Indicators for Assessing the Quality of Refractive Error Care.

SIGNIFICANCE: Quality refractive error care is essential for reducing vision impairment. Quality indicators and standardized approaches for assessing the quality of refractive error care need to be established. PURPOSE: This study aimed to develop a set of indicators for assessing the quality of refractive error care and test their applicability in a real-world setting using unannounced standardized patients (USPs). METHODS: Patient outcomes and three quality of refractive error care (Q.REC) indicators (1, optimally prescribed spectacles; 2, adequately prescribed spectacles; 3, vector dioptric distance) were developed using existing literature, refraction training standards, and consulting educators. Twenty-one USPs with various refractive errors were trained to visit optical stores across Vietnam to have a refraction, observe techniques, and order spectacles. Spectacles were assessed against each Q.REC indicator and tested for associations with vision and comfort. RESULTS: Overall, 44.1% (184/417) of spectacles provided good vision and comfort. Of the spectacles that met Q.REC indicators 1 and 2, 62.5 and 54.9%, respectively, provided both good vision and comfort. Optimally prescribed spectacles (indicator 1) were significantly more likely to provide good vision and comfort independently compared with spectacles that did not meet any indicator (good vision: 94.6 vs. 85.0%, P = .01; comfortable: 66.1 vs. 36.3%, P < .01). Adequately prescribed spectacles (indicator 2) were more likely to provide good comfort compared with spectacles not meeting any indicator (57.7 vs. 36.3%, P < .01); however, vision outcomes were not significantly different (85.9 vs. 85.0%, P = .90). Good vision was associated with a lower mean vector dioptric distance (P < .01) but not with comfort (P = .52). CONCLUSIONS: The optimally prescribed spectacles indicator is a promising approach for assessing the quality of refractive error care without additional assessments of vision and comfort. Using USPs is a practical approach and could be used as a standardized method for evaluating the quality of refractive error care.

Determining the impacts of hospital cost-sharing on the uninsured near-poor households in Vietnam.

OBJECTIVES: The study objective was to identify the size of different hospital financing sources for different hospital services and their impact on the uninsured. METHODS: A panel dataset of 84 public general hospitals (2005-2008) with cross-section data on hospital activity and hospital revenue was created and used to calculate unit costs of different hospital services by applying multiple regression models. The resulting risk of catastrophic health expenditure (CHE) was estimated based on official income statistics. RESULTS: Average user fees (UF) for outpatient visits and inpatient bed days were US$4.13 and US$20.27, while actual full costs (AFC) were US$8.41 and US$36.66, respectively. These unit costs were 2.5 times higher in hospitals at the central versus the provincial level. UF for surgical inpatient bed days were 3.6 times that of non-surgical treatments (US$47.50 vs. 12.87) and AFC 5.0 times (US$101.72 vs. 20.08). UF accounted for 44.6%-77.9% of the AFC, the rest (22.1%-55.4%) was provided by direct government support (DGS). One surgical inpatient treatment at either central or provincial hospital level and one non-surgical inpatient treatment at central hospital level, immediately pushed uninsured near-poor households at risk of CHE. CONCLUSIONS: Around 45% of hospital AFC was paid by DGS, the larger rest by UF. UF have become a great financial burden on the uninsured near-poor households, who have to pay for these out-of-pocket and therefore may not utilize even necessary services. If the rate of DGS were reduced, this would have the effect of increasing UF, but the savings to Government could be spent on subsidizing insurance to ensure that a larger part of the population can cover UF through insurance, especially the near-poor households.

Comparing the cost-effectiveness of two brain metastasis treatment modalities from a payer's perspective: stereotactic radiosurgery versus surgical resection.

OBJECTIVES: This study aims to identify the cost-effectiveness of two brain metastatic treatment modalities, stereotactic radiosurgery (SRS) versus surgical resection (SR), from the perspective of Germany's Statutory Health Insurance (SHI) System. METHODS: Retrospectively reviewing 373 patients with brain metastases (BMs) who underwent SR (n=113) and SRS (n=260). Propensity score matching was used to adjust for selection bias (n=98 each); means of survival time and survival curves were defined by the Kaplan-Meier estimator; and medical costs of follow-up treatment were calculated by the Direct (Lin) method. The bootstrap resampling technique was used to assess the impact of uncertainty. RESULTS: Survival time means of SR and SRS were 13.0, 18.4 months, respectively (P=0.000). Medians of free brain tumor time were 10.4 months for SR and 13.8 months for SRS (P=0.003). Number of repeated SRS treatments significantly influenced the survival time of SRS (R(2)=0.249; P=0.006). SRS had a lower average cost per patient (€9964 - SD: 1047; Skewness: 7273) than SR (€11647 - SD: 1594; Skewness: 0.465), leading to an incremental cost effectiveness ratio of €-3740 per life year saved (LYS), meaning that using SRS costs €1683 less than SR per targeted patient, but increases LYS by 0.45 years. CONCLUSION: SRS is more cost-effective than SR in the treatment of brain metastasis (BM) from the SHI perspective. When the clinical conditions allow it, early intervention with SRS in new BM cases and frequent SRS repetition in new BM recurrent cases should be advised.

The cost-effectiveness of stereotactic radiosurgery versus surgical resection in the treatment of brain metastasis in Vietnam from the perspective of patients and families.

BACKGROUND: This study aims to evaluate the cost-effectiveness of the treatment of brain metastasis with surgical resection (SR) and stereotactic radiosurgery (SRS) in the lower-middle-income country of Vietnam from the perspective of patients and families. METHODS: The treatment of 111 patients with brain metastases who underwent SR (n = 64) and SRS (n = 47) was retrospectively reviewed. Propensity score matching was used to adjust for selection bias (n = 30 each); mean and curves of survival time were defined by the Kaplan-Meier estimator; the cost analysis focused on the time period of relevant treatment. RESULTS: The mean survival times of SRS and SR were 11.9 and 10.5 months, and the 18-month survival rates were 32% and 14%, respectively (P = 0.346). The mean number of hospital bed days was significantly higher for SR than SRS (16.5 versus 7.6 days, P < 0.05), but direct costs of SR were significantly lower (14.5 as opposed to 35.3 million Vietnamese dong [VND] per patient, P < 0.001). However, indirect costs of SR were 10 times higher (26.0 versus 2.5 million VND per patient, P < 0.001). The cost per life year gained was higher for SR than SRS (46.4 and 38.1 million VND, respectively). CONCLUSIONS: SRS is similarly effective as SR. However, in the broader context of the cost-effectiveness from the perspective of patients and their families, SRS is more cost-effective. The lower costs directly charged by the hospital for SR may prevent poorer and older patients from choosing SRS. Thus, the overall cost-effectiveness of each treatment option should be taken into consideration in deciding on the treatment.

Extracranial metastatic patterns on occurrence of brain metastases.

Extracranial metastases and their frequency by sites have been described as prognostic factors for survival of patients with brain metastasis. However, these factors must be identified and described in more detail for a large series of patients. Using routine data from the largest German health insurance fund, 5,074 patients with brain metastasis who were diagnosed and treated in 2008 were analyzed to identify the frequency and distribution of extracranial metastatic sites concurrent with brain metastasis in relation to age, gender, and tumor type. Brain metastases were observed in males more frequently than in females (56.4 and 43.6% respectively P < 0.001), and were most often from lung (51.2%), breast (12.3%), and unknown (7.5%) primaries. Extracranial metastatic sites were observed in 58.8% of patients; the number of sites was from 1 to 7, with a mean of 1.11. For the 16 most common primary sites the range was from 0.13 to 1.91 . In 11 of these 16 sites, lungs were the most common concurrent metastatic site. Lung cancer, breast cancer, non-Hodgkin's lymphoma, and testicular cancer most commonly metastasized to bone, and bladder cancer to kidneys. Different primary tumors have different frequencies and patterns of extracranial metastatic sites concurrently with brain metastasis. The lung is the most common metastatic site of most primary tumors, bone for a few tumors, and kidneys for bladder cancer. For the unknown primary tumor type, screening for these most common metastatic sites must be intensified, in particular when molecular assessment is not available.

Mental health in Vietnam: Burden of disease and availability of services.

PURPOSE: Despite the accomplishments, the economic and social reform program of Vietnam has had negative effects, such as limited access to health care services for those disadvantaged in the new market economy. Among this group are persons with mental disorders. This paper aims to understand the burden of mental disorders and availability of mental health services (MHS) in Vietnam. METHODS: We reviewed both national as well as the international literature about the burden of mental disorders and MHS in Vietnam. This included academic literature (Medline, Pubmed), national (government) reports, World Health Organization (WHO) reports, and grey literature. RESULTS: The burden of mental disorders in Vietnam is similar to that of other Asian countries and occurs across all population groups. MHS have been made one of the national health priorities and more efforts are being made to promote equity of access by integrating MHS into other health care programs and by increasing MHS capacity. However, it is not yet sufficient to meet the care demand of persons with mental disorders. Challenges remain in various areas of MHS, including: lack of mental health legislation, human resources, hospital beds, shortage and diversification of MHS. CONCLUSION: Although MHS in Vietnam have considerably improved over the last decade, mainly in terms of accessibility, the care demand and the illness burden remain high. Therefore, more emphasis should be put on increasing MHS capacity and on human resource development. In that process, more representative epidemiological data and intervention research is needed.

Temporal trends of cancer incidence in Vietnam, 1993-2007.

PURPOSE: There is a lack of an overview of overall and site-specific cancer incidence time trends in Vietnam, especially for the period after the year 2000. This paper aims at describing the development of cancer incidence for some cancer sites during 1993-2007. METHODS: The Age Standardized Rate (ASR) of cancer incidence data from population based cancer registries of Hanoi, Ho Chi Minh and Cantho cities were used to analyze temporary trends of cancer incidence by site, age and sex group. RESULTS: The ASR of cancer incidence increased from 151.1/105 in the period 1993-1998 to 160.0/105 in the period 2006-2007 for males and from 106.8/105 to 143.9/105 for females. By age, the highest ASR was found in the group of 75+ years in males and between 70-74 years in females, with ASRs of 1,109/105 and 619/105, respectively (2006-2007). Lung remains the most frequent site, followed by stomach and liver in males. In females, the most commonly affected site has shifted from cervix uteri in 1993-1998 to breast in recent years, followed by stomach and lung. Increasing trends were observed in incidence rates of 21 out of 34 cancer sites in males and 27 out of 35 cancer sites in females. CONCLUSION: Cancer incidences in general have continuously increased during 1993-2007. More efforts should be concentrated on developing and implementing tobacco-related cancer prevention interventions.