a viral load of less than 10,000 copies per milliliter or 10,000 copies or more with no protease resistance mutations at week 96 and was analyzed with the use of imputation of data (≤4%). RESULTS: Good HIV disease control was achieved in 60% of the patients (mean, 255 patients) in the NRTI group, 64% of the patients (mean, 277) in the raltegravir group (P=0.21 for the comparison with the NRTI group; superiority of raltegravir not shown), and 55% of the patients (mean, 232) in the monotherapy group (noninferiority of monotherapy not shown, based on a 10-percentage-point margin). There was no significant difference in rates of grade 3 or 4 adverse events among the three groups (P=0.82). The viral load was less than 400 copies per milliliter in 86% of patients in the NRTI group, 86% in the raltegravir group (P=0.97), and 61% in the monotherapy group (P<0.001). CONCLUSIONS: When given with a protease inhibitor in second-line therapy, NRTIs retained substantial virologic activity without evidence of increased toxicity, and there was no advantage to replacing them with raltegravir. Virologic control was inferior with protease-inhibitor monotherapy. (Funded by European and Developing Countries Clinical Trials Partnership and others; EARNEST Current Controlled Trials number, ISRCTN37737787, and ClinicalTrials.gov number, NCT00988039.).


Assuntos
Infecções por HIV/tratamento farmacológico , Inibidores da Protease de HIV/uso terapêutico , Inibidores da Transcriptase Reversa/uso terapêutico , Adolescente , Adulto , África Subsaariana , Idoso , Contagem de Linfócito CD4 , Criança , Farmacorresistência Viral/genética , Quimioterapia Combinada , Feminino , HIV/imunologia , Inibidores da Protease de HIV/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Pirrolidinonas/uso terapêutico , Raltegravir Potássico , Inibidores da Transcriptase Reversa/efeitos adversos , Carga Viral/efeitos dos fármacos , Adulto Jovem
4.
Subst Abuse Treat Prev Policy ; 8: 25, 2013 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-23837814

RESUMO

BACKGROUND: This paper will determine whether expanding Insite (North America's first and only supervised injection facility) to more locations in Canada such as Montreal, cost less than the health care consequences of not having such expanded programs for injection drug users. METHODS: By analyzing secondary data gathered in 2012, this paper relies on mathematical models to estimate the number of new HIV and Hepatitis C (HCV) infections prevented as a result of additional SIF locations in Montreal. RESULTS: With very conservative estimates, it is predicted that the addition of each supervised injection facility (up-to a maximum of three) in Montreal will on average prevent 11 cases of HIV and 65 cases of HCV each year. As a result, there is a net cost saving of CDN$0.686 million (HIV) and CDN$0.8 million (HCV) for each additional supervised injection site each year. This translates into a net average benefit-cost ratio of 1.21: 1 for both HIV and HCV. CONCLUSIONS: Funding supervised injection facilities in Montreal appears to be an efficient and effective use of financial resources in the public health domain.


Assuntos
Análise Custo-Benefício/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Programas de Troca de Agulhas/economia , Infecções por HIV/prevenção & controle , Hepatite C/prevenção & controle , Humanos , Modelos Estatísticos , Quebeque
5.
PLoS One ; 8(2): e57580, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23437399

RESUMO

BACKGROUND: In low-income countries, viral load (VL) monitoring of antiretroviral therapy (ART) is rarely available in the public sector for HIV-infected adults or children. Using clinical failure alone to identify first-line ART failure and trigger regimen switch may result in unnecessary use of costly second-line therapy. Our objective was to identify CD4 threshold values to confirm clinically-determined ART failure when VL is unavailable. METHODS: 3316 HIV-infected Ugandan/Zimbabwean adults were randomised to first-line ART with Clinically-Driven (CDM, CD4s measured but blinded) or routine Laboratory and Clinical Monitoring (LCM, 12-weekly CD4s) in the DART trial. CD4 at switch and ART failure criteria (new/recurrent WHO 4, single/multiple WHO 3 event; LCM: CD4<100 cells/mm(3)) were reviewed in 361 LCM, 314 CDM participants who switched over median 5 years follow-up. Retrospective VLs were available in 368 (55%) participants. RESULTS: Overall, 265/361 (73%) LCM participants failed with CD4<100 cells/mm(3); only 7 (2%) switched with CD4≥250 cells/mm(3), four switches triggered by WHO events. Without CD4 monitoring, 207/314 (66%) CDM participants failed with WHO 4 events, and 77(25%)/30(10%) with single/multiple WHO 3 events. Failure/switching with single WHO 3 events was more likely with CD4≥250 cells/mm(3) (28/77; 36%) (p = 0.0002). CD4 monitoring reduced switching with viral suppression: 23/187 (12%) LCM versus 49/181 (27%) CDM had VL<400 copies/ml at failure/switch (p<0.0001). Amongst CDM participants with CD4<250 cells/mm(3) only 11/133 (8%) had VL<400 copies/ml, compared with 38/48 (79%) with CD4≥250 cells/mm(3) (p<0.0001). CONCLUSION: Multiple, but not single, WHO 3 events predicted first-line ART failure. A CD4 threshold 'tiebreaker' of ≥250 cells/mm(3) for clinically-monitored patients failing first-line could identify ∼80% with VL<400 copies/ml, who are unlikely to benefit from second-line. Targeting CD4s to single WHO stage 3 'clinical failures' would particularly avoid premature, costly switch to second-line ART.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade/estatística & dados numéricos , Linfócitos T CD4-Positivos/imunologia , Infecções por HIV/tratamento farmacológico , HIV/efeitos dos fármacos , Adulto , Fármacos Anti-HIV/farmacologia , Terapia Antirretroviral de Alta Atividade/economia , Biomarcadores/análise , Contagem de Linfócito CD4 , Linfócitos T CD4-Positivos/virologia , Feminino , HIV/imunologia , Infecções por HIV/imunologia , Infecções por HIV/virologia , Humanos , Masculino , Falha de Tratamento , Uganda , Carga Viral/efeitos dos fármacos , Zimbábue
6.
PLoS One ; 7(4): e33672, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22545079

RESUMO

BACKGROUND: Despite funding constraints for treatment programmes in Africa, the costs and economic consequences of routine laboratory monitoring for efficacy and toxicity of antiretroviral therapy (ART) have rarely been evaluated. METHODS: Cost-effectiveness analysis was conducted in the DART trial (ISRCTN13968779). Adults in Uganda/Zimbabwe starting ART were randomised to clinically-driven monitoring (CDM) or laboratory and clinical monitoring (LCM); individual patient data on healthcare resource utilisation and outcomes were valued with primary economic costs and utilities. Total costs of first/second-line ART, routine 12-weekly CD4 and biochemistry/haematology tests, additional diagnostic investigations, clinic visits, concomitant medications and hospitalisations were considered from the public healthcare sector perspective. A Markov model was used to extrapolate costs and benefits 20 years beyond the trial. RESULTS: 3316 (1660LCM;1656CDM) symptomatic, immunosuppressed ART-naive adults (median (IQR) age 37 (32,42); CD4 86 (31,139) cells/mm(3)) were followed for median 4.9 years. LCM had a mean 0.112 year (41 days) survival benefit at an additional mean cost of $765 [95%CI:685,845], translating into an adjusted incremental cost of $7386 [3277,dominated] per life-year gained and $7793 [4442,39179] per quality-adjusted life year gained. Routine toxicity tests were prominent cost-drivers and had no benefit. With 12-weekly CD4 monitoring from year 2 on ART, low-cost second-line ART, but without toxicity monitoring, CD4 test costs need to fall below $3.78 to become cost-effective (<3xper-capita GDP, following WHO benchmarks). CD4 monitoring at current costs as undertaken in DART was not cost-effective in the long-term. CONCLUSIONS: There is no rationale for routine toxicity monitoring, which did not affect outcomes and was costly. Even though beneficial, there is little justification for routine 12-weekly CD4 monitoring of ART at current test costs in low-income African countries. CD4 monitoring, restricted to the second year on ART onwards, could be cost-effective with lower cost second-line therapy and development of a cheaper, ideally point-of-care, CD4 test.


Assuntos
Fármacos Anti-HIV/economia , Contagem de Linfócito CD4/economia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Testes de Toxicidade/economia , Adulto , Fármacos Anti-HIV/uso terapêutico , Fármacos Anti-HIV/toxicidade , Análise Custo-Benefício , Atenção à Saúde/economia , Feminino , Infecções por HIV/diagnóstico , Humanos , Masculino , Anos de Vida Ajustados por Qualidade de Vida , Uganda , Zimbábue
7.
Otol Neurotol ; 32(8): 1192-7, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21909045

RESUMO

OBJECTIVE: To establish the cost-effectiveness of a bone-anchored hearing device (BAHD). To date, there has not been any formal economic analysis of this treatment. STUDY DESIGN: A prospective cohort case-control analysis. SETTING: Tertiary referral center, university hospital. PATIENTS: Between April 2007 and June 2008, all adult patients undergoing their first BAHD were contacted and invited to take part in this study. Data of 70 patients were completed during the study period and were analyzed. INTERVENTIONS: A health utility measure was made before and after the insertion of a BAHD to estimate the utility gain associated with this intervention. MAIN OUTCOME MEASURES: The cost and quality-adjusted life year (QALY) gain for each patient was established, and an incremental cost-effectiveness ratio (ICER) was calculated. RESULTS: The results of our analysis are that, compared with current standard care, the BAHD has an ICER of £17,610 (US $26,415) per QALY gained. The National Institute for Health and Clinical Excellence will endorse a health intervention as cost-effective if the ICER is below £20,000 to £30,000 per QALY (US $30,000-45,000). CONCLUSION: This technology is likely to be cost-effective at the current thresholds used by National Institute for Health and Clinical Excellence. Therefore, this study suggests the BAHD may be a cost-effective method of auditory rehabilitation.


Assuntos
Custos de Cuidados de Saúde , Auxiliares de Audição/economia , Perda Auditiva Condutiva/economia , Estudos de Casos e Controles , Análise Custo-Benefício , Feminino , Perda Auditiva Condutiva/reabilitação , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Inquéritos e Questionários , Resultado do Tratamento
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