Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals

BACKGROUND

Stroke burden challenges global health, and social and economic policies. Although stroke recovery encompasses a wide range of care, including in-hospital, outpatient, and community-based rehabilitation, there are no published cost-effectiveness studies of integrated post-stroke pathways.

OBJECTIVE

To determine the most cost-effective rehabilitation pathway during the first 12 months after a first-ever stroke.

METHODS

A cohort of people in the acute phase of a first stroke was followed after hospital discharge; 51 % women, mean (SD) age 74.4 (12.9) years, mean National Institute of Health Stroke Scale score 11.7 (8.5) points, and mode modified Rankin Scale score 3 points. We developed a decision tree model of 9 sequences of rehabilitation care organised in 3 stages (3, 6 and 12 months) through a combination of public, semi-public and private entities, considering both the individual and healthcare service perspectives. Health outcomes were expressed as quality-adjusted life years (QALY) over a 1-year time horizon. Costs included healthcare, social care, and productivity losses. Sensitivity analyses were conducted on model input values.

RESULTS

From the individual perspective, pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective, followed by pathway 1 (Rehabilitation Centre » Community Clinic). From the healthcare service perspective, pathway 3 was the most cost-effective followed by pathway 7 (Outpatient Hospital » Private Clinic). All other pathways were considered strongly dominated and excluded from the analysis. The total 1-year mean cost ranged between €12104 and €23024 from the individual's perspective and between €10992 and €31319 from the healthcare service perspective.

CONCLUSION

Assuming a willingness-to-pay threshold of one times the national gross domestic product (€20633/QALY), pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective strategy from both the individual and healthcare service perspectives. Rehabilitation pathway data contribute to the development of a future integrated care system adapted to different stroke profiles.

From healthcare system to individuals through stroke rehabilitation pathways.Outcomes, information, and satisfaction along 12 months prospective cohort in Portugal

BACKGROUND

The nature and quality of stroke survivor rehabilitation varies throughout Europe, including in Portugal, having not been widely monitored or benchmarked.

OBJECTIVES

This study analyses the stroke care pathway from three perspectives: healthcare system, process, and patient.

METHODS

The study uses data from a one-year single-center prospective cohort of first stroke patients, assessed at baseline, 3, 6, and 12 months. Care pathways and settings were described in terms of organizational model, funding, patient involvement, frequency and intensity and multidisciplinary team. Patient-level information and satisfaction were evaluated using a 10-point numeric rating scale. Kruskal - Wallis and post-hoc tests were used to compare EQ-5D-3 L, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index, Mini-Mental State Examination scores between pathways and settings.

RESULTS

A total of 391 acute stroke patients, with a mean disability of 3.7 (mRS) and severity of 11.7 (NIHSS) participated. Six pathways and eight settings were described. A lack of compliance between guidelines and care was identified. There were significant differences in the four outcomes between the six pathways (p-values 0.007 to 0.020) suggesting inefficiency and inequalities, with an inadequate level of information and patient satisfaction. After post-hoc analysis, pathways 1 and 2 showed highest outcomes (p-values 0.001 to 0.002). Within settings, short-term units showed high scores, followed by rehabilitation center, outpatient hospital, and community clinic (p-values 0.001 to 0.040).

CONCLUSION

A multilevel characterization of the post-stroke rehabilitation pathway showed a more complete perspective on stroke management which may contribute to future rehabilitation and stroke policies.

Messaging, monetary incentives, and participation in wellness programs

Purpose

Many companies in the USA have corporate wellness programs but are having trouble encouraging employees to take part in these programs. Even with monetary incentives, many employees do not join. The purpose of this paper is to consider whether timely reminders combined with monetary incentives improve participation in health benefit programs.

Design/methodology/approach

Employees of a large manufacturing company across multiple facilities were encouraged to enroll in a messaging service. Once a week, members received an SMS or e-mail reminder to complete a Health Risk Assessment (HRA) and Health Action Plan (HAP). The authors segmented employees based on prior year health insurance plan choice and HRA participation to analyze current HRA and HAP completion, with and without intervention.

Findings

The intervention increased completion rates 6 percent for subgroups that completed the HRA in the prior year and 34–37 percent for those that did not.

Practical implications

Corporate wellness programs should develop good communication channels with employees. The effectiveness of such programs will depend also on employee engagement.

Originality/value

With better communication, companies could raise participation in corporate wellness programmes and potentially reduce some of the monetary incentives that they currently offer.

Daily tobacco use and problem drinking among urban adults in South Africa: a longitudinal study

Introduction

There is a lack of longitudinal studies investigating daily tobacco use and problem drinking in Africa. The aim of this study was to explore the prevalence of daily tobacco use and problem drinking and to determine the factors associated with daily tobacco use and problem drinking among urban dwellers in a longitudinal study in South Africa.

Methods

Electronic interview data were collected from 2213 adults (mean age 45.7 years, SD=15.1; range 20-97) at time 1 (baseline assessment) and Time 2 (12 months follow-up assessment) from one urban centre in South Africa.

Results

Daily tobacco use only, was at time 1 24.0% and at time 2 23.4%, a decrease of 0.5%. Problem drinking only was at time 1 19.6% and at time 2 21.1%, an increase of 1.5%. Concurrent daily tobacco use and problem drinking increased from time 1 9.5% to 10.3% at time 2, an increase of 0.8%. In longitudinal regression analyses, being male and being born in current city were significantly associated with all three substance use indicators (daily tobacco use; problem drinking; and concurrent daily tobacco use and problem drinking). In addition, older age, not currently married, lower education, underweight and higher levels of perceived stress were associated with daily tobacco use and younger age was associated with problem drinking.

Conclusion

High prevalence of daily tobacco use and problem drinking were found among urban dwellers and several socio-demographic (being male, being born in the city, not married and lower education) and health variables (being underweight and perceived stress) were identified which can guide substance use intervention programmes for this population.

Do Customers Flee From HIV? A Survey of HIV Stigma and Its Potential Economic Consequences on Small Businesses in Tshwane (Pretoria), South Africa

HIV stigma and discrimination affect care-seeking behavior and may also affect entrepreneurial activity. We interview 2382 individuals in Pretoria, South Africa, and show that respondents believe that businesses with known HIV+ workers may lose up to half of their customers, although the impact depends on the type of business. Survey respondents' fear of getting HIV from consuming everyday products sold by the business-despite a real infection risk of zero-was a major factor driving perceived decline in customers, especially among food businesses. Respondents' perceptions of the decline in overall life satisfaction when one gets sick from HIV and the respondent's dislike of people with HIV were also important predictors of potential customer exit. We suggest policy mechanisms that could improve the earnings potential of HIV+ workers: reducing public health scare tactics that exacerbate irrational fear of HIV infection risk and enriching public health education about HIV and ARVs to improve perceptions about people with HIV.

Going beyond life expectancy in assessments of health systems' performance: life expectancy adjusted by perceived health status

International comparisons of health systems data have been used to guide health policy. Health systems performance is generally evaluated on how different factors contribute to mortality and longevity. Fewer studies scrutinize the factors that determine morbidity in different countries, partly because indicators that assess morbidity on a country level are not as widely available as mortality and longevity data. We introduce a new health status indicator able to combine mortality and morbidity in a single composite measure for each country and gender at a point in time (LEAPHS), yielding the average number of years that men (women) can expect to live in "good" (or better) health. Using the Sullivan method we combine the mortality risk, calculated for specific age and gender groups, with perceived health status for the same age and gender groups, and we estimate how medical care and various socio-economic, environmental and structural, lifestyle, and technological factors affect LEAPHS and life expectancy at birth for a large panel of thirty OECD countries. We find that some variables (alcohol consumption, urbanization) have a significant effect on both LEAPHS and life expectancy, while one variable (the number of hospitals) has a significant effect for both genders on life expectancy only. However, the effects of many other variables (health expenditure per capita, health expenditure per capita squared, GDP growth, and technology) were only significant predictors for LEAPHS. This leads us to conclude that LEAPHS is able to capture the impact of some health determinants not captured by life expectancy at birth. While we believe this new measure may be useful for health economists and statisticians doing cross-country analyses, further comparisons with other measures may be useful.

Risks deter but pleasures allure: Is pleasure more important?

The pursuit of unhealthy behaviors, such as smoking or binge drinking, not only carries various downside risks, but also provides pleasure. A parsimonious model, used in the literature to explain the decision to pursue an unhealthy activity, represents that decision as a tradeoff between risks and benefits. We build on this literature by surveying a rural population in South Africa to elicit the perceived riskiness and the perceived pleasure for various risky activities and to examine how these perceptions relate to the pursuit of four specific unhealthy behaviors: frequent smoking, problem drinking, seatbelt nonuse, and risky sex. We show that perceived pleasure is a significant predictor for three of the behaviors and that perceived riskiness is a significant predictor for two of them. We also show that the correlation between the riskiness rating and behavior is significantly different from the correlation between the pleasure rating and behavior for three of the four behaviors. Finally, we show that the effect of pleasure is significantly greater than the effect of riskiness in determining drinking and risky sex, while the effects of pleasure and riskiness are not different from each other in determining smoking and seatbelt nonuse. We discuss how our findings can be used to inform the design of health promotion strategies.

Depression and social functioning among HIV-infected and uninfected persons in South Africa

Depression and other health problems are common co-morbidities among persons living with human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS). The aim of this study was to investigate depression, health status, and substance use in relation to HIV-infected and uninfected individuals in South Africa. Using a cross-sectional case-control design, we compared depression, physical health, mental health, problem alcohol use, and tobacco use in a sample of HIV-infected (N = 143) and HIV-uninfected (N = 199) respondents who had known their HIV status for two months. We found that depression was higher, and physical health and mental health were lower in HIV-positive than HIV-negative individuals. Poor physical health also moderated the effect of HIV infection on depression; HIV-positive individuals were significantly more depressed than HIV-negative controls, but only when general physical health was also poor. We did not find an association between alcohol or tobacco use and HIV status. These results suggest the importance of incorporating the management of psychological health in the treatment of HIV.

Enrollment in prescription drug insurance: the interaction of numeracy and choice set size

OBJECTIVE

To determine how choice set size affects decision quality among individuals of different levels of numeracy choosing prescription drug plans.

METHOD

Members of an Internet-enabled panel age 65 and over were randomly assigned to sets of prescription drug plans varying in size from 2 to 16 plans from which they made a hypothetical choice. They answered questions about enrollment likelihood and the costs and benefits of their choice. The measure of decision quality was enrollment likelihood among those for whom enrollment was beneficial. Enrollment likelihood by numeracy and choice set size was calculated. A model of moderated mediation was analyzed to understand the role of numeracy as a moderator of the relationship between the number of plans and the quality of the enrollment decision and the roles of the costs and benefits in mediating that relationship.

RESULTS

More numerate adults made better decisions than less numerate adults when choosing among a small number of alternatives but not when choice sets were larger. Choice set size had little effect on decision making of less numerate adults. Differences in decision making costs between more and less numerate adults helped explain the effect of choice set size on decision quality.

CONCLUSIONS

Interventions to improve decision making in the context of Medicare Part D may differentially affect lower and higher numeracy adults. The conflicting results on choice overload in the psychology literature may be explained in part by differences amongst individuals in how they respond to choice set size.

Predicting (un)healthy behavior: A comparison of risk-taking propensity measures

We compare four different risk-taking propensity measures on their ability to describe and to predict actual risky behavior in the domain of health. The risk-taking propensity measures we compare are: (1) a general measure of risk-taking propensity derived from a one-item survey question (Dohmen et al., 2011), (2) a risk aversion index calculated from a set of incentivized monetary gambles (Holt & Laury, 2002), (3) a measure of risk taking derived from an incentive compatible behavioral task-the Balloon Analog Risk Task (Lejuez et al., 2002), and (4) a composite score of risk-taking likelihood in the health domain from the Domain-Specific Risk Taking (DOSPERT) scale (Weber et al., 2002). Study participants are 351 clients of health centers around Witbank, South Africa. Our findings suggest that the one-item general measure is the best predictor of risky health behavior in our population, predicting two out of four behaviors at the 5% level and the remaining two behaviors at the 10% level. The DOSPERT score in the health domain performs well, predicting one out of four behaviors at the 1% significance level and two out of four behaviors at the 10% level, but only if the DOSPERT instrument contains a hypothetical risk-taking item that is similar to the actual risky behavior being predicted. Incentivized monetary gambles and the behavioral task were unrelated to actual health behaviors; they were unable to predict any of the risky health behaviors at the 10% level. We provide evidence that this is not because the participants had trouble understanding the monetary trade-off questions or performed poorly in the behavioral task. We conclude by urging researchers to further test the usefulness of the one-item general measure, both in explaining health related risk-taking behavior and in other contexts.

A Comparison of EPI Sampling, Probability Sampling, and Compact Segment Sampling Methods for Micro and Small Enterprises

Finding an efficient method for sampling micro- and small-enterprises (MSEs) for research and statistical reporting purposes is a challenge in developing countries, where registries of MSEs are often nonexistent or outdated. This lack of a sampling frame creates an obstacle in finding a representative sample of MSEs. This study uses computer simulations to draw samples from a census of businesses and non-businesses in the Tshwane Municipality of South Africa, using three different sampling methods: the traditional probability sampling method, the compact segment sampling method, and the World Health Organization's Expanded Programme on Immunization (EPI) sampling method. Three mechanisms by which the methods could differ are tested, the proximity selection of respondents, the at-home selection of respondents, and the use of inaccurate probability weights. The results highlight the importance of revisits and accurate probability weights, but the lesser effect of proximity selection on the samples' statistical properties.

Age and the purchase of prescription drug insurance by older adults

The Medicare Part D Prescription Drug Program places an unprecedented degree of choice in the hands of older adults despite concerns over their ability to make effective decisions and desire to have extensive choice in this context. While previous research has compared older adults to younger adults along these dimensions, our study, in contrast, examines how likelihood to delay decision making and preferences for choice differ by age among older age cohorts. Our analysis is based on responses of older adults to a simulation of enrollment in Medicare Part D. We examine how age, numeracy, cognitive reflection, and the interaction between age and performance on these instruments are related to the decision to enroll in a Medicare prescription drug plan and preference for choice in this context. We find that numeracy and cognitive reflection are positively associated with enrollment likelihood and that they are more important determinants of enrollment than age. We also find that greater numeracy is associated with a lower willingness to pay for choice. Hence, our findings raise concern that older adults, and, in particular, those with poorer numerical processing skills, may need extra support in enrolling in the program: they are less likely to enroll than those with stronger numerical processing skills, even though they show greater willingness to pay for choice.

Choice set size and decision making: the case of Medicare Part D prescription drug plans

BACKGROUND

The impact of choice on consumer decision making is controversial in US health policy.

OBJECTIVE

The authors' objective was to determine how choice set size influences decision making among Medicare beneficiaries choosing prescription drug plans.

METHODS

The authors randomly assigned members of an Internet-enabled panel age 65 and older to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. The authors used ordered probit models to estimate the effect of choice set size on the study outcomes.

RESULTS

Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan.

CONCLUSIONS

Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries.

Time preference and its relationship with age, health, and survival probability

Although theories from economics and evolutionary biology predict that one's age, health, and survival probability should be associated with one's subjective discount rate (SDR), few studies have empirically tested for these links. Our study analyzes in detail how the SDR is related to age, health, and survival probability, by surveying a sample of individuals in townships around Durban, South Africa. In contrast to previous studies, we find that age is not significantly related to the SDR, but both physical health and survival expectations have a U-shaped relationship with the SDR. Individuals in very poor health have high discount rates, and those in very good health also have high discount rates. Similarly, those with expected survival probability on the extremes have high discount rates. Therefore, health and survival probability, and not age, seem to be predictors of one's SDR in an area of the world with high morbidity and mortality.

Poor health kills small business: illness and microenterprises in South Africa

Small businesses contribute almost 50 percent of total employment and 30 percent of gross domestic product in South Africa, but the impact of poor health and AIDS on these businesses is poorly documented. Using three waves of longitudinal data from predominantly African neighborhoods in peri-urban Durban, South Africa, this project investigates the connections between the health of the owner of a micro- and small enterprise (MSE) and the MSE's growth, survival, or exit. The results show that poor baseline health and declines in health over time are both significantly associated with subsequent business closure.

Measuring the effects of work loss on productivity with team production

Using data from a survey of 800 managers in 12 industries, we find empirical support for the hypothesis that the cost associated with missed work varies across jobs according to the ease with which a manager can find a perfect replacement for the absent worker, the extent to which the worker functions as part of a team, and the time sensitivity of the worker's output. We then estimate wage 'multipliers' for 35 different jobs, where the multiplier is defined as the cost to the firm of an absence as a proportion (often greater than one) of the absent worker's daily wage. The median multiplier is 1.28, which supports the view that the cost to the firm of missed work is often greater than the wage.