Background
The US Veterans Affairs (VA) healthcare system began reporting risk-adjusted mortality for intensive care (ICU) admissions in 2005. However, while the VA’s mortality model has been updated ...and adapted for risk-adjustment of all inpatient hospitalizations, recent model performance has not been published. We sought to assess the current performance of VA’s 4 standardized mortality models: acute care 30-day mortality (acute care SMR-30); ICU 30-day mortality (ICU SMR-30); acute care in-hospital mortality (acute care SMR); and ICU in-hospital mortality (ICU SMR).
Methods
Retrospective cohort study with split derivation and validation samples. Standardized mortality models were fit using derivation data, with coefficients applied to the validation sample. Nationwide VA hospitalizations that met model inclusion criteria during fiscal years 2017–2018(derivation) and 2019 (validation) were included. Model performance was evaluated using c-statistics to assess discrimination and comparison of observed versus predicted deaths to assess calibration.
Results
Among 1,143,351 hospitalizations eligible for the acute care SMR-30 during 2017–2019, in-hospital mortality was 1.8%, and 30-day mortality was 4.3%. C-statistics for the SMR models in validation data were 0.870 (acute care SMR-30); 0.864 (ICU SMR-30); 0.914 (acute care SMR); and 0.887 (ICU SMR). There were 16,036 deaths (4.29% mortality) in the SMR-30 validation cohort versus 17,458 predicted deaths (4.67%), reflecting 0.38% over-prediction. Across deciles of predicted risk, the absolute difference in observed versus predicted percent mortality was a mean of 0.38%, with a maximum error of 1.81% seen in the highest-risk decile.
Conclusions and Relevance
The VA’s SMR models, which incorporate patient physiology on presentation, are highly predictive and demonstrate good calibration both overall and across risk deciles. The current SMR models perform similarly to the initial ICU SMR model, indicating appropriate adaption and re-calibration.
There is a growing recognition of the need to effectively assess the social value of public health interventions through a wider, comprehensive approach, capturing their social, economic and ...environmental benefits, outcomes and impacts. Social Return on Investment (SROI) is a methodological approach which incorporates all three aspects for evaluating interventions. Mental health problems are one of the leading causes of ill health and disability worldwide. This study aims to map existing evidence on the social value of mental health interventions that uses the SROI methodology.
A scoping evidence search was conducted on Medline, PubMed, Google Scholar and relevant gray literature, published in English between January 2000 and March 2021 to identify studies which capture the SROI of mental health interventions in high- and middle-income countries. Studies that reported mental health outcomes and an SROI ratio were included in this review. The quality of included studies was assessed using Krlev's 12-item quality assessment framework.
The search identified a total of 435 records; and 42 of them with varying quality met the study inclusion criteria. Most of the included studies (93%) were non-peer reviewed publicly available reports, predominantly conducted in the United Kingdom (88%); and majority (60%) of those studies were funded by charity/non-for-profit organizations. Out of 42 included studies, 22 were targeted toward individuals experiencing mental health problems and the remainder 20 were targeted to vulnerable groups or the general population to prevent, or reduce the risk of poor mental health. Eighty-one percent of included studies were graded as high quality studies based on Krlev's 12-item quality assessment framework. The reported SROI ratios of the included studies ranged from £0.79 to £28.00 for every pound invested.
This scoping review is a first of its kind to focus on SROI of mental health interventions, finding a good number of SROI studies that show a positive return on investment of the identified interventions. This review illustrates that SROI could be a useful tool and source of evidence to help inform policy and funding decisions for investment in mental health and wellbeing, as it accounts for the wider social, economic and environmental benefits of public health interventions. More SROI research in the area of public health is needed to expand the evidence base and develop further the methodology.
Neuro-surgical emergencies are serious (long-term disability and high mortality) and costly to the national health services. Tele-medicine intervention can facilitate to reduce this gap. Our study ...aims to evaluate the cost-effectiveness of tele-video-consultation intervention for the management of neuro-surgical emergencies in the general hospitals.
We retrieved health service data from the tele-consultation service, online tele-medicine database portal and hospital patient registry, between January 2009 and December 2012 and evaluated cost-effectiveness of the tele-video-consultation intervention from an Italian National Health Service perspective.
Seventy-five percent of the tele-consultations were completed within 15 min and 90% within 30 min. The average costs were €2,326 in the intervention group and €4,173 in the care as usual group. The intervention avoided 73% potential transfer (saving of 139,916 km travel distance during a 4-years period). The incremental cost-saving per transfer avoided from the tele-medicine intervention was €365.
Tele-medicine intervention could be worth investing from the Italian National Health Service perspective.
Capacity development of health volunteers and text messaging to pregnant women through mobile phones have shown improved maternal and child health (MCH) outcomes and is associated with increased ...utilisation of MCH services. However, such interventions are uncommon in Nepal. We aim to carry out an intervention with the hypothesis that capacity building and text messaging intervention will increase the MCH service utilisation.
MATRI-SUMAN is a 12-month cluster randomized controlled trial (RCT). The trial involves pregnant women from 52 clusters of six village development committees (VDCs) covering 66,000 populations of Dhanusha district of Nepal. In the intervention clusters, Female Community Health Volunteers (FCHVs) will receive capacity development skills through reinforcement training, supervision and monitoring skills for the promotion of health seeking behaviour among pregnant women and study participants will receive periodic promotional text messaging service about MCH components through mobile phones. A sample of 354with equal numbers in each study arm is estimated using power calculation formula. The primary outcomes of this study are the rate of utilization of skilled birth attendants and consumption of a specified diversified meal. The secondary outcomes are: four antenatal (ANC) visits, weight gain of women during pregnancy, delivery of a baby at the health facility, postnatal care (PNC) visits, positive changes in child feeding practices among mothers, performance of FCHVs in MCH service utilization.
The intervention is designed to enhance the capacity of health volunteers for the promotion of health seeking behaviour among pregnant women and text messaging through a mobile phone to expecting mothers to increase MCH service utilization. The trial if proven effective will have policy implications in poor resource settings.
ISRCTN60684155, ( https://doi.org/10.1186/ISRCTN60684155 ). The trial was registered retrospectively.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Cardiovascular diseases (CVDs) have dramatically infiltrated populations living in abject poverty in Low- and Middle-income Countries (LMICs), and poor maternal and child health outcomes have been ...frequently reported for those with CVD risk factors. However, few studies have explored the behavioral risk factors of CVDs among pregnant women in rural settings. This study aimed at determining the prevalence and identifying the socio-economic predictors of behavioral risk factors of CVDs among pregnant women in rural area in Southern Nepal.
A Community-based cross-sectional study was conducted in 52 clusters of Dhanusha District of Nepal in a total of 426 pregnant women in their second trimester using multistage cluster sampling method. Multivariable logistic regression model was used to assess independent associations between behavioral risk factors during pregnancy and maternal socio-economic characteristics.
Of the 426 study participants, 86.9, 53.9, 21.3 and 13.3%, respectively, reported insufficient fruits and vegetables consumption, insufficient physical activity, tobacco use, and harmful alcohol drinking. Socio-economic factors significantly associated with more than one behavioral risk factors in expectant mothers with a primary level education (adjusted odds ratio (AOR) 2.78; 95% Confidence Interval (CI) (1.35-5.72)), 20-34 years age group (Adjusted Odds Ratio (AOR) 0.27; 95% CI (0.13-0.56)), and those with the highest wealth index (AOR 0.36; 95% CI (0.16-0.84)).
Higher prevalence of behavioral risk factors for CVDs and their socio-economic factors prevailing among pregnant women living in rural Nepal call for immediate health promotion interventions such as community awareness and appropriate antenatal counseling.
Forty years from the seminal work of Welsh GP Julian Tudor Hart on the Inverse Care Law, inequalities in health and healthcare remain deeply embedded in Wales. There is a wider gap (over 17 years) in ...healthy life expectancy between people living in the most and least deprived neighborhoods in Wales. This health inequality is reflected in additional healthcare use. In this study we estimate the cost of inequality associated with this additional healthcare use to the publicly funded National Health Service (NHS) in Wales.
We retrieved administrative data on all NHS inpatient admissions, outpatient and accident and emergency attendances in Wales between April 2018 and March 2019 from Digital Health and Care Wales (DHCW). Hospital service use data were translated to costs using Healthcare Resource Group (HRG) and health service specific unit cost data and linked with area level mid-year population and deprivation indices in order to calculate the healthcare costs associated with socioeconomics deprivation.
Inequality in healthcare use between people from more and less deprived neighborhoods was associated with an additional cost of £322 million per year to the NHS in Wales, accounting for 8.7% of total NHS hospital expenditure in the country. Emergency inpatient admissions made up by far the largest component of this additional cost contributing £247.4 million, 77% of the total. There are also substantial costs of inequality for A&E attendances and outpatient visits, though not maternity services. Elective admissions overall have a negative cost of inequality, since among men aged 50-75 and women aged 60-70, elective utilization is actually negatively associated with deprivation.
There are wide inequalities in health and healthcare use between people living in more deprived neighborhoods and those living in less deprived neighborhoods in Wales. Tackling health inequality through a combination of health promotion and early intervention policies targeted toward deprived communities could yield substantial improvement in health and wellbeing, as well as savings for the Welsh NHS through reduced use of emergency hospital care.
To estimate the health and financial burden of adverse childhood experiences (ACEs) in England and Wales.
The study combined data from five randomly stratified cross-sectional ACE studies. Population ...attributable fractions (PAFs) were calculated for major health risks and causes of ill health and applied to disability adjusted life years (DALYs), with financial costs estimated using a modified human capital method.
Households in England and Wales.
15 285 residents aged 18-69.
The outcome measures were PAFs for single (1 ACE) and multiple (2-3 and ≥4 ACEs) ACE exposure categories for four health risks (smoking, alcohol use, drug use, high body mass index) and nine causes of ill health (cancer, type 2 diabetes, heart disease, respiratory disease, stroke, violence, anxiety, depression, other mental illness); and annual estimated DALYs and financial costs attributable to ACEs.
Cumulative relationships were found between ACEs and risks of all outcomes. For health risks, PAFs for ACEs were highest for drug use (Wales 58.8%, England 52.6%), although ACE-attributable smoking had the highest estimated costs (England and Wales, £7.8 billion). For causes of ill health, PAFs for ACEs were highest for violence (Wales 48.9%, England 43.4%) and mental illness (ranging from 29.1% for anxiety in England to 49.7% for other mental illness in Wales). The greatest ACE-attributable costs were for mental illness (anxiety, depression and other mental illness; England and Wales, £11.2 billion) and cancer (£7.9 billion). Across all outcomes, the total annual ACE-attributable cost was estimated at £42.8 billion. The majority of costs related to exposures to multiple rather than a single ACE (ranging from 71.9% for high body mass index to 98.3% for cancer).
ACEs impose a substantial societal burden in England and Wales. Policies and practices that prevent ACEs, build resilience and develop trauma-informed services are needed to reduce burden of disease and avoidable service use and financial costs across health and other sectors.
The Welsh Health Equity Status Report initiative (WHESRi) applies an innovative WHO framework to map the wider impacts of COVID-19 on health equity. The framework is a mechanism to promote policy ...action and commitment for health equity and identifies five essential conditions needed to live a healthy life; namely, health services, income security, living conditions, social and human capital, and working conditions. We used the framework to assess the immediate health equity impacts of COVID-19 in Wales.
Ten relevant variables from Public Health Wales' public engagement survey on health and wellbeing during COVID-19 (captured April 3–July 25, 2020) were mapped to each of the five essential conditions, as defined by the European Health Equity Status Report initiative. Variables were chosen based on alignment to the essential conditions, research objectives and data quality. Estimated marginal means were disaggregated by sociodemographic factors on a nationally representative study sample ranging from 862 to 4747 participants (dependent on duration for which question was asked). Ethical approval was not required as per guidance from the National Health Service Health Research Association ethics decision tool.
The WHESRi framework allowed the assessment and quantification of the immediate impacts of COVID-19 on the wider determinants of health through the lens of the five essential conditions. For example, in relation to income security, a significantly higher proportion (181 50·6% of 358; p<0·05) of survey respondents aged 18–24 years reported being worried about losing their job, or not being able to find one, than any other age group. Of those respondents aged 18–24 years, 54·4% (p<0·05) of men (equivalent to 78 000) reported being worried, compared with 44·3% (p<0·05) of women (equivalent to 72 000), a difference of 10·1%.
Application of the WHESRi framework allowed us to draw a holistic picture of health and its determinants at the population level. This application has highlighted quantifiable differences in impacts between population groups, and encouraged the dialogue around policy action. A priority moving forward is to apply the framework to vulnerable population groups and population health priorities to assess the health equity impacts according to factors such as rurality, disability, and ethnicity. Our findings resulting from the application of this WHO framework can be used to enable an equitable and sustainable recovery from the pandemic; they form part of a European initiative for health equity and provide learning to other countries from Wales' role as an innovation site.
None.
Post-Traumatic Stress Disorder (PTSD) is a prevalent, disabling anxiety disorder. This prospective cohort study reports on a new exposure-based therapy known as Accelerated Resolution Therapy ...(ART(®)) that incorporates the use of eye movements administered in a brief treatment period (1-5 one-hour sessions within three weeks). Eighty adults aged 21-60 years with symptoms of PTSD were recruited from the Tampa Bay area. The ART-based psychotherapy was designed to minimize anxiety and body sensations associated with recall of traumatic memories and to replace distressing images with favorable ones. Participants' mean age was 40 years, 77% were female, and 29% were Hispanic. Participants underwent a median of three ART sessions, 66 of 80 (82.5%) completed treatment, and 54 of 66 (81.8%) provided 2-month follow-up data. Mean scores pre- and post-ART and at 2-month follow-up were: PTSD Checklist: 54.5 ± 12.2 vs. 31.2 ± 11.4 vs. 30.0 ± 12.4; Brief Symptom Inventory: 30.8 ± 14.6 vs. 10.1 ± 10.8 vs. 10.1 ± 12.1; Center for Epidemiologic Studies Depression Scale: 29.5 ± 10.9 vs. 11.8 ± 11.1 vs. 13.5 ± 12.1; Trauma Related Growth Inventory-Distress scale: 18.9 ± 4.1 vs. 7.4 ± 5.9 vs. 8.2 ± 5.9 (p < 0.0001 for all pre-ART vs. post-ART and 2-month comparisons). No serious adverse events were reported. ART appears to be a brief, safe, and effective treatment for symptoms of PTSD.
Underutilisation of antenatal care services due to intimate partner violence during pregnancy has been well documented elsewhere, but it is understudied in Nepal. Our study aimed at exploring the ...impact of intimate partner violence on antenatal care service utilisation in southern Terai of Nepal.
A community-based cross-sectional study was performed in 6 village development committees in Dhanusha district, Nepal. A total of 426 pregnant women in their second trimester were selected using a multistage cluster sampling method. Multivariable regression analyses were used to examine the association between exposure to intimate partner violence and selected antenatal care services, adjusting for covariates.
Among 426 pregnant women, almost three out of ten women (28.9%) were exposed to intimate partner violence at some point during their pregnancy. Pregnant women who were exposed to intimate partner violence were less likely to: register for antenatal care (OR 0.31; 95% CI (0.08–0.50)), take iron and folic acid (OR 0.55; 95% CI (0.12–0.90)), report dietary diversity (middle vs low: OR 0.34; 95% CI (0.11–0.58) and high vs low: OR 0.18; 95% CI (0.08–0.37)), have rest and sleep during day time (OR 0.47; 95% CI (0.61–0.58)), and attend mother’s group meetings (OR 0.29; 95% CI (0.10–0.83)).
Intimate partner violence during pregnancy is associated with low utilisation of antenatal care services. Therefore, effective strategies to prevent or reduce intimate partner violence during pregnancy is needed, which may lead to improved antenatal care service utilization in Nepal with healthier mothers and children’s outcome.
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