RESUMEN

BACKGROUND: Understanding and mitigating the societal economic impact of vision impairment (VI) is important for achieving the Sustainable Development Goals. AIM: To estimate the prevalent societal economic impact of presenting VI in Trinidad and Tobago using bottom-up cost and utilisation data from the 2014 National Eye Survey of Trinidad and Tobago. METHODS: We took a societal perspective to combine comprehensive, individual-level cost and utilisation data, with population-based prevalence estimates for VI, and additional data from a contemporaneous national eyecare system survey. We included direct (medical and non-medical) and indirect (productivity loss) costs, and intangible losses in total cost estimates, presented in 2014 Trinidad & Tobago (TT) dollars and UK sterling equivalent. We considered but excluded transfer payments and dead weight losses. Sensitivity analyses explored impact on total cost of parameter uncertainty and assumptions. RESULTS: Individual utilisation and cost data were available for 65.5% (n = 2792/4263) and 59.0% (n = 2516/4263) eligible participants aged ≥40 years, respectively. Participant mean age was 58.4(SD 11.8, range 40-103) years, 56.3% were female. We estimated total societal cost of VI in 2014 at UK£365,650,241 (TT$3,842,324,655), equivalent to £675 per capita (population ≥40 years). Loss of wellbeing accounted for 73.3%. Excluding this, the economic cost was UK£97,547,222 (TT$1,025,045,399), of which indirect costs accounted for 70.5%, followed by direct medical costs (17.9%), and direct non-medical costs (11.6%). CONCLUSION: This study provides a comprehensive estimate of the economic impact of vision loss in a Caribbean country, and highlights the extent to which affected individuals and their families bear the societal economic cost of vision impairment.

RESUMEN

Objective: There has been some discussion in the literature concerning health inequality in Trinidad and Tobago (T&T) associated with specific illnesses. This study sought to quantify inequality in health across the T&T population using a generic multiattribute utility instrument. Design and Methodology: A representative sample of 2,036 T&T adults completed the EQ-5D-5L self-reported health instrument. Mean EQ-5D-index values and EQVAS (Visual Analogue Scale) values were calculated by age-group, ethnicity, gender, income, educational attainment, employment status, insurance status, and place of residence. Logistic regression models and Kakwani Indices were used to evaluate and decompose inequalities in health. An Ordinary Least Squares model was developed to provide the expected VAS value of a T&T citizen based on their demographic characteristics. Results: Women were more likely than men to report 53 problems on all five EQ-5D dimensions. The dimension with the highest rate of reported problems was Pain/Discomfort (22%). Selfreported EQ-5D Index and VAS values decrease with age however the decreases are faster for women, and they accelerate after the mid-fifties age group. The Kakwani index for Trinidad and Tobago was estimated to be 0.103 placing T&T in the lower quartile when compared with other countries. Using odds ratios, age, gender, education, and income were found to have significant effects (p<0.05) on self-reported health. Conclusions: This study presents empirical data on the health status of different demographic groups for T&T, identifies the sub groups with the most acute differences in health status, and compares T&T to other countries for which such data are available.

Asunto(s)

RESUMEN

OBJECTIVE: Anti-AMPAR encephalitis is a recently discovered disorder characterized by the presence of antibodies in serum or cerebrospinal fluid against the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor. Here, we examine the antigenic specificity of anti-AMPAR antibodies, screen for new patients, and evaluate functional effects of antibody treatment of neurons. METHODS: We developed a fusion protein-based western blotting test for anti-AMPAR encephalitis antibodies. Antibody specificity was also evaluated using immunocytochemistry of HEK293 cells expressing deletion mutants of AMPAR subunits. Purified patient IgG or AMPAR antibody-depleted IgG was applied to live neuronal cultures; amplitude and frequency of miniature excitatory postsynaptic currents (mEPSCs) were measured to evaluate functional effects of antibodies. RESULTS: Using both immunocytochemistry and fusion protein western blots, we defined an antigenic region of the receptor in the bottom lobe of the amino terminal domain. Additionally, we used fusion proteins to screen 70 individuals with neurologic symptoms of unknown cause and 44 patients with no neurologic symptoms or symptoms of known neuroimmunological origin for anti-AMPAR antibodies. Fifteen of the 70 individuals had anti-AMPAR antibodies, with broader antigenic reactivity patterns. Using purified IgG from an individual of the original cohort of anti-AMPAR encephalitis patients and a newly discovered patient, we found that application of IgG from either patient cohort caused an AMPAR antibody-dependent decrease in the amplitude and frequency of mEPSCs in cultured neurons. INTERPRETATION: These results indicate that anti-AMPAR antibodies are widespread and functionally relevant; given the robust response of patients to immunomodulation, this represents a significant treatable patient population.

RESUMEN

OBJECTIVE: No country can afford to provide all necessary healthcare for its citizens, so prioritization among interventions must feature in all health systems. Resources in health should be allocated among interventions/facilities/patients in such a way as to be in line with the objectives of the health system. To achieve this, resource allocation decisions must be informed by the relative contributions that prospective interventions will make to societal health and to costs. Internationally, the EQ-5D based quality adjusted life year (QALY) now dominates this kind of analysis. This paper reports on a pilot study to develop an EQ-5D-3L value set for Trinidad and Tobago based on a protocol that avoids some of the issues that are associated with other approaches to developing such value sets such as the complex elicitation tasks that respondents must carry out, and the large respondent samples required for collecting multiple valuation subset values using blocked designs. METHODS: An orthogonal discrete choice experiment design was used to elicit a set of choices from a sample of respondents. RESULTS: The choice data were analysed using mixed multinomial logistic regression to produce an internally valid model that predicts well. CONCLUSION: This paper marks an important milestone in the development of health resource allocation in the Caribbean. It sets out the importance of incorporating the impact of health interventions to inform health resource allocation decisions, describes the elicitation and analysis methods used in the pilot and provides an illustration ofthe use ofthe EQ-5D value set.

OBJETIVO: Ningún país puede permitirse ofrecer toda la atención a la salud necesaria para sus ciudadanos, de modo que la necesidad de establecer prioridades en las intervenciones constituye un rasgo característico de todos los sistemas de salud. Los recursos de salud deben asignarse entre las intervenciones/instalaciones/pacientes de tal manera que se correspondan con los objetivos del sistema de salud. Para lograr esto, las decisiones en cuanto a la asignación de recursos deben reportarse en términos de las contribuciones relativas que las intervenciones prospectivas representarán para la salud social y los costos. Internacionalmente, el EQ - 5D basado en el año de vida ajustado por calidad (AVAC), domina ahora este tipo de análisis. El presente trabajo reporta un estudio piloto para desarrollar un conjunto de valores EQ - 5D - 3L para Trinidad y Tobago, basado en un protocolo que evite algunos de los problemas asociados con otros enfoques usados para desarrollar estos conjuntos de valores, tales como tareas complejas de obtención de datos, que los encuestados tienen que llevar a cabo, y las grandes muestras de respuestas requeridas para recoger varios subconjuntos de valoración múltiple utilizando diseños bloqueados. MÉTODOS: Un diseño de experimento de elección discreta ortogonal se utiliza para obtener un conjunto de opciones de una muestra de encuestados. RESULTADOS: Los datos de la elección se analizaron mediante regresión logística multinomial mixta para producir un modelo internamente válido que predice bien. CONCLUSION: Este documento marca un hito importante en el desarrollo de la asignación de recursos de salud en el Caribe. El mismo establece la importancia de incorporar el impacto de las intervenciones de salud para informar las decisiones de asignación de recursos de salud, describe los métodos de obtención y análisis utilizados en el programa piloto, y proporciona una ilustración del uso del conjunto de valores EQ - 5D.

Asunto(s)

RESUMEN

OBJECTIVE: No country can afford to provide all necessary healthcare for its citizens, so prioritization among interventions must feature in all health systems. Resources in health should be allocated among interventions/facilities/patients in such a way as to be in line with the objectives of the health system. To achieve this, resource allocation decisions must be informed by the relative contributions that prospective interventions will make to societal health and to costs. Internationally, the EQ-5D based quality adjusted life year (QALY) now dominates this kind of analysis. This paper reports on a pilot study to develop an EQ-5D-3L value set for Trinidad and Tobago based on a protocol that avoids some of the issues that are associated with other approaches to developing such value sets such as the complex elicitation tasks that respondents must carry out, and the large respondent samples required for collecting multiple valuation subset values using blocked designs. METHODS: An orthogonal discrete choice experiment design was used to elicit a set of choices from a sample of respondents. RESULTS: The choice data were analysed using mixed multinomial logistic regression to produce an internally valid model that predicts well. CONCLUSION: This paper marks an important milestone in the development of health resource allocation in the Caribbean. It sets out the importance of incorporating the impact of health interventions to inform health resource allocation decisions, describes the elicitation and analysis methods used in the pilot and provides an illustration of the use of the EQ-5D value set.

Asunto(s)

RESUMEN

Laparoscopic Cholecystectomy (LC) is compared to the Open and Minilap approaches in a Cost Minimization Analysis for public hospitals in Trinidad and Tobago. The analysis shows that despite the high initial equipment cost required to perform LC, substantial savings can be achieved at the hospital level by converting from a minilap or open regime to a laparoscopic regime for cholecystectomy. Because of the reduced recovery period for the patient, LC represents further savings to other sectors of the economy as patients return to work much earlier after LC than after the other two approaches.

Asunto(s)

RESUMEN

Laparoscopic Cholecystectomy (LC) is compared to the Open and Minilap approaches in a Cost Minimization Analysis for public hospitals in Trinidad and Tobago. The analysis shows that despite the high initial equipment cost required to perform LC, substantial savings can be achieved at the hospital level by converting from a minilap or open regime to a laparoscopic regime for cholecystectomy. Because of the reduced recovery period for the patient, LC represents further savings to other sectors of the economy as patients return to work much earlier after LC than after the other two approaches

La colecistectomía laparoscópica (CL) es comparado aquí con la cirugía abierta y la mini-laparotomía en un análisis de minimización de costos para los hospitales públicos en Trinidad y Tobago. El análisis muestra que a pesar del alto costo inicial del equipo requerido para realizar la CL, pueden lograrse ahorros sustanciales a nivel de hospital mediante la conversión del régimen de minilaparotomía o el de cirugía abierta a un régimen laparoscópico en la realización de la cole-cistectomía. En virtud de la reducción del periodo de recuperación de los pacientes, la CL representa ahorros ulteriores en otros sectores de la economía, ya que los pacientes regresan a sus trabajos en un espacio de tiempo mucho más corto, en comparación con lo que ocurre con las otras dos vías de acceso.

Asunto(s)