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The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA. [ABSTRACT FROM AUTHOR]

Background: Influenza accounts for a substantial number of deaths and hospitalisations annually in South Africa. To address this disease burden, the South African National Department of Health introduced a trivalent inactivated influenza vaccination programme in 2010. Methods: We adapted and populated the WHO Seasonal Influenza Immunization Costing Tool (WHO SIICT) with country‐specific data to estimate the cost of the influenza vaccination programme in South Africa. Data were obtained through key‐informant interviews at different levels of the health system and through a review of existing secondary data sources. Costs were estimated from a public provider perspective and expressed in 2018 prices. We conducted scenario analyses to assess the impact of different levels of programme expansion and the use of quadrivalent vaccines on total programme costs. Results: Total financial and economic costs were estimated at approximately USD 2.93 million and USD 7.91 million, respectively, while financial and economic cost per person immunised was estimated at USD 3.29 and USD 8.88, respectively. Expanding the programme by 5% and 10% increased economic cost per person immunised to USD 9.36 and USD 9.52 in the two scenarios, respectively. Finally, replacing trivalent inactivated influenza vaccine (TIV) with quadrivalent vaccine increased financial and economic costs to USD 4.89 and USD 10.48 per person immunised, respectively. Conclusion: We adapted the WHO SIICT and provide estimates of the total costs of the seasonal influenza vaccination programme in South Africa. These estimates provide a basis for planning future programme expansion and may serve as inputs for cost‐effectiveness analyses of seasonal influenza vaccination programmes. [ABSTRACT FROM AUTHOR]

BACKGROUND Recent US blood pressure (BP) guidelines recommend using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to screen adults for masked hypertension. However, limited evidence exists of the expected long-term effects of screening for and treating masked hypertension. METHODS We estimated the lifetime health and economic outcomes of screening for and treating masked hypertension using the Cardiovascular Disease (CVD) Policy Model, a validated microsimulation model. We simulated a cohort of 100,000 US adults aged ≥20 years with suspected masked hypertension (i.e. office BP 120–129/<80 mm Hg, not taking antihypertensive medications, without CVD history). We compared usual care only (i.e. no screening), usual care plus ABPM, and usual care plus HBPM. We projected total direct healthcare costs (2021 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Future costs and QALYs were discounted 3% annually. Secondary outcomes included CVD events and serious adverse events. RESULTS Relative to usual care, adding masked hypertension screening and treatment with ABPM and HBPM was projected to prevent 14.3 and 20.5 CVD events per 100,000 person-years, increase the proportion experiencing any treatment-related serious adverse events by 2.7 and 5.1 percentage points, and increase mean total costs by $1,076 and $1,046, respectively. Compared with usual care, adding ABPM was estimated to cost $85,164/QALY gained. HBPM resulted in lower QALYs than usual care due to increased treatment-related adverse events and pill-taking disutility. CONCLUSIONS The results from our simulation study suggest screening with ABPM and treating masked hypertension is cost-effective in US adults with suspected masked hypertension. [ABSTRACT FROM AUTHOR]

Background: Cholesterol guidelines typically prioritize primary prevention statin therapy on the basis of 10-year risk of cardiovascular disease. The advent of generic pricing may justify expansion of statin eligibility. Moreover, 10-year risk may not be the optimal approach for statin prioritization. We estimated the cost-effectiveness of expanding preventive statin eligibility and evaluated novel approaches to prioritization from a Scottish health sector perspective.Methods: A computer simulation model predicted long-term health and cost outcomes in Scottish adults ≥40 years of age. Epidemiologic analysis was completed using the Scottish Heart Health Extended Cohort, Scottish Morbidity Records, and National Records of Scotland. A simulation cohort was constructed with data from the Scottish Health Survey 2011 and contemporary population estimates. Treatment and cost inputs were derived from published literature and health service cost data. The main outcome measure was the lifetime incremental cost-effectiveness ratio, evaluated as cost (2020 GBP) per quality-adjusted life-year (QALY) gained. Three approaches to statin prioritization were analyzed: 10-year risk scoring using the ASSIGN score, age-stratified risk thresholds to increase treatment rates in younger individuals, and absolute risk reduction (ARR)-guided therapy to increase treatment rates in individuals with elevated cholesterol levels. For each approach, 2 policies were considered: treating the same number of individuals as those with an ASSIGN score ≥20% (age-stratified risk threshold 20, ARR 20) and treating the same number of individuals as those with an ASSIGN score ≥10% (age-stratified risk threshold 10, ARR 10).Results: Compared with an ASSIGN score ≥20%, reducing the risk threshold for statin initiation to 10% expanded eligibility from 804 000 (32% of adults ≥40 years of age without CVD) to 1 445 500 individuals (58%). This policy would be cost-effective (incremental cost-effectiveness ratio, £12 300/QALY [95% CI, £7690/QALY-£26 500/QALY]). Incremental to an ASSIGN score ≥20%, ARR 20 produced ≈8800 QALYs and was cost-effective (£7050/QALY [95% CI, £4560/QALY-£10 700/QALY]). Incremental to an ASSIGN score ≥10%, ARR 10 produced ≈7950 QALYs and was cost-effective (£11 700/QALY [95% CI, £9250/QALY-£16 900/QALY]). Both age-stratified risk threshold strategies were dominated (ie, more expensive and less effective than alternative treatment strategies).Conclusions: Generic pricing has rendered preventive statin therapy cost-effective for many adults. ARR-guided therapy is more effective than 10-year risk scoring and is cost-effective. [ABSTRACT FROM AUTHOR]

This article presents the findings of a secondary analysis of data arising from a quantitative study of 3769 nurses on co-worker relationships and their impact on nurses working in public healthcare settings in Ireland. The overall findings from this analysis suggest moderate to high levels of satisfaction with co-worker relationships, with an average scale mean of 77%. Statistically significant lower scale means were identified in respect of nurses whose basic nursing qualification was awarded in a country outside the EU, among students and among those working in the west of Ireland. Respondents intending to leave the healthcare workforce reported significantly lower scores (74%) on this index compared with those intending to stay (79%). Significant positive correlations between co-worker relationships and workplace engagement (0.233), job satisfaction (0.225), organisational commitment (0.221) and perception of managers (0.259) were identified. These findings have implications for the retention of nurses working in Irish public healthcare services. [ABSTRACT FROM AUTHOR]

Overweight and obesity are major risk factors for noncommunicable diseases. This presents a major burden to health systems and to society in South Africa. Collectively, these conditions are overwhelming public healthcare. This is happening when the country has embarked on a journey to universal health coverage, hence the need to estimate the cost of overweight and obesity. Our objective was to estimate the healthcare cost associated with treatment of weight-related conditions from the perspective of the South African public sector payer. Using a bottom-up gross costing approach, this study draws data from multiple sources to estimate the direct healthcare cost of overweight and obesity in South Africa. Population Attributable Fractions (PAF) were calculated and multiplied by each disease's total treatment cost to apportion costs to overweight and obesity. Annual costs were estimated for 2020. The total cost of overweight and obesity is estimated to be ZAR33,194 million in 2020. This represents 15.38% of government health expenditure and is equivalent to 0.67% of GDP. Annual per person cost of overweight and obesity is ZAR2,769. The overweight and obesity cost is disaggregated as follows: cancers (ZAR352 million), cardiovascular diseases (ZAR8,874 million), diabetes (ZAR19,861 million), musculoskeletal disorders (ZAR3,353 million), respiratory diseases (ZAR360 million) and digestive diseases (ZAR395 million). Sensitivity analyses show that the total overweight and obesity cost is between ZAR30,369 million and ZAR36,207 million. This analysis has demonstrated that overweight and obesity impose a huge financial burden on the public health care system in South Africa. It suggests an urgent need for preventive, population-level interventions to reduce overweight and obesity rates. The reduction will lower the incidence, prevalence, and healthcare spending on noncommunicable diseases. [ABSTRACT FROM AUTHOR]

Abstract Anthelmintic resistance has been reported in most sheep producing countries. Prior to the mid 1990s, reports of anthelmintic resistance in Ireland were sparse and focused on benzimidazole, one of the three classes of anthelmintic available during this period. This evidence for efficacy issues on Irish farms combined with awareness that anthelmintic resistance was increasingly being reported in other countries prompted the need for more comprehensive investigations on Irish farms. Faecal egg count reduction and micro-agar larval development tests were employed to investigate resistance to benzimidazole, levamisole and macrocyclic lactone. There is compelling evidence for resistance to both benzimidazole (>88% of flocks) and levamisole (>39% of flocks). Resistance of nematode populations to macrocyclic lactone was suspected on a small number of farms (11%) but needs to be confirmed. The recent introduction of two new classes of anthelmintics, after over a 25 year interval, together with the evidence that anthelmintic resistance is reported within a relatively short time following the introduction of a new anthelmintic compound means that the challenge to the industry is immediate. Actions are urgently required to manage anthelmintic resistance so as to prolong the lifespan of anthelmintics.

• CETSIV is useful for assessing the cost-effectiveness of influenza vaccines. • Influenza vaccination is cost-effective for most vulnerable groups in South Africa. • A budget impact analysis is useful for supporting expansions of the programme. Seasonal influenza imposes a significant health and economic burden in South Africa, particularly in populations vulnerable to severe consequences of influenza. This study assesses the cost-effectiveness of South Africa's seasonal influenza vaccination strategy, which involves vaccinating vulnerable populations with trivalent inactivated influenza vaccine (TIV) during routine facility visits. Vulnerable populations included in our analysis are persons aged ≥ 65 years; pregnant women; persons living with HIV/AIDS (PLWHA), persons of any age with underlying medical conditions (UMC) and children aged 6–59 months. We employed the World Health Organisation's (WHO) Cost Effectiveness Tool for Seasonal Influenza Vaccination (CETSIV), a decision tree model, to evaluate the 2018 seasonal influenza vaccination campaign from a public healthcare provider and societal perspective. CETSIV was populated with existing country-specific demographic, epidemiologic and coverage data to estimate incremental cost-effectiveness ratios (ICERs) by comparing costs and benefits of the influenza vaccination programme to no vaccination. The highest number of clinical events (influenza cases, outpatient visits, hospitalisation and deaths) were averted in PLWHA and persons with other UMCs. Using a cost-effectiveness threshold of US$ 3 400 per quality-adjusted life year (QALY), our findings suggest that the vaccination programme is cost-effective for all vulnerable populations except for children aged 6–59 months. ICERs ranged from ~US$ 1 750 /QALY in PLWHA to ~US$ 7 500/QALY in children. In probabilistic sensitivity analyses, the vaccination programme was cost-effective in pregnant women, PLWHA, persons with UMCs and persons aged ≥65 years in >80% of simulations. These findings were robust to changes in many model inputs but were most sensitive to uncertainty in estimates of influenza-associated illness burden. South Africa's seasonal influenza vaccination strategy of opportunistically targeting vulnerable populations during routine visits is cost-effective. A budget impact analysis will be useful for supporting future expansions of the programme. [ABSTRACT FROM AUTHOR]

This paper presents the findings from an analysis of survey data which was collected from public health nurses (N = 136) as part of a larger study with more than 4000 nurses and midwives in Ireland. The purpose of the study was to examine the prevalence of burnout using the Oldenburg Burnout Inventory and to compare relationships between burnout, demographic and work characteristics across this group of nurses. Younger PHNs were most likely to report feeling burnout (68%) compared with those aged 51 or over (47%) who reported the lowest levels. PHNs whose highest level of qualification was a primary degree were least likely to report feeling burnout (31%) compared with those who held a Masters / Doctoral degree (54.5%). PHNs who reported working on a fixed-term full-time contract were most likely to report feeling burnout (70%) compared with those who were on a permanent part-time contract (49%). Quantitative analysis, using both descriptive and inferential statistics, was carried out and the findings show that PHNs reported moderate levels of burnout. The findings also show that burnout among PHNs is strongly correlated with the physical demands placed on individuals during work, having constant time pressures, too much being expected of individuals, the work environment being too demanding and dissatisfaction with the physical conditions. [ABSTRACT FROM AUTHOR]

The population health effect and cost-effectiveness of implementing intensive blood pressure goals in high-cardiovascular disease (CVD) risk adults have not been described. Using the CVD Policy Model, CVD events, treatment costs, quality-adjusted life years, and drug and monitoring costs were simulated over 2016 to 2026 for hypertensive patients aged 35 to 74 years. We projected the effectiveness and costs of hypertension treatment according to the 2003 Joint National Committee (JNC)-7 or 2014 JNC8 guidelines, and then for adults aged ≥50 years, we assessed the cost-effectiveness of adding an intensive goal of systolic blood pressure <120 mm Hg for patients with CVD, chronic kidney disease, or 10-year CVD risk ≥15%. Incremental cost-effectiveness ratios <$50 000 per quality-adjusted life years gained were considered cost-effective. JNC7 strategies treat more patients and are more costly to implement compared with JNC8 strategies. Adding intensive systolic blood pressure goals for high-risk patients prevents an estimated 43 000 and 35 000 annual CVD events incremental to JNC8 and JNC7, respectively. Intensive strategies save costs in men and are cost-effective in women compared with JNC8 alone. At a willingness-to-pay threshold of $50 000 per quality-adjusted life years gained, JNC8+intensive had the highest probability of cost-effectiveness in women (82%) and JNC7+intensive the highest probability of cost-effectiveness in men (100%). Assuming higher drug and monitoring costs, adding intensive goals for high-risk patients remained consistently cost-effective in men, but not always in women. Among patients aged 35 to 74 years, adding intensive blood pressure goals for high-risk groups to current national hypertension treatment guidelines prevents additional CVD deaths while saving costs provided that medication costs are controlled. [ABSTRACT FROM AUTHOR]

Renal disease is a well-recognized manifestation of cystic fibrosis (CF) and people with CF are at increased risk of nephrolithiasis. Lithotripsy is the preferred treatment but has occasionally been associated with pulmonary complications. Here we report the case of a person with CF who developed a pneumothorax soon after lithotripsy and discuss the potential mechanism of injury. We hope this case highlights some of the additional considerations clinicians should take into account when managing patients with advanced pulmonary disease in CF. [ABSTRACT FROM AUTHOR]

Introduction: Intensive blood pressure (BP) goals are considered for high cardiovascular disease (CVD) risk adults ≥50 years old; the long-term value of intensive BP goals in younger high CVD risk patients has not been studied. Objectives: We used individual patient computer simulations to assess the incremental value of intensive BP goals in high CVD risk patients as young as 40 years. Methods: Six age/sex cohorts of 100,000 individuals were assembled by sampling NHANES surveys 1999-2010. BP and other risk factor trajectories were projected from ages 60 to 69, 50 to 69, and 40 to 69 years based on Framingham Offspring Cohort analyses. One BP treatment scenario simulated treating BP <140/90 mmHg in all patients ≥140/90; a second scenario added to the first a goal

Introduction: Extended periods of exposure to elevated blood pressure (BP) in early adult life contribute independently to later life coronary heart disease (CHD) risk. Currently, there are significant gaps in hypertension awareness, treatment, and control in young adults. The long-term health benefits of controlling high BP in young adults have not previously been quantified. Objective: This study aimed to project CHD prevention benefits from controlling raised blood pressure starting in early adulthood compared with control at age 40 or older. Method: A state-transition microsimulation model estimated individual-level CHD outcomes, dependent on risk factors exposures and accounting for competing risk of stroke or non-cardiovascular death. Risk for first CHD event after age 40 was conditioned both on time-weighted average of early adult (ages 20-39) diastolic blood pressure (DBP), and raised DBP or systolic blood pressure (SBP) at age ≥ 40. We simulated CHD outcomes in a cohort of US adults with DBP ≥ 85 mmHg any time in young adulthood in 3 scenarios: no treatment, later life SBP control alone, or early DBP control plus later life BP control. Results: By age 39, 2.2% of the CVD-free young adult U.S. population was estimated to have early elevated DBP and was eligible for treatment. With follow up until age 69 years, early BP control prevented twice the number of primary CHD events (Table). Conclusion: This study quantifies the opportunity cost of failing to control hypertension identified in young adulthood. It is unclear whether early blood pressure control should be achieved by lifestyle or pharmacological intervention. [ABSTRACT FROM AUTHOR]

Metastatic renal-cell carcinoma (RCC) is resistant to chemotherapy, and patients with this disease have a poor outlook. Immunotherapy by use of cytokines and vaccines against tumour antigens has shown encouraging results in a small group of patients. Advances in the understanding of the graft-versus-tumour effect in haematological malignant disorders have led to the use of stem-cell transplantation for treatment of solid-organ malignant diseases such as RCC. Techniques of bone-marrow ablation have been superseded by safer conditioning regimens, with occasional complete remission and partial remission in some patients. Graft-versus-host disease, engraftment failure, and disease progression remain important obstacles to the widespread use of new techniques for metastatic RCC. Here, we summarise important issues surrounding immunotherapy for RCC, the problems encountered with use of immunotherapy, and the present use of non-myeloablative techniques for treatment of this disease. [Copyright &y& Elsevier]

Targeted selective treatment (TST) has been proposed as a sustainable method of gastrointestinal nematode control that reduces the number of anthelmintic treatments administered, thereby preserving a susceptible nematode population in refugia . In order to minimise the impact of withholding treatment on animal performance, animals that would benefit most should be selected for treatment. However, the most suitable criteria for selecting which animals to treat remain a subject of research. The impact of implementing a TST strategy based on lamb live weight was investigated, and whether heavy lambs were more resilient than light lambs if left untreated. The study was conducted using weaned lambs on 3 sheep farms, and over 2 years. On each farm lambs were weighed and divided into heavy, medium and light weight classes. Within the heavy (n = 225) and light (n = 218) weight classes lambs were randomly allocated to two treatments; anthelmintic treatment or no anthelmintic treatment. All lambs in the medium weight class were treated. Animal performance and parasitological parameters were assessed over a 28-day period. Anthelmintic treatment had a significant effect (P < 0.01) on faecal egg count, average daily weight gain, body condition score and dag score; there was no treatment by weight class interaction. Anthelmintic treatment had no effect on plasma pepsinogen concentration or on blood leukocyte numbers. Withholding anthelmintic treatment from lambs therefore had a negative effect on worm egg count and animal performance with no evidence that heavy lambs were more resilient than light lambs when left untreated. [ABSTRACT FROM AUTHOR]