The impact of inclusion criteria in health economic assessments

The debate surrounding whether the findings of efficacy studies are applicable to real-world treatment situations is ongoing. The issue of lack of applicability due to a lack of clinical heterogeneity could be addressed by employing less restrictive inclusion criteria. Given that health economic assessments based on cost-effectiveness measures are required by many governments and insurance providers, the impact of this choice may be far reaching. The objective of this article was to explore the use of a pilot study to examine the impact of inclusion criteria on cost-effectiveness results and clinical heterogeneity. A health economic assessment was conducted using QRISK®2 and simulation modelling of different population groups within the pilot study in Lower Austria. Patients were referred by their family physicians to ‘Active Prevention’ (Vorsorge Aktiv), a community-based lifestyle intervention focused on exercise and nutritional programmes. Cardiovascular risk factors were recorded before and after the intervention and translated to cardiovascular events. As expected, enforcing restrictive inclusion criteria produced stronger and more irrefutable computations — in the expected number of events, the number of deaths, the incremental cost per life-year saved and in the 95% confidence interval. These findings provide insight into the issues surrounding clinical heterogeneity and the need for restrictive inclusion criteria. This is not a full health economic assessment of the intervention. While inclusion criteria provide stronger results by limiting populations to those who would benefit the most, they must be enforced, both within and outside the clinical trial setting. Enforcement has costs, both monetary and arising from unintended negative consequences of enforcement mechanisms. All these considerations will affect the results realized by the payer organization. A pilot study can reveal whether an intervention may be cost effective ‘enough’ without restrictive inclusion criteria and can enable researchers to search for population subgroups in which the intervention remains cost effective. When the pilot study does not indicate sufficiently strong cost-effectiveness results, the broader trade-offs between clinical heterogeneity and the strength of the submission package to the reimbursement agency can be discussed by all parties. Payer concerns about the ability to generalize the results beyond the clinical trial can also be discussed at this time. Applicability then depends on the ability to enforce inclusion criteria similar to those used in the trials in the real world.     

Criteria for use in the evaluation of health impact assessments

This paper reports the conclusions of a recent workshop that was established to discuss how health impact assessments (HIAs) might be evaluated. The main purposes of HIA are: (a) to predict the consequences of different decisions; (b) to make the decision-making process more open by involving stakeholders; and (c) to inform the decision makers. 'Prediction', 'participation' and 'informing decision makers' are thus the three domains in which HIA should be evaluated. In the 'prediction' domain, process criteria scrutinize the methods used to see if it is likely that they would produce reliable predictions. Outcome criteria involve verifying the predictions, but this is frequently impractical and predictions for the counter factual (the option not chosen) can never be verified. In the 'participation' domain, process criteria examine the ways in which stakeholders were involved, while outcome criteria explore the degree to which the stakeholders felt included. In the 'informing decision makers' domain, process criteria are concerned with the communication between decision makers and those doing the HIA, and should reflect upon the relevance of the HIA content to the decision makers' agenda. Outcome criteria explore the degree to which the decision makers considered that they had been informed by the HIA. This paper concludes with suggestions for the types of information that should be included in HIA reports in order to permit the readers to make an assessment of the 'quality' of the HIA using the three domain criteria outlined above.     

中国流动人口重复参加基本医疗保险现状及影响因素

  目的  深入分析流动人口健康档案建立现状及影响因素,促进流动人口健康意识和健康水平。  方法  基于2015年全国流动人口动态监测调查数据,利用SPSS 20.0软件进行统计分析。  结果  2015年流动人口健康档案建立比例为29.1 %（59 934/205 990）,未建立健康档案及不清楚的比例分别为54.5 %（112 228/205 990）和16.4 %（33 828/205 990）。同时发现,健康档案建设在人群间、区域间差异显著,未婚、低学历、跨省流动、流动时间短的青年男性是健康档案建立的薄弱人群;东部地区（41.6%）流入人口的健康档案建立比例仅为中部地区（20.5%）的一半;未接受过健康教育人群的健康档案建立比例最低,仅为8.3 %（1 380/16 645）,健康教育对健康档案建设具有明显的正向作用。  结论  流动人口健康档案建设工作亟待加强,各级政府、相关部门和社会各界均需主动发挥积极作用。     

The use and impact of rapid health technology assessments

OBJECTIVES: To consider the impact of rapid health technology assessments undertaken as part of a program in a provincial healthcare system in response to urgent requests for advice. METHODS: Review of the development and preparation of 20 rapid assessment reports, communication with decision makers within the healthcare system, and appraisal of data subsequent to preparation of the reports. RESULTS: Fourteen of the assessments were judged to have had an influence on policy and other decisions, as judged by responses from those who had requested advice. Another four were considered to have provided guidance, while having less immediate influence on decisions, and two others had no apparent impact. Quality of the assessments was considered acceptable, on the basis of literature that subsequently became available and from comments received. CONCLUSIONS: These brief reports are considered to be a useful component of a health technology assessment program. However, they should be regarded as provisional appraisals and followed up with more detailed evaluation where possible.     

Bridging health and foreign policy: the role of health impact assessments

Health impact assessment (HIA) is an important tool for exploring the intersection between health and foreign policy, offering a useful analytical approach to increase positive health impacts and minimize negative impacts. Numerous subject areas have brought health and foreign policy together. Yet further opportunities exist for HIA to address a broader range of health impacts that otherwise may not be seen as relevant to foreign policy. HIA may also improve the quality of scientific evidence available to policy-makers. The Framework Convention on Tobacco Control offers lessons for the strategic use of HIA. However, HIA alone is limited in influencing these decision-making processes, notably when issues diverge from other core concerns such as economics and security. In such cases, HIA is an important tool to be used alongside the mobilization of key constituencies and public support.     

大连市979名流动人口健康素养调查

摘要:目的　对大连市流动人口健康素养进行调查,并分析健康素养的影响因素,为制定相应策略和政策提供科学依据。方法　采用整群抽样方法,调查大连市979名流动人口。采用问卷调查法收集资料,Epidata3.0建立数据库,SPSS19.0进行统计分析。结果　去年得到过健康方面宣传教育的流动人口仅占29.70%,健康生活方式认知水平较低,健康的行为和生活方式欠缺,健康素养较差。流动人口健康素养影响因素分析结果表明,大连市流动人口健康素养水平的主要影响因素为性别（P＜0.01）、文化程度（两项P＝0.01,P＝0.02）、职业类别（P＜0.01）,年龄和收入水平也有一定影响。结论　应重点加强流动人口的健康教育和管理工作,根据大连市流动人口的特点采取适当措施提高流动人口的健康素养。     

我国城乡流动人口健康教育现状及其影响因素的差异性分析

目的 了解城乡流动人口健康教育现状及其影响因素,为促进中国流动人口健康素养和健康水平提供参考。方法 利用中国2017年全国流动人口动态监测调查数据,共纳入 169 989名流动人口进行分析。t检验和χ2检验用于组间比较。二元 logistic 回归模型用于分析城乡流动人口健康教育现状及其影响因素。结果 2017年全国流动人口中,农村流动人口健康教育接受率为65.6%;城镇流动人口健康教育接受率为69.6%;二元 logistic 回归分析结果显示,文化程度为中等教育（OR = 1.236, P = 0.003, 95%CI:1.065～1.361)、年人均GRP（gross regional product）在100 000元以上(OR = 0.833, P = 0.007, 95%CI:0.730～0.951)、患有高血压(OR = 0.702, P = 0.002, 95%CI:0.562～0.878)或者患有高血压和糖尿病(OR = 0.072, P = 0.043, 95%CI:0.530～0.989)、本地建立健康档案(OR = 4.238, P＜0.001, 95%CI:3.509～5.119)、和完全认同自己为本地人(OR = 1.412,P = 0.046,95%CI:1.006～1.981)的农村流动人口更愿意接受健康教育;已婚(OR = 0.692,P = 0.000,95%CI:0.671～0.804)、老年人（OR = 0.500, P = 0.020, 95%CI:0.278～0.898)、年人均GRP在100 000元(OR = 0.911,P = 0.034,95%CI:0.837～0.992)以上、患有高血压(OR = 0.820, P = 0.021, 95%CI:0.693～0.970)、自评健康(OR = 1.363, P = 0.018, 95%CI:1.041～1.533)、本地建立健康档案(OR = 3.892, P＜0.001, 95%CI:3.424～4.425)的城镇流动人口更愿意接受健康教育。结论 城乡流动人口接受健康教育水平不均,健康教育影响因素具有差异性。将城乡流动人口作为健康教育服务的重点关注对象,加大对于该群体健康教育服务的投入 ,针对城乡流动人口健康教育影响因素的差异性,进行个性化、差异化的健康教育。     

天津市流动人口相关流动特征和性病艾滋病求医行为分析

目的了解天津市流动人口流动特征以及求医行为,为开展针对性的流动人口性病艾滋病的预防和控制工作提供科学依据。方法对天津市南开区、河北区以及东丽区的四类流动人口进行整群抽样,共抽取4 804名调查对象,收集流动人口流动特征以及求医行为,用SPSS 13.0软件进行分析,率的比较采用χ2检验,P<0.05为差异有统计学意义。结果首次外出打工通过同乡介绍占44.44%(2 135/4 804)。流动人口城市流动率、行业流动率和单位流动率的中位数分别为0.33个/年、0.40个/年和0.50个/年。有过商业性性行为者性病症状发生率(16.77%)远高于未发生过商业性性行为者(4.01%)(χ2=61.618,P<0.001)。最近一年5.06%(74/1 462)的女性调查对象出现过妇科症状,其中40.54%(30/74)的调查对象未作处理。结论流动人口具有较高的流动性,针对流动人口的艾滋病宣教工作较薄弱。出现妇科症状的流动人口中,多数人不能正确寻求治疗,应加强正确求医行为的知识宣传,多渠道提供生殖道感染诊疗服务。     

Lessons from San Francisco: health impact assessments have advanced political conditions for improving population health

Health impact assessment is a structured decision support tool used to systematically characterize the anticipated health effects, both adverse and beneficial, of societal decisions. In San Francisco, the use of health impact assessments has not only produced evidence to inform health policy decision making but has also contributed to the political conditions needed to achieve optimal population health. Health impact assessments have helped increase public awareness of the determinants of health, routine monitoring of these determinants, cooperation among institutions, health-protective laws and regulations, and organizational networks for health advocacy and accountability. Drawing on more than a decade of local experience, we identify the direct and indirect effects of the assessments on the politics of governance as well as on health. We demonstrate that health impact assessment is both an analytic tool and a process that helps build the social institutions that can improve health.     

当前我国人口流动形势及其影响研究

  目的  了解少数民族流动人口健康状况及其影响因素,为提高其健康水平提供参考依据。  方法  利用2017年全国流动人口卫生计生动态监测调查数据,14 226名少数民族流动人口纳入研究。采用非条件logistic回归模型分析其健康状况及影响因素。  结果  11 207人自评健康,占79.2 %;2 384人自评基本健康,占16.8 %;555人自评不健康但生活可自理,占3.9 %,17人自评不健康且生活不可自理,占0.1 %。男性、15～34岁、本科及以上学历、流动时间 < 10年、有稳定工作、月收入 ≥ 6 001元、已经在本地建立健康档案、至少接受过一项健康教育、无慢性病、听说过“国家基本公共卫生服务项目”的少数民族流动人口自评健康状况更好。  结论  应该重点关注女性、流动时间长、年龄较大、无工作、月收入较低的少数民族流动人口的健康状况,促进其树立正确的健康观。     

Including health in transport policy agendas: the role of health impact assessment analyses and procedures in the European experience

From the mid-1990s, research began to highlight the importance of a wide range of health impacts of transport policy decisions. The Third Ministerial Conference on Environment and Health adopted a Charter on Transport, Environment and Health based on four main components: bringing awareness of the nature, magnitude and costs of the health impacts of transport into intergovernmental processes; strengthening the arguments for integration of health into transport policies by developing in-depth analysis of the evidence; developing national case studies; and engaging ministries of environment, health and transport as well as intergovernmental and nongovernmental organizations. Negotiation of the Charter was based on two converging processes: the political process involved the interaction of stakeholders in transport, health and environment in Europe, which helped to frame the issues and the approaches to respond to them; the scientific process involved an international group of experts who produced state-of- the-art reviews of the health impacts resulting from transportation activities, identifying gaps in existing knowledge and methodological tools, specifying the policy implications of their findings, and suggesting possible targets for health improvements. Health arguments were used to strengthen environmental ones, clarify costs and benefits, and raise issues of health equity. The European experience shows that HIA can fulfil the need for simple procedures to be systematically applied to decisions regarding transport strategies at national, regional and local levels. Gaps were identified concerning models for quantifying health impacts and capacity building on how to use such tools.     

Recommendations in health technology assessments worldwide

OBJECTIVES: The objective of this study is to analyze statistically the possible determinants and implications of including or not including recommendations in health technology assessments (HTAs). METHODS: A sample of 433 HTAs published by eleven leading institutions or agencies in nine countries was reviewed and analyzed statistically by multiple logistic regression. RESULTS: The extent of policy and research recommendations in HTAs varies greatly from country to country. The content and scope of HTAs have some impact on recommendations. Extensive assessment of economic and organizational aspects increases the likelihood of including policy recommendations. Extensive assessment of technological and patient aspects increases the likelihood of including research recommendations, whereas extensive focus on economic aspects is negatively related to research recommendations. The most striking result is that the use of external partners for assessment increases the likelihood of including research recommendations in HTAs but not policy recommendations. CONCLUSIONS: HTA commissioners, agencies, institutions, and funding authorities need to be aware of the consequences of the choices they make in advance of assessing health technologies. Outsourcing HTA to external partners suggests a greater likelihood of being told that "more research is needed." The scope and content of HTAs has an impact on the type of recommendations, and country-specific preferences are strong predictors of recommendations in HTAs.     

The health of migrant children in Switzerland

Objective

Over 22?% of children and adolescents living in Switzerland have a migrant background. The aim of this systematic literature review is to give an overview of health needs of paediatric migrants in Switzerland.

Methods

Three databases (Embase, Medline, Global health) were systematically searched for quantitative primary research on the health outcomes of migrant minors (<18-year old) in Switzerland, including articles published since 2000 in French, German, Italian or English. Citation chasing and search of non-indexed literature was also performed.

Results

Thirty publications were identified. Compared to their Swiss peers, migrant children had higher hospitalisation (+40?%) and intensive care admission rates, more dental cavities, twice the odds of being obese, and migrant adolescents seemed more frequently affected by psychological problems and twice as often requesting abortions. Certain infectious diseases (tuberculosis, intestinal parasites, H. pylori infection, Hepatitis A) were more prevalent. Increased neonatal and infant mortality rates were found in Turkish and African babies.

Conclusion

Children of migrants may have distinct health needs. They should benefit from migrant paediatric care and health promotion activities that recognise these.