Thesis

Contribution à l’analyse économique des technologies de compensation de la perte d’autonomie fonctionnelle liée au vieillissement

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Abstract

Les chutes sont la cause de mortalité et de morbidité importante des personnes âgées. Ainsi, la problématique de leur prévention est une priorité dans les systèmes socio-sanitaire du monde entier. Cette problématique n’est pas récente car elle est un sujet de recherche depuis plus d’une trentaine d’années. Elle se justifie par le fait que plus de 50% des chutes des personnes âgées sont évitables. Les technologies d’assistance (TA) pour la mobilité occupent une place importante dans les stratégies de prévention. En effet, elles modifient l’environnement physique afin de faciliter ou restaurer le rendement occupationnel dans les activités de soins personnels, de travail et de loisirs. Mais ces prouesses ne sont réalisables que si ces assistances sont acceptées et bien utilisées par le patient. Pour cela, l’accompagnement par un tiers (professionnel et / ou familial) est essentiel en raison des difficultés d’apprentissage aux grands âges. Dans le cadre du dispositif UPSAVECOCAT du CHU de Limoges, l’abandon de ces technologies figurait parmi les facteurs de risque de chutes graves à domicile (OR : 17,41 ; IC à 95% = [2,59 ;117,02] ; p = 0,003), en plus du fait de vivre en zone urbaine (OR : 11,46 ; IC à 95% = [1,48 ;88,98] ; p = 0,020) et de la réalisation des activités de la vie quotidienne (OR : 34,04 ; IC à 95% = [1,59 ;727,86] ; p = 0,024). En effet, l’incidence de chutes graves à 6 mois est plus dans « le groupe d’utilisateurs » comparativement « au groupe d’abandonneurs » : respectivement 57% (IC à 95% : [46% ; 68%]), contre 21% (IC à 95% : [12% ; 33%]), avec p = 0,001. Les scores de qualité de vie et de bien-être sont également plus élevés auprès des utilisateurs, respectivement 0,15 (IC à 95% : [0,13 ; 0,17]) contre 0,11 (IC à 95% : [0,08 ; 0,14]) pour les « abandonneurs » avec p = 0,009 pour les QALYs, et 0,32 (IC à 95% : [0,30 ; 0,34]) contre 0,25 (IC à 95% : [0,23 ; 0,27]) avec p < 0,001 pour le bien-être. Le gain supplémentaire par QALY gagné, le plus élevé était de 81 125,00 euros et le plus faible 20 271,50 euros. Suivants les mêmes extrêmes, on trouve 46 428,57 euros et 11 583,71 euros pour le gain supplémentaire par bien-être gagné. L’utilisation des TAs pour la mobilité dans le cadre du projet UPSAV-ECOCAT était donc coût-utile.

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[Purpose] We report a case in which rehabilitation that targeted the paralyzed side’s upper limb in a hemiplegic stroke patient remarkably accelerated the patient’s ability to perform activities of daily living, improved her Functional Independence Measure score, and facilitated the patient’s return to home. [Subject and Methods] We provided rehabilitation training to a female patient who experienced a cerebral infarction at a nursing home for the elderly and was admitted to the Kaifukuki recovery phase rehabilitation ward in order to improve her activities of daily living and return home. An intensive rehabilitation program incorporating occupational therapy and physical training for upper-limb function on the affected side was instituted over 170 days. [Results] At presentation, the patient had functional disorders and load-induced pain in both lower limbs requiring her to walk with a fixed-type walker. After the intensive rehabilitation program, her activities of daily living improved and she was able to return home. [Conclusion] This case suggests that activities of daily living training and simultaneous active training of upper-limb function on the affected side in patients with functional disorders or lower-limb pain could effectively improve their Functional Independence Measure scores, promote functional recovery, and facilitate their return to home.
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A good match of person and technology requires attention to aspects of the environments in which the technology will be used, the needs and preferences of the user, and the functions and features of the technology. If the match is not a quality one from the standpoint of the consumer, the technology may not be used or will not be used optimally. There is a need for an improved person-AT matching and outcome assessment process because studies and reports show in general that there is a high level of dissatisfaction and nonuse of technology by consumers.
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Purpose: Active ageing is defined as the process of optimizing opportunities for physical, social and mental health to enable older people to actively take part in society without discrimination and to enjoy independence and good quality of life. The World Health Organization assumed this to be a process for increasing and maintaining an individual’s participation in activities to enhance his/her quality of life. In this survey, the authors addressed the following question: is assistive technology (AT) for mobility contributing to enhancement of lifelong capacity and performance? Method: From June 2015 until February 2016, 96 community dwelling adults, AT users for mobility (powered wheelchairs, manual wheelchairs, lower limb prostheses, walkers, crutches and canes), aged 45–97, mean 67.02 ± 14.24 years old, 56.3% female, were interviewed using the Psychosocial Impact of Assistive Devices Scale (P-PIADS), the Activities and Participation Profile related to Mobility (APPM) and demographics, clinical and questions about AT use and training. Results and Discussion: The participants’ profiles revealed moderate limitation and restrictions in participation, measured by the APPM (2.03). Most participants displayed a positive impact from AT; average scores obtained from the P-PIADS subscales were: Self-esteem 0.62, Competency 1.11 and Adaptability 1.10. The P-PIADS total was 0.96, with the powered wheelchair users scoring the highest (1.53) and the walker users scoring the lowest (0.73). All subscales and the P-PIADS total were positively correlated with the activities and participation profile. There was no relation between age and the psychosocial impact of AT or activities and participation profile. These results encourage the authors to follow up with these participants for a lifelong intervention. To accomplish that aim, currently, the protocol is implemented at the AT prescribing centers in Coimbra, Portugal in order to assess the impact of AT on participation in society, one of the domains of the Active Ageing Index, a new analytical tool to help policy makers in developing policies for active and healthy ageing.
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Introduction: In an aging population, new strategies are required to identify individuals at risk of adverse health outcomes. Frailty syndrome is related to negative health events. This increased risk may be used to identify individuals in which interventions can delay the onset of physical and functional complications. The aim of the study was to determine the relationship between the onset of frailty and the beginning of functional disability. Materials and Methods: This was a cross-sectional observational study with consecutive sampling to analyze 146 patients aged seventy and older who come to the primary care center. The level of frailty was registered according to fatigue, resistance, ambulation, illnesses, and loss of weight scale. Disability for Instrumental Activities of Daily Live dependency, comorbidity, and social risk factors was registered too. Results: The prevalence of frailty and prefrailty was 17.8% and 39%, respectively, and were associated with age, level of disability, and the presence of gastrointestinal disease. Prefrail patients had initial levels of dependency, while those who were not frail were mostly independent. Conclusion: Frailty syndrome is easily detectable. The intermediate stage known as prefrailty is related to the start of the functional disability. The syndrome screening identifies individuals at risk in whom we can potentially intervene to delay the onset of the syndrome and delay functional disability. Control of comorbidity in frail patients must be studied. Screening age could be set in patients between 75 and 81 years old.
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Background Previous findings indicate that people with dementia and their informal carers experience difficulties accessing and using formal care services due to a mismatch between needs and service use. This mismatch causes overall dissatisfaction and is a waste of the scarce financial care resources. This article presents the background and methods of the Actifcare (ACcess to Timely Formal Care) project. This is a European study aiming at best-practice development in finding timely access to formal care for community-dwelling people with dementia and their informal carers. There are five main objectives: 1) Explore predisposing and enabling factors associated with the use of formal care, 2) Explore the association between the use of formal care, needs and quality of life and 3) Compare these across European countries, 4) Understand the costs and consequences of formal care services utilization in people with unmet needs, 5) Determine the major costs and quality of life drivers and their relationship with formal care services across European countries. Methods In a longitudinal cohort study conducted in eight European countries approximately 450 people with dementia and informal carers will be assessed three times in 1 year (baseline, 6 and 12 months). In this year we will closely monitor the process of finding access to formal care. Data on service use, quality of life and needs will be collected. DiscussionThe results of Actifcare are expected to reveal best-practices in organizing formal care. Knowledge about enabling and predisposing factors regarding access to care services, as well as its costs and consequences, can advance the state of the art in health systems research into pathways to dementia care, in order to benefit people with dementia and their informal carers.
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(1) Knowledge about the assistive technology (AT) needs and psychosocial impact of AT in different populations is needed because the adoption, retention, or abandonment of AT may be influenced by the psychosocial impact that AT has on its users. The aims of this study were to: (a) identify the AT needs of a sample of Hispanic older adults with functional limitations; (b) describe the psychosocial impact of these technologies on the sample’s quality of life; and (c) describe the methodological challenges in using the Puerto Rican version of the Psychosocial Impact of Assistive Device Scale (PR-PIADS) with a Hispanic sample; (2) Methods: This study used a cross-sectional design conducted with a sample of 60 participants. Data was collected using the Assistive Technology Card Assessment Questionnaire (ATCAQ) and the PR-PIADS. Data analyses included descriptive statistics and bivariate analysis; (3) Results: The sample’s most frequently reported needs for AT devices were in the areas of cooking, home tasks, and home safety activities. The sample reported a positive impact of AT use in their quality of life. Several methodological challenges of the PIADS were identified; (4) Conclusions: The sample has unmet needs for using AT devices to overcome difficulties in daily living activities.
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The U.S. health care sector is highly interconnected with industrial activities that emit much of the nation’s pollution to air, water, and soils. We estimate emissions directly and indirectly attributable to the health care sector, and potential harmful effects on public health. Negative environmental and public health outcomes were estimated through economic input-output life cycle assessment (EIOLCA) modeling using National Health Expenditures (NHE) for the decade 2003–2013 and compared to national totals. In 2013, the health care sector was also responsible for significant fractions of national air pollution emissions and impacts, including acid rain (12%), greenhouse gas emissions (10%), smog formation (10%) criteria air pollutants (9%), stratospheric ozone depletion (1%), and carcinogenic and non-carcinogenic air toxics (1–2%). The largest contributors to impacts are discussed from both the supply side (EIOLCA economic sectors) and demand side (NHE categories), as are trends over the study period. Health damages from these pollutants are estimated at 470,000 DALYs lost from pollution-related disease, or 405,000 DALYs when adjusted for recent shifts in power generation sector emissions. These indirect health burdens are commensurate with the 44,000–98,000 people who die in hospitals each year in the U.S. as a result of preventable medical errors, but are currently not attributed to our health system. Concerted efforts to improve environmental performance of health care could reduce expenditures directly through waste reduction and energy savings, and indirectly through reducing pollution burden on public health, and ought to be included in efforts to improve health care quality and safety.
Article
Background: Although frailty of older people has been shown to be associated with numerous adverse health outcomes, evidence on healthcare costs associated with frailty is scarce. Methods: Medline, Embase, PsycINFO, and AMED were electronically searched in January 2019 based on a protocol in accordance with the PRISMA statement using Medical Subjective Heading and free text terms, with explosion functions. Language restriction was not applied. Studies were considered if they were published between 2000 to January 2019 and provided healthcare costs stratified by the frailty status categories among community-dwelling older people with a mean age of 60 years or higher. Reference lists of the included studies were reviewed for additional studies. Healthcare costs according to frailty status were compared using standardized mean difference random-effects meta-analysis. Results: The systematic review found 3116 citations. After screening for title, abstract, and full-text for eligibility, 5 studies involving 3742362 participants were included. Healthcare costs were compared across three frailty status, robust, prefrailty, and frailty. Both prefrailty (5 studies, Hedges' g = 0.24, 95% confidence interval (CI) = 0.15-0.33, p < 0.001) and frailty (5 studies, Hedges' g = 0.62, 95%CI = 0.61-0.62, p < 0.001) were associated with significantly higher healthcare costs when compared with robustness. There was a high degree of heterogeneity. The risk of publication bias was considered to be low in funnel plots. Conclusions: This systematic review and meta-analysis found a dose-response increase in the healthcare costs associated with frailty among community-dwelling older adults. Future research should recognize frailty as an important factor associated with increased healthcare costs.
Article
Sustainability can be considered a domain of quality in healthcare, extending the responsibility of health services to patients not just of today but of the future. The longer term perspective highlights the impacts of our healthcare system on our environment and communities and in turn back onto population health. A sustainable approach will therefore expand the healthcare defi nition of value to measure health outcomes against environmental and social impacts alongside fi nancial costs. We set out a practical framework for including these new dimensions in an already well-defi ned model of quality improvement. This has the potential to harness the growing quality improvement movement to shape a more sustainable health service, while improving patient outcomes. Early experience suggests that the new model may also provide immediate benefi ts, including additional motivation for clinicians to engage in quality improvement, directing their efforts towards high value interventions and enabling capture and communication of a wider range of impacts on patients, staff and communities.
Article
Objectives: To conduct a systematic review of the literature on prospective cohort studies examining mortality risk according to frailty defined by FRAIL scale, and to perform a meta-analysis to synthesize the pooled risk estimates. Design: Systematic review and meta-analysis. Setting: Embase, Scopus, MEDLINE, CINAHL, and PsycINFO were systematically searched in March 2018. References of included studies were reviewed and a forward citation tracking was performed on relevant review papers for additional studies. Additional data necessary for a meta-analysis were requested from corresponding authors. Participants: Community-dwelling middle-aged and older adults. Measurements: Mortality risk due to frailty as defined by the FRAIL scale. Results: After removing duplicates, there are 81 citations for title, abstract, and full-text screening. Eight studies were included in this review. Four studies calculated the area under the receiver operating characteristic curve, which ranged from 0.54 to 0.70. A random-effects meta-analysis was conducted on 3 studies that provided adjusted hazard ratios (HRs) of mortality risk according to 3 frailty groups (robust, prefrail, and frail) defined by FRAIL scale. Both frailty and prefrailty were significantly associated with higher mortality risk than robustness [pooled HR = 3.53, 95% confidence interval (CI) = 1.66-7.49, P = .001; pooled HR = 1.75, 95% CI = 1.14-2.70, P = .01, respectively]. No evidence of publication bias was observed. Conclusion: This study demonstrated that FRAIL scale is a tool that can effectively identify frailty/prefrailty status, as well as quantify frailty status in a graded manner in relation to mortality risk. Although its feasibility is of note, not many studies are yet using this relatively new tool. More studies are warranted regarding mortality and other health outcomes.
Article
Aim: The effects of frailty and multiple chronic conditions (MCCs) on cost of care are rarely disentangled in archival data studies. We identify the marginal contribution of frailty to medical care cost estimates using Medicare data. Materials & methods: Use of the Faurot frailty score to identify differences in acute medical events and cost of care for patients, controlling for MCCs and medication use. Results: Estimated marginal cost of frailty was US$10,690 after controlling for demographics, comorbid conditions, polypharmacy and use of potentially inappropriate medications. Conclusion: Frailty contributes greatly to cost of care, but while often correlated, is not synonymous with MCCs. Thus, it is important to control separately for frailty in studies that compare medical care use and cost.
Article
Aim There is a lack of studies on the prevalence of frailty, and the association between frailty and mortality in a Norwegian general population. Findings regarding sex differences in the association between frailty and mortality have been inconsistent. The aim of the present study was to investigate the association between the frailty phenotype and all‐cause mortality in men and women in a Norwegian cohort study. Methods We followed 712 participants (52% women) aged ≥70 years participating in the population‐based Tromsø 5 Study in 2001–2002 for all‐cause mortality up to 2016. The frailty status at baseline was defined by a modified version of Fried's frailty criteria. Cox regression models were used to analyze the association between frailty and mortality with adjustment for age, sex, disability, comorbidity, smoking status and years of education. Results In total, 3.8% (n = 27) of participants were frail (women 4.4%, men 3.2%) and 38.1% (n = 271) were pre‐frail (women 45.8%, men 29.9%). During follow‐up (mean 10.1 years), 501 (70%) participants died. We found an increased risk of mortality for frail older adults (multivariable‐adjusted HR 4.16, 95% CI 2.40–7.22) compared with non‐frail older adults. In sex‐stratified analysis, the adjusted HR was 7.09 (95% CI 3.03–16.58) for frail men and 2.93 (95% CI 1.38–6.22) for frail women. Results for pre‐frailty showed an overall weaker association with mortality. Conclusions While frailty was more prevalent in women than in men, the findings suggest that the association between frailty and mortality is stronger in men than in women. Geriatr Gerontol Int 2018; ••: ••–••.
Article
Objective: Unintentional falls in older adults (persons 65 years of age and older) impose a significant economic burden on the health care system. Methods for calculating state-specific health care costs are limited. This study describes 2 methods to estimate state-level direct medical spending due to older adult falls and explains their differences, advantages, and limitations. Design: The first method, partial attributable fraction, applied a national attributable fraction to the total state health expenditure accounts in 2014 by payer type (Medicare, Medicaid, and private insurance). The second method, count applied to cost, obtained 2014 state counts of older adults treated and released from an emergency department and hospitalized because of a fall injury. The counts in each state were multiplied by the national average lifetime medical costs for a fall-related injury from the Web-based Injury Statistics Query and Reporting System. Costs are reported in 2014 US dollars. Setting: United States. Participants: Older adults. Main outcome measure: Health expenditure on older adult falls by state. Results: The estimate from the partial attributable fraction method was higher than the estimate from the count applied to cost method for all states compared, except Utah. Based on the partial attributable fraction method, in 2014, total personal health care spending for older adult falls ranged from $48 million in Alaska to $4.4 billion in California. Medicare spending attributable to older adult falls ranged from $22 million in Alaska to $3.0 billion in Florida. For the count applied to cost method, available for 17 states, the lifetime medical costs of 2014 fall-related injuries ranged from $68 million in Vermont to $2.8 billion in Florida. Conclusions: The 2 methods offer states options for estimating the economic burden attributable to older adult fall injuries. These estimates can help states make informed decisions about how to allocate funding to reduce falls and promote healthy aging.
Article
Objectives To determine the association of the frailty phenotype with subsequent healthcare costs and utilization. Design Prospective cohort study (Study of Osteoporotic Fractures (SOF)). Setting Four U.S. sites. Participants Community‐dwelling women (mean age 80.2) participating in SOF Year 10 (Y10) examination linked with their Medicare claims data (N=2,150). Measurements At Y10, frailty phenotype defined using criteria similar to those used in the Cardiovascular Health Study frailty phenotype and categorized as robust, intermediate stage, or frail. Participant multimorbidity burden ascertained using claims data. Functional limitations assessed by asking about difficulty performing instrumental activities of daily living. Total direct healthcare costs and utilization ascertained during 12 months after Y10. Results Mean total annualized cost±standard deviation (2014 dollars) was $3,781±6,920 for robust women, $6,632±12,452 for intermediate stage women, and $10,755 ± 16,589 for frail women. After adjustment for age, site, multimorbidity burden, and cognition, frail women had greater mean total (cost ratio (CR)=1.91, 95% confidence interval (CI)=1.59–2.31) and outpatient (CR=1.55, 95% CI=1.36–1.78) costs than robust women and greater odds of hospitalization (odds ratio (OR)=2.05, 95% CI=1.47–2.87) and a skilled nursing facility stay (OR=3.85, 95% CI=1.88–7.88). There were smaller but significant effects of the intermediate stage category on these outcomes. Individual frailty components (shrinking, poor energy, slowness, low physical activity) were also each associated with higher total costs. Functional limitations partially mediated the association between the frailty phenotype and total costs (CR further adjusted for self‐reported limitations=1.32, 95% CI=1.07–1.63 for frail vs robust; CR=1.35, 95% CI=1.18–1.55 for intermediate stage vs robust women). Conclusion Intermediate stage and frail older community‐dwelling women had higher subsequent total healthcare costs and utilization after accounting for multimorbidity and functional limitations. Frailty phenotype assessment may improve identification of older adults likely to require costly, extensive care.
Article
Depuis 2012, en France, les industries pharmaceutiques qui sollicitent l’admission au remboursement pour un traitement innovant sont contraintes de soumettre une évaluation économique auprès de la Commission d’évaluation économique et de santé publique (CEESP) de la Haute Autorité de santé (HAS) afin qu’un avis sur son efficience puisse être rendu. Comme dans la plupart des pays européens, le résultat de ces évaluations est mis en perspective, dans le cadre des délibérations, avec d’autres critères de décision plus ou moins explicites, tels que la sévérité de la maladie, l’âge des patients, les situations de fin de vie, etc. L’objectif de cet article est de rapporter ces critères mobilisés par les agences pour moduler l’utilisation des ratios coût-résultat à quelques grands principes normatifs de l’économie du bien-être. Cette analyse permet d’expliciter les motivations distributives du régulateur, et d’évoquer les voies possibles d’amendement du calcul économique en santé pour prendre en considération les critères de priorisation mobilisés par les agences dans leurs processus de décision, en particulier la priorité accordée aux patients les plus sévèrement atteints ou encore à ceux dont l’espérance de vie est la plus diminuée. L’article rend ainsi compte des possibilités pratiques proposées dans la littérature. Dans quelle mesure ces approches pourraient-elles favoriser l’acceptabilité sociale des méthodes d’évaluation économique auprès des différentes parties prenantes (décideurs, communautés médicales, patients, grand public) et accroître l’utilisation des conclusions de ces évaluations dans les décisions en matière de fixation des prix et du remboursement des produits de santé ? // Taking redistributive principles into account in the economic evaluation of health care: a review of available methods Since 2012, pharmaceutical industries in France that apply for reimbursement for innovative treatment have been obliged to submit an economic evaluation to the Commission for Economic and Public Health Evaluation (CEESP) of the Haute Autorité de Santé (HAS) in order to make an assessment of their efficiency. As is the case in most European countries, the results of evaluation proceedings, along with other decision-making criteria, are put into perspective alongside other more or less explicit decisions such as the severity of the disease, the age of the patients, end-of-life situations, etc. The objective of this article is to analyze the criteria mobilized by agencies in modulating the use of cost / result ratios of some major normative principles of the economy of well-being. This analysis makes it possible to explain the distributive motivations of the regulator and to discuss the possible ways of modifying health economy calculations, taking those priority criteria into account which are mobilized by agencies in their decision-making processes, in particular the priority given to the most severely affected or to those whose life expectancy has been most seriously reduced. The article gives an account of the practical possibilities proposed in the literature. To what degree do these measures promote the social acceptability of economic evaluation methods by the different stakeholders (decision-makers, medical communities, patients, and the general public) and increase the use of evaluation findings in decision-making such as in the setting of prices and reimbursing health products ?
Article
Purpose: To investigate whether technology-assisted toilets (TATs) could be used to improve toileting hygiene and independence for geriatric rehabilitation patients. TATs are commercially available toilet seats that use a stream of warm water to clean the user, have a fan for drying and are operated by a remote control. Materials and methods: Twenty-five geriatric rehabilitation in-patients were recruited, six completed the study, and seven partially completed the study. Each participant had two trial bowel movements. One trial involved cleaning themselves with toilet paper; the other involved cleaning themselves with the TAT functions. After each trial, participants received a visual inspection for cleanliness and answered the Psychosocial Impact of Assistive Devices Scale (PIADS), a validated scale, to assess their sense of competence, adaptability and self-esteem in the bathroom. A toileting cleanliness scale, designed for this study, was completed by a nurse after TAT usage. Participants received a score from 1 (completely clean) to 4 (completely soiled) based on a visual inspection after cleaning. Results: TAT and toileting cleanliness scores were similar. PIADS scores showed a trend towards higher scores when using the TAT, but results were not statistically significant. Conclusions: TATs cleaned as well as standard toileting in geriatric rehabilitation inpatients. Participants indicated that TATs improved their sense of competence, adaptability and self-esteem. Geriatricians and rehabilitation professionals should consider prescribing TATs in their practice as an assistive device in order to promote patient independence and dignity and reduce the burden of care for patients requiring toileting assistance. Implications for rehabilitation Technology-assisted toilets (TATs) are commercially-available toilet seats that could be used to allow rehabilitation patients to clean themselves more independently in the bathroom. Improved toileting independence can reduce burden of care of geriatric rehabilitation and reduce the impact of toileting assistance on patient dignity and self-esteem. Physiatrists should consider recommending TATs to their patients but should take into account whether a patient's particular set of disabilities will allow them to use a TAT effectively.
Article
Although there are many models which are used to calculate the health benefits (and thus the cost-effectiveness) of vaccination programmes, they can be divided into two groups: those which assume a constant force of infection, that is a constant per-susceptible rate of infection; and those which assume that the force of infection (at time t) is a function of the number of infectious individuals in the population at that time (dynamic models). In constant force of infection models the per-susceptible rate of infection is not altered, whereas in dynamic models mass immunization results in fewer infectious individuals in the community and thus a lower force of infection acting on those who were not immunized. We take an example of each of these types of model, examine their underlying assumptions and compare their predictions of the cost-effectiveness of a mass immunization programme against a hypothetical close contact infection, such as measles. We show that if cases of infection are the outcome of interest then the constant force of infection model will always underestimate the cost-effectiveness of the immunization programme except at the extremes when no one or everyone is immunized. However, unlike the constant force of infection model, the dynamic model predicts an increase in the average age at infection after immunization which could impact on the estimate of the cost-effectiveness of the programme if the risk of developing serious disease is a function of the age at infection (as, for instance, is the case for congenital rubella syndrome). Taking cases of infection as the outcome measure and using the dynamic model, the undiscounted cost-effectiveness ratio will tend to decline over time and approach a constant value, as the system moves from pre- to post-immunization equilibrium. We go on to show how the cost-effectiveness of a fixed-term immunization programme might change over time, and discuss why, under most circumstances, decision makers should not assume that elimination (permitting termination of mass immunization) will occur. Copyright © 1999 John Wiley & Sons, Ltd.
Article
The aim of this study was to explore the potential of ZORA robot-based interventions in rehabilitation and special education for children with severe physical disabilities. A two-centre explorative pilot study was carried out over a 2.5-month period involving children with severe physical disabilities with a developmental age ranging from 2 to 8 years. Children participated in six sessions with the ZORA robot in individual or in group sessions. Qualitative and quantitative methods were used to collect data on aspects of feasibility, usability, barriers and facilitators for the child as well as for the therapist and to obtain an indication of the effects on playfulness and the achievement of goals. In total, 17 children and seven professionals participated in the study. The results of this study show a positive contribution of ZORA in achieving therapy and educational goals. Moreover, sessions with ZORA were indicated as playful. Three main domains were indicated to be the most promising for the application of ZORA: movement skills, communication skills and cognitive skills. Furthermore, ZORA can contribute towards eliciting motivation, concentration, taking initiative and improving attention span of the children. On the basis of the results of the study, it can be concluded that ZORA has potential in therapy and education for children with severe physical disabilities. More research is needed to gain insight into how ZORA can be applied best in rehabilitation and special education.
Article
Objectives Demographic changes are requiring people to work longer. No previous studies, however, have focused on whether the ‘frailty’ phenotype (which predicts adverse events in the elderly) is associated with employment difficulties. To provide information, we assessed associations in the Health and Employment After Fifty Study, a population-based cohort of 50–65-year olds. Methods Subjects, who were recruited from 24 English general practices, completed a baseline questionnaire on ‘prefrailty’ and ‘frailty’ (adapted Fried criteria) and several work outcomes, including health-related job loss (HRJL), prolonged sickness absence (>20 days vs less, past 12 months), having to cut down substantially at work and difficulty coping with work's demands. Associations were assessed using logistic regression and population attributable fractions (PAFs) were calculated. Results In all, 3.9% of 8095 respondents were classed as ‘frail’ and 31.6% as ‘prefrail’. Three-quarters of the former were not in work, while 60% had left their last job on health grounds (OR for HRJL vs non-frail subjects, 30.0 (95% CI 23.0 to 39.2)). Among those in work, ORs for prolonged sickness absence, cutting down substantially at work and struggling with work's physical demands ranged from 10.7 to 17.2. The PAF for HRJL when any frailty marker was present was 51.8% and that for prolonged sickness absence was 32.5%. Associations were strongest with slow reported walking speed. Several associations were stronger in manual workers than in managers. Conclusions Fried frailty symptoms are not uncommon in mid-life and are strongly linked with economically important adverse employment outcomes. Frailty could represent an important target for prevention.
Article
Objectives: Pennsylvania's Department of Aging has offered a falls prevention program, "Healthy Steps for Older Adults" (HSOA), since 2005, with about 40,000 older adults screened for falls risk. In 2010 to 2011, older adults 50 years or older who completed HSOA (n = 814) had an 18% reduction in falls incidence compared with a comparison group that attended the same senior centers (n = 1019). We examined the effect of HSOA on hospitalization and emergency department (ED) treatment, and estimated the potential cost savings. Study design: Decision-tree analysis. Methods: The following were included in a decision-tree model based on a prior longitudinal cohort study: costs of the intervention, number of falls, frequency and costs of ED visits and hospitalizations, and self-reported quality of life of individuals in each outcome condition. A Monte Carlo probabilistic sensitivity analysis assigned appropriate distributions to all input parameters and evaluated model results over 500 iterations. The model included all ED and hospitalization episodes rather than just episodes linked to falls. Results: Over 12 months of follow-up, 11.3% of the HSOA arm and 14.8% of the comparison group experienced 1 or more hospitalizations (P = .04). HSOA participants had less hospital care when matched for falls status. Observed values suggest expected costs per participant of $3013 in the HSOA arm and $3853 in the comparison condition, an average savings of $840 per person. Results were confirmed in Monte Carlo simulations ($3164 vs $3882, savings of $718). Conclusions: The savings of $718 to $840 per person is comparable to reports from other falls prevention economic evaluations. The advantages of HSOA include its statewide reach and integration with county aging services.
Article
Objective To estimate the prevalence of pre-frailty, frailty and multimorbidity in individuals without disability in France. To describe independent determinants of each indicators. DesignTwo nationally representative cross-sectional French surveys. SettingsWave 2012 of the Health, Health Care and Insurance Survey (Enquête Santé et Protection Sociale, ESPS) and data from the Disability Healthcare Household section Survey (Enquête Handicap Santé–Ménages, HSM) from 2008. ParticipantsTwo representative samples of the French population aged 55 and older (n=4,328 and n=12,295). MeasurementsFrailty was assessed using Fried’s frailty phenotype and multimorbidity was defined as having had at least two groups of the following groups of comorbidities in the last 12 months (cardio or cerebrovascular disease, diabetes, chronic respiratory disease, arthralgia, depression). Independent determinants were studied using weighted logistic regressions. ResultsIn the French population over 55 and free of disability, 55 to 62% of individuals were either frail, pre-frail or multimorbid, 22 to 25% being frail or multimorbid. ESPS and HSM prevalences for frailty (11.1% [9.3%-12.1%] and 12.3% [11.5%-13.0%]) and multimorbidity (14.9% [13.6%-16.2%] and 16.8% [15.9%-17.7%]) were consistent across studies. Both frailty and multimorbidity prevalences were associated with age. On the other hand, pre-frailty prevalence varied consistently between studies (from 38 to 48%) and was not significantly associated with age. We found that more than 60% of frail subjects did not present with multimorbidity and around 70% of subjects with multimorbidity were not frail. Determinants of pre-frailty and multimorbidity but not frailty depended on sex. Similar factors were associated with frailty and multimorbidity in women (older age, functional decline, poor mental health, financial difficulties) while only poor mental health was independently associated with both indicators in men. Conclusion Our study highlights that in France, among individuals older than 55 years-old and free of disability, around 25% are either frail or multimorbid; another 30% to 40% being pre-frail. Pre-frailty, frailty and multimorbidity are known to be associated with adverse health outcomes and important economic costs. The health system must adapt to respond to the needs of its aging population. In addition, given the efficient impact of prevention actions, our findings emphasize the need to implement prevention strategies against Frailty and multimorbidity in France.
Article
To identify prospective studies examining associations between frailty and fractures and to combine the risk measures to synthesize pooled evidence on frailty as a predictor of fractures among community-dwelling older people. A systematic literature search was conducted using five databases: Embase, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library for prospective studies on associations between frailty and fracture risk published from 2000 to August 2015 without language restriction. Odds ratios (OR) and hazard ratios (HR) extracted from the studies or calculated from available data were combined to synthesize pooled effect measures using random-effects or fixed-effects models. Heterogeneity, methodological quality, and publication bias were assessed. Meta-regression analyses were performed to explore the cause of high heterogeneity. Of 1305 studies identified, six studies involving 96,564 older people in the community were included in this review. Frailty and prefrailty were significantly associated with future fractures among five studies with OR (pooled OR = 1.70, 95% confidence interval (95% CI) = 1.34–2.15, p < 0.0001; pooled OR = 1.31, 95% CI = 1.18–1.46, p < 0.00001, respectively) and four studies with HR (pooled HR = 1.57, 95% CI = 1.31–1.89, p < 0.00001; pooled HR = 1.30, 95% CI = 1.12–1.51, p = 0.0006, respectively). High heterogeneity was observed among five studies with OR of frailty (I2 = 66%). The studies from the United States were found to have a higher fracture risk than from those from other countries in a meta-regression model (regression coefficient = 0.39, p = 0.04). No evidence of publication bias was identified. This systematic review and meta-analysis showed evidence that frailty and prefrailty are significant predictors of fractures among community-dwelling older people. Treating frailty may potentially lead to lowering fracture risks.
Article
Objective To investigate whether frailty is associated with an increased risk of incident type 2 diabetes mellitus (T2DM) in a prospective cohort of community-dwelling older people. Design Longitudinal study, mean follow-up of 4.4 years. Setting Progetto Veneto Anziani (Pro.V.A.) study that involved older community-dwellers. Participants 1754 men and women older than 65 years without T2DM at baseline. Measurements Frailty status was defined according to Fried criteria and categorized as frailty (≥3 criteria), prefrailty (1-2 criteria), or no frailty (0 criterion). Incident T2DM was defined as fasting plasma glucose (FPG) ≥7.0 mmol/L, or glycosylated hemoglobin ≥6.5%, the use of glucose-lowering drugs, or FPG ≥11.1 mmol/L on a 2-hour oral glucose tolerance test during the follow-up. All T2DM diagnoses were confirmed by endocrinologists. Results At baseline, frail participants (n = 174) were significantly (a) more obese and had higher waist circumference, (b) experienced a higher rate of cardiovascular disease (including hypertension), and (c) presented with higher, but not pathologic, values of glycosylated hemoglobin and FPG than prefrail (n = 830) and nonfrail participants (n = 750). Over a 4.4-year follow-up, 265 individuals developed T2DM. In a logistic regression analysis, adjusted for potential baseline confounders, frailty [odds ratio (OR) = 1.87, 95% confidence interval (CI) = 1.31-2.13, P < .0001] and prefrailty (OR = 1.60, 95% CI = 1.27-2.00, P < .0001) were associated with a significantly higher incidence of T2DM than in nonfrail individuals. Conclusion Among community-dwelling older people, frailty and prefrailty were significant and independent predictors of T2DM, which is a major and potentially preventable risk factor for multiple comorbidities.
Article
Introduction: This study sought to estimate the incidence, average cost, and total direct medical costs for fatal and non-fatal fall injuries in hospital, ED, and out-patient settings among U.S. adults aged 65 or older in 2012, by sex and age group and to report total direct medical costs for falls inflated to 2015 dollars. Method: Incidence data came from the 2012 National Vital Statistics System, 2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, 2012 Health Care Utilization Program National Emergency Department Sample, and 2007 Medical Expenditure Panel Survey. Costs for fatal falls were derived from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System; costs for non-fatal falls were based on claims from the 1998/1999 Medicare fee-for-service 5% Standard Analytical Files. Costs were inflated to 2015 estimates using the health care component of the Personal Consumption Expenditure index. Results: In 2012, there were 24,190 fatal and 3.2 million medically treated non-fatal fall related injuries. Direct medical costs totaled $616.5 million for fatal and $30.3 billion for non-fatal injuries in 2012 and rose to $637.5 million and $31.3 billion, respectively, in 2015. Fall incidence as well as total cost increased with age and were higher among women. Conclusion: Medically treated falls among older adults, especially among older women, are associated with substantial economic costs. Practical application: Widely implementing evidence-based interventions for fall prevention is essential to decrease the incidence and healthcare costs associated with these injuries.