Health Economic Assessment Research Articles

Role of Health Services Research in Producing High-Value Rehabilitation Care.

The concept of value is receiving greater attention in rehabilitation and the broader health care environment. The overall purpose of this article is to present a framework to help clinicians, researchers, educators, and policy makers better understand the role of health services research in developing and evaluating evidence on value in rehabilitation. Value in health care is a multidimensional concept and may be defined differently by various stakeholders, but assessing value typically involves considering a combination of several health and economic outcomes. However, health care stakeholders often lack sufficient information on these outcomes to make well-informed decisions. Health services approaches such as comparative effectiveness research, patient-centered outcomes research, and health economics assessments are some ways to evaluate value. The evidence generated from such studies directly informs decision making and health policy. Rehabilitation professionals have a great opportunity to increase their engagement in describing, evaluating, delivering, and disseminating high-value care, but there are several barriers they need to consider to be most successful. Embracing health services research best practices is essential for advancing appropriate rehabilitation practice, research, and policy and for addressing challenges to implementing high-value care.

Optima: A Model for HIV Epidemic Analysis, Program Prioritization, and Resource Optimization.

Optima is a software package for modeling HIV epidemics and interventions that we developed to address practical policy and program problems encountered by funders, governments, health planners, and program implementers. Optima's key feature is its ability to perform resource optimization to meet strategic HIV objectives, including HIV-related financial commitment projections and health economic assessments. Specifically, Optima allows users to choose a set of objectives (such as minimizing new infections, minimizing HIV-related deaths, and/or minimizing long-term financial commitments) and then determine the optimal resource allocation (and thus program coverage levels) for meeting those objectives. These optimizations are based on the following: calibrations to epidemiological data; assumptions about the costs of program implementation and the corresponding coverage levels; and the effects of these programs on clinical, behavioral, and other epidemiological outcomes. Optima is flexible for which population groups (specified by behavioral, epidemiological, and/or geographical factors) and which HIV programs are modeled, the amount of input data used, and the types of outputs generated. Here, we introduce this model and compare it with existing HIV models that have been used previously to inform decisions about HIV program funding and coverage targets. Optima has already been used in more than 20 countries, and there is increasing demand from stakeholders to have a tool that can perform evidence-based HIV epidemic analyses, revise and prioritize national strategies based on available resources, set program coverage targets, amend subnational program implementation plans, and inform the investment strategies of governments and their funding partners.

Dutch Cycling: Quantifying the Health and Related Economic Benefits.

The Netherlands is well known for their high bicycle use. We used the Health Economic Assessment Tool and life table calculations to quantify the population-level health benefits from Dutch cycling levels. Cycling prevents about 6500 deaths each year, and Dutch people have half-a-year-longer life expectancy because of cycling. These health benefits correspond to more than 3% of the Dutch gross domestic product. Our study confirmed that investments in bicycle-promoting policies (e.g., improved bicycle infrastructure and facilities) will likely yield a high cost-benefit ratio in the long term.

Meniscal Transplantation and its Effect on Osteoarthritis Risk: an abridged protocol for the MeTEOR study: a comprehensive cohort study incorporating a pilot randomised controlled trial.

ObjectivesSubtotal or total meniscectomy in the medial or lateral compartment of the knee results in a high risk of future osteoarthritis. Meniscal allograft transplantation has been performed for over thirty years with the scientifically plausible hypothesis that it functions in a similar way to a native meniscus. It is thought that a meniscal allograft transplant has a chondroprotective effect, reducing symptoms and the long-term risk of osteoarthritis. However, this hypothesis has never been tested in a high-quality study on human participants. This study aims to address this shortfall by performing a pilot randomised controlled trial within the context of a comprehensive cohort study design.MethodsPatients will be randomised to receive either meniscal transplant or a non-operative, personalised knee therapy program. MRIs will be performed every four months for one year. The primary endpoint is the mean change in cartilage volume in the weight-bearing area of the knee at one year post intervention. Secondary outcome measures include the mean change in cartilage thickness, T2 maps, patient-reported outcome measures, health economics assessment and complications.ResultsThis study is expected to report its findings in 2016.Cite this article: Bone Joint Res 2015;4:93–8

A09 Health and economic benefits of active transport policies in Barcelona

Background Since the first Road Safety Plan was approved in Barcelona in 2000, other plans followed and were integrated into the overall mobility plans of the city. Actions stimulating active transportation included increasing pedestrian priority areas, implementation of zones 30, audits of crosswalks, bike lanes, public bicycle program, reduction of car use by limiting parking for residents, increasing public transport, etc. This paper aims to estimate the health and economic benefits of these policies that promoted walking and cycling. Methods We conducted a pre-post evaluation study, comparing walking and cycling trips in 2009 to 2013. We used the HEAT (Health Economic Assessment Tool) developed by WHO. The study population are persons older than 14 who made a trip walking or cycling in Barcelona city during the period of study. Data on the number of trips walking or cycling and the duration of the trips were obtained from the annual daily travel survey carried out in Barcelona (EMEF). It collects information on all trips carried out on the previous working day. We used the value of statistical life provided by HEAT for Spain: 3.203.000€. We estimated the number of deaths per year that were prevented due to changes in the level of walking and cycling from 2009 to 2013 and the economic benefit resulting from prevented deaths. Results The number of people reporting walking for travel increased from 783,518 in 2009 to 862,021 in 2013: This gives an increase in average daily time spent walking per person from 47.5 min to 49.6 min per day. Taking this into account, 86.1 deaths per year are prevented by this change in walking. The current value of the average annual benefit averaged across 5 years of this level of walking is: 47.355 million €. The number of people reporting cycling for travel the day before increased from 40,430 in 2009 to 60,274 in 2013: The average daily time spent cycling per person was 51,8 min in 2009 and 49,8 min in 2013. Taking this into account, 8,2 deaths per year are prevented by this change in cycling. The current value of the average annual benefit averaged across 5 years of this level of cycling is: 4.492 million €. Conclusions Changes in transport policies in Barcelona city, which promoted active transportation, produced a clear impact on health benefits related to physical activity. Language: en

A67 The Health Economic Assessment Tools (HEAT) for Walking and Cycling: supporting the integration of active mobility in healthy and sustainable transport solutions

A67 The Health Economic Assessment Tools (HEAT) for Walking and Cycling: supporting the integration of active mobility in healthy and sustainable transport solutions

Health economics and outcomes methods in risk-based decision-making for blood safety.

Analytical methods appropriate for health economic assessments of transfusion safety interventions have not previously been described in ways that facilitate their use. Within the context of risk-based decision-making (RBDM), health economics can be important for optimizing decisions among competing interventions. The objective of this review is to address key considerations and limitations of current methods as they apply to blood safety. Because a voluntary blood supply is an example of a public good, analyses should be conducted from the societal perspective when possible. Two primary study designs are recommended for most blood safety intervention assessments: budget impact analysis (BIA), which measures the cost to implement an intervention both to the blood operator but also in a broader context, and cost-utility analysis (CUA), which measures the ratio between costs and health gain achieved, in terms of reduced morbidity and mortality, by use of an intervention. These analyses often have important limitations because data that reflect specific aspects, for example, blood recipient population characteristics or complication rates, are not available. Sensitivity analyses play an important role. The impact of various uncertain factors can be studied conjointly in probabilistic sensitivity analyses. The use of BIA and CUA together provides a comprehensive assessment of the costs and benefits from implementing (or not) specific interventions. RBDM is multifaceted and impacts a broad spectrum of stakeholders. Gathering and analyzing health economic evidence as part of the RBDM process enhances the quality, completeness, and transparency of decision-making.

How to Address Small- and Medium-Sized Acoustic Neuromas with Hearing: A Systematic Review and Decision Analysis

Small- and medium-sized acoustic neuromas (ANs) increase in both number and proportion. Observation, radiosurgery, and microsurgery are all used to treat this disease; however, the appropriate treatment is controversial, especially in patients with hearing. We searched the MEDLINE, EMBASE, CENTRAL (Cochrane Central Register of Con-trolled Trials), LILACS (Latin American and Caribbean Center on Health Sciences Information), and CMB (Chinese Biomedical Database) databases without limits on the language and the time of publication. For the wait-and-scan strategy, we included the population-based prospective studies with sufficient follow-up time and information. We also attempted to locate high-level evidence that compared radiosurgery with microsurgery. The data were extracted from the studies to synthesize the probabilities. We surveyed 60 patients with small- and medium-sized ANs to plot the outcomes on a linear scale to measure the utility. Eight studies met the inclusion criteria of the wait-and-scan strategy, and 3 grade II evidence studies were found that compared microsurgery with radiosurgery. After synthesizing the data in 3 groups, the preservation of useful hearing was 58.9%, 60.2%, and 4.3%, whereas the rate of tumor control was 71.1%, 97.0%, and 94.3%, respectively. The expected value for radiosurgery was 0.68, whereas the expected values for wait-and-scan and surgery were 0.64 and 0.28, respectively. On the basis of the evidence, radiosurgery is the optimal choice for small- and medium-sized ANs. Because of the current difficulty with understanding the natural history of ANs, we suggest that there is a need for new evidence and a health economics assessment to update this result.

The view of European experts regarding health economics for medical nutrition in disease-related malnutrition.

Health-care systems are currently facing tremendous budget constraints resulting in growing pressure on decision makers and health-care providers to obtain the maximum possible health benefits of the resources available. Choices have to be made, and health economics can help in allocating limited health-care resources among unlimited wants and needs. Attempts to achieve cost reductions often focus on severe pathologies and chronic diseases as they commonly represent high health-care expenditures. In this context, awareness of the considerable financial burden caused by disease-related malnutrition (DRM) is lacking. Possibilities of reducing costs by optimising the management of DRM through medical nutrition will mostly not even be taken into account. During a European expert meeting, the total evaluation of medical nutrition was viewed and discussed. The aim of this meeting was to gain an experts' outline of the key issues relating to the health economic assessment of the use of medical nutrition. This article provides a summary of the observations per discussed item and describes the next steps suggested.

Cost-effectiveness in Clostridium difficile treatment decision-making.

To develop a framework for the clinical and health economic assessment for management of Clostridium difficile infection (CDI). CDI has vast economic consequences emphasizing the need for innovative and cost effective solutions, which were aim of this study. A guidance model was developed for coverage decisions and guideline development in CDI. The model included pharmacotherapy with oral metronidazole or oral vancomycin, which is the mainstay for pharmacological treatment of CDI and is recommended by most treatment guidelines. A design for a patient-based cost-effectiveness model was developed, which can be used to estimate the cost-effectiveness of current and future treatment strategies in CDI. Patient-based outcomes were extrapolated to the population by including factors like, e.g., person-to-person transmission, isolation precautions and closing and cleaning wards of hospitals. The proposed framework for a population-based CDI model may be used for clinical and health economic assessments of CDI guidelines and coverage decisions for emerging treatments for CDI.

Current process and future path for health economic assessment of pharmaceuticals in France

The Social Security Funding Law for 2012 introduced the Economic and Public Health Assessment Committee (Commission Evaluation Economique et de Santé Publique, or CEESP) in the Social Security Code as a specialised committee affiliated with the Haute Autorité de Santé in charge of providing recommendations and health economic opinions. This article provides an in-depth description of the CEESP's structure and working methods, and analyses the impact of health economic assessment on market access of drugs in France. It also points out the areas of uncertainty and the conflicting rules following the introduction of the health economic assessment in France. The authors also provide their personal opinion on the likely future of health economic assessment of drugs in France, including the possible merge of the CEESP and the Transparency Committee, the implementation of a French threshold, and the extension of health economic assessment to a larger number of products.

Health Impacts of Increased Physical Activity from Changes in Transportation Infrastructure: Quantitative Estimates for Three Communities.

Recently, two quantitative tools have emerged for predicting the health impacts of projects that change population physical activity: the Health Economic Assessment Tool (HEAT) and Dynamic Modeling for Health Impact Assessment (DYNAMO-HIA). HEAT has been used to support health impact assessments of transportation infrastructure projects, but DYNAMO-HIA has not been previously employed for this purpose nor have the two tools been compared. To demonstrate the use of DYNAMO-HIA for supporting health impact assessments of transportation infrastructure projects, we employed the model in three communities (urban, suburban, and rural) in North Carolina. We also compared DYNAMO-HIA and HEAT predictions in the urban community. Using DYNAMO-HIA, we estimated benefit-cost ratios of 20.2 (95% C.I.: 8.7–30.6), 0.6 (0.3–0.9), and 4.7 (2.1–7.1) for the urban, suburban, and rural projects, respectively. For a 40-year time period, the HEAT predictions of deaths avoided by the urban infrastructure project were three times as high as DYNAMO-HIA's predictions due to HEAT's inability to account for changing population health characteristics over time. Quantitative health impact assessment coupled with economic valuation is a powerful tool for integrating health considerations into transportation decision-making. However, to avoid overestimating benefits, such quantitative HIAs should use dynamic, rather than static, approaches.

PRS56 - Impact of Allergen Immunotherapy on Quality of Life and Health Care Costs in Adults and Children With Grass Pollen-Induced Allergic Rhinitis in Germany

• According to the World Health Organization (WHO), allergic respiratory diseases have been recognized as the fourth most important chronic disease in the world and represent a major public health problem with significant quality of life (QoL) impairment. Approximately 90 million Europeans are affected by allergic respiratory diseases. • In Germany, 25% of the adult population and 21% of the paediatric population suffer from allergic rhinoconjunctivitis (AR). • According to the ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines, 10–40% of patients suffer from co-existing allergic asthma. A health economic assessment, reflective of German clinical practice, was conducted to determine the relative impact of treatment with Oralair, Grazax, ALK Depot SQ or SDT on clinical effects and healthcare costs in adults and children with moderate-to-severe grass pollen-induced allergic rhinoconjunctivitis.

PRS52 - Impact of Allergen Immunotherapy on Symptom-Free Days and Health Care Costs in Patients With Grass Pollen-Induced Allergic Rhinitis in Germany

• According to the World Health Organization (WHO), allergic respiratory diseases respiratory diseases have been recognized as the fourth most important chronic disease in the world and represent a major public health problem with significant quality of life (QoL) impairment. Approximately 90 million Europeans are affected by allergic respiratory diseases. • In Germany, 25% of the adult population and 21% of children suffer from allergic rhinoconjunctivitis (AR). • According to the ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines, 10–40% of patients suffer from co-existing allergic asthma. • Treatment of AR mainly consists of symptom control achieved by allergen avoidance or use of symptomatic drug treatment (SDT). In poorly controlled AR patients in Germany, causal treatments such as allergen immunotherapy (AIT) may be required. A health economic assessment, reflective of German clinical practice, was conducted to determine the relative impact on clinical effects, expressed as SFD, and healthcare costs when treating patients with moderate-to-severe grass polleninduced allergic rhinoconjunctivitis with Oralair® or Grazax®.

The role of decision analytic modeling in the health economic assessment of spinal intervention.

Narrative review. To review the common tenets, strengths, and weaknesses of decision modeling for health economic assessment and to review the use of decision modeling in the spine literature to date. For the majority of spinal interventions, well-designed prospective, randomized, pragmatic cost-effectiveness studies that address the specific decision-in-need are lacking. Decision analytic modeling allows for the estimation of cost-effectiveness based on data available to date. Given the rising demands for proven value in spine care, the use of decision analytic modeling is rapidly increasing by clinicians and policy makers. This narrative review discusses the general components of decision analytic models, how decision analytic models are populated and the trade-offs entailed, makes recommendations for how users of spine intervention decision models might go about appraising the models, and presents an overview of published spine economic models. A proper, integrated, clinical, and economic critical appraisal is necessary in the evaluation of the strength of evidence provided by a modeling evaluation. As is the case with clinical research, all options for collecting health economic or value data are not without their limitations and flaws. There is substantial heterogeneity across the 20 spine intervention health economic modeling studies summarized with respect to study design, models used, reporting, and general quality. There is sparse evidence for populating spine intervention models. Results mostly showed that interventions were cost-effective based on $100,000/quality-adjusted life-year threshold. Spine care providers, as partners with their health economic colleagues, have unique clinical expertise and perspectives that are critical to interpret the strengths and weaknesses of health economic models. Health economic models must be critically appraised for both clinical validity and economic quality before altering health care policy, payment strategies, or patient care decisions. 4.

G.P.166: Comparative economic impact of therapeutic innovation on health care burden of Duchenne Muscular Dystrophy (DMD) using Becker Muscular Dystrophy (BMD) as a comparator for potential clinical outcome corridor

DMD is a fatal incurable progressive disorder resulting in disability, reduced working capacity and high health care utilization often along with intense care. Promising innovative therapies (e.g. exon skipping) enabling transforming disease severity close to the milder BMD phenotype are currently under assessment. Clinical development of these promising therapies is costly and once approved these interventions may add high cost to health care budgets but also saving may be considerable. We aim to assess the cost of illness (COI) and quality of life (QoL) of DMD and BMD patients to pursue comparative modelling of innovative therapies from different perspectives. Patients and caring relatives were surveyed using an established German DMD/BMD patient registry. Direct and indirect cost were assessed in the perspectives of patients, caregivers, relatives and society. The patients’ current QoL was analyzed using a disease-specific questionnaire. 248 DMD and 117 BMD patients were included. Differences between the consumption of resources of direct medical services, indirect cost and QoL between DMD and BMD but also between the different clinical DMD stages were analyzed. Relevant socio-political implications have been identified and compiled. First results show that modifying the disease severity of DMD into a milder BMD clinical phenotype is likely to produce considerably lower cost while improving QoL. Early assessments of economic aspects and modelling of potential outcome corridors represent the first analytical steps towards a systematic health economic assessment of innovative DMD therapies. Our results can contribute to investment decisions on the developer side and may enable to speed up payer negotiations regarding pricing and reimbursement to contribute to the facilitation of a smooth translation of innovations from clinical research over marketing authorization to patient access to a reimbursed therapy.

748TiP - Abc-06: a Randomised Phase Iii, Multi-Centre, Open-Label Study of Active Symptom Control (Asc) Alone or Asc with Oxaliplatin / 5-Fu Chemotherapy for Patients with Locally Advanced / Metastatic Biliary Tract Cancers (Abc) Previously Treated with Cisplatin / Gemcitabine Chemotherapy.

ABSTRACT Background: Since the randomized NCRN phase III ABC-02 trial, there exists level A evidence for first-line chemotherapy with cisplatin and gembitabine combination in ABC. To date, no robust evidence is available supporting the use of second-line treatment, where only a few retrospective and prospective (phase II) studies employing multiple different chemotherapy schedules have been conducted (level C). Therefore, currently, ASC (i.e. proactive management of biliary obstruction / sepsis, etc.) is the standard of care for second-line treatment in ABC. After progression on a first-line gemcitabine-based chemotherapy switching to a fluoropyrimidine-based schedule may be considered appropriate. Moreover, oxaliplatin is known for its activity in gastrointestinal tumours with synergistic activity and a favourable toxicity profile when used in combination with 5-FU. Several studies using mFOLFOX for biliary tract tumours are available, with promising results and acceptable toxicity. The aim of this trial is to determine if patients (pts) with ABC benefit with respect to survival from the addition of mFOLFOX chemotherapy to ASC in the second-line setting after progression to first-line treatment with cisplatin and gemcitabine. Trial design: This is a randomised phase III, multi-centre, controlled, open-label trial of pts with advanced biliary tract cancer with evidence of disease progression after prior cisplatin / gemcitabine chemotherapy treatment. Eligible pts (ECOG 0-1, adequate haematological, renal and liver function, adequate biliary drainage, with no evidence of ongoing infection) will be randomised (1:1) to receive either ASC (“standard” arm) or ASC with oxaliplatin/5-FU chemotherapy (“experimental” arm). The total number of participants planned is 162 (randomised 1:1). Randomisation and analysis will adjust for serum albumin levels, platinum sensitivity (determined from first-line therapy) and disease extent (locally advanced vs metastatic). The primary end point is overall survival. Quality of life and health economics assessments will be performed. Archival paraffin-embedded tissue will be collected at baseline and prospective blood samples will be collected for translational research. First patient was recruited on 27th March 2014; 4 pts have been randomized to date (6th May 2014) across 20 UK sites. Disclosure: All authors have declared no conflicts of interest.

Impact of Treatment with Eribulin (Eri) or Capecitabine (Cap) for Metastatic Breast Cancer (Mbc) on Eq–5D Utility Derived from Eortc Qlq–C30

ABSTRACT Aim: MBC is associated with significant worsening of health-related quality of life (HRQOL). HRQOL levels related to appetite loss, fatigue and physical functioning are significant independent factors associated with survival. Utility values for different stages of MBC and toxicities commonly associated with chemotherapy regimens are useful for health economic assessments. However, there are limited such data derived from clinical trials. Methods: In a phase 3, randomized study (N = 1102), median overall survival with ERI was 15.9 months vs 14.5 months for CAP (HR 0.88; P = 0.056) in MBC patients (pts) previously treated with anthracyclines and taxanes. Our post-hoc analysis used a published regression algorithm to convert the European Organization for Research and Treatment of Cancer questionnaire QLQ-C30 to the European QOL-5 Dimensions (EQ-5D) questionnaire (utility). Mean (SD) utility values were estimated for relevant health states: stable disease, tumor response, disease progression. Independent linear mixed-effects models adjusting for baseline health state predicted dis-utilities for the Grade 3/4 toxicities recorded in ≥2% of pts, and alopecia. Results: Observed mean (SD) baseline MBC utilities for ERI vs CAP were 0.704 (0.228) vs 0.691 (0.238); consistent with published values. Tumor response was associated with utility improvement: ERI vs CAP, 0.780 (0.194) vs 0.783 (0.185). Disease progression led to a detrimental utility change in CAP pts (ERI vs CAP: 0.705 vs 0.651). The following toxicities were associated with statistically significant reductions in utility vs no toxicity: vomiting (0.05 [SE = 0.02]), fatigue/asthenia (0.03 [0.01]) and dyspnea (0.03 [0.01]), all P Conclusions: There is limited information on assessing the impact of MBC treatment using EQ-5D utilities. Mapping health state utility from the QLQ-C30, in the absence of EQ-5D data, offers valuable perspective on the reduction in HRQOL associated with disease progression and treatment toxicity. Disclosure: S. Hudgens: Clinical Outcomes Solutions conducted Eisai-sponsored quality of life post hoc analysis through funding by Eisai; A. Briggs: I have received consultancy payments from Eisai; G. Velikova: I have acted as a consultant to Eisai in 2013 advising them on the methodology for QoL analysis. I have prepared and presented one training session in 2013. I was paid for my consultancy time and the travel from Leeds, UK to Chicago, IL, USA; A. Forsythe: Anna Forsythe is an employee of Eisai; S. McCutcheon: Susan McCutcheon is an employee of Eisai. All other authors have declared no conflicts of interest.

Functional Status Three Months after the First Ischemic Stroke Is Associated with Long-Term Outcome: Data from a Community-Based Cohort

Background: The impact of public health interventions to reduce disability after stroke may be underestimated if only the modest effects on short-term disability are measured. We estimated the impact of differences in short-term functional outcome on long-term functional outcome. Methods: In a prospective community-based study from October 1998 to September 2000, the first-ever ischemic strokes were registered in a population of 95,816 in Northern Portugal. Patients were examined at baseline and followed-up at three months, one and seven years. The Oxfordshire classification and the Unified Neurological Stroke Scale were used to define the stroke type and the severity of neurological impairments. The functional status was assessed with the modified Rankin Scale (mRS). Ridit analysis was used to estimate the odds of a more serious 7-year outcome based on the adjacent values of the 3-month mRS. Cox proportional hazards models were used for estimating the effect of 3-month mRS on survival, adjusting for patients' characteristics, stroke type and severity. Results: The odds of a more serious 7-year outcome was different among patients with mRS = 1 and 2 and also with mRS = 3 and 4, defining the no significant (mRS = 0-1), moderate (mRS = 2-3) and severe disability (mRS = 4-5). Of the 380 first-ever strokes, at 3 months, 126 (33.2%) had mRS <2, 114 (30.0%) mRS = 2-3, 73 (19.2%) mRS = 4-5, and 67 (17.6%) had died. We found linear relations between the 3-month mRS and the patient's baseline profile, stroke type and severity. The Kaplan-Meier 7-year survival estimates for 3-month survivors with mRS 0-1, 2-3 and 4-5 were 67, 50 and 23%, respectively. For mRS at 3 months of 2-3 versus 0-1 the hazard ratio (HR) for death was 1.61, (95% CI: 1.10-2.38) and for mRS = 4-5 versus 2-3 the HR was 2.20 (95% CI: 1.52-3.20); after adjustment the HRs were 1.19 (95% CI: 0.77-1.84) and HR = 1.87 (95% CI: 1.18-2.95), respectively. A change in the 3-month mRS from 4-5 to 2-3 would have a ‘number needed to change' of 9 (95% CI: 6-18) patients to avoid one death in the long run; identical outcome is obtained by shifting the mRS from 2-3 to 0-1 in 27 (95% CI: 15-141) patients. Conclusions: In patients with ischemic stroke who survive to 3 months, a three grade simplified mRS summarizes the patient risk profile and stroke characteristics. These data confirm that modest differences in the functional status at 3 months are associated with significant differences in survival and functional status over 7 years follow-up and have implications for health care planning and the health economic assessment of treatments for acute stroke.

Health Equilibrium Initiative: a public health intervention to narrow the health gap and promote a healthy weight in Swedish children.

BackgroundInequity in health is a global concern. Even in Sweden there are considerable health gaps between different social groups, not least concerning life-style related conditions. Interventions drawing on Community-based participatory research (CBPR) have potential to build prerequisites for complex, supportive structures that constitute basis for implementation of sustainable health promoting programs. CBPR rests on principles of empowerment. The researchers are responsible for the scientific quality and that ethical standards are met. Health Equilibrium Initiative (HEI) aims at narrowing the health gap and promoting healthy weight in children; “healthy weight” including both anthropometric criteria and aspects having to do with self-esteem and self-efficacy. Evaluation objectives are to compare outcome between children in intervention and control areas, conduct health economic assessments (HEA) and evaluate the processes of the project.Methods/designHEI is a repeated cross-sectional and longitudinal study. The Program Logic Model is based on Social Cognitive Theory and Intervention Mapping. Primary contact groups are children in disadvantaged communities. Core efforts are to confirm and convey knowledge, elucidate and facilitate on-going health work and support implementation of continuous health work. Socioeconomic status is assessed on area level by the parameters yearly average income, degree of employment, tertiary education and percent of inhabitants born in countries where violent conflicts recently have taken place or were ongoing. Anthropometry, food patterns, physical activity and belief in ability to affect health; together with learning, memory and attention assessment will be assessed in 350 children (born 2006). Examinations will be repeated after two years, forming the basis of a health economic analysis. The process evaluation procedure will use document analysis (such as structured reports from meetings and dialogues, school/workplaces policies and curriculum, food service menus); key informant interviews and focus groups with parents, children and professionals.DiscussionInviting, awaiting and including local perspectives create mutual confidence and collaboration. Enhanced self-efficacy and access to relevant knowledge has potential to enable individuals and communities to choose alternatives that are relevant for their health and well-being in a long perspective. The economic of this study may contribute in decision- making processes regarding appropriate public health interventions.