An ecological relationship between economic development and reduction in tuberculosis prevalence has been observed. Between 2007 and 2017, Việt Nam experienced rapid economic development with ...equitable distribution of resources and a 37% reduction in tuberculosis prevalence. Analysing consecutive prevalence surveys, we examined how the reduction in tuberculosis (and subclinical tuberculosis) prevalence was concentrated between socioeconomic groups.
We combined data from 2 nationally representative Việt Nam tuberculosis prevalence surveys with provincial-level measures of poverty. Data from 94,156 (2007) and 61,763 (2017) individuals were included. Of people with microbiologically confirmed tuberculosis, 21.6% (47/218) in 2007 and 29.0% (36/124) in 2017 had subclinical disease. We constructed an asset index using principal component analysis of consumption data. An illness concentration index was estimated to measure socioeconomic position inequality in tuberculosis prevalence. The illness concentration index changed from -0.10 (95% CI -0.08, -0.16; p = 0.003) in 2007 to 0.07 (95% CI 0.06, 0.18; p = 0.158) in 2017, indicating that tuberculosis was concentrated among the poorest households in 2007, with a shift towards more equal distribution between rich and poor households in 2017. This finding was similar for subclinical tuberculosis. We fitted multilevel models to investigate relationships between change in tuberculosis prevalence, individual risks, household socioeconomic position, and neighbourhood poverty. Controlling for provincial poverty level reduced the difference in prevalence, suggesting that changes in neighbourhood poverty contribute to the explanation of change in tuberculosis prevalence. A limitation of our study is that while tuberculosis prevalence surveys are valuable for understanding socioeconomic differences in tuberculosis prevalence in countries, given that tuberculosis is a relatively rare disease in the population studied, there is limited power to explore socioeconomic drivers. However, combining repeated cross-sectional surveys with provincial deprivation estimates during a period of remarkable economic growth provides valuable insights into the dynamics of the relationship between tuberculosis and economic development in Việt Nam.
We found that with equitable economic growth and a reduction in tuberculosis burden, tuberculosis became less concentrated among the poor in Việt Nam.
IMPORTANCE: Banning electronic cigarette (e-cigarette) sales to minors has been a key policy to protect children from e-cigarettes in the United States and Canada, but to date little is known about ...the outcome of such a ban. OBJECTIVES: To investigate the association of banning e-cigarette sales to minors in Canada with e-cigarette use among youths and the mechanisms through which a ban might be associated with their e-cigarette use. DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental difference-in-differences and triple-differences study used data from the nationally representative Canadian Tobacco, Alcohol and Drugs Survey (2013-2017) and Canadian Student Tobacco, Alcohol and Drugs Survey (2014-2017). Study samples consisted of respondents aged 15 to 18 years (in difference-in-differences analysis; n = 8212) and aged 15 to 25 years (in triple-differences analysis; n = 20 934) in the Canadian Tobacco, Alcohol and Drugs Survey, and students in grades 6 to 12 (in difference-in-differences analysis; n = 78 650) in the Canadian Student Tobacco, Alcohol and Drugs Survey. INTERVENTIONS: Canada’s provincial bans on e-cigarette sales to youths younger than 18 or 19 years (depending on province) implemented between 2015 and 2017. MAIN OUTCOMES AND MEASURES: The primary outcome was past 30-day e-cigarette use among youths. Secondary outcomes were difficulty of access to e-cigarettes, perception of e-cigarette harm, and use of social sources of e-cigarettes. RESULTS: After the bans, e-cigarette use among youths increased in all provinces, but the increase was 3.1 percentage points (95% CI, 0.2-6.0; P = .04), or 79%, lower in provinces with a ban than in provinces without a ban. Youths in provinces with a ban were 2.6 percentage points (95% CI, 1.5-3.7; P = .001), or 18%, less likely to believe that regular e-cigarette use poses no harm and 6.2 percentage points (95% CI, 1.1-11.4; P = .02), or 16%, more likely to self-report greater difficulty in obtaining e-cigarettes. Among youths who reported using e-cigarettes, the likelihood of obtaining e-cigarettes from social sources was 17.3 percentage points (95% CI, 5.2 -29.4; P = .01), or 29%, higher in provinces with a ban. These findings were robust to several sensitivity analyses. CONCLUSIONS AND RELEVANCE: Banning e-cigarette sales to minors was associated with a significant reduction in the rate of increase in e-cigarette use by youths, but this policy alone could not reverse the overall increase in e-cigarette use. The findings from this study suggest that this policy should be supplemented with other measures that can reduce young people’s desire to obtain e-cigarettes through social sources, such as a ban on e-cigarettes with flavors that appeal to youths and children.
Background and Aims
Existing research on mental health comorbidities of youth e‐cigarette use is subject to confounding bias and reverse causality. This study aimed to measure the effects of ...e‐cigarette use on youth mental health, using e‐cigarette minimum legal age (MLA) law in Canada as a natural experiment.
Design
We used difference‐in‐differences (DD), difference‐in‐differences‐in‐differences (DDD) and two‐sample instrumental variables (TSIV) methods.
Setting
Data were from nationally representative Canadian Community Health Surveys 2008–2019 and Canadian Student Tobacco Alcohol and Drugs Surveys 2008–2019.
Participants
The study sample comprised of respondents aged 15 to 18 (in DD analysis; n = 33 858) and aged 15 to 24 (in DDD analysis; n = 78 689).
Measurements
Primary outcomes were self‐reported mood disorders and anxiety disorders. Secondary outcomes were cannabis use, illicit drug use, cigarette use and strength of peer relationships at schools.
Findings
After the e‐cigarette MLA laws, risks of mood disorders declined by 1.9 percentage points (95% CI, 0.0–3.8; P = 0.05) in the DD analysis and by 2.6 percentage points (95% CI, 0.2–5.0; P = 0.03) in the DDD analysis. For anxiety disorders, while the DD estimate was negative but imprecisely estimated, the MLA law reduced risks of anxiety disorder by 3.6 percentage points (95% CI, 0.9–6.2; P = 0.01) in the DDD analysis. Youths in provinces with MLA laws were also less likely to report cannabis use and illicit drug use and more likely to feel being part of schools. TSIV analysis indicates that youth e‐cigarette use increased the likelihood of mood and anxiety disorders by 44% and 37%, respectively.
Conclusion and Relevance
In Canada, the e‐cigarette minimum legal age law appears to have reduced risks of mood and anxiety disorders, lowered substance use and improved peer relationships at schools. Combined with previous evidence of lower e‐cigarette use following the minimum legal age law, our findings indicate that youth e‐cigarette use increases risks of mood and anxiety disorders.
Current guidelines for mammography screening for breast cancer vary across agencies, especially for women aged 40-49. Using artificial Intelligence (AI) to read mammography images has been shown to ...predict breast cancer risk with higher accuracy than alternative approaches including polygenic risk scores (PRS), raising the question whether AI-based screening is more cost-effective than screening based on PRS or existing guidelines. This study provides the first evidence to shed light on this important question.
This study is a model-based economic evaluation. We used a hybrid decision tree/microsimulation model to compare the cost-effectiveness of eight strategies of mammography screening for women aged 40-49 (screening beyond age 50 follows existing guidelines). Six of these strategies were defined by combinations of risk prediction approaches (AI, PRS or family history) and screening frequency for low-risk women (no screening or biennial screening). The other two strategies involved annual screening for all women and no screening, respectively. Data used to populate the model were sourced from the published literature.
Risk prediction using AI followed by no screening for low-risk women is the most cost-effective strategy. It dominates (i.e., costs more and generates fewer quality adjusted life years (QALYs)) strategies for risk prediction using PRS followed by no screening or biennial screening for low-risk women, risk prediction using AI or family history followed by biennial screening for low-risk women, and annual screening for all women. It also extendedly dominates (i.e., achieves higher QALYs at a lower incremental cost per QALY) the strategy for risk prediction using family history followed by no screening for low-risk women. Meanwhile, it is cost-effective versus no screening, with an incremental cost-effectiveness ratio of $23,755 per QALY gained.
Risk prediction using AI followed by no breast cancer screening for low-risk women is the most cost-effective strategy. This finding can be explained by AI's ability to identify high-risk women more accurately than PRS and family history (which reduces the possibility of delayed breast cancer diagnosis) and fewer false-positive diagnoses from not screening low-risk women.
Background Procedure-less intragastric balloon (PIGB) eliminates costs and risks of endoscopic placement/removal and involves lower risk of serious complications compared with bariatric surgery, ...albeit with lower weight loss. Given the vast unmet need for obesity treatment, an important question is whether PIGB treatment is cost-effective-either stand-alone or as a bridge to bariatric surgery. Methods We developed a microsimulation model to compare the costs and effectiveness of six treatment strategies: PIGB, gastric bypass or sleeve gastrectomy as stand-alone treatments, PIGB as a bridge to gastric bypass or sleeve gastrectomy, and no treatment. Results PIGB as a bridge to bariatric surgery is less costly and more effective than bariatric surgery alone as it helps to achieve a lower post-operative BMI. Of the six strategies, PIGB as a bridge to sleeve gastrectomy is the most cost-effective with an ICER of $3,781 per QALY gained. While PIGB alone is not cost-effective compared with bariatric surgery, it is cost-effective compared with no treatment with an ICER of $21,711 per QALY. Conclusions PIGB can yield cost savings and improve health outcomes if used as a bridge to bariatric surgery and is cost-effective as a stand-alone treatment for patients lacking access or unwilling to undergo surgery.
The differences in cost and efficacy between dapagliflozin and empagliflozin in combination with standard of care (SoC) raise the question of which regimen would be cost-effective in treating heart ...failure with reduced ejection fraction (HFrEF). This study evaluates the cost-effectiveness of dapagliflozin plus SoC (dapagliflozin-SoC) versus empagliflozin plus SoC (empagliflozin-SoC) or SoC alone for treatment of HFrEF.
We developed a Markov model to estimate the cost-effectiveness of dapagliflozin-SoC, empagliflozin-SoC, and SoC alone from the healthcare system perspective over a lifetime horizon. Data on efficacy of dapagliflozin-SoC, empagliflozin-SoC, and SoC were obtained from randomized controlled trials. Costs were measured in 2022 US dollars, and effectiveness was measured in quality-adjusted life years (QALYs).
Among three strategies, dapagliflozin-SoC was the most cost-effective strategy and dominated empagliflozin-SoC in an extended sense. Compared with SoC alone, dapagliflozin-SoC and empagliflozin-SoC had incremental cost-effectiveness ratios (ICER) of $56,782 and $89,258 per QALY, respectively. Dapagliflozin-SoC cost more $5524 but yielded more 0.20 QALYs than empagliflozin-SoC, with the ICER of $27,861 per QALY. The cost-effectiveness of dapagliflozin-SoC, empagliflozin-SoC, and SoC alone did not depend on diabetic status. However, empagliflozin-SoC was no longer cost-effective versus SoC alone in HFrEF patients without CKD, and dapagliflozin-SoC was not cost-effective versus empagliflozin-SoC in HFrEF patients with CKD.
Dapagliflozin-SoC was cost-effective versus empagliflozin-SoC or SoC alone for treatment of HFrEF.
•Dapagliflozin is more effective but costs more than empagliflozin for treating HFrEF.•Evidence on the cost-effectiveness of dapagliflozin versus empagliflozin is limited.•Dapagliflozin was cost-effective versus empagliflozin or standard of care for HFrEF.•Cost-effectiveness results varied by CKD status of HFrEF patients.
ObjectivesBanning e-cigarette use in public places has attracted considerable debate, with governments adopting different policies. However, little is known about the outcomes of such bans. We ...investigated the association of banning e-cigarette use in public places and workplaces in Canadian provinces with adults’ vaping and smoking behaviours.DesignDifference-in-differences.SettingNationally representative Canadian Tobacco Use Monitoring Survey (CTUMS) and Canadian Tobacco, Alcohol and Drugs Survey (CTADS).ParticipantsAdults aged 19 and older from CTADS 2013–2017 for e-cigarette outcomes (N=36 562) and from CTUMS/CTADS 2004–2017 for combustible cigarette outcomes (N=178 654).InterventionsBans on e-cigarette use in public places and workplaces in Canadian provinces.Main outcome measuresPast 30-day e-cigarette use, current combustible cigarette use, use of e-cigarettes when unable to smoke combustible cigarettes.ResultsAfter the bans, e-cigarette use in the past 30 days did not change significantly in provinces with a ban compared with provinces without a ban (0.004; 95% CI −0.025 to 0.032; p=0.783). The bans also had no impact on current combustible cigarette use (0.009; 95% CI −0.019 to 0.037; p=0.488). There is evidence of ban evasion among young people aged 19–24 who, after the bans, reported higher use of e-cigarettes when unable to smoke combustible cigarettes (0.114; 95% CI −0.023 to 0.250; p=0.092).ConclusionsTwo years after implementation, the aerosol-free laws in Canada had no impacton adults’ vaping and smoking behaviours. Policy efforts are urgently needed to improve the ban enforcement and to deal with discreet vaping among young adults.
There is increasing interest in understanding the impact of non-medical cannabis legalization on use of other substances, especially alcohol. Evidence on whether cannabis is a substitute or ...complement for alcohol is both mixed and limited. This study provides the first quasi-experimental evidence on the impact of Canada’s legalization of non-medical cannabis on beer and spirits sales.
We used the interrupted time series design and monthly data on beer sales between January 2012 and February 2020 and spirits sales between January 2016 and February 2020 across Canada to investigate changes in beer and spirits sales following Canada’s cannabis legalization in October 2018. We examined changes in total sales, nationally and in individual provinces, as well as changes in sales of bottled, canned and kegged beer.
Canada-wide beer sales fell by 96 hectoliters per 100,000 population (p=0.011) immediately after non-medical cannabis legalization and by 4 hectoliters per 100,000 population (p>0.05) each month thereafter for an average monthly reduction of 136 hectoliters per 100,000 population (p<0.001) post-legalization. However, the legalization was associated with no change in spirits sales. Beer sales reduced in all provinces except the Atlantic provinces. By beer type, the legalization was associated with declines in sales of canned and kegged beer but there was no reduction in sales of bottled beer.
Non-medical cannabis legalization was associated with a decline in beer sales in Canada, suggesting substitution of non-medical cannabis for beer. However, there was no change in spirits sales following the legalization.
•Canada’s non-medical cannabis legalization was associated with decline in beer sales.•All provinces except the Atlantic provinces experienced a decline in beer sales.•Sales of canned and kegged beer declined but there was no reduction in sales of bottled beer.•The non-medical cannabis legalization was associated with no change in spirits sales.
To determine the incremental cost-effectiveness of a new telemedicine technician-based assessment relative to an existing model of family physician (FP)-based assessment of diabetic retinopathy (DR) ...in Singapore from the health system and societal perspectives.
Model-based, cost-effectiveness analysis of the Singapore Integrated Diabetic Retinopathy Program (SiDRP).
A hypothetical cohort of patients aged 55 years with type 2 diabetes previously not screened for DR.
The SiDRP is a new telemedicine-based DR screening program using trained technicians to assess retinal photographs. We compared the cost-effectiveness of SiDRP with the existing model in which FPs assess photographs. We developed a hybrid decision tree/Markov model to simulate the costs, effectiveness, and incremental cost-effectiveness ratio (ICER) of SiDRP relative to FP-based DR screening over a lifetime horizon. We estimated the costs from the health system and societal perspectives. Effectiveness was measured in terms of quality-adjusted life-years (QALYs). Result robustness was calculated using deterministic and probabilistic sensitivity analyses.
The ICER.
From the societal perspective that takes into account all costs and effects, the telemedicine-based DR screening model had significantly lower costs (total cost savings of S$173 per person) while generating similar QALYs compared with the physician-based model (i.e., 13.1 QALYs). From the health system perspective that includes only direct medical costs, the cost savings are S$144 per person. By extrapolating these data to approximately 170 000 patients with diabetes currently being screened yearly for DR in Singapore's primary care polyclinics, the present value of future cost savings associated with the telemedicine-based model is estimated to be S$29.4 million over a lifetime horizon.
While generating similar health outcomes, the telemedicine-based DR screening using technicians in the primary care setting saves costs for Singapore compared with the FP model. Our data provide a strong economic rationale to expand the telemedicine-based DR screening program in Singapore and elsewhere.
PDF
