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OBJECTIVE: During COVID-19, governments imposed restrictions that reduced pandemic-related health risks but likely increased personal and societal mental health risk, partly through reductions in household income. This study aimed to quantify the public's willingness to accept trade-offs between pandemic health risks, household income reduction, and increased risk of mental illness that may result from future pandemic-related policies. METHODS: A total of 547 adults from an online panel participated in a discrete choice experiment where they were asked to choose between hypothetical future pandemic scenarios. Each scenario was characterized by personal and societal risks of dying from the pandemic, experiencing long-term complications, developing anxiety/depression, and reductions in household income. A latent class regression was used to estimate trade-offs. RESULTS: Respondents state a willingness to make trade-offs across these attributes if the benefits are large enough. They are willing to accept 0.8% lower household income (0.7-1.0), 2.7% higher personal risk of anxiety/depression (1.8-3.6), or 3.2% higher societal rate of anxiety/depression (1.7-4.7) in exchange for 300 fewer deaths from the pandemic. CONCLUSION: Results reveal that individuals are willing to accept lower household income and higher rates of mental illness, both personal and societal, if the physical health benefits are large enough. Respondents placed greater emphasis on maintaining personal, as opposed to societal, mental health risk and were most interested in preventing pandemic-related deaths. Governments should consider less restrictive policies when pandemics have high morbidity but low mortality to avoid the prospect of improving physical health while simultaneously reducing net social welfare.
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COVID-19 , Renda , Saúde Mental , Política Pública , Humanos , COVID-19/epidemiologia , COVID-19/prevenção & controle , COVID-19/economia , COVID-19/psicologia , Masculino , Adulto , Feminino , Pessoa de Meia-Idade , Pandemias , Nível de Saúde , Adulto Jovem , Ansiedade/epidemiologia , Ansiedade/psicologia , Idoso , SARS-CoV-2 , Adolescente , Depressão/epidemiologia , Depressão/psicologiaRESUMO
INTRODUCTION: Hyperkalaemia (HK) is prevalent among patients with chronic kidney disease (CKD) and chronic heart failure, especially if they are treated with renin-angiotensin-aldosterone system inhibitors (RAASi). This study evaluated the cost-effectiveness of a newly developed anti-HK therapy, sodium zirconium cyclosilicate (SZC), to the current standard of care for treating HK in advanced CKD patients from the Singapore health system perspective. METHODS: We adapted a global microsimulation model to simulate individual patients' potassium level trajectories with baseline potassium ≥5.5 mmol/L, CKD progression, changes in treatment, and other fatal and non-fatal events. Effectiveness data was derived from ZS-004 and ZS-005 trials. Model parameters were localised using CKD patients' administrative and medical records at the Singapore General Hospital Department of Renal Medicine. We estimated the lifetime cost and quality-adjusted life years (QALYs) of each HK treatment, and the incremental cost-effectiveness ratio of SZC. RESULTS: SZC demonstrated cost-effectiveness with an incremental cost-effectiveness ratsio of SGD 45 068 per QALY over a lifetime horizon, below the willingness-to-pay threshold of SGD 90 000 per QALY. Notably, SZC proved most cost-effective for patients with less severe CKD who were concurrently using RAASi. Sensitivity analyses confirmed the robustness of the findings, accounting for alternative parameter values and statistical uncertainty. CONCLUSION: This study establishes the cost-effectiveness of SZC as a treatment for HK, highlighting its potential to mitigate the risk of hyperkalaemia and optimise RAASi therapy. These findings emphasise the value of integrating SZC into the Singapore health system for improved patient outcomes and resource allocation.
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Glomerulonefrite , Hiperpotassemia , Insuficiência Renal Crônica , Silicatos , Humanos , Hiperpotassemia/tratamento farmacológico , Análise Custo-Benefício , Singapura/epidemiologia , Potássio , Doença Crônica , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/tratamento farmacológico , RimRESUMO
BACKGROUND: For patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care. METHODS: Participants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework's decisional-needs manual was used as a guide for data collection and analysis, with two independent team members coding the data. RESULTS: Four themes reflecting perceptions and support for decision-making were identified: a) poor knowledge and fatalistic perceptions; b) inadequate resources and support for decision-making; c) complexity of decision-making, unclear timing, and unpreparedness; and d) internal emotions of decisional conflict and regret. Participants displayed limited awareness of dialysis withdrawal and palliative care, often perceiving dialysis withdrawal as medical abandonment. Patient preferences regarding decision-making ranged from autonomous control to physician or family-delegated choices. Cultural factors contributed to hesitancy and reluctance to discuss end-of-life matters, resulting in a lack of conversations between patients and providers, as well as between patients and their caregivers. CONCLUSIONS: Decision-making for dialysis withdrawal is complicated, exacerbated by a lack of awareness and conversations on end-of-life care among patients, caregivers, and providers. These findings emphasize the need for a culturally-sensitive tool that informs and prepares patients and their caregivers to navigate decisions about dialysis withdrawal and the transition to palliative care. Such a tool could bridge information gaps and stimulate meaningful conversations, fostering informed and culturally aligned decisions during this critical juncture of care.
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Nefropatias , Falência Renal Crônica , Assistência Terminal , Humanos , Diálise Renal/métodos , Falência Renal Crônica/terapia , Falência Renal Crônica/psicologia , Qualidade de Vida , Tomada de Decisões , Pesquisa QualitativaRESUMO
BACKGROUND: The Diabetic Retinopathy Extended Screening Study (DRESS) aims to develop and validate a new DR/diabetic macular edema (DME) risk stratification model in patients with Type 2 diabetes (DM) to identify low-risk groups who can be safely assigned to biennial or triennial screening intervals. We describe the study methodology, participants' baseline characteristics, and preliminary DR progression rates at the first annual follow-up. METHODS: DRESS is a 3-year ongoing longitudinal study of patients with T2DM and no or mild non-proliferative DR (NPDR, non-referable) who underwent teleophthalmic screening under the Singapore integrated Diabetic Retinopathy Programme (SiDRP) at four SingHealth Polyclinics. Patients with referable DR/DME (> mild NPDR) or ungradable fundus images were excluded. Sociodemographic, lifestyle, medical and clinical information was obtained from medical records and interviewer-administered questionnaires at baseline. These data are extracted from medical records at 12, 24 and 36 months post-enrollment. Baseline descriptive characteristics stratified by DR severity at baseline and rates of progression to referable DR at 12-month follow-up were calculated. RESULTS: Of 5,840 eligible patients, 78.3% (n = 4,570, median [interquartile range [IQR] age 61.0 [55-67] years; 54.7% male; 68.0% Chinese) completed the baseline assessment. At baseline, 97.4% and 2.6% had none and mild NPDR (worse eye), respectively. Most participants had hypertension (79.2%) and dyslipidemia (92.8%); and almost half were obese (43.4%, BMI ≥ 27.5 kg/m2). Participants without DR (vs mild DR) reported shorter DM duration, and had lower haemoglobin A1c, triglycerides and urine albumin/creatinine ratio (all p < 0.05). To date, we have extracted 41.8% (n = 1909) of the 12-month follow-up data. Of these, 99.7% (n = 1,904) did not progress to referable DR. Those who progressed to referable DR status (0.3%) had no DR at baseline. CONCLUSIONS: In our prospective study of patients with T2DM and non-referable DR attending polyclinics, we found extremely low annual DR progression rates. These preliminary results suggest that extending screening intervals beyond 12 months may be viable and safe for most participants, although our 3-year follow up data are needed to substantiate this claim and develop the risk stratification model to identify low-risk patients with T2DM who can be assigned biennial or triennial screening intervals.
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Diabetes Mellitus Tipo 2 , Retinopatia Diabética , Edema Macular , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Estudos de Coortes , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Estudos Longitudinais , Estudos Prospectivos , Singapura/epidemiologiaRESUMO
BACKGROUND: Parent-reported experience measures are part of pediatric Quality of Care (QoC) assessments. However, existing measures were not developed for use across multiple healthcare settings or throughout the illness trajectory of seriously ill children. Formative work involving in-depth interviews with parents of children with serious illnesses generated 66 draft items describing key QoC processes. Our present aim is to develop a comprehensive parent-reported experience measure of QoC for children with serious illnesses and evaluate its content validity and feasibility. METHODS: For evaluating content validity, we conducted a three-round Delphi expert panel review with 24 multi-disciplinary experts. Next, we pre-tested the items and instructions with 12 parents via cognitive interviews to refine clarity and understandability. Finally, we pilot-tested the full measure with 30 parents using self-administered online surveys to finalize the structure and content. RESULTS: The Delphi expert panel review reached consensus on 68 items. Pre-testing with parents of seriously ill children led to consolidation of some items. Pilot-testing supported feasibility of the measure, resulting in a comprehensive measure comprising 56 process assessment items, categorized under ten subthemes and four themes: (1) Professional qualities of healthcare workers, (2) Supporting parent-caregivers, (3) Collaborative and holistic care, and (4) Efficient healthcare structures and standards. We named this measure the PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS). CONCLUSIONS: PRECIOUS is the first comprehensive measure and has the potential to standardize assessment of QoC for seriously ill children from parental perspectives. PRECIOUS allows for QoC process evaluation across contexts (such as geographic location or care setting), different healthcare workers, and over the illness trajectory for children suffering from a range of serious illnesses.
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Pais , Qualidade da Assistência à Saúde , Criança , Humanos , Pais/psicologia , Cuidadores , Pessoal de Saúde , Consenso , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Specialist palliative care is often provided late in the patient's disease trajectory in response to uncontrolled symptoms. Shifting from this reactionary illness-stress paradigm to a proactive health-wellness approach, the ENABLE (Educate, Nurture, Advise, Before Life Ends) telehealth model aims to enhance the coping, stress and symptom management, self-care, and advance care planning skills of patients with advanced cancers and their caregivers. The ENABLE model has been culturally adapted to Singapore (ENABLE-SG) and pilot-tested. A hybrid type 1 effectiveness-implementation design will be used to evaluate the effectiveness of ENABLE-SG while collecting real-world implementation data. METHODS: This single-centre, assessor-blind, wait-list (immediately vs. 6 months) randomized controlled trial will recruit 300 adult patients within 60 days of an advanced cancer diagnosis and their family caregivers from the National Cancer Centre of Singapore. ENABLE-SG comprises structured psychoeducational sessions with a telehealth coach, covering essential topics of early palliative care. Participants will be assessed at baseline and every 3 months until patient's death, 12 months (caregivers), or end of study (patients). The primary outcome is patient quality of life 6 months after baseline. Secondary patient-reported outcomes include mood, coping, palliative care concerns, and health status. Secondary caregiver-reported outcomes include caregiver quality of life, mood, coping, and care satisfaction. Mixed-effects regression modelling for repeated measurements will be used. To assess the effectiveness of ENABLE-SG versus usual care, patient and caregiver outcomes at 6 months will be compared. To compare earlier versus delayed ENABLE-SG, patient and caregiver outcomes at 12 months will be compared. Within the hybrid type 1 effectiveness-implementation design, implementation outcomes will be evaluated in both the early and delayed groups. Acceptability, adoption, appropriateness, and feasibility will be assessed using a feedback survey and semi-structured interviews with a purposive sample of patients, caregivers, and healthcare providers. Transcribed interviews will be analysed thematically. Other implementation outcomes of penetration, fidelity, and cost will be assessed using records of study-related processes and summarized using descriptive statistics. A cost-effectiveness analysis will also be conducted. DISCUSSION: This study will assess both effectiveness and implementation of ENABLE-SG. Insights into implementation processes can facilitate model expansion and upscaling. TRIAL REGISTRATION: Registered prospectively on ClinicalTrials.gov, NCT06044441. Registered on 21/09/2023.
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Enfermagem de Cuidados Paliativos na Terminalidade da Vida , Neoplasias , Assistência Terminal , Adulto , Humanos , Cuidados Paliativos/métodos , Qualidade de Vida , Singapura , Assistência Terminal/métodos , Neoplasias/terapia , Cuidadores , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: The prevalence of obesity and its associated comorbidities continue to rise in the United States. Populations who are uninsured and from racial and ethnic minority groups continue to be disproportionately affected. These populations also experience fewer clinically meaningful outcomes in most weight loss trials. Weight gain prevention presents a useful strategy for individuals who experience barriers to weight loss. Given the often-limited weight management resources available to patients in primary care settings serving vulnerable patients, evaluating interventions with pragmatic designs may help inform the design of comprehensive obesity care delivered in primary care. OBJECTIVE: This study aims to evaluate the effectiveness of Balance, a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention, delivered to patients receiving primary care within federally qualified community health centers. METHODS: Balance was a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention delivered to individuals who had a BMI of 25-40 kg/m2, spoke English or Spanish, and were receiving primary care within a network of federally qualified community health centers in North Carolina. The Balance intervention was designed to encourage behavioral changes that result in a slight energy deficit. Intervention participants received tailored goal setting and tracking, skills training, self-monitoring, and responsive health coaching from registered dietitians. Weight was measured at regular primary care visits and documented in the electronic health record. We compared the percentage of ≤3% weight gain in each arm at 24 months after randomization-our primary outcome-using individual empirical best linear unbiased predictors from the linear mixed-effects model. We used individual empirical best linear unbiased predictors from participants with at least 1 electronic health record weight documented within a 6-month window centered on the 24-month time point. RESULTS: We randomized 443 participants, of which 223 (50.3%) participants were allocated to the intervention arm. At baseline, participants had a mean BMI of 32.6 kg/m2. Most participants were Latino or Hispanic (n=200, 45.1%) or non-Latino or Hispanic White (n=115, 26%). In total, 53% (n=235) of participants had at least 1 visit with weight measured in the primary time window. The intervention group had a higher proportion with ≤3% weight gain at 6 months (risk ratio=1.12, 95% CI 0.94-1.28; risk difference=9.5, 95% CI -4.5 to 16.4 percentage points). This difference attenuated to the null by 24 months (risk ratio=1.00, 95% CI 0.82-1.20; risk difference=0.2, 95% CI -12.1 to 11.0 percentage points). CONCLUSIONS: In adults with overweight or obesity receiving primary care at a community health center, we did not find long-term evidence to support the dissemination of a digital health intervention for weight gain prevention. TRIAL REGISTRATION: ClinicalTrials.gov NCT03003403; https://clinicaltrials.gov/study/NCT03003403. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-6926-7.
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Saúde Digital , Etnicidade , Adulto , Humanos , Grupos Minoritários , Aumento de Peso , Obesidade/prevenção & controle , Redução de Peso , Centros Comunitários de SaúdeRESUMO
[This corrects the article DOI: 10.2196/50330.].
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BACKGROUND AND OBJECTIVES: Advanced cancer patients' understanding of their illness is key for making informed treatment decisions. Despite the known importance of patients' awareness of their disease prognosis, it is debatable whether this awareness is positively, negatively, or not associated with clinical and psychological outcomes among patients with advanced cancer. This paper aims to determine the prevalence of and factors associated with prognostic awareness and its association with quality of life (QoL), spiritual well-being, pain control, and psychological distress in patients with advanced cancer in Indonesia. METHODS: This cross-sectional questionnaire-based survey was part of a multicountry study titled "Asian Patient Perspectives Regarding Oncology Awareness, Care and Health (APPROACH)." Patients were asked what they knew about their cancer and treatment. QoL and spiritual well-being were measured using the Functional Assessment of Cancer Therapy - General (FACT-G) and Functional Assessment of Chronic Illness Therapy - Spiritual Well-being (FACIT-Sp) questionnaire. Psychological distress experienced by patients was recorded via the Hospital Anxiety and Depression Scale. Pain severity was also assessed. Data from 160 patients were analyzed using descriptive statistics and multivariable regression models. RESULTS: Of the 160 patients who participated, 55 (34.4%) were unaware of their cancer stage. Those who were aware of their stage of cancer were younger than those who were not aware (45.7 years vs 50.4 years, p = .015). There was no significant difference in spiritual well-being and other domains of QoL between those who were aware and those who were not aware of their advanced cancer stage. There was also no significant difference in anxiety depression or pain severity, even after adjustment for demographic and clinical characteristics. SIGNIFICANT OF RESULTS: Given the high prevalence of patients who wrongly thought their cancer was curable, more could be done to improve disease and prognostic understanding among patients with advanced cancer in Indonesia. Those who were aware of their advanced cancer stage did not have a poorer QoL, nor did they have more anxiety or depression than those who were unaware. This finding suggests that concerns about the negative impact of prognostic disclosure may be unfounded.
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Introduction: Physical inactivity is a risk factor for obesity and non-communicable diseases. Despite myriad health and non-health benefits resulting from physical activity (PA), most individuals do not meet PA recommendations. Providing an incentive for meeting activity goals may increase activity levels. Classical economists argue that cash is the best incentive. Behavioral economists have posited that hedonic (pleasurable) incentives (e.g., massages, restaurant meals) may be superior to cash when incentives are offered over multiple time periods. To date, no studies have directly compared the effectiveness of cash versus hedonic incentives in promoting PA across multiple time periods. Methods: We conducted a two-arm, parallel, 4-month randomized controlled trial with healthy adults in Singapore where participants were randomized to either cash or hedonic incentives. Participants could earn up to SGD50 (≈USD37) in cash or hedonic incentives each month they met the study's step target of 10,000 steps daily on at least 20/25 days out of the first 28 days of a month. The primary objective was to compare the mean proportion of months that participants met the step target between the two arms. Results: By month 4, participants in the cash (N = 154) and hedonic incentive (N = 156) arms increased their mean daily steps by 870 (p < 0.001) and 1,000 steps (p < 0.001), respectively. The mean proportion of months the step target was achieved was 90.53 and 88.34 for participants in the cash and hedonic incentive arms respectively, but differences across arms were small and not statistically significant for this or any outcome assessed. Conclusion: Our findings suggest that both cash and hedonic incentives are effective at promoting physical activity but that neither strategy is clearly superior.Clinical trial registration: ClinicalTrials.gov, NCT04618757 registered on November 6, 2020.
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Exercício Físico , Motivação , Humanos , Feminino , Masculino , Singapura , Adulto , Pessoa de Meia-Idade , Promoção da Saúde/métodos , Promoção da Saúde/economia , RecompensaRESUMO
OBJECTIVES: Cost-effectiveness analyses are increasingly used to inform subvention decisions for moderately life extending treatments but apply several simplifying assumptions that may be inconsistent with public preferences. Contrary to standard assumptions, we hypothesize that societal willingness to allocate public funding toward these treatments is (1) diminishing for incremental improvements in survival and quality of life (QoL) and (2) greater for subvention policies that exclude the oldest old (>80 years). METHODS: We tested these hypotheses using a web-based discrete choice experiment (n = 425) in Singapore. In each of 5 questions, respondents were shown 2 hypothetical treatments targeting patients with an expected prognosis of 2 months at very poor QoL and asked which treatment they wanted the government to subsidize, if any. Treatments were defined by 4 attributes: cost to the government, age of beneficiaries, expected gain in survival (2-12 months), and QoL (poor, fair, and good). RESULTS: Latent class models were used to analyze results. Results revealed 2 classes. In the majority class (69.7% of sample), respondents value incremental gains in survival and QoL at a diminishing rate. Their willingness to allocate public funding estimates (Singapore dollars 16 825-91 027 per patient per month) were much higher than traditional cost-effectiveness thresholds. In the second class, respondents were unwilling to subsidize treatments offering less than 2 months of life extension or poor QoL. Neither class preferred subvention policies that exclude the oldest old. CONCLUSIONS: These findings suggest that the Singapore government should consider cost-effectiveness thresholds that rise with increases in life extension. Age-based restrictions should not be imposed.
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Importance: Understanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences. Objectives: To investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient's life and the associations of the goals of care with patient-caregiver characteristics. Design, Setting, and Participants: This prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient's death or February 28, 2022. Data from the last 2 years of the patients' lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore. Main Outcomes and Measures: Goals of care were examined via the tradeoffs between life extension and symptom management and between life extension and cost containment. The actor-partner interdependence framework was implemented using mixed-effects linear regressions. Results: This study included 210 dyads (patients: mean [SD] age, 62.6 [10.5] years; 108 men [51.4%]; caregivers: mean [SD] age, 49.4 [14.6] years; 132 women [62.9%]). On average, 34% of patients (264 of 780 observations; range, 23%-42%) and 29% of caregivers (225 of 780 observations; range, 20%-43%) prioritized symptom management over life extension, whereas 24% of patients (190 of 780 observations; range, 18%-32%) and 19% of caregivers (148 of 780 observations; range, 8%-26%) prioritized life extension. Between cost containment and life extension, on average, 28% of patients (220 of 777 observations; range, 22%-38%) and 17% of caregivers (137 of 780 observations; range, 10%-25%) prioritized cost containment, whereas 26% of patients (199 of 777 observations; range, 18%-34%) and 35% of caregivers (271 of 780 observations; range, 25%-45%) prioritized life extension. Goals of care did not change as patients approached death. Patients prioritized symptom management if they experienced higher symptom burden (average marginal effect [SE], 0.04 [0.01]), worse spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and accurate (vs inaccurate) prognostic awareness (average marginal effect [SE], 0.40 [0.18]) and if their caregivers reported accurate prognostic awareness (average marginal effect [SE], 0.53 [0.18]), lower impact of caregiving on finances (average marginal effect [SE], -0.28 [0.08]), and poorer caregiving self-esteem (average marginal effect [SE], -0.48 [0.16]). Compared with patients, caregivers expressed lower preferences for cost containment (average marginal effect [SE], -0.63 [0.09]). Patients prioritized cost containment if they were older (average marginal effect [SE], 0.03 [0.01]), had higher symptom burden (average marginal effect [SE], 0.04 [0.01]), had poorer spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and their caregivers reported poorer caregiving self-esteem (average marginal effect [SE], -0.51 [0.16]) and more family support (average marginal effect [SE], -0.30 [0.14]). Conclusions and Relevance: In this cohort study of patient-caregiver dyads, findings suggested the importance of interventions aimed at reducing discordance in goals of care between patients and caregivers and helping them develop realistic expectations to avoid costly, futile treatments.
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Cuidadores , Neoplasias , Masculino , Humanos , Feminino , Pessoa de Meia-Idade , Estudos de Coortes , Estudos Prospectivos , Neoplasias/terapia , Planejamento de Assistência ao PacienteRESUMO
Background: Cognitive impairment (CI) raises risks for unplanned healthcare utilisation and expenditures and for premature mortality. It may also reduce risks for planned expenditures. Therefore, the net cost implications for those with CI remain unknown. Method: We examined differences in healthcare utilisation and cost between those with and without CI. Using administrative healthcare utilisation and cost data linked to the Singapore Chinese Health Study cohort, we estimated regression-adjusted differences in annual healthcare utilisation and costs by CI status determined by modified Mini-Mental State Exam. Estimates were stratified by ex ante mortality risk constructed from out-of-sample Cox model predictions applied to the full sample, with a separate analysis restricted to decedents. These estimates were used to project differential healthcare costs by CI status over 5 years. Results: Patients with CI had 17% higher annual cost compared to those without CI (SGD4870 versus SGD4177, P<0.01). Accounting for the greater mortality risk, individuals with CI cost 9% to 17% more over 5 years, or SGD2500 (95% confidence interval 1000-4200) to SGD3600 (95% confidence interval 1300-6000) more, depending on their age. Higher cost was mainly due to more emergency department visits and subsequent admissions (i.e. unplanned). Differences attenuated in the last year of life when costs increased dramatically for both groups. Conclusion: Ageing populations and higher rates of CI will further strain healthcare resources primarily through greater use of emergency department visits and unplanned admissions. Efforts should be made to identify at risk patients with CI and take appropriate remediation strategies.
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Disfunção Cognitiva , Custos de Cuidados de Saúde , Humanos , Singapura/epidemiologia , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/economia , Idoso , Masculino , Feminino , Pessoa de Meia-Idade , Custos de Cuidados de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso de 80 Anos ou mais , Efeitos Psicossociais da Doença , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Modelos de Riscos Proporcionais , Estudos de CoortesRESUMO
BACKGROUND: Cancer is the third leading cause of death in Kenya. Yet, little is known about prognostic awareness and preferences for prognostic information. AIM: To assess the prevalence of prognostic awareness and preference for prognostic information among advanced cancer patients in Kenya. SETTING: Outpatient medical oncology and palliative care clinics and inpatient medical and surgical wards of Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya. METHODS: The authors surveyed 207 adults with advanced solid cancers. The survey comprised validated measures developed for a multi-site study of end-of-life care in advanced cancer patients. Outcome variables included prognostic awareness and preference for prognostic information. RESULTS: More than one-third of participants (36%) were unaware of their prognosis and most (67%) preferred not to receive prognostic information. Increased age (OR = 1.04, 95% CI: 1.02, 1.07) and education level (OR: 1.18, CI: 1.08, 1.30) were associated with a higher likelihood of preference to receive prognostic information, while increased symptom burden (OR= 0.94, CI: 0.90, 0.99) and higher perceived household income levels (lower-middle vs low: OR= 0.19; CI: 0.09, 0.44; and upper middle- or high vs low: OR= 0.22, CI: 0.09, 0.56) were associated with lower odds of preferring prognostic information. CONCLUSION: Results reveal low levels of prognostic awareness and little interest in receiving prognostic information among advanced cancer patients in Kenya.Contribution: Given the important role of prognostic awareness in providing patient-centred care, efforts to educate patients in Kenya on the value of this information should be a priority, especially among younger patients.
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Conhecimentos, Atitudes e Prática em Saúde , Neoplasias , Preferência do Paciente , Humanos , Quênia , Masculino , Feminino , Pessoa de Meia-Idade , Neoplasias/psicologia , Prognóstico , Adulto , Idoso , Inquéritos e Questionários , Assistência Terminal , Estudos Transversais , Idoso de 80 Anos ou mais , Cuidados Paliativos/estatística & dados numéricosRESUMO
Discrete Choice Experiments (DCEs) are widely employed survey-based methods to assess preferences for healthcare services and products. While they offer an experimental way to represent health-related decisions, the stylized representation of scenarios in DCEs may overlook contextual factors that could influence decision-making. The aim of this paper was to evaluate the predictive validity of preferences elicited through a DCE in decisions likely influenced by a hot-cold empathy gap, and compare it to another commonly used method, a direct-elicitation question. We focused on preferences for pain-relief modalities, especially for an epidural during childbirth - a context where direct-elicitation questions have shown a preference for or intention to have a natural birth (representing the "cold" state), yet individuals often opt for an epidural during labor (representing the "hot" state). Leveraging a unique dataset collected from 248 individuals, we incorporated both the stated preferences collected through a survey administered upon hospital admission for childbirth and the actual pain-relief modality usage data documented in medical records. The DCE allowed for the evaluation of scenarios outside of those expected by respondents to simulate decision-making during childbirth. When we compared the predicted epidural use with the actual epidural use during labor, we observed a choice concordance of 71-60%, depending on the model specification. The concordance rate between the predicted and actual choices increased to 77-76% when accounting for the initial use of other ineffective modalities. In contrast, the direct-elicitation choices, relying solely on respondents' baseline expectations, yielded a lower concordance rate of 58% with actual epidural use. These findings highlight the flexibility of the DCE method in simulating complex decision contexts, including those involving hot-cold empathy gaps. The DCE proves valuable in assessing nuanced preferences, providing a more accurate representation of the decision-making processes in healthcare scenarios.
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Comportamento de Escolha , Preferência do Paciente , Humanos , Feminino , Adulto , Preferência do Paciente/estatística & dados numéricos , Preferência do Paciente/psicologia , Gravidez , Inquéritos e Questionários , Tomada de Decisões , Analgesia Epidural/psicologia , Analgesia Epidural/estatística & dados numéricos , Manejo da Dor/métodosRESUMO
BACKGROUND: The SingHypertension primary care clinic intervention, which consisted of clinician training in hypertension management, subsidized single-pill combination medications, nurse-delivered motivational conversations and telephone follow-ups, improved blood pressure control and cardiovascular disease (CVD) risk scores relative to usual care among patients with uncontrolled hypertension in Singapore. This study quantified the incremental cost-effectiveness, in terms of incremental cost per unit reduction disability-adjusted life years, of SingHypertension relative to usual care for patients with hypertension from the health system perspective. METHODS AND RESULTS: We developed a Markov model to simulate CVD events and associated outcomes for a hypothetical cohort of patients over a 10-year period. Costs were measured in US dollars, and effectiveness was measured in disability-adjusted life years averted. We present base-case results and conducted deterministic and probabilistic sensitivity analyses. Based on a willingness-to-pay threshold of US $55 500 per DALY averted, SingHypertension was cost-effective for patients with hypertension (incremental cost-effectiveness ratio: US $24 765 per disability-adjusted life year averted) relative to usual care. This result held even if risk reduction was assumed to decline linearly to 0 over 10 years but not sooner than 7 years. Incremental cost-effectiveness ratios were most sensitive to the magnitude of the reduction in CVD risk; at least a 0.13% to 0.16% point reduction in 10-year CVD risk is required for cost-effectiveness. Probabilistic sensitivity analysis indicates that SingHypertension has a 78% chance of being cost-effective at the willingness-to-pay threshold. CONCLUSIONS: SingHypertension represents good value for the money for reducing CVD incidence, morbidity, and mortality and should be considered for wide-scale implementation in Singapore and possibly other countries. REGISTRATION INFORMATION: REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02972619.
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Hipertensão , Humanos , Análise Custo-Benefício , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Pressão Sanguínea , Atenção Primária à Saúde , Singapura/epidemiologia , Anos de Vida Ajustados por Qualidade de VidaRESUMO
OBJECTIVES: To determine the measurement properties of PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS), a parent-reported measure of Quality of Care for seriously ill children across care settings and illness trajectories. STUDY DESIGN AND SETTING: Parents self-administered baseline and 2-week follow-up surveys online. Exploratory Factor Analysis was used to determine PRECIOUS's factor structure and select items. Internal consistency was evaluated with Cronbach's α, test-retest reliability with intraclass correlation coefficients, and convergent validity with Spearman's correlations between PRECIOUS scales and subscales of Measure of Processes of Care and Quality of Children's Palliative Care Instrument. RESULTS: Of 152 parents [108 (71%) mothers, 44 (29%) fathers] who completed the baseline survey, 123 (81%) completed follow-up. Exploratory Factor Analysis grouped PRECIOUS into five scales: collaborative and goal-concordant care (12 items), caregiver support and respectful care (15 items), access to financial and medical resources (five items), reducing caregiving stressors (nine items), and hospitalization-specific processes (four items). Root Mean Square Error of Approximation was 0.040 and Comparative Fit Index was 0.980. Cronbach's α ranged from 0.85 to 0.96. Intraclass correlation coefficients ranged from 0.72 to 0.86. Significant correlations with Measure of Processes of Care and Quality of Children's Palliative Care Instrument confirmed convergent validity. The original 56-item tool was reduced to 45 items. CONCLUSION: PRECIOUS demonstrates satisfactory measurement properties for assessing Quality of Care for seriously ill children.
Assuntos
Pais , Qualidade de Vida , Criança , Humanos , Reprodutibilidade dos Testes , Psicometria , Inquéritos e Questionários , Análise FatorialRESUMO
BACKGROUND: The Bridging Income Generation with Group Integrated Care (BIGPIC) trial in rural Kenya showed that integrating usual care with group medical visits or microfinance interventions reduced systolic blood pressure and cardiovascular risk in participants. We aimed to estimate the incremental cost-effectiveness of three BIGPIC interventions for a modelled cohort and by sex, as well as the cost of implementing these interventions. METHODS: For this analysis, we used data collected during the BIGPIC trial, a four-group, cluster-randomised trial conducted in the western Kenyan catchment area of the Academic Model Providing Access to Healthcare. BIGPIC enrolled participants from 24 rural health facilities in rural western Kenya aged 35 years or older with either increased blood pressure or diabetes. Participants were assigned to receive either usual care, group medical visits, microfinance, or a combination of group medical visits and microfinance (GMV-MF). Our model estimated the incremental cost-effectiveness of the three BIGPIC interventions via seven health states (ie, a hypertensive state, five chronic cardiovascular-disease states, and a death state) by simulating transitions between health states for a hypothetical cohort of individuals with hypertension on the basis of QRISK3 scores. In every cycle, participants accrued costs and disability-adjusted life-years (DALYs) associated with their health state. Incremental cost-effectiveness ratios (ICERs) were calculated for the entire modelled cohort and by sex by dividing the incremental cost by the incremental effectiveness of the next most expensive intervention. The main outcome of this analysis was ICERs for each intervention evaluated. This analysis is registered at ClinicalTrials.gov (NCT02501746). FINDINGS: Between Feb 6, 2017, and Dec 29, 2019, 2890 people were recruited to the BIGPIC trial. 2020 (69·9%) of 2890 participants were female and 870 (30·1%) were male. At baseline, mean QRISK3 score was 11·5 (95% CI 11·1-11·9) for the trial population, 11·9 (11·5-12·2) for male participants, and 11·3 (11·0-11·6) for female participants. For the population of Kenya, group medical visits were estimated to cost US$7 more per individual than usual care and result in 0·005 more DALYs averted (ICER $1455 per DALY averted). Microfinance was estimated to cost $19 more than group medical visits but was only estimated to avert 0·001 more DALYs. Relative to group medical visits, GMV-MF was estimated to cost $29 more and avert 0·009 more DALYs ($3235 per DALY averted). Relative to usual care, GMV-MF was estimated to cost $37 more and avert 0·014 more DALYs ($2601 per DALY averted). In the first year of the intervention, usual care was estimated to be the least expensive intervention to implement ($87 per participant; $10â238 per health-facility catchment area [HFCA]), then group medical visits ($99 per participant; $12â268 per HFCA), then microfinance ($120 per participant; $14â172 per HFCA), with GMV-MF estimated to be the most expensive intervention to implement ($139 per participant; $16â913 per HFCA). INTERPRETATION: Group medical visits and GMV-MF were estimated to be cost-effective strategies to improve blood-pressure control in rural Kenya. However, which intervention to pursue depends on resource availability. Policy makers should consider these factors, in addition to sex differences in programme effectiveness, when selecting optimal implementation strategies. FUNDING: US National Institutes of Health.
Assuntos
Análise Custo-Benefício , Hipertensão , Humanos , Quênia , Masculino , Feminino , Hipertensão/terapia , Hipertensão/economia , Pessoa de Meia-Idade , Adulto , População Rural , Idoso , Prestação Integrada de Cuidados de Saúde/economiaRESUMO
OBJECTIVE: The objective of this study was to evaluate the efficacy of a mobile health (mHealth)-delivered behavioral intervention on changes in postpartum weight and cardiometabolic risk factors (blood pressure [BP], lipids, and hemoglobin A1c) over 12 months. METHODS: A randomized controlled trial of 300 African American postpartum people with overweight and obesity enrolled in Philadelphia Women, Infants, and Children (WIC) clinics was conducted. Participants were randomized to usual WIC care (n = 151) or a 12-month mHealth-delivered intervention (n = 149) comprising behavior change goals, interactive self-monitoring text messages, and counseling support. RESULTS: Intervention and usual-care participants did not significantly differ in 12-month mean postpartum weight change (1.1 vs. 1.6 kg, p = 0.5; difference -0.6 kg, 95% CI: -2.3 to 1.2). However, high intervention engagement led to weight loss compared with weight gain among those who were less engaged (-0.6 vs. 2.4 kg, p = 0.01; difference -3.0 kg, 95% CI: -5.4 to -0.6). The intervention reduced systolic BP relative to usual care (-1.6 vs. 2.4 mm Hg, p = 0.02; difference -4.0 mm Hg, 95% CI: -7.5 to -0.5), but this effect did not extend to other cardiometabolic risk factors. CONCLUSIONS: Among African American postpartum people enrolled in WIC, an mHealth-delivered intervention reduced systolic BP but not additional cardiometabolic risk factors or weight. Intervention participants with high engagement had significantly better postpartum weight outcomes, and thus, next steps include addressing barriers to engagement.
RESUMO
Background: Cancer is the third leading cause of death in Kenya. Yet, little is known about prognostic awareness and preferences for prognostic information. Aim: To assess the prevalence of prognostic awareness and preference for prognostic information among advanced cancer patients in Kenya. Setting: Outpatient medical oncology and palliative care clinics and inpatient medical and surgical wards of Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya. Methods: The authors surveyed 207 adults with advanced solid cancers. The survey comprised validated measures developed for a multi-site study of end-of-life care in advanced cancer patients. Outcome variables included prognostic awareness and preference for prognostic information. Results: More than one-third of participants (36%) were unaware of their prognosis and most (67%) preferred not to receive prognostic information. Increased age (OR = 1.04, 95% CI: 1.02, 1.07) and education level (OR: 1.18, CI: 1.08, 1.30) were associated with a higher likelihood of preference to receive prognostic information, while increased symptom burden (OR= 0.94, CI: 0.90, 0.99) and higher perceived household income levels (lower-middle vs low: OR= 0.19; CI: 0.09, 0.44; and upper middle- or high vs low: OR= 0.22, CI: 0.09, 0.56) were associated with lower odds of preferring prognostic information. Conclusion: Results reveal low levels of prognostic awareness and little interest in receiving prognostic information among advanced cancer patients in Kenya. Contribution: Given the important role of prognostic awareness in providing patient-centred care, efforts to educate patients in Kenya on the value of this information should be a priority, especially among younger patients.