[Show abstract][Hide abstract] ABSTRACT: Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid.
Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 μgm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 μgm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 μgm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study.
By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively.
Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints.
Maternal and Infant Nutrition Interventions, Matlab; ISRCTN16581394 ; Date of registration: Feb 16, 2009.
[Show abstract][Hide abstract] ABSTRACT: Background
Type 2 diabetes (T2D) decreases health-related quality of life, but there is a lack of information about the health status of people in pre-diabetic states. However, information on health utility weights (HUWs) for pre-diabetic states and T2D are essential to estimate the effect of prevention initiatives. We estimated and compared HUWs for healthy individuals, those with pre-diabetes and those with T2D in a Swedish population and evaluated the influence of age, sex, education and body mass index on HUWs.Methods
Participants of the Västerbotten Intervention Program, Sweden, between 2002 and 2012, who underwent an oral glucose tolerance test or indicated they had T2D and who filled in the Short Form-36 questionnaire (SF-36) were included. Individuals were categorized as healthy, being in any of three different pre-diabetic states, or as T2D. The pre-diabetic states are impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or a combination of both (IFG&IGT). The SF-6D index was used to convert SF-36 responses to HUWs. HUWs were stratified by age, sex, education and body mass index. Beta regression analyses were conducted to estimate the effect of multiple risk factors on the HUWs.ResultsIn total, 55 882 individuals were included in the analysis. The overall mean HUW was 0.764. The mean HUW of healthy individuals was 0.768, 0.759 for those with IFG, 0.746 for those with IGT, 0.745 for those with IFG&IGT, and 0.738 for those with T2D. In the overall model, all variables except underweight vs. normal weight were significantly associated with HUW. Younger age, male sex, and higher education were associated with increased HUW. Normal weight, or being overweight was associated with elevated HUW, while obesity was associated with lower HUW.Conclusions
Healthy individuals had higher HUWs than participants with T2D, while individuals with IFG, IGT or IFG&IGT had HUWs that ranged between those for NGT and T2D. Therefore, preventing the development of pre-diabetic states would improve health-related quality of life in addition to lowering the risk of developing T2D.
Health and Quality of Life Outcomes 10/2014; 12(1):150. DOI:10.1186/s12955-014-0150-z · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
There are three different types of ambulance systems, all of which can manage the same secondary intensive care patient transport mission: road ambulance, rotor-wing ambulance, and fixed-wing ambulance. We hypothesized that costs for specific transport distances would differ between systems. We aimed to analyze distances and observed times for ambulance intensive care secondary transport missions together with system costs to assess this.
We prospectively collected data for consecutive urgent intensive care transports into the regional tertiary care hospital in the northern region of Sweden. Distances and transport times were gathered, and a cost model was generated based on these together with fixed and operating costs from the three different ambulance systems. Distance-cost and time–cost estimations were then generated for each transport system.
Road ambulance cost relatively less for shorter distances (within 250 kilometers/155 miles) but were relatively time ineffective. The rotor-wing systems were most expensive regardless of distance; but were most time-effective up to 400–500 km (248–310 miles). Fixed-wing systems were more cost-effective for longer distance (300 km/186 miles), and time effective for transports over 500 km (310 miles).
In summary, based on an economic model developed from observed regional ICU patient transports, and cost estimations, different ambulance system cost-distances could be compared. Distance-cost and time results show that helicopters can be effective up to moderate ICU transport distances (400–500), though are expensive to operate. For longer ICU patient transports, fixed-wing transport systems are both cost and time effective compared to helicopter-based systems.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 06/2014; 22(1):36. DOI:10.1186/1757-7241-22-36 · 2.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence is often missing on social differentials in effects of nutrition interventions. We evaluated the adherence to and effect of prenatal food and micronutrient supplementations on mortality before the age of five years in different social groups as defined by maternal schooling.
Data came from the MINIMat study (Maternal and Infant Nutrition Interventions, Matlab), a randomized trial of prenatal food supplementation (invitation early, about 9 weeks [E], or at usual time, about 20 weeks [U] of pregnancy) and 30 mg or 60 mg iron with 400 mugm folic acid, or multiple micronutrients (Fe30F, Fe60F, MMS) resulting in six randomization groups, EFe30F, UFe30F, EFe60F, UFe60F, EMMS, and UMMS (n = 4436). Included in analysis after omissions (fetal loss and out-migration) were 3625 women and 3659 live births of which 3591 had information on maternal schooling. The study site was rural Matlab, Bangladesh. The main stratifying variable was maternal schooling dichotomized as <6 years and >=6 years. We used Cox proportional hazard model for survival analyses.
Overall, women having <6 years of schooling adhered more to food (81 vs. 61 packets, P=0.0001) but a little less to micronutrient (104 vs. 120 capsules, P = 0.0001) supplementation compared to women having more schooling, adjusted for maternal age (years), parity and body mass index (BMI, kg/m2). Children of mothers with >=6 years of schooling had lower under-five mortality, but the EMMS supplementation reduced the social difference in mortality risk (using standard program and schooling <6 years as reference; standard program and schooling >=6 years HR 0.54, 95% CI 0.27-1.11; EMMS and schooling >=6 years HR 0.28, 95% CI 0.12-0.70; EMMS and schooling <6 years HR 0.26, 95% CI 0.11-0.63), adjusted for maternal age (years), parity and body mass index (kg/m2) at week 8 pregnancy.
The combination of an early invitation to prenatal food supplementation and multiple micronutrient supplementation lowered mortality in children before the age of five years and reduced the gap in child survival chances between social groups. The pattern of adherence to the supplementations was complex; women with less education adhered more to food supplementation while those with more education had higher adherence to micronutrients.Trial registration: ISRCTN16581394.
BMC Public Health 01/2014; 14(1):5. DOI:10.1186/1471-2458-14-5 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several studies investigated transitions and risk factors from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2D). However, there is a lack of information on the probabilities to transit from normal glucose tolerance (NGT) to different pre-diabetic states and from these states to T2D. The objective of our study is to estimate these risk equations and to quantify the influence of single or combined risk factors on these transition probabilities.
Individuals who participated in the VIP program twice, having the first examination at ages 30, 40 or 50 years of age between 1990 and 1999 and the second examination 10 years later were included in the analysis. Participants were grouped into five groups: NGT, impaired fasting glucose (IFG), IGT, IFG&IGT or T2D. Fourteen potential risk factors for the development of a worse glucose state (pre-diabetes or T2D) were investigated: sex, age, education, perceived health, triglyceride, blood pressure, BMI, smoking, physical activity, snus, alcohol, nutrition and family history. Analysis was conducted in two steps. Firstly, factor analysis was used to find candidate variables; and secondly, logistic regression was employed to quantify the influence of the candidate variables. Bootstrap estimations validated the models.
In total, 29 937 individuals were included in the analysis. Alcohol and perceived health were excluded due to the results of the factor analysis and the logistic regression respectively. Six risk equations indicating different impacts of different risk factors on the transition to a worse glucose state were estimated and validated. The impact of each risk factor depended on the starting or ending pre-diabetes state. High levels of triglyceride, hypertension and high BMI were the strongest risk factors to transit to a worsened glucose state.
The equations could be used to identify individuals with increased risk to develop any of the three pre-diabetic states or T2D and to adapt prevention strategies.
BMC Public Health 10/2013; 13(1):1014. DOI:10.1186/1471-2458-13-1014 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: AimsAlthough hypertensive patients with low baseline HDL cholesterol levels have a higher incidence of diabetes mellitus, whether changing levels of HDL over time are more strongly related to the risk of new diabetes in hypertensive patients has not been examined. Methods
Incident diabetes mellitus was examined in relation to baseline and in-treatment HDL levels in 7485 hypertensive patients with no history of diabetes randomly assigned to losartan- or atenolol-based treatment. ResultsDuring 4.71.2years follow-up, 520 patients (6.9%) developed new diabetes. In univariate Cox analyses, compared with the highest quartile of HDL levels (>1.78mmol/l), baseline and in-treatment HDL in the lowest quartile (<1.21mmol/l) identified patients with >5-fold and >9fold higher risks of new diabetes, respectively; patients with baseline or in-treatment HDL in the 2nd and 3rd quartiles had intermediate risk of diabetes. In multivariable Cox analyses, adjusting for randomized treatment, age, sex, race, prior anti-hypertensive therapy, baseline uric acid, serum creatinine and glucose entered as standard covariates, and in-treatment non-HDL cholesterol, Cornell product left ventricular hypertrophy, diastolic and systolic pressure, BMI, hydrochlorothiazide and statin use as time-varying covariates, the lowest quartile of in-treatment HDL remained associated with a nearly 9-fold increased risk of new diabetes (hazard ratio8.7, 95%CI 5.0-15.2), whereas the risk of new diabetes was significantly attenuated for baseline HDL <1.21mmol/l (hazard ratio3.9, 95%CI 2.8-5.4). Conclusions
Lower in-treatment HDL is more strongly associated with increased risk of new diabetes than baseline HDL level.
Diabetic Medicine 04/2013; 30(10). DOI:10.1111/dme.12213 · 3.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
In many developing countries, including Vietnam, out-of-pocket payment is the principal source of health financing. The economic growth is widening the gap between rich and poor people in many aspects, including health care utilization. While inequities in health between high- and low-income groups have been well investigated, this study aims to investigate how the health care utilization changes when the economic condition is changing at a household level.
We analysed a panel data of 11,260 households in a rural district of Vietnam. Of the sample, 74.4% having an income increase between 2003 and 2007 were defined as households with economic growth. We used a double-differences propensity score matching technique to compare the changes in health care expenditure as percentage of total expenditure and health care utilization from 2003 to 2005, from 2003 to 2007, and from 2005 to 2007, between households with and without economic growth.
Households with economic growth spent less percentage of their expenditure for health care, but used more provincial/central hospitals (higher quality health care services) than households without economic growth. The differences were statistically significant.
The results suggest that households with economic growth are better off also in terms of health services utilization. Efforts for reducing inequalities in health should therefore consider the inequality in income growth over time.
International Journal for Equity in Health 03/2013; 12(1):19. DOI:10.1186/1475-9276-12-19 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The challenge of an aging population in the society makes it important to find strategies to promote health for all. The aim of this study is to evaluate if repeated health coaching in terms of motivational interviewing, and an offer of wide range of activities, will contribute to positive lifestyle modifications and health among persons aged 60-75 years, with moderately elevated risk for cardiovascular disease (CVD), diabetes, or mild depression.
Men and women between 60 and 75 are recruited in four regions in Sweden if they fulfill one or more of the four inclusion criteria.•Current reading of blood pressure (140-159/90-99) without medication.•Current reading of blood sugar (Hba1c 42-52 mmol/mol) without medication.•A current waist-circumference of ≥94 cm for men and ≥80 for women.•A minor/mild depression (12-20 points) according to Montgomery-Åsberg Depression Rating Scale without medication.Individuals with a worse result than inclusion criteria are treated according to regular guidelines at the PHCs and therefore not included. Exclusion criteria for the study are dementia, mental illness or other condition deemed unsuitable for participation.All participants fill out a questionnaire at baseline, and at the 6-, 12- and 18-month follow-ups containing questions on demographic characteristics, social life, HRQoL, lifestyle habits, general health/medication, self-rated mental health, and sense of coherence. At the 12-month follow-up, the health coach will give each participant a second questionnaire to capture attitudes and perceptions related to health coaching and venues/activities offered.Qualitative data will be collected twice to obtain a deeper understanding of perceptions and attitudes related to health and lifestyle/lifestyle modifications. A health economic assessment will be performed. Individual costs for health care utilisation will be collected and QALY-scores will be estimated.
Several drawbacks can be identified when conducting research in real life. However, many of the identified problems can diminish the positive results of the intervention and if the intervention shows positive effects they might be underestimated.
Current Controlled Trials ISRCTN01396033.
BMC Public Health 03/2013; 13:199. DOI:10.1186/1471-2458-13-199 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IntroductionWe recently developed and validated in existing trials a novel algorithm (PRE score) to predict long-term drug efficacy based on short-term (month-6) drug-induced changes in multiple risk markers. To show the value of the PRE score for ongoing and planned clinical trials, we here report the predicted long-term cardio-renal efficacy of aliskiren in type 2 diabetes, which was investigated in the ALTITUDE trial, but unknown at the time this study was conducted.Methods
We established the relation between multiple risk markers and cardio-renal endpoints (as defined in ALTITUDE) using a background database from past clinical trials. The short-term effect of aliskiren on multiple risk markers was taken from the AVOID trial. A PRE score was developed by multivariate Cox analysis in the background population and was then applied to the baseline and month-6 measurements of the aliskiren treatment arm of the AVOID trial to predict cardio-renal risk. The net risk difference at these time-points, after correction for placebo effects, was taken to indicate the estimated long-term cardio-renal risk change.ResultsBased on the PRE score, we predicted that aliskiren treatment in ALTITUDE would confer a relative risk change of -7.9% (95% CI -2.5 to -13.4) for the cardio-renal endpoint, a risk change of -5.1% (-1.2 to -9.0) for the CV endpoint and a non-significant risk change of -19.9% (-42.1 to +2.1) for the renal endpoint.ConclusionsPRE score estimations suggested that aliskiren has only a marginal additive protective effect on cardio-renal endpoints. These predictions were validated by the results of the ALTITUDE trial, confirming the potential of the PRE score to prospectively predict drug efficacy on cardio-renal outcomes.
[Show abstract][Hide abstract] ABSTRACT: Celiac disease (CD) is a chronic disorder in genetically predisposed individuals in which a small intestinal immune-mediated enteropathy is precipitated by dietary gluten. It can be difficult to diagnose because signs and symptoms may be absent, subtle, or not recognized as CD related and therefore not prompt testing within routine clinical practice. Thus, most people with CD are undiagnosed and a public health intervention, which involves screening the general population, is an option to find those with unrecognized CD. However, how these screening-detected individuals experience the diagnosis and treatment (gluten-free diet) is not fully understood. The aim of this study is to investigate the health-related quality of life (HRQoL) of adolescents with screening-detected CD before and one year after diagnosis and treatment.
A prospective nested case-referent study was done involving Swedish adolescents who had participated in a CD screening study when they were in the sixth grade and about 12 years old. Screening-detected adolescents (n = 103) and referents without CD who participated in the same screening (n = 483) answered questionnaires at the time of the screening and approximately one year after the screening-detected adolescents had received their diagnosis that included the EQ-5D instrument used to measure health status and report HRQoL.
The HRQoL for the adolescents with screening-detected CD is similar to the referents, both before and one year after diagnosis and initiation of the gluten-free diet, except in the dimension of pain at follow-up. In the pain dimension at follow-up, fewer cases reported problems than referents (12.6% and 21.9% respectively, Adjusted OR 0.50, 95% CI 0.27-0.94). However, a sex stratified analysis revealed that the significant difference was for boys at follow-up, where fewer screening-detected boys reported problems (4.3%) compared to referent boys (18.8%) (Adjusted OR 0.17, 95% CI 0.04-0.73).
The findings of this study suggest that adolescents with unrecognized CD experience similar HRQoL as their peers without CD, both before and one year after diagnosis and initiation of gluten-free diet, except for boys in the dimension of pain at follow-up.
BMC Public Health 02/2013; 13(1):142. DOI:10.1186/1471-2458-13-142 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The elderly population is increasing in Vietnam. Access to health services for the elderly is often limited, especially for those in rural areas. User fees at public health care facilities and out-of-pocket payments for health care services are major barriers to access. With the aim of helping the poor access public health care services and reduce health care expenditures (HCE), the Health Care Funds for the Poor policy (HCFP) was implemented in 2002. The aim of this study is to investigate the impacts of this policy on elderly households.
Elderly households were defined as households which have at least one person aged 60 years or older. The impacts of HCFP on elderly household HCE as a percentage of total expenditure and health care utilization were assessed by a double-difference propensity score matching method using panel data of 3,957 elderly households in 2001, 2003, 2005 and 2007, of which 509 were classifies as “treated” (i.e. covered by the policy). Variables included in a logistic regression for estimating the propensity scores to match the treated with the control households, were household and household-head characteristics.
In the first time period (2001–2003) there were no significant differences between treated and controls. This can be explained by the delay in implementing the policy by the local governments. In the second (2001–2005) and third period (2001–2007) the utilizations of Communal Health Stations (CHS) and go-to-pharmacies were significant. The treated were using CHS and pharmacies more between 2001 and 2007 while control households decreased their use.
The main findings suggest HCFP met some goals but not all in the group of households having at least one elderly member. Utilization of CHS and pharmacies increased while the change in HCE as a proportion of total expenditures was not significant. To some extent, private health care and self-treatment are replaced by more utilization of CHS, indicating the poor elderly are better off. However, further efforts are needed to help them access higher levels of public health care (e.g. district health centers and provincial/central hospitals) and to reduce their HCE.
BMC Health Services Research 09/2012; 12(1). DOI:10.1186/1472-6963-12-333 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The aim of this study was to investigate potential associations between gender equality at work and self-rated health.
2861 employees in 21 companies were invited to participate in a survey. The mean response rate was 49.2%. The questionnaire contained 65 questions, mainly on gender equality and health. Two logistic regression analyses were conducted to assess associations between (i) self-rated health and a register-based company gender equality index (OGGI), and (ii) self-rated health and self-rated gender equality at work.
Even though no association was found between the OGGI and health, women who rated their company as “completely equal” or “quite equal” had higher odds of reporting “good health” compared to women who perceived their company as “not equal” (OR = 2.8, 95% confidence interval = 1.4 – 5.5 and OR = 2.73, 95% CI = 1.6-4.6). Although not statistically significant, we observed the same trends in men. The results were adjusted for age, highest education level, income, full or part-time employment, and type of company based on the OGGI.
No association was found between gender equality in companies, measured by register-based index (OGGI), and health. However, perceived gender equality at work positively affected women’s self-rated health but not men’s. Further investigations are necessary to determine whether the results are fully credible given the contemporary health patterns and positions in the labour market of women and men or whether the results are driven by selection patterns.
BMC Public Health 09/2012; 12(1):795. DOI:10.1186/1471-2458-12-795 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
A gluten-free diet is the only available treatment for celiac disease. Our aim was to investigate the effect of a gluten-free diet on celiac disease related symptoms, health care consumption, and the risk of developing associated immune-mediated diseases.
A questionnaire was sent to 1,560 randomly selected members of the Swedish Society for Coeliacs, divided into equal-sized age- and sex strata; 1,031 (66%) responded. Self-reported symptoms, health care consumption (measured by health care visits and hospitalization days), and missed working days were reported both for the year prior to diagnosis (normal diet) and the year prior to receiving the questionnaire while undergoing treatment with a gluten-free diet. Associated immune-mediated diseases (diabetes mellitus type 1, rheumatic disease, thyroid disease, vitiligo, alopecia areata and inflammatory bowel disease) were self-reported including the year of diagnosis.
All investigated symptoms except joint pain improved after diagnosis and initiated gluten-free diet. Both health care consumption and missed working days decreased. Associated immune-mediated diseases were diagnosed equally often before and after celiac disease diagnosis.
Initiated treatment with a gluten-free diet improves the situation for celiac disease patients in terms of reduced symptoms and health care consumption. An earlier celiac disease diagnosis is therefore of great importance.
[Show abstract][Hide abstract] ABSTRACT: The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study has previously demonstrated a beneficial effect of losartan compared to atenolol-based antihypertensive treatment in patients with essential hypertension and left-ventricular hypertrophy (LVH). However, patient age often influences the choice of antihypertensive drugs. Therefore, we investigated the influence of age on the effects of losartan versus atenolol-based antihypertensive treatment.
A total of 9193 hypertensive patients with LVH aged 45-83 years were followed for a mean of 4.8 years. Blood pressure, high-density lipoprotein cholesterol (HDL-C), Sokolow-Lyon voltage, Cornell voltage-duration product and urine albumin-creatinine ratio (UACR) were measured yearly throughout the study. Patients were divided into two age groups according to the median age of 67 years and the effects of losartan versus atenolol-based antihypertensive treatment on the primary composite endpoint (CEP) consisting of cardiovascular death, nonfatal stroke or nonfatal myocardial infarction were investigated.
The beneficial effect of losartan versus atenolol-based treatment was greater in the group of patients older than 67 years [hazard ratio 0.79 (0.69-0.91), P = 0.001] compared to the group of patients younger than 67 years [hazard ratio 1.03 (0.82-1.28), P = 0809], P = 0.045 for interaction. The beneficial effects of losartan versus atenolol-based antihypertensive treatment on pulse pressure, HDL-C, UACR, and Cornell and Sokolow-Lyon voltage were not more pronounced in patients older than 67 years compared to patients younger than 67 years. All five risk factors considered as time-varying covariates predicted CEP independently (P < 0.01) with the exception of pulse pressure (P = 0.37) and the interaction between age and treatment on outcome remained significant (P = 0.042).
We showed a greater beneficial effect of losartan versus atenolol-based antihypertensive treatment in the group of patients older than 67 years compared to the group of patients younger than 67 years. This difference was not explained by a more pronounced effect of losartan-based treatment on any of the cardiovascular risk factors demonstrated to have independent prognostic importance.
Journal of Hypertension 04/2012; 30(6):1252-9. DOI:10.1097/HJH.0b013e328352f7f6 · 4.72 Impact Factor