The effectiveness of interventions to reduce the household economic burden of illness and injury: a systematic review

Objective

To determine the nature, scope and effectiveness of interventions to reduce the household economic burden of illness or injury.

Methods

We systematically reviewed reports published on or before 31 January 2014 that we found in the CENTRAL, CINAHL, Econlit, Embase, MEDLINE, PreMEDLINE and PsycINFO databases. We extracted data from prospective controlled trials and assessed the risk of bias. We narratively synthesized evidence.

Findings

Nine of the 4330 studies checked met our inclusion criteria – seven had evaluated changes to existing health-insurance programmes and two had evaluated different modes of delivering information. The only interventions found to reduce out-of-pocket expenditure significantly were those that eliminated or substantially reduced co-payments for a given patient population. However, the reductions only represented marginal changes in the total expenditures of patients. We found no studies that had been effective in addressing broader household economic impacts – such as catastrophic health expenditure – in the disease populations investigated.

Conclusion

In general, interventions designed to reduce the complex household economic burden of illness and injury appear to have had little impact on household economies. We only found a few relevant studies using rigorous study designs that were conducted in defined patient populations. The studies were limited in the range of interventions tested and they evaluated only a narrow range of household economic outcomes. There is a need for method development to advance the measurement of the household economic consequences of illness and injury and facilitate the development of innovative interventions to supplement the strategies based on health insurance.     

Health Policy,Ethics, and the Kansas Legislative Health Academy

We describe a unique program, the Kansas Legislative Health Academy, that brings together state legislators from across the political spectrum to build their capacity in advancing policies that can improve the health of Kansans.To that end, the academy helps legislators develop new skills to deliberate the ethics of health policy, use systems thinking to understand the long- and short-term effects of policy action and inaction, and engage in acts of civic leadership. The academy also seeks to foster an environment of respectful open dialogue and to build new cross-chamber and cross-party relationships.Among the most important outcomes cited by program participants is the value of sustained, personal interaction and problem solving with individuals holding differing political views.Health policy often elicits controversy. Recent examples include the uproar over recommendations for mammography screening for women 40 to 49 years old and human papillomavirus vaccination for adolescent girls and boys. Perhaps the most dramatic controversy relates to the passage of the Patient Protection and Affordable Care Act (Pub L No. 111-148); despite being signed into law in 2010 and found substantially constitutional by the US Supreme Court in 2012 (Medicaid expansion was made optional for states), this legislation remains subject to vigorous dissent. Such controversies, although no doubt a function of interest-driven politics, also reflect deep differences in ethical values.Ethical values and premises underpin all public policy.1,2 Ideas about individual liberty, personal responsibility, solidarity, justice, and the role of the government are just a few of the moral constructs that often clash in the making of policy. Policy analysis often ignores these dimensions of policy-making, although that is beginning to change.3–5Here we describe a project based in part on the premise that training policymakers to recognize and talk openly about the ethical values entailed in health policy might improve its content and process. This project, the Kansas Legislative Health Academy (hereafter Health Academy), brought together state legislators from across the political spectrum to build their capacity to respond to complex health policy challenges in Kansas. To that end, the curriculum sought to help legislators develop new skills in 3 areas: health policy ethics, systems thinking, and civic leadership. The Health Academy also sought to foster an environment of open, respectful dialogue and to build new cross-chamber and cross-party relationships.To our knowledge, the Health Academy is a unique program. Many educational programs exist for legislators to focus on leadership development or specific health policy issues, but none we are aware of are specifically designed to cover a broad range of health policy issues while also addressing underlying barriers to effective policy-making within legislative bodies. In what follows, we describe the Health Academy’s origins, structure, substance, and lessons learned.     

Advantage of Whole Exome Sequencing over Allele-Specific and Targeted Segment Sequencing in Detection of Novel TULP1 Mutation in Leber Congenital Amaurosis

Background: Leber congenital amaurosis (LCA) is a severe form of retinal dystrophy with marked underlying genetic heterogeneity. Until recently, allele-specific assays and Sanger sequencing of targeted segments were the only available approaches for attempted genetic diagnosis in this condition. A broader next-generation sequencing (NGS) strategy, such as whole exome sequencing, provides an improved molecular genetic diagnostic capacity for patients with these conditions.

Materials and Methods: In a child with LCA, an allele-specific assay analyzing 135 known LCA-causing variations, followed by targeted segment sequencing of 61 regions in 14 causative genes was performed. Subsequently, exome sequencing was undertaken in the proband, unaffected consanguineous parents and two unaffected siblings. Bioinformatic analysis used two independent pipelines, BWA-GATK and SOAP, followed by Annovar and SnpEff to annotate the variants.

Results: No disease-causing variants were found using the allele-specific or targeted segment Sanger sequencing assays. Analysis of variants in the exome sequence data revealed a novel homozygous nonsense mutation (c.1081C?>?T, p.Arg361*) in TULP1, a gene with roles in photoreceptor function where mutations were previously shown to cause LCA and retinitis pigmentosa. The identified homozygous variant was the top candidate using both bioinformatic pipelines.

Conclusions: This study highlights the value of the broad sequencing strategy of exome sequencing for disease gene identification in LCA, over other existing methods. NGS is particularly beneficial in LCA where there are a large number of causative disease genes, few distinguishing clinical features for precise candidate disease gene selection, and few mutation hotspots in any of the known disease genes.     

支架置入治疗气管恶性狭窄

目的 探讨气管内支架留置的方法,及观察自胀式金属内支架在气管恶性狭窄中的疗效。方法 12例患者全部采用在透视下．经口、喉、气道内支架留置术。结果 患者呼吸困难在支架留置后即刻改善。l2例均获成功．没有技术上失败。结论 气管恶性狭窄的内支架留置术安全、有效．能明显提高患者的生活质量。