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PubMed2000

Socio-economic status and the utilisation of physicians' services: results from the Canadian National Population Health Survey.

This paper assesses the extent to which Canada's universal health care system has eliminated socio-economic barriers in the use of physician services by examining the role of socio-economic status in the differential use of specific, publicly-insured, primary and specialist care services. Data from the 1994 National Population Health Survey, a nationally representative survey, were analysed using multiple logistic regression. In order to control for the association between primary and specialist utilisation, a two-staged least squares method was used for models explaining specialist utilisation. Health need, as measured by perceived health status and number of health problems, was found to be consistently associated with increased physician utilisation, for both primary and specialist visits. Whereas the likelihood of an individual making at least one visit to a primary care physician was found to be independent of income, those with lower incomes were more likely to be frequent users of primary care, that is, make at least six visits to a primary care physician. Even after adjusting for the greater utilisation of primary care services by those in lower socio-economic groups, and, therefore, their higher exposure to the risk of referral, the utilisation of specialist visits was greater for those in higher socio-economic groups. Canadians lacking a regular medical doctor were less likely to receive primary and specialist care, even after adjustments for socio-economic variables such as income and education. Although financial barriers may not directly impede access to health care services in Canada, differential use of physician services with respect to socio-economic status persists. After adjusting for differences in health need, Canadians with lower incomes and fewer years of schooling visit specialists at a lower rate than those with moderate or high incomes and higher levels of education attained despite the existence of universal health care.

Adolescent↗
PubMed1997

Economic analysis of alternative AD control programmes.

The threat imposed by its virulence brings a presumption that Aujeszky's disease (AD) must be controlled because potential losses are high. Viewed as an economic problem, the decision on whether and how to control AD hinges on comparing the costs of doing so with the benefits (in terms of reduced production losses) to be gained. Four strategies are considered: (a) doing nothing, (b) suppressing and maintaining the disease at low prevalence levels by vaccination, (c) suppressing to low levels and then eradicating by culling remaining positive animals and (d) eradicating in one step by means of a test-and-slaughter policy. The net economic merits of each strategy are examined using data derived from specific vaccination studies established in Germany and the Netherlands. A computer model is developed to estimate disease costs under different technical, epidemiological and economic assumptions, allowing the economically optimal strategies to be explored. In general no single strategy can be recommended as the 'best' for dealing with AD, since it depends on a host of factors relating to pig density, prevalence levels, production system, trade relations, etc. As usual, economic realities complicate the quest for operational simplicity in disease control. However, for the regions of high pig density studied the most economic AD control strategy is to lower herd prevalence by intensive vaccination before completing eradication by test-and-removal of remaining positive animals.

Animals↗
PubMed2000

The role of economic evaluation in the diagnosis and treatment of Helicobacter pylori infection.

The unfolding of the H. pylori story coupled with the high prevalence and economic burden associated with upper gastrointestinal symptoms makes H. pylori-associated disorders an ideal candidate for economic evaluation. As a result of the high quality and quantity of data emerging, H. pylori eradication is cost-effective in individuals with either newly diagnosed or past PUD. The role of eradication in other areas, for example, patients with nonulcer dyspepsia and screening to prevent gastric cancer, may never be worked out to some clinicians' satisfaction. Conflicting reports and the lack of definitive clinical trials have frustrated clinicians. H. pylori diagnosis and treatment have not been integrated into everyday clinical practice. As a result, the enormous potential benefits associated with H. pylori eradication have not been achieved. Economic evaluation is not a panacea to the problems confronting medical services delivery. Assessments of medical practice are methodologically challenging, time-consuming, and expensive. Once the answers are in, it remains difficult to alter an individual provider's patterns of care and integrate the research findings into everyday practice. Further research into physician decision making is necessary to complement the advances being made in determining the value of medical interventions. The fruits of these efforts will be the more efficient delivery of health care services, which, it is hoped, ultimately will improve the health of patients. There is no reason to believe, however, that more attention to effectiveness research would lead to a reduction in health care expenditures. Increasing demands for accountability of medical interventions will propel effectiveness movements. Economic analyses, performed in concert with carefully designed clinical studies, will spur more critical review of health care resource allocation decisions. Despite the limitations, the findings generated from effectiveness research will have a major impact on physician practices, guideline development, and reimbursement decisions. The tendency of clinicians not to pay attention to economic evaluations may lead to missed clinical benefits and unnecessary expenditures. Physicians who have been reluctant to appreciate the information provided by economic evaluation must understand what other stakeholders in health care delivery already have accepted: that the rational basis for cost-effectiveness analysis is the overall improvement in the quality of health care services--not simply a tool to reduce health care costs.

Cost-Benefit Analysis↗
PubMed2005

Cross-sectional study of care, socio-economic status and complications in young French patients with type 1 diabetes mellitus.

OBJECTIVES: To describe the present status of type 1 diabetes care in France and study the relations between clinical and socio-economic variables on one hand and disease management and prevalence of complications on the other hand. METHODS: A random sample of 365 French specialists in diabetes care performed a cross-sectional study and included consecutively 562 children aged 10-16 and 1691 adults aged 16-45, with more than 2 years of type 1 diabetes. The main outcome measures were the prevalence of complications (retinal, renal, lower-limb, cardiovascular, ketoacidosis); disease management parameters (blood pressure, HbA1c, daily number of insulin injections, frequency of visits to a specialist in diabetes, membership of a patient association); socio-economic status as a score, and treatments received. RESULTS: Retinal complications were rare in children (0.7%) and common in adults (28.3%). 10.2% children and 15.2% adults had micro- or macro-albuminuria, 4.7% adults had plasma creatinine >or=150 micromol/L. Only 15% children and 26% adults had HbA1c<7%, 86.2% children and 62.7% adults had blood pressure<130/85 mmHg; 58% children and 80% adults had at least 3 daily insulin injections. In adults, the risk of experiencing at least one complication was linked significantly with diabetes duration, HbA1c, and socio-economic status. Age, sex, type of insulin therapy, tobacco consumption, and blood pressure control were not significant parameters. Ketoacidosis in the preceding year was only linked with HbA1C and socio-economic status. CONCLUSION: Although this sample of patients had overall a fair socio-economic status and were followed-up by specialists of diabetes care, metabolic and blood pressure control were not optimal. The care of French type 1 diabetics could probably be improved by a stricter control of glycaemia and blood pressure, and an earlier use of intensive insulin treatment, with a particular focus on adolescents and patients with the lowest socio-economic status.

Adolescent↗
PubMed2003

Costs and effectiveness--the impact of economic studies on TB control.

This paper assesses the impact of economic studies on TB control during the period 1982-2002, with a focus on cost and cost-effectiveness studies. It begins by identifying broad categories of economic study relevant to TB control, and how economic studies can, theoretically, have an impact on TB control. The impact that economic studies of TB control have had in practice is then analysed through a systematic review of the literature on cost and cost-effectiveness studies related to TB control, and three case studies (one cost study and two cost-effectiveness studies). The results show that in the past 20 years, 66 cost-effectiveness studies and 31 cost studies have been done on a variety of important TB control topics, with a marked increase occurring after 1994. In terms of numbers, these studies have had most potential for impact in industrialized countries, and within industrialized countries are most likely to have had an impact on policy and practice related to screening and preventive therapy. In developing countries with a high burden of tuberculosis, far fewer studies have been undertaken. Here, the main impact of economic studies has been influencing policy and practice on the use of short-course chemotherapy, justifying the implementation of community-based care in Africa, and helping to mobilize funding for TB control based on the argument that short-course treatment for TB is one of the most cost-effective health interventions available. For the future, cost and cost-effectiveness studies will continue to be relevant, as will other types of economic study.

Antineoplastic Agents↗
PubMed2003

Economic evaluation in obstetrics and gynaecology: principles and practice.

Greater attention in health care over the last 2 decades has been placed on determining how best to spend the resources available. Economic evaluation is a commonly used tool to compare health-care services and treatments on the basis of costs and benefits. However, the principles on which economic evaluations are based are not well understood, and guidelines for conducting such evaluations in practice are often not followed. This paper describes the overarching principle of opportunity cost, and highlights the implication that decision-making in health care should necessarily be based on both costs and benefits. Two notions of efficiency, technical and allocative, are also presented, and the important point is made that the specific type of economic evaluation chosen must be based not on the unit of benefit in the given study, as is commonly done, but rather on the type of efficiency being addressed. The 3 primary types of economic evaluation are outlined, and a common pitfall in economic evaluation, the incremental cost-effectiveness ratio, is critiqued. Finally, a number of methodological considerations when conducting economic evaluations in practice are presented.

Canada↗
PubMed2004

Higher socio-economic status of parents may increase risk for bipolar disorder in the offspring.

BACKGROUND: There are conflicting data regarding the socio-economic risk factors for bipolar disorders. The aim of the present study was to explore the association between the socio-economic status of an individual or the parent and the risk for bipolar disorder. METHOD: Two Danish registers were merged. From the data source, we extracted those born in 1960 or later, and those with a first-ever admission to, or contact with, Danish psychiatric facilities during 1981-1998 with a diagnosis of bipolar disorder. Fifty time-matched controls per case were chosen by the incidence-density sampling method. Effects of marital status, occupation, education, income, and wealth, of both subjects and the parents, were estimated using conditional logistic regression. RESULTS: A total of 947 cases were matched to 47 350 controls. Those at high risk of bipolar disorders were: single subjects, those in receipt of social assistance, pension or sickness payments, unemployed, subjects with a shorter educational history, and subjects with lower income. Conversely, parental higher education and higher level of paternal wealth were associated with increased risk. These associations remained significant after adjustment for gender, family history of psychiatric diagnoses, and other socio-economic variables, and are unlikely to be explained by known biases. CONCLUSIONS: The associations of lower socio-economic indices of subjects may be explained as a consequence of the disease. The association of higher socio-economic indices of parents may be explained by socio-economic achievement in the family of origin.

Adolescent↗
PubMed1999

Economic evaluation of diagnostic tests. A review of published studies.

OBJECTIVES: The purpose of this review was to examine whether studies from the medical literature focusing on efficiency of diagnostic facilities reported economic evaluation methods appropriately, following guidelines for conducting and reporting economic evaluations. METHODS: A Medline search was conducted, and studies that concerned a diagnostic technology and fulfilled the Drummond criteria were selected for methodological review. The reliability of selection and methodological review based on the abstracts was determined by scoring a random sample of both abstracts and full articles. Interrater reliability was determined by scoring a random sample of abstracts by both authors. Kappa values were calculated. Nine methodological aspects were reviewed: study design, the type of economic evaluation, the comparison made, the study's perspective, the cost-effectiveness ratio used, the definition of cost-effective, the types of costs analyzed, the cost calculation method, and the use of sensitivity analysis. RESULTS: Two hundred fifty studies published between 1992 and 1997 were found regarding efficiency of diagnostic facilities; 134 studies fulfilled the Drummond criteria and were selected for methodological review. Kappa values showed reliability of selection and methodological review and interrater reliability. The existing literature on the economic evaluation of diagnostic facilities does not adhere well to guidelines for economic evaluation. In 95%, no perspective was mentioned, in 50% of the cases no ratio was given, in 82% the cost calculation method was not mentioned, and in 66% no sensitivity analysis was reported. CONCLUSIONS: Our review suggests that to improve the quality of reporting economic evaluations, editorial boards could issue and enforce guidelines for standard reporting of such studies.

Cost-Benefit Analysis↗
PubMed2001

The psychological sense of economic hardship: measurement models, validity, and cross-ethnic equivalence for urban families.

Poverty is a community stressor that disproportionally affects ethnic minority families. One aspect of programmatic research on poverty focuses on the psychological sense of economic hardship. In a study of 319 African American, European American, and Mexican American urban families, parents completed objective measures of economic status and scales of perceived economic hardship that were adapted from previous research. Measurement models identified a coherent construct of psychological sense of economic hardship that was essentially equivalent for mothers and fathers, English- and Spanish-speaking Mexican Americans, and the 3 ethnic groups. In support of the validity of this construct, relations between objective indicators of economic status and perceived economic hardship showed equivalence across these same groups.

Adolescent↗
PubMed1999

Pathways of economic influence on adolescent adjustment.

An important part of a science aimed at the prevention of human dysfunction involves the development of empirically based models that identify processes of risk for or protection from emotional distress or behavioral problems over time. The present study developed and evaluated such a model that proposed two pathways through which family economic pressure was expected to influence change in adolescent internalizing symptoms (depression and anxiety) during the period from the eighth to the tenth grades. A total of 377 rural families in a midwestern state provided data for the analyses. The results were generally consistent with the conceptual model in that family economic pressure increased adolescent perceptions of family economic hardship, which, in turn, reduced the adolescent's sense of control or mastery over time. Lowered mastery was associated with increases in emotional distress. Also consistent with the model, prior levels of mastery appeared to reduce the magnitude of economic stress experienced by the adolescent, whereas prior emotional distress intensified the economic stress process. Although gender differences were found in these processes, the overall pattern of results suggests that girls and boys are both at risk for internalizing problems when families experience economic pressure. Implications of the findings for the development of effective preventive interventions with financially stressed families in rural areas are discussed.

Adaptation, Psychological↗
PubMed1999

Couple resilience to economic pressure.

Over 400 married couples participated in a 3-year prospective study of economic pressure and marital relations. The research (a) empirically evaluated the family stress model of economic stress influences on marital distress and (b) extended the model to include specific interactional characteristics of spouses hypothesized to protect against economic pressure. Findings provided support for the basic mediational model, which proposes that economic pressure increases risk for emotional distress, which, in turn, increases risk for marital conflict and subsequent marital distress. Regarding resilience to economic stress, high marital support reduced the association between economic pressure and emotional distress. In addition, effective couple problem solving reduced the adverse influence of marital conflict on marital distress. Overall, the findings provided substantial support for the extended family stress model.

Adaptation, Psychological↗
PubMed2006

Neurons in the orbitofrontal cortex encode economic value.

Economic choice is the behaviour observed when individuals select one among many available options. There is no intrinsically 'correct' answer: economic choice depends on subjective preferences. This behaviour is traditionally the object of economic analysis and is also of primary interest in psychology. However, the underlying mental processes and neuronal mechanisms are not well understood. Theories of human and animal choice have a cornerstone in the concept of 'value'. Consider, for example, a monkey offered one raisin versus one piece of apple: behavioural evidence suggests that the animal chooses by assigning values to the two options. But where and how values are represented in the brain is unclear. Here we show that, during economic choice, neurons in the orbitofrontal cortex (OFC) encode the value of offered and chosen goods. Notably, OFC neurons encode value independently of visuospatial factors and motor responses. If a monkey chooses between A and B, neurons in the OFC encode the value of the two goods independently of whether A is presented on the right and B on the left, or vice versa. This trait distinguishes the OFC from other brain areas in which value modulates activity related to sensory or motor processes. Our results have broad implications for possible psychological models, suggesting that economic choice is essentially choice between goods rather than choice between actions. In this framework, neurons in the OFC seem to be a good candidate network for value assignment underlying economic choice.

Animals↗
PubMed2004

Economics and obesity: costing the problem or evaluating solutions?

There is no doubt that obesity is a major public health problem. However, what is the contribution of economics to solving it? In this report, we make the case that the role of economics is not in measuring the economic burden of obesity, through so-called cost-of-illness studies. Such studies merely confirm that obesity is a serious societal issue; adding a monetary figure to this does not add much. The economic foundations of such estimates can also be questioned, thus lessening their policy relevance. The real value of economics in the arena of obesity care is in evaluating, through formal economic evaluation, the use of our scarce health care resources in different strategies to prevent and treat obesity.

Cost of Illness↗
PubMed2001

Iron status of premenopausal women in two regions of Bangladesh: prevalence of deficiency in high and low socio-economic groups.

OBJECTIVE: The objective of the study was to assess iron status in women of different physiological status of two socio-economic groups in Bangladesh. DESIGN: Cross sectional study, using 3-day food record and blood haemoglobin, serum iron, serum ferritin concentrations. SETTING: Two regions of Bangladesh. The Dhaka city area and west region of Nandail, Mymensingh. SUBJECTS: Women aged 16-40 y. The low socio-economic group (group L, n=101) consisted of rural women with precarious income levels. The high socio-economic group (group H, n=90) consisted of women with high income and educational levels. The groups were composed of three sub-groups (non-pregnant non-lactating=1, pregnant = 2 and lactating = 3). RESULTS: There was no significant difference between the corresponding sub-groups of the two socio-economic groups in dietary intake of iron. In all sub-groups, the intake of iron was much higher than the RDA level and mainly based on non-haem iron. Blood haemoglobin (B-Hb) concentration (P=0.000), serum iron concentration (P=0.005) and serum ferritin (SF) concentration (P=0.000) were affected by socio-economic status. Physiological status (PS) influenced the B-Hb concentration (P=0.000). Prevalence of anaemia ranged from 63 to 70% in group L and 27 to 66% in group H, respectively. The prevalence of empty iron store (SF concentration<12 microg/l) ranged from 35 to 59% in group L and 15 to 32% in group H, respectively. The prevalence of anaemia and iron deficiency (70 and 35% for sub-group L2; 66 and 32% for sub-group H2, respectively) were similar in the pregnant subjects of the two groups. CONCLUSIONS: Subclinical iron deficiency was common in women of low socio-economic status. The pregnant subjects in the two groups was similar as regards iron status. SPONSORSHIP: The study was supported by the Academy of Finland, University of Helsinki and NorFa, Norway.

Adolescent↗
PubMed2001

Geographical pattern of female deaths from myocardial infarction in an urban population: fatal outcome out-of-hospital related to socio-economic deprivation.

OBJECTIVE: This study of myocardial infarction (MI) amongst urban women has sought to assess whether there are differences in fatal outcome, in-hospital respectively out-of-hospital, between residential areas defined in terms of socio-economic circumstances. DESIGN: Register-based surveillance study 1986-95. SETTING: Seventeen residential areas in the city of Malmö, Sweden. SUBJECTS: Women 20-74 years of age. MAIN OUTCOME MEASURES: Differences in fatal outcome, in-hospital respectively out-of-hospital, between residential areas were expressed in terms of age-adjusted odds ratios (ORs), calculated by means of logistic regression. Socio-economic circumstances in the areas were expressed in terms of a composite score. RESULTS: Between residential areas there were marked and statistically significant differences in incidence (range 124-328/10(5), P < 0.001, d.f.=16) and mortality (range 38-132/10(5), P < 0.005, d.f.=16). Area rates of mortality covaried with incidence (r=0.85, P < 0.001) and with odds ratios of fatal outcome out-of-hospital (r=0.52, P=0.031) but not in-hospital. The odds ratios of fatal outcome out-of-hospital decreased in a statistically significant stepwise fashion from areas in the lowest socio-economic quintile (reference) to areas in the highest socio-economic quintile (OR: 0.67, 95% CI: 0.48-0.94). There was no corresponding association with the odds ratios of fatal outcome in-hospital. CONCLUSIONS: The high rate of mortality from MI amongst women in areas with deprived socio-economic circumstances was related to deaths occurring out-of-hospital. In order to assess the preventive potential there is a need for further studies that may clarify to what extent the association with socio-economic circumstances can be explained by other factors and conditions known to influence the probability of survival.

Adult↗
PubMed1998

Socio-economic and dietary influences on leg length and trunk length in childhood: a reanalysis of the Carnegie (Boyd Orr) survey of diet and health in prewar Britain (1937-39).

Social class differences in height have been recognised for many centuries. However, few studies have examined the extent to which these differences are made up of differences in leg length or trunk length. This paper reanalyses cross-sectional information on children examined in Britain in the 1930s. We assess associations between socio-economic status and diet and the components of childhood stature. The analyses were based on the records of 2990 children aged 2 years to 14 years 9 months who were examined in the Carnegie (Boyd Orr) survey of diet and health (1937-39). z-Scores for the measures of childhood stature were calculated using polynomial regression techniques with the study population as the standard. Univariable and multivariable statistical techniques were used to assess the relationships between childhood height, leg length and trunk length, and dietary and socio-economic factors measured at the level of the household. Leg length was the component of stature most strongly associated with measures of childhood diet and socio-economic status. A greater part of the difference in stature between socio-economic groups was caused by differences in leg length rather than trunk length. In multiple regression analyses, district of residence and family food expenditure were generally the two factors most strongly related to stature. In a subsample of the surveyed children, for whom birthweight information was available, trunk length and leg length were equally strongly related to birthweight. Leg length appears to be a particularly sensitive indicator of childhood socio-economic circumstances. Although contemporary studies highlight the importance of biological factors in determining childhood height, the data analysed in this study suggest that socio-economic circumstances were also important in explaining height differentials in prewar Britain.

Adolescent↗
PubMed2000

Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly?

In this paper, we review the evidence bearing on socio-economic disparities in pregnancy outcome, focusing on aetiological factors mediating the disparities in intrauterine growth restriction (IUGR) and preterm birth. We first summarise what is known about the attributable determinants of IUGR and preterm birth, emphasising their quantitative contributions (aetiological fractions) from a public health perspective. We then review studies relating these determinants to socio-economic status and, combined with the evidence about their aetiological fractions, reach some tentative conclusions about their roles as mediators of the socio-economic disparities. Cigarette smoking during pregnancy appears to be the most important mediating factor for IUGR, with low gestational weight gain and short stature also playing substantial roles. For preterm birth, socio-economic gradients in bacterial vaginosis and cigarette smoking appear to explain some of the socio-economic disparities; psychosocial factors may prove even more important, but their aetiological links with preterm birth require further clarification. Research that identifies and quantifies the causal pathways and mechanisms whereby social disadvantage leads to higher risks of IUGR and preterm birth may eventually help to reduce current disparities and improve pregnancy outcome across the entire socio-economic spectrum.

Canada↗
PubMed2001

Cerebral palsy, low birthweight and socio-economic deprivation: inequalities in a major cause of childhood disability.

There is currently little and conflicting evidence concerning the existence of socio-economic inequalities in cerebral palsy prevalence, or the extent to which this is influenced by socio-economic inequalities in low birthweight, a strong risk factor for cerebral palsy. The study is based on 753 children registered with cerebral palsy, resident in the former Oxford Regional Health Authority area and born in the years 1984-90. Two population definitions were used: 1. Children with cerebral palsy resident at birth in the area, with resident births as denominator, 2. Children with cerebral palsy resident at age 5 in the area, with children of ages 1-7 resident in the area in the 1991 census as denominator. Children with cerebral palsy and all births/children were classified according to the Carstairs area deprivation index (grouped into quintiles) of their ward of residence. The prevalence among residents at birth varied from 2.08 per 1000 births in the most affluent quintile to 3.33 in the most deprived quintile (trend P < 0.001). Although there was a tendency for children to move to more affluent areas during early childhood, the socio-economic gradient was similar at age 5. A greater proportion of births in the more deprived quintiles were of low or very low birthweight, the proportion rising from 5.6% in the most affluent quintile to 8.2% in the most deprived. Within the normal birthweight category there was a trend for higher prevalence of cerebral palsy in more deprived quintiles, from 1.29 per 1000 in the most affluent quintile to 2.42 in the most deprived quintile (trend P < 0.001). Within the low birthweight and very low birthweight groups, separately or combined, there was no evidence of any relationship between cerebral palsy prevalence and deprivation. We estimate that up to 17% of cerebral palsy cases might be "preventable" in terms of the reduction to be expected if the whole population had the rate of cerebral palsy of the most affluent quintile. Although the strong socio-economic gradient for cerebral palsy was restricted to the normal birthweight category, we estimate that two-thirds of the excess cases in the population associated with greater socio-economic deprivation were normal birthweight cases, and one-third were low birthweight cases owing to the greater prevalence of low birthweight in more deprived populations. The pattern of socio-economic inequalities should be further explored in other regions, and should be taken into account in aetiological research, and in the effective delivery and evaluation of services.

Cerebral Palsy↗