Terms Of Chronic Diseases Research Articles

E-Health, m-Health, personalised medicine – challenges faced by healthcare systems in Central and Eastern Europe

Background and purpose: The purpose of this study aims to explore measures intended to remove barriers to the implementation of innovative interventions and identify best practices applicable in European countries that support the implementation of cutting-edge e-health, m-health and personalised medicine (PM) interventions at the micro-, meso- and macro-regional levels. Thanks to PM, people are closer to more accurate, predictable and powerful healthcare tailored to individual patients [1]. PM indicates treatment adapted to the patient's characteristics, needs and preferences. PM categorises patients according to the risk of developing a particular disease or degree of response to a given treatment using appropriate diagnostic markers. PM also aims to increase control over the optimisation of medical treatment outcomes and increase the precision of medical treatment, as well as improve disease prediction [2]. The study concept constitutes one of the indicators of the Regions4PerMed project entitled "Interregional coordination for a fast and deep uptake of personalised health" (Horizon 2020).
 Group of respondents: The group of respondents included stakeholders of the Regions4PerMed project - members of the Regions4PerMed Advisory Board, organisations associated with the Patients’ Organisations Council, small and medium enterprises involved in e-health innovation, presenters at conferences and workshops associated with research institutions, private funders, policymakers, policy advisors, project managers, researchers, patient representatives, physicians, academic staff and healthcare consultants.
 Techniques and tools: The qualitative research took the form of online questionnaires and focus group interviews (semi-structured) to identify key barriers and facilitators to the implementation of innovative e-health interventions at the micro-, meso- and macro-regional levels within health and social care systems conducted according to the following five thematic priorities of the Regions4PerMed project which are:
 1.Medical Big Data, Electronic Health Records and Health Governance
 2.Connected health: Better system integration and patient management
 3.Health industry: Driving healthcare innovations
 4.Facilitation of the flow of innovation in healthcare
 5.Socio-Economic Aspects – basic principles.
 
 Outcomes and contexts: The ongoing research will provide data for the development of recommendations that identify the limitations to and benefits of the implementation of innovative e-health interventions for health and social care, with regard to chronic diseases, at the micro-, meso-, and macro-regional levels. In Poland (as well as throughout Eastern Europe), there are still tangible barriers to the development of e-health and m-health in terms of chronic diseases.
 

Chronic disease management in patients with intellectual disabilities: a matched study in Dutch general practice.

Disease management programmes (DMPs) aim to deliver standardised, high- quality care to patients with chronic diseases. Although chronic diseases are common among people with intellectual disabilities (ID), this approach may be suboptimal for meeting their care needs. To examine differences between patients with and without ID who have a chronic illness in DMP enrolment and disease monitoring in Dutch general practice. Observational study utilising the Nivel Primary Care Database (2015-2018) comparing patients with ID and cardiovascular disease, diabetes mellitus, or chronic obstructive pulmonary disease (COPD) with matched (1:5) controls with these conditions but without ID. Using conditional logistic regression, enrolment in DMP per chronic disease was examined and differences tested between groups in the frequencies of consultations, medication prescriptions, and routine examinations. A total of 2653 patients with chronic illness with ID were matched with 13 265 controls without ID. Patients with both diabetes mellitus and ID were more likely than controls to be enrolled in DMP (odds ratio [OR] = 1.44, 95% confidence interval [CI] = 1.27 to 1.64). Independent of DMP enrolment, patients with chronic illness with ID were more likely than controls to have frequent consultations. Patients with both diabetes mellitus and ID and patients with both COPD and ID who were not enrolled in DMPs had more medication prescriptions than non-enrolled patients with diabetes or COPD but without ID (OR = 1.46, 95% CI = 1.10 to 1.95; OR = 1.28, 95% CI = 0.99 to 1.66, respectively). Most patients with ID and their controls enrolled in DMPs received routine examinations at similar frequencies. Although DMPs do not specifically address the needs of patients with both chronic illness and ID, these patients do not seem underserved in the management of chronic diseases in terms of consultation, medication, and tests.

Kronik Hastalığı Olan Hastalarda Bağırsak Parazitlerinin Değerlendirilmesi

Objective: Parasitic diseases concern all segments of society, especially children in the growing age. Intestinal parasites not only cause mental and physical development retardation, but also cause loss of work force with the complaints they cause, negatively affecting both physical and mental health and the country's economy. In this study, we aimed to evaluate intestinal parasites in patients with chronic diseases. Methods: The files of patients who applied to the internal medicine outpatient clinic between 01.01.2022 and 31.12.2022 and underwent direct stool microscopy in the Parasitology Laboratory of Ordu University Medical Faculty were retrospectively scanned. The patients were divided into 2 groups as those with chronic disease and those without chronic disease. As a chronic disease; Diabetes Mellitus, hypertension, chronic heart disease, chronic heart failure, asthma, chronic obstructive pulmonary disease, other chronic lung diseases, chronic kidney failure, chronic liver failure, goiter diseases, rheumatic diseases were taken as. Socio-demographic characteristics of the patients such as age, gender, educational status, economic status and marital status, and stool microscopic examinations were recorded. Results: 385 patients were evaluated in the study. It consisted of 281 female and 104 male patients. 209 patients with chronic disease were identified. There is a significant relationship between age, marital and educational status and chronic diseases in the comparison of those with and without chronic disease according to their socio-demographic characteristics (P<0.005). Conclusion: There was no significant difference between those with and without chronic disease in terms of intestinal parasites. However, it has been suggested that controlled studies are needed by increasing the number of patients in the patient groups.

Hospital discharge intervention developed in a dialogical way with families to prepare them to care for children with chronic diseases at home: Mixed methods study.

A convergent parallel mixed methods design with qualitative data collection embedded in a quasi-experimental study was developed to examine the potential of three modalities of preparation for hospital discharge of the families of children with chronic diseases in terms of uncertainty levels and management of the disease at home. Caregivers of these children were divided into three groups: two experimental groups and one control group. Two scales were applied: one measured family management, and the other evaluated uncertainties in relation to the disease. In addition, an in-depth interview was conducted. Wilcoxon's test and the integrated response index were used in data analysis to compare performance between the groups. Inductive thematic analysis was employed for the qualitative data. The data were integrated, comparing the groups before and after preparation for hospital discharge. Twenty-five family caregivers completed this study. Data integration showed that the intervention group, in which the families developed planning to prepare for discharge in a dialogical way with professionals, presented better perceptions regarding care management when compared to structured guide and usual care groups. Participation of families in planning for hospital discharge showed a reduction in uncertainties regarding the disease and better care management of children at home.

The relationship between physical activity and diabetes in middle-aged and elderly people.

To investigate the association between diabetes symptoms and physical activity (PA) levels among middle-aged and older Chinese adults. Data for this study were obtained from 2018 Charles data. Z test, logistic regression analysis, and linear hierarchical regression analysis were performed in 5352 individuals aged ≥50 years with complete information. In terms of diabetes, 6.8% of the middle-aged and elderly people with diabetes were detected, and 93.2% of the middle-aged and elderly people without diabetes symptoms. The proportion of middle-aged and elderly people with high PA levels was 50.5%, and the proportion of middle-aged and elderly people with low PA was 49.5%. There was a significant positive correlation between low PA and diabetes (P < .05). After adjusting demographic characteristics (gender, registered permanent residence type, education level, age, widowhood) and health status characteristics (poor mood, asthma, hyperlipidemia, disability, memory disease, self-assessment of health status, hypertension, smoking, stroke, depression), there was still a statistical significance between PA level and diabetes (P < .05). The risk of diabetes of middle-aged and elderly people in China increases with age, while the risk of diabetes of middle-aged and elderly people with low level of PA is higher. The risk of diabetes is high among middle-aged and elderly people who are old, have poor self-evaluation health, suffer from hyperlipidemia, memory disease, and asthma. The middle-aged and old people should increase their PA levels to prevent and improve diabetes.

Psychosocial factors associated with health-related quality of life in patients with chronic disease: Results of a cross-sectional survey.

The impact of various psychosocial factors (sense of coherence, illness perception, patient enablement, self-efficacy, health literacy, personality) is not fully understood across a wide range of chronic diseases, and in particular in patients with multimorbidity. As such, this study assessed the key psychosocial factors associated with impaired health-related quality of life (HRQoL) in patients with one or more chronic diseases based on cross-sectional data collected in Flanders (Belgium). Cross-sectional data on 544 chronically ill patients were analysed. Multiple linear regression models were built to analyze the key psychosocial factors associated with HRQoL (EQ-5D-5Lindex as dependent factor). Overall, the strongest independently associated factor with HRQoL was illness perceptions (β = -0.52, P < 0.001). In addition, sense of coherence (β = 0.14, P = < 0.05) was independently positively associated with HRQoL. Moreover, after stratification for multimorbidity, the negative association of illness perceptions with HRQoL was stronger when multimorbidity is present compared to when it is absent (β = -0.62, P < 0.001 vs β = -0.38, P < 0.001). This study revealed interesting associations of the modifiable psychosocial factors of illness perceptions and sense of coherence with HRQoL in a population of chronically ill persons. Given that the burden of chronic diseases will rise in the next decades, designing and implementing interventions that enhance these psychosocial abilities of patients, especially illness perceptions in multimorbid patients, is needed in order to reduce the burden of chronic diseases in terms of impaired HRQoL.

Redefinition of BNP as a prognostic biomarker in intensive care at COVID-19 infection

Aim&#x0D; Coronavirus disease 2019 (COVID-19) has caused a global pandemic and increased mortality has forced researchers to identify prognostic factors to identify patients at higher risk of mortality. In this study, we aimed to investigate the usability of Brain natriuretic peptide (BNP) as a predictor of mortality in critically ill patients hospitalized in the intensive care unit.&#x0D; Material and Method&#x0D; This retrospective study included 50 patients diagnosed with COVID-19 and followed in the intensive care unit. Patients with known heart failure who were found to have heart failure on echocardiography during follow-up were excluded from the study.&#x0D; Results &#x0D; The patients were divided into two groups based on their mortality status during hospitalization in the intensive care unit. These groups were found to be statistically similar in terms of chronic disease, gender and age (p&gt;0.05). Non-survivor group had higher levels of BNP at the admission to intensive care unit when compared to survivor group (93.2 pg/mL (43.5-357.3) vs. 62.9 (25.0-147.1), p=0.004, respectively). Regression analysis revealed that higher BNP levels and lower lymphocyte counts can be used as a predictor of mortality for these patients. ROC curve analysis indicated that best cut-off value for predicting in-hospital death for BNP was 85.6 pg/mL with a sensitivity of 73.1% and a specificity of 70.8%.&#x0D; Conclusions&#x0D; High BNP levels at admission to the intensive care unit can be used as an in-hospital mortality indicator in COVID-19 patients followed up in the intensive care unit.

The effects of body weight and pneumoperitoneum on pleth variability index and total haemoglobin in patients undergoing laparoscopic cholecystectomy: A prospective observational study

It is not clear if there is an inaccurate effect of obesity and pneumoperitoneum on non-invasive monitoring parameters. The aim of this study is to determine the effects of CO2 pneumoperitoneum and desufflation on non-invasive monitoring variables between obese and non-obese patients undergoing laparoscopic surgery. Sixty patients were included in the study that underwent laparoscopic cholecystectomy between February 2019 and November 2019. After induction of anaesthesia, systolic and diastolic blood pressures, heart rate, duration of operation and pneumoperitoneum, pleth variability index (PVI) and total hemoglobin (SpHb) data were recorded. The patients were divided into two groups. There was no significant difference between the groups in terms of chronic diseases and duration of operation and pneumoperitoneum. No significant difference was found between the groups in PVI and SpHb values. In comparison of PVI measurement values with T0, a significant difference was found in T3, T4 and T5 in Group 2 (p = 0.010, 0.012 and 0.041, respectively). In comparison of SpHb measurement values with T0, a significant difference was found in T1, T2 and T3 in Group 2 (p = 0.008, 0.010 and 0.037, respectively). In comparison with T5, a significant difference was found in T1, T2 and T3 in Group 2 (p = 0.023, 0.005 and 0.006, respectively). In obese people, pneumoperitoneum can lead to errors in PVI and SpHb monitoring. Although these two parameters are very valuable in intraoperative follow-up, they should be used carefully during laparoscopic procedures in obese patients. If these parameters (PVI and SpHb) are considered to be used in bariatric surgeries, this information should be considered.

QALY losses for chronic diseases and its social distribution in the general population: results from the Belgian Health Interview Survey

BackgroundThe burden of chronic diseases is rapidly rising, both in terms of morbidity and mortality. This burden is disproportionally carried by socially disadvantaged population subgroups. Quality-adjusted life years (QALYs) measure the impact of disease on mortality and morbidity into a single index. This study aims to estimate the burden of chronic diseases in terms of QALY losses and to model its social distribution for the general population.MethodsThe Belgian Health Interview Survey 2013 and 2018 provided data on self-reported chronic conditions for a nationally representative sample. The annual QALY loss per 100,000 individuals was calculated for each condition, incorporating disease prevalence and health-related quality of life (HRQoL) data (EQ-5D-5L). Socioeconomic inequalities, based on respondents’ socioeconomic status (SES), were assessed by estimating population attributable fractions (PAF).ResultsFor both years, the largest QALY losses were observed in dorsopathies, arthropathies, hypertension/high cholesterol, and genitourinary problems. QALY losses were larger in women and in older individuals. Individuals with high SES had consistently lower QALY loss when facing a chronic disease compared to those with low SES. In both years, a higher PAF was found in individuals with hip fracture and stroke. In 2013, the health inequality gap amounts to 33,731 QALYs and further expanded to 42,273 QALYs in 2018.ConclusionGiven that chronic diseases will rise in the next decades, addressing its burden is necessary, particularly among the most vulnerable (i.e. older persons, women, low SES). Interventions in these target groups should get priority in order to reduce the burden of chronic diseases.

PH Roundtable: Tailoring CTEPH Imaging for Evaluation and Postintervention Assessment—What Works and What’s New?

PH Roundtable: Tailoring CTEPH Imaging for Evaluation and Postintervention Assessment—What Works and What’s New?

Evaluation of Knowledge and Attitudes About The Traditional and Complementary Medicine Practices of the Patients with Neuropatic Pain Who Applied to the Physıcal Medicine and Rehabilitation Clinic

Objective: To evaluate the frequency of traditional and complementary medicine (TCM) use, the variety of applications, the sociodemographic and clinical characteristics of patients with neuropathic pain, and their knowledge and attitudes about TCM practices.Material and Methods: A total of 250 patients with neuropathic pain were included in this, cross-sectional study. The patients were divided into two groups: medication only (group 1, n=119) and medication with TCM practices (group 2, n=131). Questionnaires were completed by the patients in face-to-face interviews by a blinded physician.Results: The mean age of the patients in group 2 (50.68±16.39) was found to be higher than in group 1 (p=0.043). In terms of chronic diseases, hypertension, cardiovascular diseases, and other diseases were found to be more common in group 2 than in group 1 (p&amp;lt;0.05). The number of patients with duration of neuropathic pain more than 5 years, the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale and the Neuropathic Pain 4 (DN4) scale scores were found to be higher in group 2 than in group 1 (p&amp;lt;0.05). At least one TCM is known by %78.6 of group 2 and 61.3% of group 1 (p=0.003). The three most commonly used TCM practice in group 2 were wet cupping/cupping therapy (24%), leeches (22.8%), and acupuncture (11.6%).Conclusion: It was determined that the mean age of patients who used medication with TCM practices together for the treatment of neuropathic pain was higher, neuropathic pain severity was higher, and neuropathic pain duration was longer than patients who used medication only for the treatment of neuropathic pain.

Comparison of Bayesian Spatio-Temporal Models for Chronic Diseases

This paper discusses a comprehensive statistical approach that will be useful in answering health-related questions concerning mortality and incidence rates of chronic diseases such as cancer and hypertension. The developed spatio-temporal models will be useful to explain the patterns of mortality rates of chronic disease in terms of environmental changes and social-economic conditions. In addition to age and time effects, models include two components of normally distributed residual effects and spatial effects, one to represent average regional effects and another to represent changes of subgroups within region over time. Numerical analysis is based on male lung cancer mortality data from the state of Missouri. Gibbs sampling is used to obtain the posterior quantities. As a result, all models discussed in this article fit well in stabilizing the mortality rates, especially in the less populated areas. Due to the richness of hierarchical settings, easy interpretation of parameters and ease of implementation, any models proposed in this paper can be applied generally to other sets of data.

Health-related quality of life and determinants in North-China urban community residents

BackgroundThe objectives of this study were to investigate the HRQoL of residents living in central urban areas (CUA) and developing neighborhoods (DN) areas of North-China and to examine the relationship between health conditions and the physical and mental components of quality of life.MethodsA stratified random sample was taken and health survey scoring system questionnaire SF-36 was used to conduct the HRQoL survey among community residents in the two selected districts in 10 cities. A general questionnaire was also administered with questions that collected general information, population demographic characteristics and health behaviours, social relationships and perception of life satisfaction.ResultsFive thousand eight hundred eighty-one questionnaires were returned from 6059 invitations with a effective response rate of 97%. The residents in DN had a higher score of physical function, role limitation due to physical problems and vitality than those living in CUA. The prevalence of several chronic diseases was lower in DN’s residents than CUA’s residents. Age, presence/absence of chronic diseases, leisure time exercise, regular daily routine, sleep quality, appetite, family and social relationships and life satisfaction were significant determinants of HRQoL.ConclusionsResidents living in newly developed neighborhoods in China while keeping some habits and lifestyles of their original rural communities are healthier in terms of chronic diseases and HRQoL. Together with other risk factors chronic diseases are an important determinant on HRQoL. Several healthy habits and behaviors such as having a regular daily routine and exercising during leisure time improved HRQoL in Chinese urban communities. Targeted policies of public health based on these findings can better the health-related quality of life.

The reproductive health and sexual behavior of HIV-infected women: the review

The increased access to effective anti-retroviral treatment (ART) has made HIV comparable to chronic disease in terms of life expectancy. The advances in scientific knowledge and, in particular, in management of HIV-infected pregnant woman have reduced the risk of mother-to-child transmission of HIV. The analysis of current research demonstrates that HIV has been a problem in terms of sexuality and reproduction. The needs related to sexuality and reproduction are crucial ones to overall health and well-being of HIV-infected population. The future research is to focus not only on how sexual relations and relationships of HIV-positive women are manifested, but also on how health care system is to provide adequate support to women in relation with sexuality and reproduction. The purpose of study was to apply analysis of current research on sexuality, sexual and contraceptive behavior and implementation of reproductive function in HIV-infected women and the conditions affecting this realization. The review of national and international scientific publications concerning such areas as gynecology, reproductive health, sexuality and reproductive behavior of HIV-positive women from indexed on-line journals and relevant websites using such search engines as PubMed and Google in 1997-2019. The sample included 34 peer-reviewed qualitative studies, which covered 9523 HIV-positive surveyed women. The technique of interpretative meta-synthesis was applied to generalize and evaluate how experiences of HIV-positive women in sexuality and reproduction behavior have been described in qualitative studies. The effective anti-retroviral treatment has made HIV comparable to chronic disease in terms of life expectancy. The analysis of current research on this topic established that HIV was a problem in terms of sexuality and reproduction. The conditions that make the burden of HIV more severe are: HIV is an obstacle for starting and continuing relationship, providing sense of fear and loss. At the same time motherhood, spiritual beliefs, and supportive relationships made the burden of HIV easier. The HIV-positive test in women makes their sexual and reproductive health more complicated because of HIV status. Therefore, women face such unique challenges as problems in partnerships, sexual satisfaction and childbearing. The study results are important for developing optimal medical care to alleviate the burden of HIV infection. In addition to medical care, health care workers should consider social and psychological needs to support HIV-positive patients in improving their health and their sexual and reproductive health as well.

Role of nutritional support provided by qualified dietitians in the prevention and treatment of non-communicable diseases

The role of dietitians is to counsel patients on special dietary modifications, develop dietary plans and provide dietary advice for healthy lifestyle in order to promote health and prevent disease. As lifestyle changes have become a primary reason for the increasing prevalence of non-communicable diseases in recent decades, it appears that nutritional therapy should play an important role in the multidisciplinary healthcare system. The aim of the review was to evaluate the role of nutritional support provided by dietitians in the prevention and treatment of chronic diseases in terms of its clinical and cost-effectiveness, according to their range of activity and qualifications. The evaluation was based on the review of the current literature. The costs of the treatment of non-communicable diseases encompass the costs of the treatment of the disease itself, costs of its complications and costs resulting from the decline of the productivity of patients. The results of studies indicate that nutritional support provides not only clinical but also cost benefits in the prevention and treatment of various non-communicable diseases. Every €1 spend on dietary counseling of patients with obesity or obesity-related diseases approximately returns a net €14 to €63 over a period of five years. Dietitians appear to be more effective in counseling overweight or obese patients with present risk factors compared to other specialists, however the barriers to accessing a qualified dietitian and problems with the reimbursement for services still exist. As adequate professional qualifications of dietitians appear to be an important factor determining the effectiveness of implemented dietary care, an additional training courses for dietitians and enhanced cooperation of hospitals and medical universities are needed.

Illness-Death Model in Chronic Disease Epidemiology: Characteristics of a Related, Differential Equation and an Inverse Problem.

Chronic diseases impose a huge burden for mankind. Recently, a mathematical relation between the incidence and prevalence of a chronic disease in terms of a differential equation has been described. In this article, we study the characteristics of this differential equation. Furthermore, we prove the ill-posedness of a related inverse problem arising in chronic disease epidemiology. An example application for the inverse problem about type 1 diabetes in German women aged up to 35 years is given.

Entornos y actividad física en enfermedades crónicas: Más allá de factores asociados

Introducción: Las enfermedades crónicas no transmisibles son la mayor causa de morbimortalidad. La estrategia más costo-efectiva es la realización de actividad física pero hay una relación directa entre el incremento de estas enfermedades con la alta prevalencia de personas físicamente inactivas. Objetivo: Recoger los elementos esenciales de las enfermedades crónicas en términos del impacto y sus efectos negativos y mostrar, dentro de los factores de riesgo, a la inactividad física como uno de los determinantes clave en su aparición y el rol de los entornos construidos en esta conducta no saludable. Materiales y métodos: Estudio descriptivo mediante revisión documental sobre el papel de los entornos como factores determinante entre la inactividad física y el desarrollo de las enfermedades crónicas no transmisibles. Resultados: Se describen los efectos negativos de las enfermedades crónicas, los factores que influyen en su aparición y se destaca a la inactividad física como uno de los determinantes de las enfermedades crónicas. La evidencia empírica sugiere que las características del entorno obran como determinantes en este comportamiento dentro de los estilos de vida. Conclusión: Los entornos en que habitan las personas se constituyen en factores asociados y determinantes en la realización o no de actividad física y deben ser considerados, más allá de los factores individuales, si se quiere tener éxito en la prevención y control de las enfermedades no transmisibles.

Obesity and Diabetes as Risk Factors for Severe Plasmodium falciparum Malaria: Results From a Swedish Nationwide Study.

Noncommunicable diseases and obesity are increasing in prevalence globally, also in populations at risk of malaria. We sought to investigate if comorbidity, in terms of chronic diseases and obesity, is associated with severe Plasmodium falciparum malaria. We performed a retrospective observational study in adults (≥18 years of age) diagnosed with malaria in Sweden between January 1995 and May 2015. We identified cases through the surveillance database at the Public Health Agency of Sweden and reviewed clinical data from 18 hospitals. Multivariable logistic regression was used to assess associations between comorbidities and severe malaria. Among 937 adults (median age, 37 years; 66.5% were male), patients with severe malaria had higher prevalence of chronic diseases (28/92 [30.4%]) compared with nonsevere cases (151/845 [17.9%]) (P = .004). Charlson comorbidity score ≥1 was associated with severe malaria (adjusted odds ratio [aOR], 2.63 [95% confidence interval {CI}, 1.45-4.77), as was diabetes among individual diagnoses (aOR, 2.98 [95% CI, 1.25-7.09]). Median body mass index was higher among severe (29.3 kg/m2) than nonsevere cases (24.7 kg/m2) (P < .001). Obesity was strongly associated with severe malaria, both independently (aOR, 5.58 [95% CI, 2.03-15.36]) and in combination with an additional metabolic risk factor (hypertension, dyslipidemia, or diabetes) (aOR, 6.54 [95% CI, 1.87-22.88]). The associations were observed among nonimmune travelers as well as immigrants from endemic areas. Comorbidities, specifically obesity and diabetes, are previously unidentified risk factors for severe malaria in adults diagnosed with P. falciparum. Noncommunicable diseases should be considered in the acute management and prevention of malaria.

Menopausal hormone therapy: a systematic review of cost-effectiveness evaluations

BackgroundSeveral evaluations of the cost-effectiveness (CE) of menopausal hormone therapy (MHT) have been reported. The aim of this study was to systematically and critically review economic evaluations of MHT since 2002, after the Women’s Health Initiative (WHI) trial results on MHT were published.MethodsThe inclusion criteria for the review were: CE analyses of MHT versus no treatment, published from 2002-2016, in healthy women, which included both symptom relief outcomes and a range of longer term health outcomes (breast cancer, coronary heart disease, stroke, fractures and colorectal cancer). Included economic models had outcomes expressed in cost per quality-adjusted life year or cost per life year saved. MEDLINE, EMBASE, Evidence-Based Medicine Reviews databases and the Cost-Effectiveness Analysis Registry were searched. CE evaluations were assessed in regard to (i) reporting standards using the CHEERS checklist and Drummond checklist; (ii) data sources for the utility of MHT with respect to menopausal symptom relief; (iii) cost derivation; (iv) outcomes considered in the models; and (v) the comprehensiveness of the models with respect to factors related to MHT use that impact long term outcomes, using breast cancer as an example outcome.ResultsFive studies satisfying the inclusion criteria were identified which modelled cohorts of women aged 50 and older who used combination or estrogen-only MHT for 5-15 years. For women 50-60 years of age, all evaluations found MHT to be cost-effective and below the willingness-to-pay threshold of the country for which the analysis was conducted. However, 3 analyses based the quality of life (QOL) benefit for symptom relief on one small primary study. Examination of costing methods identified a need for further clarity in the methodology used to aggregate costs from sources. Using breast cancer as an example outcome, risks as measured in the WHI were used in the majority of evaluations. Apart from the type and duration of MHT use, other effect modifiers for breast cancer outcomes (for example body mass index) were not considered.ConclusionsThis systematic review identified issues which could impact the outcome of MHT CE analyses and the generalisability of their results. The estimated CE of MHT is driven largely by estimates of QOL improvements associated with symptom relief but data sources on these utility weights are limited. Future analyses should carefully consider data sources and the evidence on the long term risks of MHT use in terms of chronic disease. This review highlights the considerable difficulties in conducting cost-effectiveness analyses in situations where short term benefits of an intervention must be evaluated in the context of long term health outcomes.

Non-Medical Risk Factors as Avoidable Determinants of Excess Mortality in Children with Chronic Kidney Disease. A Prospective Cohort Study in Nicaragua, a Model Low Income Country.

BackgroundThe widely recognized clinical and epidemiological relevance of the socioeconomic determinants of health-disease conditions is expected to be specifically critical in terms of chronic diseases in fragile populations in low-income countries. However, in the literature, there is a substantial gap between the attention directed towards the medical components of these problems and the actual adoption of strategies aimed at providing solutions for the associated socioeconomic determinants, especially in pediatric populations. We report a prospective outcome study on the independent contribution and reciprocal interaction of the medical and socioeconomic factors to the hard end-point of mortality in a cohort of children with chronic kidney disease in Nicaragua.Methods and FindingsEvery child (n = 309) diagnosed with chronic kidney disease (CKD) and referred to the tertiary unit of Pediatric Nephrology in Managua (Nicaragua) from a network of nine hospitals serving 80% of the country’s pediatric population was registered between January 2005 and December 2013. The three main socioeconomic determinants evaluated were family income, living conditions and the family’s level of education. Further potential determinants of the outcomes included duration of exposure to disease, CKD stage at the first visit as suggested by the KDOQI guidelines in children, the time it took the patients to reach the reference centre and rural or urban context of life. Well-defined and systematically collected medical and socioeconomic data were available for 257 children over a mean follow-up period of 2.5±2.5 years. Mortality and lost to follow-up were considered as outcome end-points both independently and in combination, because of the inevitably progressive nature of the disease. A high proportion (55%) of children presented in the advanced stages of CKD (CKD stage IV and V) at the first visit. At the end of follow-up, 145 (57%) of the 257 cohort children were alive, 47 (18%) were lost to follow-up and 65 (25%) had died. Cox regression analysis showed an independent contribution to mortality of CKD stage at diagnosis and of level of education, with overlapping HR values (HR and 95%CI: 2.66; 1.93–3.66 and 2.72; 1.71–4.33, respectively).ConclusionsThe unfavourable socioeconomic and cultural background of the pediatric study cohort and the severity of kidney damage at diagnosis were the key determinants of the clinical risk conditions at baseline and of the mortality outcome. Long-term structural interventions on such backgrounds must be adopted to assure effectiveness of medical care and to assure an earlier diagnosis of CKD in these patients. The translation-extension of our results is currently underway with an agenda which includes: 1) better integration of chronic pediatric conditions into primary care strategies to promote prevention and early timely referral; 2) the consideration of socioeconomic conditions as a mandatory component of the packages of best-care; 3) the formulation and flexible adaptation of guidelines and educational programs, based on the information generated by a context-specific, epidemiological monitoring of needs and outcomes, guaranteed by an effective database.