Abstract Objective To model the social distribution of quality-adjusted life expectancy (QALE) in England by combining survey data on health-related quality of life with administrative data on ...mortality. Methods Health Survey for England data sets for 2010, 2011, and 2012 were pooled (n = 35,062) and used to model health-related quality of life as a function of sex, age, and socioeconomic status (SES). Office for National Statistics mortality rates were used to construct life tables for age-sex-SES groups. These quality-of-life and length-of-life estimates were then combined to predict QALE as a function of these characteristics. Missing data were imputed, and Monte-Carlo simulation was used to estimate standard errors. Sensitivity analysis was conducted to explore alternative regression models and measures of SES. Results Socioeconomic inequality in QALE at birth was estimated at 11.87 quality-adjusted life-years (QALYs), with a sex difference of 1 QALY. When the socioeconomic-sex subgroups are ranked by QALE, a differential of 10.97 QALYs is found between the most and least healthy quintile groups. This differential can be broken down into a life expectancy difference of 7.28 years and a quality-of-life adjustment of 3.69 years. Conclusions The methods proposed in this article refine simple binary quality-adjustment measures such as the widely used disability-free life expectancy, providing a more accurate picture of overall health inequality in society than has hitherto been available. The predictions also lend themselves well to the task of evaluating the health inequality impact of interventions in the context of cost-effectiveness analysis.
ObjectiveTo measure changes in socioeconomic inequality in the distribution of family physicians (general practitioners (GPs)) relative to need in England from 2004/2005 to ...2013/2014.DesignWhole-population small area longitudinal data linkage study.SettingEngland from 2004/2005 to 2013/2014.Participants32 482 lower layer super output areas (neighbourhoods of 1500 people on average).Main outcome measuresSlope index of inequality (SII) between the most and least deprived small areas in annual full-time equivalent GPs (FTE GPs) per 100 000 need adjusted population.ResultsIn 2004/2005, inequality in primary care supply as measured by the SII in FTE GPs was 4.2 (95% CI 3.1 to 5.3) GPs per 100 000. By 2013/2014, this SII had fallen to −0.7 (95% CI −2.5 to 1.1) GPs per 100 000. The number of FTE GPs per 100 000 serving the most deprived fifth of small areas increased over this period from 54.0 to 60.5, while increasing from 57.2 to 59.9 in the least deprived fifth, so that by the end of the study period there were more GPs per 100 000 need adjusted population in the most deprived areas than in the least deprived. The increase in GP supply in the most deprived fifth of neighbourhoods was larger in areas that received targeted investment for establishing new practices under the ‘Equitable Access to Primary Medical Care’.ConclusionsThere was a substantial reduction in socioeconomic inequality in family physician supply associated with national policy. This policy may not have completely eliminated socioeconomic inequality in family physician supply since existing need adjustment formulae do not fully capture the additional burden of multimorbidity in deprived neighbourhoods. The small area approach introduced in this study can be used routinely to monitor socioeconomic inequality of access to primary care and to indicate workforce shortages in particular neighbourhoods. http://creativecommons.org/licenses/by/4.0
We introduce a summary wellbeing measure for economic evaluation of cross‐sectoral public policies with impacts on health and living standards. We show how to calculate period‐specific and lifetime ...wellbeing using quality‐adjusted life years based on widely available data on health‐related quality of life and consumption and normative assumptions about three parameters—minimal consumption, standard consumption, and the elasticity of the marginal value of consumption. We also illustrate how these three parameters can be tailored to the decision‐making context and varied in sensitivity analysis to provide information about the implications of alternative value judgments. As well as providing a general measure for cost‐effectiveness analysis and cost‐benefit analysis in terms of wellbeing, this approach also facilitates distributional analysis in terms of how many good years different population subgroups can expect to live under different policy scenarios.
Reducing health inequality is a major policy concern for low-and middle-income countries (LMICs) on the path to universal health coverage. However, health inequality impacts are rarely quantified in ...cost-effectiveness analyses of health programmes. Distributional cost-effectiveness analysis (DCEA) is a method developed to analyse the expected social distributions of costs and health benefits, and the potential trade-offs that may exist between maximising total health and reducing health inequality. This is the first paper to show how DCEA can be applied in LMICs. Using the introduction of rotavirus vaccination in Ethiopia as an illustrative example, we analyse a hypothetical re-designed vaccination programme, which invests additional resources into vaccine delivery in rural areas, and compare this with the standard programme currently implemented in Ethiopia. We show that the re-designed programme has an incremental cost-effectiveness ratio of US$69 per health-adjusted life year (HALY) compared with the standard programme. This is potentially cost-ineffective when compared with current estimates of health opportunity cost in Ethiopia. However, rural populations are typically less wealthy than urban populations and experience poorer lifetime health. Prioritising such populations can thus be seen as being equitable. We analyse the trade-off between cost-effectiveness and equity using the Atkinson inequality aversion parameter, ε, representing the decision maker’s strength of concern for reducing health inequality. We find that the more equitable programme would be considered worthwhile by a decision maker whose inequality concern is greater than ε = 5.66, which at current levels of health inequality in Ethiopia implies that health gains are weighted at least 3.86 times more highly in the poorest compared with the richest wealth quintile group. We explore the sensitivity of this conclusion to a range of assumptions and cost-per-HALY threshold values, to illustrate how DCEA can inform the thinking of decision makers and stakeholders about health equity trade-offs.
La réduction des inégalités en matière de santé est un sujet de préoccupation majeur pour les pays à revenu faible ou intermédiaire (PRFI) sur la voie de la couverture sanitaire universelle. Cependant, les impacts des inégalités en matière de santé sont rarement quantifiés dans les analyses de rentabilité des programmes sanitaires. L’analyse distributionnelle de la rentabilité (DCEA) est une méthode mise au point pour étudier la redistribution sociale des coûts et des bénéfices sanitaires attendus, et les compromis éventuels entre la maximisation de la santé dans son ensemble et la réduction des inégalités de santé. C’est le premier article qui montre comment la DCEA peut être appliquée dans les PRFI. En prenant l’introduction de la vaccination antirotavirus en Ethiopie comme exemple illustratif, nous analysons un hypothétique programme de vaccination reconçu, qui investit des ressources supplémentaires dans la fourniture de vaccins dans les zones rurales, et le comparons au programme standard actuellement mis en œuvre en Ethiopie. Nous montrons que le programme remanié a un rapport coût-efficacité incrémentiel de 69 US$par année de vie ajustée sur la santé (HALY) en comparaison au programme standard. Cette mesure est potentiellement inefficace lorsqu’on fait le parallèle avec les estimations actuelles du coût d’opportunité de la santé en Ethiopie. Cependant, les populations rurales sont généralement moins riches que les populations urbaines et leur état de santé est généralement plus fragile. Il est donc équitable de faire du bien-être de ces populations une priorité. Nous analysons le compromis entre la rentabilité et l’équité en utilisant le paramètre d’Atkinson d’aversion pour les inégalités, qui représente le degré d’appréhension du décideur cherchant à réduire les inégalités de santé. Nous estimons qu’un programme plus équitable serait jugé utile par un décideur dont l’appréhension pour l’inégalité est supérieure à =5,66; ce qui revient à dire qu’avec les niveaux actuels d’inégalité de santé en Ethiopie, les gains de santé pondérés sont au moins 3,86 fois supérieurs dans le groupe des moins nantis par rapport au quintile de richesse supérieur. Nous explorons la sensibilité de cette conclusion face à une série d’hypothèses et de valeurs de seuil de coût par HALY, pour illustrer comment la DCEA peut éclairer les décideurs et les parties prenantes sur les compromis d’équité en matière de santé.
降低健康不平等是中低收入国家 （LMICs） 迈向全民健康覆 盖的主要政策问题。但是, 卫生项目的成本效果分析很少量化 健康不平等的影响。分配成本效果分析 （DCEA） 用于分析成 本和健康获益的预期社会分配, 以及总体健康最大化和降低健 康不平等之间的权衡。本文是首次将DCEA用于LMICs。以埃 塞俄比亚启动轮状病毒免疫接种为示例, 我们假设重新设计了 一个免疫接种项目, 在农村地区投入更多资源, 对其进行分析, 并与埃塞俄比亚目前实施的标准项目进行对比。研究显示, 与 标准项目相比, 重新设计的项目增量成本效果比是每健康调整 生命年 （HALY） 69美元。与目前埃塞俄比亚健康机会成本的 估计值比较没有成本效果。但是, 农村人口通常不如城市人口 富裕, 健康较差。因此优先考虑农村人口可被视为体现公平 性。为分析成本效果和公平性之间的平衡, 我们采用了阿特金 森不平等厌恶参数ε, 该参数体现决策者对降低健康不平等的 关注程度。我们发现, 决策者对不平等的关注程度超 过ε=5.66时, 更侧重公平性的项目会被认为有价值, 在目前 埃塞俄比亚的健康不公平水平下, 意味着贫困人口的健康获益 权重超过最富裕的五分之一人口至少3.86倍。我们分析了这 一结论在各种假设下的敏感性以及每HALY成本阈值, 说明了 DCEA可为决策者和利益相关者权衡健康公平提供证据。
La reducción de la desigualdad en la salud es una de las principales preocupaciones de política para los países de ingresos bajos y medios (PIBM) en el camino hacia la cobertura universal de salud. Sin embargo, los impactos de la desigualdad en la salud son raramente cuantificados en los análisis de costo-efectividad de los programas de salud. El análisis distributivo de costo-efectividad (ADCE) es un método desarrollado para analizar las distribuciones sociales esperadas de los costos y los beneficios para la salud, y las posibles compensaciones que pueden existir entre la maximización de la salud total y la reducción de la desigualdad en salud. Este es el primer artículo que muestra cómo se puede aplicar el ADCE en los PIBM. Usando la introducción de la vacunación contra el rotavirus en Etiopía como un ejemplo ilustrativo, analizamos un programa hipotético de vacunación rediseñado, que invierte recursos adicionales en el suministro de vacunas en áreas rurales, y lo comparamos con el programa estándar actualmente implementado en Etiopía. Mostramos que el programa rediseñado tiene una relación costo-efectividad incremental de US$69 por año de vida ajustado por la salud (AVAS) comparado con el programa estándar. Esto es potencialmente costo-inefectivo cuando se compara con los estimativos actuales del costo de oportunidad de la salud en Etiopía. Sin embargo, las poblaciones rurales son típicamente menos ricas que las poblaciones urbanas y sufren peor salud durante sus vidas. La priorización de tales poblaciones puede ser vista como un acto equitativo. Analizamos el equilibrio entre la costo-efectividad y la equidad usando el parámetro de aversión a la desigualdad de Atkinson, ϵ, que representa el grado de preocupación del responsable de toma de decisiones por reducir la desigualdad en salud. Encontramos que el programa más equitativo sería considerado valioso por un tomador de decisiones cuya preocupación por la desigualdad es mayor que ϵ=5.66, que en los niveles actuales de desigualdad en salud en Etiopía implica que los beneficios de salud son ponderados al menos 3.86 veces más en los más pobres en comparación con el grupo quintil de riqueza más alto. Exploramos la sensibilidad de esta conclusión sobre una gama de suposiciones y valores de umbral de costo por AVAS, para ilustrar cómo el ADCE puede informar el pensamiento de los tomadores de decisiones y las partes interesadas acerca de las compensaciones de equidad en salud.
The rate of homeless mortality is known to be significantly below the national average, with mortality rates varying geographically. This study aims to look at the rates and causes of homeless ...mortality within East London.
To characterise homeless mortality of patients registered in two specialist homeless practices, between 2001 and 2016 in the London boroughs of Tower Hamlets and Hackney, by age at death and cause of death.
A retrospective study of general practice electronic patient records.
Electronic patient records across two general practice surgeries specialising in care for the homeless in East London were examined and their mortality data extracted.
Two hundred and three deaths recorded in the two general practice surgeries were examined. The average age at death was 47 years, with the highest numbers of deaths being attributed to substance misuse, liver disease and cardiac-related deaths. Those dying of cardiac-related causes died at an average of 51, those dying of liver-related causes died at an average age of 49 years and those dying from substance misuse died at an average age of 38.
Those dying of substance misuse-related causes died much younger than the average homeless patient did.
Living in an area with high levels of child poverty predisposes children to poorer mental and physical health. ActEarly is a 5-year research programme that comprises a large number of interventions ...(>20) with citizen science and co-production embedded. It aims to improve the health and well-being of children and families living in two areas of the UK with high levels of deprivation; Bradford in West Yorkshire, and the London Borough of Tower Hamlets. This protocol outlines the meta-evaluation (an evaluation of evaluations) of the ActEarly programme from a systems perspective, where individual interventions are viewed as events in the wider policy system across the two geographical areas. It includes investigating the programme's impact on early life health and well-being outcomes, interdisciplinary prevention research collaboration and capacity building, and local and national decision making.
The ActEarly meta-evaluation will follow and adapt the five iterative stages of the 'Evaluation of Programmes in Complex Adaptive Systems' (ENCOMPASS) framework for evaluation of public health programmes in complex adaptive systems. Theory-based and mixed-methods approaches will be used to investigate the fidelity of the ActEarly research programme, and whether, why and how ActEarly contributes to changes in the policy system, and whether alternative explanations can be ruled out. Ripple effects and systems mapping will be used to explore the relationships between interventions and their outcomes, and the degree to which the ActEarly programme encouraged interdisciplinary and prevention research collaboration as intended. A computer simulation model ("LifeSim") will also be used to evaluate the scale of the potential long-term benefits of cross-sectoral action to tackle the financial, educational and health disadvantages faced by children in Bradford and Tower Hamlets. Together, these approaches will be used to evaluate ActEarly's dynamic programme outputs at different system levels and measure the programme's system changes on early life health and well-being.
This meta-evaluation protocol presents our plans for using and adapting the ENCOMPASS framework to evaluate the system-wide impact of the early life health and well-being programme, ActEarly. Due to the collaborative and non-linear nature of the work, we reserve the option to change and query some of our evaluation choices based on the feedback we receive from stakeholders to ensure that our evaluation remains relevant and fit for purpose.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IntroductionConcern for health inequalities is an important driver of health policy in India; however, much of the empirical evidence regarding health inequalities in the country is piecemeal ...focusing only on specific diseases or on access to particular treatments. This study estimates inequalities in health across the whole life course for the entire Indian population. These estimates are used to calculate the socioeconomic disparities in life expectancy at birth in the population.MethodsPopulation mortality data from the Indian Sample Registration System were combined with data on mortality rates by wealth quintile from the National Family Health Survey to calculate wealth quintile specific mortality rates. Results were calculated separately for males and females as well as for urban and rural populations. Life tables were constructed for each subpopulation and used to calculate distributions of life expectancy at birth by wealth quintile. Absolute gap and relative gap indices of inequality were used to quantify the health disparity in terms of life expectancy at birth between the richest and poorest fifths of households.ResultsLife expectancy at birth was 65.1 years for the poorest fifth of households in India as compared with 72.7 years for the richest fifth of households. This constituted an absolute gap of 7.6 years and a relative gap of 11.7 %. Women had both higher life expectancy at birth and narrower wealth-related disparities in life expectancy than men. Life expectancy at birth was higher across the wealth distribution in urban households as compared with rural households with inequalities in life expectancy widest for men living in urban areas and narrowest for women living in urban areas.ConclusionAs India progresses towards Universal Health Coverage, the baseline social distributions of health estimated in this study will allow policy makers to target and monitor the health equity impacts of health policies introduced.
It is not known whether equity-oriented primary care investment that seeks to scale up the delivery of effective care in disadvantaged communities can reduce health inequality within high-income ...settings that have pre-existing universal primary care systems. We provide some non-randomised controlled evidence by comparing health inequality trends between two similar jurisdictions-one of which implemented equity-oriented primary care investment in the mid-to-late 2000s as part of a cross-government strategy for reducing health inequality (England), and one which invested in primary care without any explicit equity objective (Ontario, Canada).
We analysed whole-population data on 32,482 neighbourhoods (with mean population size of approximately 1,500 people) in England, and 18,961 neighbourhoods (with mean population size of approximately 700 people) in Ontario. We examined trends in mortality amenable to healthcare by decile groups of neighbourhood deprivation within each jurisdiction. We used linear models to estimate absolute and relative gaps in amenable mortality between most and least deprived groups, considering the gradient between these extremes, and evaluated difference-in-difference comparisons between the two jurisdictions.
Inequality trends were comparable in both jurisdictions from 2004-6 but diverged from 2007-11. Compared with Ontario, the absolute gap in amenable mortality in England fell between 2004-6 and 2007-11 by 19.8 per 100,000 population (95% CI: 4.8 to 34.9); and the relative gap in amenable mortality fell by 10 percentage points (95% CI: 1 to 19). The biggest divergence occurred in the most deprived decile group of neighbourhoods.
In comparison to Ontario, England succeeded in reducing absolute socioeconomic gaps in mortality amenable to healthcare from 2007 to 2011, and preventing them from growing in relative terms. Equity-oriented primary care reform in England in the mid-to-late 2000s may have helped to reduce socioeconomic inequality in health, though other explanations for this divergence are possible and further research is needed on the specific causal mechanisms.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ObjectivesThe pandemic and public health response to contain the virus had impacts on many aspects of young people’s lives including disruptions to daily routines, opportunities for social, academic, ...recreational engagement and early employment. Consequently, children, adolescents and young adults may have experienced mental health challenges that required use of mental health services. This study compared rates of use for inpatient and outpatient mental health services during the pandemic to pre-pandemic rates.DesignPopulation-based repeated cross-sectional study.SettingPublicly delivered mental healthcare in primary and secondary settings within the province of Ontario, Canada.ParticipantsAll children 6–12 years of age (n=2 043 977), adolescents 13–17 years (n=1 708 754) and young adults 18–24 years (n=2 286 544), living in Ontario and eligible for provincial health insurance between March 2016 and November 2021.Primary outcome measuresOutpatient mental health visits to family physicians and psychiatrists for: mood and anxiety disorders, alcohol and substance abuse disorders, other non-psychotic mental health disorders and social problems. Inpatient mental health visits to emergency departments and hospitalisations for: substance-related and addictive disorders, anxiety disorders, assault-related injuries, deliberate self-harm and eating disorders. All outcomes were analysed by cohort and sex.ResultsDuring the pandemic, observed outpatient visit rates were higher among young adults by 19.01% (95% CI: 15.56% to 22.37%; 209 vs 175 per 1000) and adolescent women 24.17% (95% CI: 18.93% to 29.15%; 131 vs 105 per 1000) for mood and anxiety disorders and remained higher than expected. Female adolescents had higher than expected usage of inpatient care for deliberate self-harm, eating disorders and assault-related injuries.ConclusionsStudy results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns.
IntroductionCulturally appropriate interventions to promote COVID-19 health protective measures among Black and South Asian communities in the UK are needed. We aim to carry out a preliminary ...evaluation of an intervention to reduce risk of COVID-19 comprising a short film and electronic leaflet.Methods and analysisThis mixed methods study comprises (1) a focus group to understand how people from the relevant communities interpret and understand the intervention’s messages, (2) a before-and-after questionnaire study examining the extent to which the intervention changes intentions and confidence to carry out COVID-19 protective behaviours and (3) a further qualitative study exploring the views of Black and South Asian people of the intervention and the experiences of health professionals offering the intervention. Participants will be recruited through general practices. Data collection will be carried out in the community.Ethics and disseminationThe study received Health Research Authority approval in June 2021 (Research Ethics Committee Reference 21/LO/0452). All participants provided informed consent. As well as publishing the findings in peer-reviewed journals, we will disseminate the findings through the UK Health Security Agency, NHS England and the Office for Health Improvement and Disparities and ensure culturally appropriate messaging for participants and other members of the target groups.
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