Health outcomes and healthcare utilization associated with four undiagnosed chronic conditions: evidence from nationally representative survey data in Sri Lanka.

Background: Low awareness of chronic conditions raises the risk of poorer health outcomes and may result in healthcare utilization and spending in response to symptoms of undiagnosed conditions. Little evidence exists, particularly from lower-middle-income countries, on the health and healthcare use of undiagnosed people with an indication of a condition. This study aimed to compare health (physical, mental, and health-related quality of life (HRQoL)) and healthcare (inpatient and outpatient visits and out-of-pocket (OOP) medical spending) outcomes of undiagnosed Sri Lankans with an indication of coronary heart disease (CHD), hypertension, diabetes, and depression with the outcomes of their compatriots who were diagnosed or had no indication of these conditions. Methods: This study used a nationally representative survey of Sri Lankan adults to identify people with an indication of CHD, hypertension, diabetes, or depression, and ascertain if they were diagnosed. Outcomes were self-reported measures of physical and mental functioning (12-Item Short Form Survey (SF-12)), HRQoL (EQ-5D-5L), inpatient and outpatient visits, and OOP spending. For each condition, we estimated the mean of each outcome for respondents with (a) no indication, (b) an indication without diagnosis, and (c) a diagnosis. We adjusted the group differences in these means for socio-demographic covariates using ordinary least squares (OLS) regression for physical and mental function, Tobit regression for HRQoL, and a generalized linear model (GLM) for healthcare visits and OOP spending. Results: An indication of each of CHD and depression, which are typically symptomatic, was associated with a lower adjusted mean of physical (CHD -2.65, 95% CI -3.66, -1.63; depression -5.78, 95% CI -6.91, -4.64) and mental functioning (CHD -2.25, 95% CI -3.38, -1.12; depression -6.70, 95% CI -7.97, -5.43) and, for CHD, more annual outpatient visits (2.13, 95% CI 0.81, 3.44) compared with no indication of the respective condition. There were no such differences for indications of hypertension and diabetes, which are often asymptomatic. Conclusions: Living with undiagnosed CHD and depression was associated with worse health and, for CHD, greater utilization of healthcare. Diagnosis and management of these symptomatic conditions can potentially improve health partly through substitution of effective healthcare for that which primarily responds to symptoms. Supplementary Information: The online version contains supplementary material available at 10.1186/s44263-024-00075-0.

Ranking Age-at-Death Distributions Using Dominance: Robust Evaluation of United States Mortality Trends, 2006-2021.

Diverging mortality trends at different ages motivate the monitoring of lifespan inequality alongside life expectancy. Conclusions are ambiguous when life expectancy and lifespan inequality move in the same direction or when inequality measures display inconsistent trends. We propose using nonparametric dominance analysis to obtain a robust ranking of age-at-death distributions. Application to U.S. period life tables for 2006-2021 reveals that, until 2014, more recent years generally dominate earlier years, implying improvement if longer lifespans that are less unequally distributed are considered better. Improvements were more pronounced for non-Hispanic Black and Hispanic individuals than for non-Hispanic White individuals. Since 2014, for all subpopulations-particularly Hispanics-earlier years often dominate more recent years, indicating worsening age-at-death distributions if shorter and more unequal lifespans are considered worse. Dramatic deterioration of the distributions in 2020-2021 during the COVID-19 pandemic is most evident for Hispanic individuals.

The Prevalence and Epidemiological Features of Ischaemic Heart Disease in Sri Lanka.

Background: There is limited evidence on the prevalence of ischaemic heart disease (IHD) and its association with risk factors and socioeconomic status (SES) in low- and middle-income countries (LMICs). Given the relatively high levels of access to healthcare in Sri Lanka, the association of IHD with SES may be different from that observed in other LMICs. Objectives: To estimate the prevalence of IHD in Sri Lanka, determine its associated risk factors and its association with SES. Methods: We analysed data from 6,513 adults aged ≥18 years examined in the 2018/19 Sri Lanka Health and Ageing Study. We used the Rose angina questionnaire to classify participants as having angina (Angina+) and used self-report or medical records to identify participants with a history of IHD (History+). The association of Angina+ and History+ with age, ethnicity, sector of residence, education level, household SES wealth quintile, area SES wealth quintile, hypertension, diabetes, smoking, total cholesterol, cholesterol-to-HDL ratio, waist-to-hip ratio and body mass index were analysed in unadjusted and adjusted models. Additional analyses were performed to investigate sensitivity to correction for missing data and to benchmark estimates against evidence from other studies. Conclusions: We estimated prevalence of History+ of 3.9% (95% CI 3.3%-4.4%) and Angina+ of 3.0% (95% CI 2.4%-3.5%) in adults aged 18 years and over. The prevalence of Angina+ was higher in women than men (3.9% vs. 1.9%, p < 0.001) whilst prevalence of History+ was lower (3.8% vs. 4.0%, p = 0.8), which may suggest a higher rate of undiagnosed IHD in women. A history of IHD was strongly associated with age, hypertension and diabetes status even after adjusting for sociodemographic factors. Though the prevalence of History+ was higher in the most developed area SES tertile and urban areas, History+ was also associated with less education but not household SES, consistent with patterns emerging from other LMICs.

Health and health system effects on poverty: A narrative review of global evidence.

Ill-health causes poverty. The effect runs through multiple mechanisms that span lifetimes and cross generations. Health systems can reduce poverty by improving health and weakening links from ill-health to poverty. This paper maps routes through which ill-health can cause poverty and identifies those that are potentially amenable to health policy. The review confirms that ill-health is an important contributor to poverty and it finds that the effect through health-related loss of earnings is often larger than that through medical expenses. Both effects are smaller in countries that are closer to universal health coverage and have higher social safety nets. The paper also reviews evidence from low- and middle-income countries (LMICs) and the United States (US) on the poverty-reduction effectiveness of public health insurance (PubHI) for low-income households. This reveals that PubHI does not always deliver financial protection to its targeted population in LMICs. Countries that have succeeded in achieving this goal often combine extension of coverage with supply-side interventions to build capacity and avoid perverse provider incentives in response to insurance. In the US, PubHI is effective in reducing poverty by shielding low-income households with children from healthcare costs and, consequently, generating long-run improvements in health that increase lifetime earnings. Poverty reduction is a potentially important co-benefit of health systems.

Aversion to health inequality - Pure, income-related and income-caused.

We design a novel experiment to identify aversion to pure (univariate) health inequality separately from aversion to income-related and income-caused health inequality. Participants allocate resources to determine health of individuals. Identification comes from random variation in resource productivity and information on income and its causal effect. We gather data (26,286 observations) from a sample of UK adults (n = 337) and estimate pooled and participant-specific social preferences while accounting for noise. The median person has strong aversion to pure health inequality, challenging the health maximisation objective of economic evaluation. Aversion to health inequality is even stronger when it is related to income. However, the median person prioritises health of poorer individuals less than is assumed in the standard measure of income-related health inequality. On average, aversion to that inequality does not become stronger when low income is known to cause ill-health. There is substantial heterogeneity in all three types of inequality aversion.

Distributionally sensitive measurement and valuation of population health.

We introduce a measure of population health that is sensitive to inequality in both age-specific health and lifespan and can be calculated from a health-extended period life table. By allowing for inequality aversion, the measure generalises health-adjusted life expectancy without requiring more data. A transformation of change in the (life-years) measure gives a distributionally sensitive monetary valuation of change in population health and disease burden. Application to Sub-Saharan Africa between 1990 and 2019 reveals that the change in population health is sensitive to allowing for lifespan inequality but is less sensitive to age-specific health inequality. Allowing for distributional sensitivity changes relative burdens of diseases, reduces convergence between the burdens of communicable and non-communicable diseases, and so could influence disease prioritisation. It increases the value of health improvements relative to GDP.

Access to health care in developing countries: breaking down demand side barriers

Effective health care interventions are underutilized in the developing world, and income-related disparities in use are large. The evidence concerning this access problem is summarized and its demand side causes are identified. Broad strategies that have been proposed to tackle the access problem through changes in economic incentives are considered. It is argued that there is a need to go beyond the identification of broad strategies to the design and evaluation of specific policy measures. Only through experimentation and evaluation will we learn what works in raising health care utilization, particularly among the poor in the developing world.

Nos países em desenvolvimento, as intervenções efetivas na saúde são subutilizadas, enquanto a utilização mostra disparidades associadas à renda. O autor resume as evidências sobre esse problema de acesso e identifica as causas existentes no lado da demanda. Em seguida, o autor analisa estratégias amplas para enfrentar o problema de acesso por meio de mudanças nos incentivos econômicos. O autor argumenta que é necessário ir além da identificação de estratégias amplas para elaborar e avaliar medidas políticas específicas. Somente por meio da experimentação e da avaliação poderemos aprender como aumentar a utilização dos cuidados em saúde, particularmente entre os pobres no mundo em desenvolvimento.