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1.
Artículo en Inglés | MEDLINE | ID: mdl-33975689

RESUMEN

Gastric cancer (GC) is a significant global health problem, with Helicobacter pylori infection estimated to be responsible for 89% of non-cardiac GC cases, or 78% of all GC cases. The International Agency for Research on Cancer has called for Helicobacter pylori test-and-treat strategies in countries with high rates of GC. However, for countries with low rates of GC, such as most Western countries, the balance between benefits, harms and costs of screening is less clear-cut. GC is a disease with a well-characterized precancerous process, providing the basis for primary and secondary prevention efforts. However, rigorous data assessing the impact of such interventions in Western countries are lacking. In the absence of clinical trials, modelling offers a unique approach to evaluate the potential impact of various screening and surveillance interventions. In this paper, we provide an overview of modelling studies evaluating the cost-effectiveness of GC screening and surveillance in Western countries.


Asunto(s)
Detección Precoz del Cáncer/métodos , Tamizaje Masivo/economía , Tamizaje Masivo/métodos , Neoplasias Gástricas , Análisis Costo-Beneficio , Humanos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/economía , Neoplasias Gástricas/epidemiología , Neoplasias Gástricas/prevención & control
2.
Value Health ; 24(3): 369-376, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33641771

RESUMEN

OBJECTIVES: To investigate the safety and cost-effectiveness of lengthening the time between surveillance ultrasound scans in the UK Abdominal Aortic Aneurysm (AAA) Screening Programme. METHODS: A discrete event simulation model was used to evaluate the cost-effectiveness of AAA screening for men aged 65, comparing current surveillance intervals to 6 alternative surveillance interval strategies that lengthened the time between surveillance scans for 1 or more AAA size categories. The model considered clinical events and costs incurred over a 30-year time horizon and the cost per quality-adjusted life year (QALY). The model adopted the National Health Service perspective and discounted future costs and benefits at 3.5%. RESULTS: Compared with current practice, alternative surveillance strategies resulted in up to a 4% reduction in the number of elective AAA repairs but with an increase of up to 1.6% in the number of AAA ruptures and AAA-related deaths. Alternative strategies resulted in a small reduction in QALYs compared to current practice but with reduced costs. Two strategies that lengthened surveillance intervals in only very small AAAs (3.0-3.9 cm) provided, at a cost-effectiveness threshold of £20 000 per QALY, the highest positive incremental net benefit. There was negligible chance that current practice is the most cost-effective strategy at any threshold below £40 000 per QALY. CONCLUSIONS: Lengthening surveillance intervals in the UK Abdominal Aortic Aneurysm Screening Programme, especially for small AAA, can marginally reduce the incremental cost per QALY of the program. Nevertheless, whether the cost savings from refining surveillance strategies justifies a change in clinical practice is unclear.


Asunto(s)
Aneurisma de la Aorta Abdominal/diagnóstico , Tamizaje Masivo/economía , Anciano , Anciano de 80 o más Años , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Modelos Económicos , Método de Montecarlo , Medicina Estatal , Factores de Tiempo , Ultrasonografía , Reino Unido
3.
JAMA Netw Open ; 4(3): e2037657, 2021 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-33704474

RESUMEN

Importance: If magnetic resonance imaging (MRI) mitigates overdiagnosis of prostate cancer while improving the detection of clinically significant cases, including MRI in a screening program for prostate cancer could be considered. Objective: To evaluate the benefit-harm profiles and cost-effectiveness associated with MRI before biopsy compared with biopsy-first screening for prostate cancer using age-based and risk-stratified screening strategies. Design, Setting, and Participants: This decision analytical model used a life-table approach and was conducted between December 2019 and July 2020. A hypothetical cohort of 4.48 million men in England aged 55 to 69 years were analyzed and followed-up to 90 years of age. Exposures: No screening, age-based screening, and risk-stratified screening in the hypothetical cohort. Age-based screening consisted of screening every 4 years with prostate-specific antigen between the ages of 55 and 69 years. Risk-stratified screening used age and polygenic risk profiles. Main Outcomes and Measures: The benefit-harm profile (deaths from prostate cancer, quality-adjusted life-years, overdiagnosis, and biopsies) and cost-effectiveness (net monetary benefit, from a health care system perspective) were analyzed. Both age-based and risk-stratified screening were evaluated using a biopsy-first and an MRI-first diagnostic pathway. Results were derived from probabilistic analyses and were discounted at 3.5% per annum. Results: The hypothetical cohort included 4.48 million men in England, ranging in age from 55 to 69 years (median, 62 years). Compared with biopsy-first age-based screening, MRI-first age-based screening was associated with 0.9% (1368; 95% uncertainty interval [UI], 1370-1409) fewer deaths from prostate cancer, 14.9% (12 370; 95% UI, 11 100-13 670) fewer overdiagnoses, and 33.8% (650 500; 95% UI, 463 200-907 000) fewer biopsies. At 10-year absolute risk thresholds of 2% and 10%, MRI-first risk-stratified screening was associated with between 10.4% (7335; 95% UI, 6630-8098) and 72.6% (51 250; 95% UI, 46 070-56 890) fewer overdiagnosed cancers, respectively, and between 21.7% fewer MRIs (412 100; 95% UI, 411 400-412 900) and 53.5% fewer biopsies (1 016 000; 95% UI, 1 010 000-1 022 000), respectively, compared with MRI-first age-based screening. The most cost-effective strategies at willingness-to-pay thresholds of £20 000 (US $26 000) and £30 000 (US $39 000) per quality-adjusted life-year gained were MRI-first risk-stratified screening at 10-year absolute risk thresholds of 8.5% and 7.5%, respectively. Conclusions and Relevance: In this decision analytical model of a hypothetical cohort, an MRI-first diagnostic pathway was associated with an improvement in the benefit-harm profile and cost-effectiveness of screening for prostate cancer compared with biopsy-first screening. These improvements were greater when using risk-stratified screening based on age and polygenic risk profile and may warrant prospective evaluation.


Asunto(s)
Biopsia , Análisis Costo-Beneficio , Detección Precoz del Cáncer , Costos de la Atención en Salud , Imagen por Resonancia Magnética , Tamizaje Masivo/métodos , Neoplasias de la Próstata/diagnóstico , Anciano , Beneficencia , Biopsia/economía , Detección Precoz del Cáncer/economía , Inglaterra , Humanos , Tablas de Vida , Imagen por Resonancia Magnética/economía , Masculino , Tamizaje Masivo/economía , Uso Excesivo de los Servicios de Salud , Persona de Mediana Edad , Probabilidad , Estudios Prospectivos , Neoplasias de la Próstata/mortalidad , Años de Vida Ajustados por Calidad de Vida , Incertidumbre
4.
PLoS One ; 16(3): e0248783, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33764982

RESUMEN

BACKGROUND: COVID-19 test sensitivity and specificity have been widely examined and discussed, yet optimal use of these tests will depend on the goals of testing, the population or setting, and the anticipated underlying disease prevalence. We model various combinations of key variables to identify and compare a range of effective and practical surveillance strategies for schools and businesses. METHODS: We coupled a simulated data set incorporating actual community prevalence and test performance characteristics to a susceptible, infectious, removed (SIR) compartmental model, modeling the impact of base and tunable variables including test sensitivity, testing frequency, results lag, sample pooling, disease prevalence, externally-acquired infections, symptom checking, and test cost on outcomes including case reduction and false positives. FINDINGS: Increasing testing frequency was associated with a non-linear positive effect on cases averted over 100 days. While precise reductions in cumulative number of infections depended on community disease prevalence, testing every 3 days versus every 14 days (even with a lower sensitivity test) reduces the disease burden substantially. Pooling provided cost savings and made a high-frequency approach practical; one high-performing strategy, testing every 3 days, yielded per person per day costs as low as $1.32. INTERPRETATION: A range of practically viable testing strategies emerged for schools and businesses. Key characteristics of these strategies include high frequency testing with a moderate or high sensitivity test and minimal results delay. Sample pooling allowed for operational efficiency and cost savings with minimal loss of model performance.


Asunto(s)
Prueba de COVID-19/economía , COVID-19/diagnóstico , COVID-19/virología , Análisis Costo-Beneficio , Diagnóstico Tardío , Humanos , Tamizaje Masivo/economía , Prevalencia , ARN Viral/análisis , ARN Viral/metabolismo , SARS-CoV-2/genética , SARS-CoV-2/aislamiento & purificación , Instituciones Académicas , Sensibilidad y Especificidad
5.
J Mol Diagn ; 23(5): 532-540, 2021 05.
Artículo en Inglés | MEDLINE | ID: mdl-33549858

RESUMEN

Routine testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in health care workers (HCWs) is critical. Group testing strategies to increase capacity facilitate mass population testing but do not prioritize turnaround time, an important consideration for HCW screening. We propose a nonadaptive combinatorial (NAC) group testing strategy to increase throughput while facilitating rapid turnaround. NAC matrices were constructed for sample sizes of 700, 350, and 250. Matrix performance was tested by simulation under different SARS-CoV-2 prevalence scenarios of 0.1% to 10%. NAC matrices were compared versus Dorfman sequential (DS) group testing approaches. NAC matrices performed well at low prevalence levels, with an average of 97% of samples resolved after a single round of testing via the n = 700 matrix at a prevalence of 1%. In simulations of low to medium (0.1% to 3%) prevalence, all NAC matrices were superior to the DS strategy, measured by fewer repeated tests required. At very high prevalence levels (10%), the DS matrix was marginally superior, although both group testing approaches performed poorly at high prevalence levels. This strategy maximizes the proportion of samples resolved after a single round of testing, allowing prompt return of results to HCWs. This methodology may allow laboratories to adapt their testing scheme based on required throughput and the current population prevalence, facilitating a data-driven testing strategy.


Asunto(s)
COVID-19/diagnóstico , SARS-CoV-2/aislamiento & purificación , Prueba de COVID-19/economía , Prueba de COVID-19/métodos , Brotes de Enfermedades , Personal de Salud , Humanos , Tamizaje Masivo/economía , Tamizaje Masivo/métodos
6.
Environ Health Prev Med ; 26(1): 18, 2021 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-33522902

RESUMEN

BACKGROUND: Despite the importance of hepatitis screening for decreasing liver cancer mortality, screening rates remain low in Japan. Previous studies show that full subsidies increase screening uptake, but full subsidies are costly and difficult to implement in low-resource settings. Alternatively, applying nudge theory to the message design could increase screening at lower costs. This study examined the effects of both methods in increasing hepatitis virus screening rates at worksites. METHODS: 1496 employees from a Japanese transportation company received client reminders for an optional hepatitis virus screening before their general health checkups. Groups A and B received a client reminder designed based on the principles of "Easy" and "Attractive," while the control group received a client reminder not developed using nudge theory. Additionally, hepatitis virus screening was offered to the control group and group A for a co-payment of JPY 612, but was fully subsidized for group B. The hepatitis virus screening rates among the groups were compared using a Chi-square test with Bonferroni correction, and the risk ratios of group A and group B to the control group were also calculated. To adjust for unobservable heterogeneity per cluster, the regression analysis was performed using generalized linear mixed models. RESULTS: The screening rate was 21.2%, 37.1%, and 86.3% for the control group, group A, and group B, respectively. And the risk ratio for group A was 1.75 (95% confidence interval [CI] 1.45-2.12) and that of group B was 4.08 (95% CI 3.44-4.83). The parameters of group A and group B also were significant when estimated using generalized linear mixed models. However, the cost-effectiveness (incremental cost-effectiveness ratio (ICER)) of the nudge-based reminder with the full subsidies was lower than that of only the nudge-based reminder. CONCLUSIONS: While fully subsidized screening led to the highest hepatitis screening rates, modifying client reminders using nudge theory significantly increased hepatitis screening uptake at lower costs per person.


Asunto(s)
Análisis Costo-Beneficio , Virus de Hepatitis/aislamiento & purificación , Tamizaje Masivo/instrumentación , Lugar de Trabajo , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Japón , Masculino , Tamizaje Masivo/economía , Persona de Mediana Edad
7.
Antimicrob Resist Infect Control ; 10(1): 44, 2021 02 27.
Artículo en Inglés | MEDLINE | ID: mdl-33640031

RESUMEN

The proportion of asymptomatic carriers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains elusive and the potential benefit of systematic screening during the SARS-CoV-2-pandemic is controversial. We investigated the proportion of asymptomatic inpatients who were identified by systematic screening for SARS-CoV-2 upon hospital admission. Our analysis revealed that systematic screening of asymptomatic inpatients detects a low total number of SARS-CoV-2 infections (0.1%), questioning the cost-benefit ratio of this intervention. Even when the population-wide prevalence was low, the proportion of asymptomatic carriers remained stable, supporting the need for universal infection prevention and control strategies to avoid onward transmission by undetected SARS-CoV-2-carriers during the pandemic.


Asunto(s)
Infecciones Asintomáticas/epidemiología , COVID-19/diagnóstico , SARS-CoV-2/aislamiento & purificación , Anciano , COVID-19/epidemiología , COVID-19/transmisión , Prueba de COVID-19/economía , Prueba de COVID-19/métodos , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Tamizaje Masivo/economía , Tamizaje Masivo/métodos , Persona de Mediana Edad , Suiza/epidemiología
8.
PLoS One ; 16(2): e0247767, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33635923

RESUMEN

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has revealed the global public health importance of robust diagnostic testing. To overcome the challenge of nucleic acid (NA) extraction and testing kit availability, an efficient method is urgently needed. OBJECTIVES: To establish an efficient, time and resource-saving and cost-effective methods, and to propose an ad hoc pooling approach for mass screening of SARS-CoV-2. METHODS: We evaluated pooling approach on both direct clinical and NA samples. The standard reverse transcriptase polymerase chain reaction (RT-PCR) test of the SARS CoV-2 was employed targeting the nucleocapsid (N) and open reading frame (ORF1ab) genomic region of the virus. The experimental pools were created using SARS CoV-2 positive clinical samples and extracted RNA spiked with up to 9 negative samples. For the direct clinical samples viral NA was extracted from each pool to a final extraction volume of 200µL, and subsequently both samples tested using the SARS CoV-2 RT-PCR assay. RESULTS: We found that a single positive sample can be amplified and detected in pools of up to 7 samples depending on the cycle threshold (Ct) value of the original sample, corresponding to high, and low SARS CoV-2 viral copies per reaction. However, to minimize false negativity of the assay with pooling strategies and with unknown false negativity rate of the assay under validation, we recommend pooling of 4/5 in 1 using the standard protocols of the assay, reagents and equipment. The predictive algorithm indicated a pooling ratio of 5 in 1 was expected to retain accuracy of the test irrespective of the Ct value samples spiked, and result in a 137% increase in testing efficiency. CONCLUSIONS: The approaches showed its concept in easily customized and resource-saving manner and would allow expanding of current screening capacities and enable the expansion of detection in the community. We recommend clinical sample pooling of 4 or 5 in 1. However, we don't advise pooling of clinical samples when disease prevalence is greater than 7%; particularly when sample size is large.


Asunto(s)
Prueba de Ácido Nucleico para COVID-19/métodos , COVID-19/diagnóstico , ARN Viral/aislamiento & purificación , SARS-CoV-2/aislamiento & purificación , Algoritmos , COVID-19/virología , Prueba de Ácido Nucleico para COVID-19/economía , Humanos , Tamizaje Masivo/economía , Tamizaje Masivo/métodos , ARN Viral/genética , SARS-CoV-2/genética , Sensibilidad y Especificidad , Manejo de Especímenes/economía , Manejo de Especímenes/métodos
9.
Am J Nurs ; 121(2): 53-55, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33497128

RESUMEN

This is the second of three articles exploring ways in which frontline nurses may be affected by recommendations of the forthcoming National Academy of Medicine Future of Nursing 2020-2030 study. As pioneering health systems begin investing in housing and other services to support individuals and bolster communities, nurses gain new opportunities and responsibilities. On the one hand, nurses should expect their work to entail more tracking and sharing of patient data. On the other, nurses can apply their creativity and holistic approach to care to assist health systems in making an overdue cultural shift.


Asunto(s)
Atención a la Salud/economía , Tamizaje Masivo/métodos , Determinantes Sociales de la Salud , Atención a la Salud/tendencias , Humanos , Tamizaje Masivo/economía
10.
Acta Diabetol ; 58(5): 643-650, 2021 May.
Artículo en Inglés | MEDLINE | ID: mdl-33483856

RESUMEN

AIMS: We aimed to determine the patient and screening-level factors that are associated with non-attendance in the Irish National Diabetic Retinal screening programme (Diabetic RetinaScreen). To accomplish this, we modelled a selection of predictors derived from the historical screening records of patients with diabetes. METHODS: In this cohort study, appointment data from the national diabetic retinopathy screening programme (RetinaScreen) were extracted and augmented using publicly available meteorological and geospatial data. A total of 653,969 appointments from 158,655 patients were included for analysis. Mixed-effects models (univariable and multivariable) were used to estimate the influence of several variables on non-attendance to screening appointments. RESULTS: All variables considered for analysis were statistically significant. Variables of note, with meaningful effect, were age (OR: 1.23 per decade away from 70; 95% CI: [1.22-1.24]), type 2 diabetes (OR: 1.10; 95% CI: [1.06-1.14]) and socio-economic deprivation (OR: 1.12; 95% CI: [1.09-1.16]). A majority (52%) of missed appointments were from patients who had missed three or more appointments. CONCLUSIONS: This study is the first to outline factors that are associated with non-attendance within the Irish national diabetic retinopathy screening service. In particular, when corrected for age and other factors, patients with type 2 diabetes had higher rates of non-attendance. Additionally, this is the first study of any diabetic screening programme to demonstrate that weather may influence attendance. This research provides unique insight to guide the implementation of an optimal and cost-effective intervention strategy to improve attendance.


Asunto(s)
Retinopatía Diabética/diagnóstico , Tamizaje Masivo , Pacientes no Presentados/estadística & datos numéricos , Anciano , Estudios de Cohortes , Análisis Costo-Beneficio , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/economía , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/economía , Diabetes Mellitus Tipo 2/epidemiología , Retinopatía Diabética/economía , Retinopatía Diabética/epidemiología , Femenino , Humanos , Masculino , Tamizaje Masivo/economía , Tamizaje Masivo/estadística & datos numéricos , Persona de Mediana Edad , Pacientes no Presentados/economía , Pobreza/estadística & datos numéricos , Factores de Riesgo , Factores Socioeconómicos
12.
Public Health ; 190: 116-122, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33450632

RESUMEN

OBJECTIVES: We develop a patient prioritization scheme for treating patients infected with hepatitis C virus (HCV) and study under which scenarios it outperforms the current practices in Spain and Chile. STUDY DESIGN: We use simulation to evaluate the performance of prioritization rules under two HCV patient cohorts, constructed using secondary data of public records from Chile and Spain, during 2015-2016. METHODS: We use the results of a mathematical model, which determines individual optimal HCV treatment policies as an input for constructing a patient prioritization rule, when limited resources are present. The prioritization is based on marginal analysis on cost increases and health-outcome gains. We construct the Chilean and Spanish case studies and used Monte Carlo simulation to evaluate the performance of our methodology in these two scenarios. RESULTS: The resulting prioritizations for the Chilean and Spanish patients are similar, despite the significant differences of both countries, in terms of epidemiological profiles and cost structures. Furthermore, when resources are scarce compared with the number of patients in need of the new drug, our prioritization significantly outperforms current practices of treating sicker patients first, both in terms of cost and healthcare indicators: for the Chilean case, we have an increase in the quality-adjusted life years (QALYs) of 0.83 with a cost reduction of 8176 euros per patient, with a budget covering 2.5% of the patients in the cohort. This difference slowly decreases when increasing the available resources, converging to the performance indicators obtained when all patients are treated immediately: for the Spanish case, we have a decrease in the QALYs of 0.17 with a cost reduction of 1134 euros per patient, with a budget covering 20% of the patients in the cohort. CONCLUSION: Decision science can provide useful analytical tools for designing efficient public policies that can excel in terms of quantitative health performance indicators.


Asunto(s)
Antivirales/uso terapéutico , Hepacivirus/aislamiento & purificación , Hepatitis C Crónica/diagnóstico , Hepatitis C Crónica/tratamiento farmacológico , Antivirales/economía , Presupuestos , Chile/epidemiología , Estudios de Cohortes , Análisis Costo-Beneficio , Femenino , Costos de la Atención en Salud , Hepacivirus/efectos de los fármacos , Hepatitis C Crónica/economía , Humanos , Tamizaje Masivo/economía , Modelos Teóricos , Método de Montecarlo , Años de Vida Ajustados por Calidad de Vida , España/epidemiología , Resultado del Tratamiento
14.
Ann Intern Med ; 174(4): 472-483, 2021 04.
Artículo en Inglés | MEDLINE | ID: mdl-33347322

RESUMEN

BACKGROUND: Colleges in the United States are determining how to operate safely amid the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To examine the clinical outcomes, cost, and cost-effectiveness of COVID-19 mitigation strategies on college campuses. DESIGN: The Clinical and Economic Analysis of COVID-19 interventions (CEACOV) model, a dynamic microsimulation model, was used to examine alternative mitigation strategies. The CEACOV model tracks infections accrued by students and faculty, accounting for community transmissions. DATA SOURCES: Data from published literature were used to obtain parameters related to COVID-19 and contact-hours. TARGET POPULATION: Undergraduate students and faculty at U.S. colleges. TIME HORIZON: One semester (105 days). PERSPECTIVE: Modified societal. INTERVENTION: COVID-19 mitigation strategies, including social distancing, masks, and routine laboratory screening. OUTCOME MEASURES: Infections among students and faculty per 5000 students and per 1000 faculty, isolation days, tests, costs, cost per infection prevented, and cost per quality-adjusted life-year (QALY). RESULTS OF BASE-CASE ANALYSIS: Among students, mitigation strategies reduced COVID-19 cases from 3746 with no mitigation to 493 with extensive social distancing and masks, and further to 151 when laboratory testing was added among asymptomatic persons every 3 days. Among faculty, these values were 164, 28, and 25 cases, respectively. Costs ranged from about $0.4 million for minimal social distancing to about $0.9 million to $2.1 million for strategies involving laboratory testing ($10 per test), depending on testing frequency. Extensive social distancing with masks cost $170 per infection prevented ($49 200 per QALY) compared with masks alone. Adding routine laboratory testing increased cost per infection prevented to between $2010 and $17 210 (cost per QALY gained, $811 400 to $2 804 600). RESULTS OF SENSITIVITY ANALYSIS: Results were most sensitive to test costs. LIMITATION: Data are from multiple sources. CONCLUSION: Extensive social distancing with a mandatory mask-wearing policy can prevent most COVID-19 cases on college campuses and is very cost-effective. Routine laboratory testing would prevent 96% of infections and require low-cost tests to be economically attractive. PRIMARY FUNDING SOURCE: National Institutes of Health.


Asunto(s)
COVID-19/prevención & control , Control de Enfermedades Transmisibles/métodos , Neumonía Viral/prevención & control , Universidades , Adulto , COVID-19/epidemiología , Prueba de COVID-19 , Control de Enfermedades Transmisibles/economía , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Máscaras , Tamizaje Masivo/economía , Pandemias , Distanciamiento Físico , Neumonía Viral/epidemiología , SARS-CoV-2 , Estados Unidos/epidemiología
15.
Soc Sci Med ; 268: 113571, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33310396

RESUMEN

The value of digital healthcare has been lauded in Canada at local, provincial, and national levels. Digital medicine is purported to enhance patient access to care while promising cost savings. Using institutional ethnography, we examined the potential for publicly funded digital testing for HIV and other sexually transmitted infections (STI) in Ontario, Canada. Our analyses draw from 23 stakeholder interviews with healthcare professionals conducted between 2019 and 2020, and textual analyses of government documents and private, for-profit digital healthcare websites. We uncovered a "two-tiered" system whereby private digital STI testing services enable people with economic resources to "pay to skip the line" queuing at public clinics and proceed directly to provide samples for diagnostics at local private medical labs. In Ontario, private lab corporations compete for fee-for-service contracts with government, which in turn organises opportunities for market growth when more patient samples are collected vis-à-vis digital testing. However, we also found that some infectious disease specimens (e.g., HIV) are re-routed for analysis at government public health laboratories, who may be unable to manage the increase in testing volume associated with digital STI testing due to state budget constraints. Our findings on public-private laboratory funding disparities thus discredit the claims that digital healthcare necessarily generates cost savings, or that it enhances patients' access to care. We conclude that divergent state funding relations together with the creeping privatisation of healthcare within this "universal" system coordinate the conditions through which private corporations capitalise from digital STI testing, compounding patient access inequities. We also stress that our findings bring forth large scale implications given the context of the global COVID-19 pandemic, the rapid diffusion of digital healthcare, together with significant novel coronavirus testing activities initiated by private industry.


Asunto(s)
Tecnología Digital , Infecciones por VIH/diagnóstico , Prueba de VIH/economía , Tamizaje Masivo/economía , Política , Enfermedades de Transmisión Sexual/diagnóstico , Prueba de VIH/métodos , Humanos , Tamizaje Masivo/métodos , Ontario
16.
J Surg Res ; 257: 616-624, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-32949994

RESUMEN

BACKGROUND: Armenia has a high incidence of and mortality from colorectal cancer (CRC). No organized screening programs for CRC exist in Armenia. This study seeks to evaluate knowledge of and attitudes toward CRC and screening programs in Armenia. METHODS: Adults aged 40-64 y were administered a survey using convenience sampling throughout polyclinics in Yerevan city. Survey questions were based on the Health Belief Model and were translated and modified for local relevance. RESULTS: A total of 368 surveys were completed. Eighty-four percent had knowledge of CRC, 91% believed that early detection leads to improved outcomes, but only 22% had knowledge of screening. Women were more likely to have knowledge of CRC (odds ratio 2.19, P < 0.05). Although 19% have personally worried about having CRC, only 7% admitted to discussing their worries with a provider and 76% were willing to undergo screening if recommended by their doctor. Seventy-eight percent of respondents would only undergo screening if free or less than ~$20 USD. CONCLUSIONS: Self-reported knowledge of CRC is high, whereas knowledge of screening remains low in Armenia. There is a willingness to undergo screening if recommended by a health care professional; however, this willingness is cost-sensitive. Interventions aimed at (1) increasing awareness of the disease and screening tests, (2) improving physician counseling, and (3) reducing financial barriers to screening should be considered along with the implementation of a national screening program in Armenia.


Asunto(s)
Neoplasias Colorrectales/diagnóstico , Conocimientos, Actitudes y Práctica en Salud , Tamizaje Masivo/psicología , Aceptación de la Atención de Salud , Armenia , Femenino , Humanos , Masculino , Tamizaje Masivo/economía , Persona de Mediana Edad , Encuestas y Cuestionarios
17.
Public Health ; 190: 23-29, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33338899

RESUMEN

OBJECTIVES: We aimed to determine whether there are any differences in all-cause and cause-specific mortality with cardiovascular disease (CVD) risk between health screening attenders and non-attenders among young adults. STUDY DESIGN: We performed a retrospective cohort study using claim data from the Korean National Health Insurance Service database. METHODS: Individuals aged 20-39 years who had received health screening at least once between 2002 and 2005 were classified as attenders, and the others were classified as non-attenders. After propensity score matching according to attendance of health screening, 2,060,409 attenders and 2,060,409 non-attenders were included. We estimated adjusted hazard ratios (HRs) and 95% confidence interval (CI) for all-cause mortality, cause-specific mortality, and hospitalization of CVD from 2006 to 2015. RESULTS: Survival from all-cause mortality was greater among attenders than among non-attenders (log rank P < 0.001). Similarly, death from CVD (log rank P = 0.007) and CVD events (log rank P < 0.001) were less likely among attenders. The risk for all-cause mortality in attenders was significantly lower than that in non-attenders (HR = 0.83, 95% CI = 0.81 to 0.84). The risk for CVD mortality (HR = 0.80, 95% CI = 0.73 to 0.87) and hospitalization of CVD (HR = 0.92, 95% CI = 0.91 to 0.94) were lower in attenders. In stratified analyses, the risk for all-cause and cause-specific mortalities was lower among attenders regardless of insurance type. CONCLUSIONS: Among young adults, the risk for all-cause mortality, CVD mortality, and hospitalization of CVD were lower for those who underwent health screenings. Future studies that evaluate the cost-effectiveness of health screening with additional consideration of psychosocial aspects are needed.


Asunto(s)
Enfermedades Cardiovasculares/diagnóstico , Tamizaje Masivo/estadística & datos numéricos , Programas Nacionales de Salud/economía , Aceptación de la Atención de Salud/estadística & datos numéricos , Adulto , Anciano , Enfermedades Cardiovasculares/economía , Enfermedades Cardiovasculares/mortalidad , Causas de Muerte/tendencias , Estudios de Cohortes , Femenino , Factores de Riesgo de Enfermedad Cardiaca , Hospitalización , Humanos , Incidencia , Masculino , Tamizaje Masivo/economía , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , República de Corea/epidemiología , Estudios Retrospectivos
18.
Cancer Epidemiol ; 70: 101861, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33310688

RESUMEN

BACKGROUND: On Nov 17, 2020, WHO launched a global initiative to accelerate the elimination of cervical cancer through the implementation of HPV vaccination, cervical cancer screening and treatment for precancer and cancer. China has the largest burden of cervical cancer in the world, but only has a national cervical cancer screening program in rural areas since 2009. Here, we aimed to evaluate the effectiveness and cost-effectiveness of cervical cancer screening in urban China, using Shenzhen City as an example. METHODS: We use an extensively validated platform ('Policy1-Cervix'), calibrated to data from Shenzhen city and Guandong Province. We evaluated a range of strategies that have previously been implemented as pilot studies in China, or recommended as guidelines within China and globally, spanning primary HPV, cytology and co-testing strategies. We additionally considered alternate triaging methods, age ranges and screening intervals, resulting in 19 algorithms in total. RESULTS: Of the 19 strategies considered, the most effective approach involved primary HPV testing. At 3- to 10-yearly intervals, primary HPV testing reduced the age-standardized cancer mortality rate by 37-71 %. The most cost-effective strategy was 5-yearly primary HPV testing with partial genotyping triage for ages 25-65, discharging to 10-yearly screening for low-risk women (ICER = US$7191/QALYS using 2018 costs; willingness-to-pay threshold<1xGDP [US$9771]). This strategy gave an incidence and mortality reduction of 56 % and 63 %, respectively. This remained the most cost-effective strategy under most conditions in sensitivity analysis. CONCLUSION: Primary HPV testing would be cost-effective in Shenzhen and could more than halve cervical cancer incidence rates to 6 per 100,000 over the long term. In order to achieve rates below 4 per 100,000, the elimination threshold set by the World Health Organization, vaccination will likely also be necessary.


Asunto(s)
Tamizaje Masivo/economía , Infecciones por Papillomavirus/virología , Adulto , Femenino , Humanos , Años de Vida Ajustados por Calidad de Vida , Población Urbana , Adulto Joven
19.
JAMA Netw Open ; 3(12): e2028195, 2020 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-33351082

RESUMEN

Importance: Approximately 356 000 people stay in homeless shelters nightly in the United States. They have high risk of contracting coronavirus disease 2019 (COVID-19). Objective: To assess the estimated clinical outcomes, costs, and cost-effectiveness associated with strategies for COVID-19 management among adults experiencing sheltered homelessness. Design, Setting, and Participants: This decision analytic model used a simulated cohort of 2258 adults residing in homeless shelters in Boston, Massachusetts. Cohort characteristics and costs were adapted from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were taken from published literature and national databases. Surging, growing, and slowing epidemics (effective reproduction numbers [Re], 2.6, 1.3, and 0.9, respectively) were examined. Costs were from a health care sector perspective, and the time horizon was 4 months, from April to August 2020. Exposures: Daily symptom screening with polymerase chain reaction (PCR) testing of individuals with positive symptom screening results, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternative care sites (ACSs) for mild or moderate COVID-19, and temporary housing were each compared with no intervention. Main Outcomes and Measures: Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case of COVID-19 prevented. Results: The simulated population of 2258 sheltered homeless adults had a mean (SD) age of 42.6 (9.04) years. Compared with no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild or moderate disease was associated with 37% fewer infections (1954 vs 1239) and 46% lower costs ($6.10 million vs $3.27 million) at an Re of 2.6, 75% fewer infections (538 vs 137) and 72% lower costs ($1.46 million vs $0.41 million) at an Re of 1.3, and 51% fewer infections (174 vs 85) and 51% lower costs ($0.54 million vs $0.26 million) at an Re of 0.9. Adding PCR testing every 2 weeks was associated with a further decrease in infections; incremental cost per case prevented was $1000 at an Re of 2.6, $27 000 at an Re of 1.3, and $71 000 at an Re of 0.9. Temporary housing with PCR every 2 weeks was most effective but substantially more expensive than other options. Compared with no intervention, temporary housing with PCR every 2 weeks was associated with 81% fewer infections (376) and 542% higher costs ($39.12 million) at an Re of 2.6, 82% fewer infections (95) and 2568% higher costs ($38.97 million) at an Re of 1.3, and 59% fewer infections (71) and 7114% higher costs ($38.94 million) at an Re of 0.9. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. Conclusions and Relevance: In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in SARS-CoV-2 infections at modest incremental cost and should be considered during future surges.


Asunto(s)
COVID-19/prevención & control , Control de Enfermedades Transmisibles/métodos , Costos de la Atención en Salud , Personas sin Hogar , Hospitalización/economía , Vivienda/economía , Tamizaje Masivo/métodos , COVID-19/economía , COVID-19/epidemiología , COVID-19/transmisión , Prueba de Ácido Nucleico para COVID-19/economía , Prueba de Ácido Nucleico para COVID-19/métodos , Estudios de Cohortes , Control de Enfermedades Transmisibles/economía , Simulación por Computador , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Humanos , Tamizaje Masivo/economía , SARS-CoV-2 , Evaluación de Síntomas/economía , Evaluación de Síntomas/métodos , Estados Unidos/epidemiología
20.
PLoS One ; 15(12): e0242408, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33315885

RESUMEN

We sought to develop a smooth and low cost sample preparation and DNA extraction protocol, streamlined with a ready-to-use qPCR in a portable instrument to overcome some of the existing hurdles. Several solutions were evaluated as to their ability to liquefy a mucin-based matrix. Each liquefied matrix, supplemented with either Mycobacterium tuberculosis (MTB) H37Rv strain DNA or intact cells, was aliquoted onto a filter paper embedded with solubilizing agents, and was subsequently dried up. Most of the nucleic acids, including genomic DNA from the bacilli and the host, binds to the filter paper. Next, several protocols were evaluated to elute the DNA from the paper, using qPCR to detect the insertion sequence IS6110, a M. tuberculosis complex genomic marker. The limit of detection (LOD) of the best protocol was then evaluated using parallel seeding and colony counting. The protocol was also evaluated using seventeen sputum samples, previously characterized by the GeneXpert or culture. Two instruments (the ABI7500 Standard and the Q3-Plus system) and two reagents storage formats (frozen or ready-to-use) were evaluated. Solutions containing guanidine isothiocyanate exerted the best liquefying effect on the mucin-based matrix extracted from one 6-mm punches, followed by a brief incubation at 95°C. The resulting DNA contained impurities, but a simple 1:10 dilution elicited the detection of MTB and human genomic targets. The described protocol presented an apparent LOD of 02 CFU/mL of MTB. Challenging the protocol with previously characterized samples showed substantial agreement with GeneXpert MTB/RIF results (sensitivity of 90%, agreement of 88.9%, kappa coefficient of 0.77), and moderate agreement with culture results (sensitivity of 100%, agreement of 78.9%, kappa coefficient of 0.58). This work presents a sensitive proof-of-concept protocol for sputum liquefaction and decontamination followed by a simple DNA extraction procedure, in which the extraction steps are streamlined with a ready-to-use qPCR in a portable instrument that can be employed in low infrastructure settings.


Asunto(s)
Tamizaje Masivo/métodos , Mycobacterium tuberculosis/aislamiento & purificación , Sistemas de Atención de Punto , Manejo de Especímenes/métodos , Tuberculosis Pulmonar/diagnóstico , Brasil , ADN Bacteriano/aislamiento & purificación , Humanos , Límite de Detección , Tamizaje Masivo/economía , Tamizaje Masivo/instrumentación , Mycobacterium tuberculosis/genética , Prueba de Estudio Conceptual , Reacción en Cadena en Tiempo Real de la Polimerasa/economía , Reacción en Cadena en Tiempo Real de la Polimerasa/instrumentación , Reacción en Cadena en Tiempo Real de la Polimerasa/métodos , Manejo de Especímenes/economía , Esputo/microbiología , Tuberculosis Pulmonar/microbiología
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