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Objectives This study tries to analyze how the crisis generated by severe acute respiratory syndrome coronavirus 2 has affected the reported mental health symptoms of informal caregivers in different European countries. Methods The Survey of Health, Ageing and Retirement in Europe-COVID-19 was used, collecting information from the beginning of June 2020 to August 2020 about individuals’ state of health and the care they received. Several probit regression models were used to analyze the differences in the probability of (1) being sad or depressed, (2) being anxious or nervous, (3) having difficulty sleeping, and (4) feeling lonely, between individuals who provided informal care and individuals who did not. Several subanalyses by geographic area, mortality rates due to coronavirus disease 2019 (COVID-19), and long-term care expenditure were also performed. Results Since the outbreak of COVID-19, informal caregivers have had a higher probability of being sad or depressed of 8 percentage points (p.p.), a 7.1 p.p. higher probability of being anxious or nervous, and a 5.9 p.p. higher probability of having difficulty sleeping than non-caregivers. Informal caregivers in Southern Europe have had an 8 p.p. higher probability of being sad or depressed than non-caregivers. In Eastern Europe, this difference in probability reaches 9.7 p.p. Finally, in countries with higher mortality rates due to COVID-19, there have been greater differences in terms of being sad or depressed between caregivers and non-caregivers, regardless of expenditure on long-term care. Conclusions Since the outbreak of COVID-19, informal caregivers in Europe have had a higher probability of reporting mental health symptoms than non-caregivers.

This study aims to assess the determinants of employment probabilities among people living with Human Immunodeficiency Virus (HIV) during a 15-year period (2001–2016) in Spain, focusing on the possible effects of occurrences such as the 2008 economic crisis. The probability of people living with HIV having a job was evaluated by applying several multivariate probit regression models. Differences between the employment status of people living with HIV and that of the general population were evaluated by applying genetic matching regression models. With respect to the former evaluation, for people living with HIV, the period before the crisis (2001–2007) was associated with a probability of being employed that was 2.43 percentage points (p.p.) higher than during the crisis, and the period after the crisis (2014–2016) with a probability that was 7.58 p.p. lower than during the crisis. Greater effects were also observed among males, the probability of being in employment before the economic crisis being higher (by 2.26 p.p.) and lower after the crisis (− 3.41 p.p.) than among women, and among those infected through drug use (6.18 p.p. and − 7.34 p.p. before and after the crisis, respectively), than among those infected through sex. When analysing the differences with respect to the general population, people living with HIV reported lower probabilities of being employed: by − 18 p.p. before the crisis, by − 15 p.p. during the crisis (years 2008–2013) and by − 10 p.p. after the crisis, implying a convergence in the prospects of employment with the passage of the years. Those differences were greater for people of basic educational level (− 23 to − 16 p.p.), a weaker immune system (− 34 p.p. to − 21 p.p.) and those infected through the use of drugs (− 31 p.p. to − 26 p.p.). Although the results suggest that the economic crisis had a greater effect on the employment prospects of people living with HIV, and that effect is still felt by that group, our findings also point towards a convergence of their employment prospects with those of the general population, over the 15-year period assessed. An analysis of the employment situation of people living with HIV might have helped when designing job-seeking methods and policies on the working environment, especially through the 15-year period considered, when the economic crisis had a greater effect on the job market.

Introducción: la atención del paciente con dermatitis atópica en Matanzas, no escapa a la complejidad de las influencias que inciden en su prevención, diagnóstico y tratamiento, constituyendo un problema práctico consultas en el área estudiada. Objetivo: Caracterizar los factores de riesgo de la dermatitis atópica en pacientes asistidos en la consulta municipal de Matanzas en el período de abril de 2016 a marzo de 2017. Metodología: Se realizó un estudio descriptivo transversal en pacientes que asistieron a la consulta municipal de Alergología en Matanzas con diagnóstico confirmado de dermatitis atópica de edades comprendidas entre un mes y 18 años, de ambos sexos, en el período de estudio (N=75) y que dieran su conformidad en participar en la investigación. Se emplearon métodos teóricos, empíricos mediante una entrevista a las madres por un cuestionario confeccionado por los autores para obtener información del período perinatal y edad pediátrica, y estadísticos. Resultados: Los factores que predominaron fueron el genético, la ablactación precoz, los alimentos alergizantes consumidos por las madres durante la lactancia, el factor psicógeno, la exposición a factores ambientales y los cambios de tiempo, encontrándose interrelación entre ellos. Conclusiones: Se evidenciaron algunas diferencias en el orden de la prioridad entre los factores de riesgo encontrados en la bibliografía y en los pacientes estudiados.

Purpose Little is known about the economic burden that malnutrition or its risk imposes on community-dwelling older adults. Using cross-sectional and longitudinal analyses, we assessed the impact of malnutrition risk on healthcare utilization and costs in a cohort of older adults living in Spanish community. Patients and Methods Data from 1660 older (range 66-98 years), community-living adults participating in the Toledo Study on Healthy Ageing, waves 2 (year 2011-2013) and 3 (year 2015), were analyzed. Nutritional status categories were defined according to the Global Leadership Initiative on Malnutrition (GLIM) criteria, using a two-step approach. First, screening for malnutrition risk. Once positive, individuals were classified as malnourished according to some phenotypic (body mass index, grip strength, and unintentional weight loss) and etiologic (disease burden/inflammation and reduced food intake or assimilation) criteria. Outcomes assessed included healthcare resources (hospital admissions, number of hospitalizations, length of hospital stay per hospitalization, and number of medications). Results Fifteen percent of the population was found to be at risk of malnutrition, while 12.6% was malnourished. Overall, patients from both groups were older, had lower functional status, and had more comorbidities compared to well-nourished counterparts (p

Improvements in medical treatment have contributed to rising health spending. Yet there is relatively little evidence on whether the spending increase is “worth it” in the sense of producing better health outcomes of commensurate value—a critical question for understanding productivity in the health sector and, as that sector grows, for deriving an accurate quality-adjusted price index for an entire economy. We analyze individual-level panel data on medical spending and health outcomes for 123,548 patients with type 2 diabetes in four health systems: Japan, The Netherlands, Hong Kong and Taiwan. Using a “cost-of-living” method that measures value based on improved survival, we find a positive net value of diabetes care: the value of improved survival outweighs the added costs of care in each of the four health systems. This finding is robust to accounting for selective survival, end-of-life spending, and a range of values for a life-year or fraction of benefits attributable to medical care. Since the estimates do not include the value from improved quality of life, they are conservative. We, therefore, conclude that the increase in medical spending for management of diabetes is offset by an increase in quality.

Las evaluaciones económicas de intervenciones sanitarias se han convertido en los últimos años en una herramienta primordial para informar las decisiones que atañen a la asignación de recursos y la adopción de nuevas tecnologías sanitarias. En el caso de la diabetes mellitus, cuya prevalencia y morbilidad a nivel mundial se ha ido incrementando considerablemente a lo largo de las últimas décadas, resulta primordial desarrollar nuevas estrategias y priorizar aquellas intervenciones que más ayuden a mejorar la salud de la población, haciendo que sea compatible con la sostenibilidad financiera de los sistemas sanitarios públicos. Así, el principal objetivo de este artículo es mostrar al lector las diferentes opciones metodológicas que se deben considerar a la hora de diseñar o de interpretar una evaluación económica en el ámbito de la diabetes mellitus, con el apoyo de ejemplos e investigaciones prácticas llevadas a cabo en el campo de esta enfermedad.

Objectives Frailty and sarcopenia have been related with adverse events, including hospitalization. However, its combined effect with hospitalization-related outcomes, including costs, has not been previously investigated. Our purpose was to explore how frailty, sarcopenia and its interaction could impact on healthcare expenditures. Methods 1358 community-dwelling older adults from the Toledo Study of Healthy Ageing (TSHA) were included. Sarcopenia was measured using the Foundation for the National Institutes of Health criteria fitted to our cohort. Frailty was defined according to Frailty Trait Scale 5 (FTS5) and the Frailty Index fitted to the cut-off points of TSHA population. Hospitalization costs were taken from hospital records and costs were attributed according to Diagnostic-Related Groups, using as the cost base year 2015. Two-part regression models were used to analyze the relationship between frailty and sarcopenia and hospital admission, number of hospitalizations, length of stay and hospitalization costs. Results Sarcopenia was associated only with the probability of being admitted to hospital. Frailty was also associated with higher hospital use, regardless of the frailty tool used, but in addition increased hospital admission costs at follow-up by 23.72% per year and by 19.73% in the full model compared with non-frail individuals. The presence of sarcopenia did not increase the costs of frailty but, by opposite, frailty significantly increased the costs in people with sarcopenia, reaching by 46–56%/patient/year at follow-up. Older adults with frailty and sarcopenia had a higher risk of hospitalization, disregarding the tool used to assess frailty, and higher hospitalization costs (FTS5) in the full model, at the cross-sectional and at the follow-up level. Conclusions Frailty is associated with increased hospitalization costs and accounts for the potential effects of sarcopenia.

To carry out a cost-effectiveness analysis of the use of Neuropad as a screening test for diabetic neuropathy together with the standard care tool, the 10-g monofilament, in people with diabetes. A cost-effectiveness analysis using a Markov model was developed to assess the impact on costs and outcomes of using Neuropad as a test for diabetic neuropathy (1) as a complement to the standard test, the 10-g monofilament (Neuropad + monofilament vs. monofilament); and (2) as a substitute for the monofilament (Neuropad vs. monofilament); from the healthcare provider perspective. The time horizon was 3 years. Data on costs and health gains were extracted from the literature. The incremental cost–utility ratio was calculated. Deterministic and probabilistic sensitivity analyses were also performed. Compared with standard care, Neuropad, in combination with the 10-g monofilament tool, is the dominant strategy as it leads to higher health gains and lower costs. In practice, compared with using the monofilament alone, performing both tests would lead to a savings of £1049.26 per patient and 0.044 QALY gain. Results were found to be consistent across the sensitivity analyses. Using both screening tools (Neuropad + monofilament) is a cost-effective strategy and the dominant alternative, when compared against using the 10-g monofilament alone. The results would be of special relevance in the early detection of diabetic peripheral neuropathy and to ensure the efficient allocation of resources and, thus, the sustainability of healthcare systems.

Objective To estimate the impact of glycaemic control and time since diabetes diagnosis on care costs incurred by people with type 2 diabetes mellitus (T2DM). Research design and methods Random-effects linear regression models were run to test the impact of average glucose control (HbA1c) and time since diabetes diagnosis on total care spending in people with T2DM, adjusting for year of onset and other covariates. Two datasets were linked, Vektis (healthcare costs reimbursed by the Dutch mandatory health insurance) and Zodiac (clinical and sociodemographic data). The sample includes 22,612 observations, grouped in 5653 individuals from the Northern part of the Netherlands, covering 4 years (2008-2011). Results A 1% point increase in HbA1c is associated with a 2.2% higher total care costs. However, when treatment modality is included, the results are modified. A 1% point increase (11 mol/mol) in HbA1c is significantly associated with 3.4% higher total care costs for individuals without glucose-lowering treatment. Being treated with insulin is significantly associated with an increase in costs of 30-38% for every additional percentage point of HbA1c, depending on the covariates included. Without controlling for year of onset, an additional year of diabetes duration relates to 2.6% higher care costs, while this is 4.9% controlling for year of onset. The effect of HbA1c and diabetes duration differs between types of costs. Conclusion HbA1c, insulin treatment and diabetes duration are the main drivers of increasing care costs. The results signal the relevance of controlling for HbA1c together with treatment modality, diabetes duration and year of diagnosis effects.

The present study aimed to explore the diagnostic and prognostic accuracy of standard and population-specific Physical Performance Measures (PPMs) cut-off points for frailty screening.Prospective cohort study.Population-based study including 2328 subjects from the Toledo Study of Healthy Aging (age = 76.37 ± 6.78). Data related to frailty status and PPMs was collected at baseline visit (2011-2013). Mortality and hospitalization were ascertained up to March 2019 and December 2017, respectively, whereas disability onset and worsening were evaluated in the 2015-2017 visit.Gait speed and Short Physical Performance Battery population-specific cut-off points for frailty were computed using receiver operating characteristics (ROC) curve analysis. Head-to-head comparison of associations with adverse events against existing reference values (SPPB≤6, GS 0.8 m/s) and classical (Frailty Phenotype, Frailty Index) and newly incorporated frailty tools (12- and 5-item Frailty Trait Scale) were explored through logistic and Cox regressions. Predictive ability was compared through areas under the curves (AUCs) for disability onset/worsening and integrated AUCs for mortality and hospitalization (time-censoring adverse events).PPMs population-specific cut-off points (SPPB ≤7 and GS ≤ 0.75 m/s for males; SPPB ≤4 and GS ≤ 0.5 for females) outperformed published reference thresholds in terms of diagnostic accuracy. Frailty identified through PPMs was associated with adverse events (death, hospitalization and incident disability) similarly to that assessed using the newly incorporated tools and showed similar prognostic accuracy (mortality [IAUCs≈0.7], hospitalization [IAUCs≈0.8] and disability onset/worsening [AUCs≈0.62]), except for the tool used to assess frailty.Our results suggest that PPMs might serve as the first screen to identify candidates for further frailty assessment and exploration of underlying mechanisms, allowing opportunistic on-time screening in different settings (community and primary care) in which frailty instruments are rarely implementable.

Background Tenosynovial Giant-Cell Tumour (TGCT) is a benign clonal neoplastic proliferation arising from the synovium, causing a variety of symptoms and often requiring repetitive surgery. This study aims to define the economic burden—from a societal perspective—associated with TGCT patients and their health-related quality of life (HRQOL) in six European countries. Methods This article analyses data from a multinational, multicentre, prospective observational registry, the TGCT Observational Platform Project (TOPP), involving hospitals and tertiary sarcoma centres from six European countries (Austria, France, Germany, Italy, the Netherlands, and Spain). It includes information on TGCT patients’ health-related quality of life and healthcare and non-healthcare resources used at baseline (the 12-month period prior to the patients entering the registry) and after 12 months of follow-up. Results 146 TGCT patients enrolled for the study, of which 137 fulfilled the inclusion criteria. Their mean age was 44.5 years, and 62% were female. The annual average total costs associated with TGCT were €4866 at baseline and €5160 at the 12-month follow-up visit. The annual average healthcare costs associated with TGCT were €4620 at baseline, of which 67% and 18% corresponded to surgery and medical visits, respectively. At the 12-month follow-up, the mean healthcare costs amounted to €5094, with surgery representing 70% of total costs. Loss of productivity represented, on average, 5% of the total cost at baseline and 1.3% at follow-up. The most-affected HRQOL dimensions, measured with the EQ-5D-5L instrument, were pain or discomfort, mobility, and the performance of usual activities, both at baseline and at the follow-up visit. Regarding HRQOL, patients declared a mean index score of 0.75 at baseline and 0.76 at the 12-month follow-up. Conclusion The results suggest that TGCT places a heavy burden on its sufferers, which increases after one year of follow-up, mainly due to the healthcare resources required—in particular, surgical procedures. As a result, this condition has a high economic impact on healthcare budgets, while the HRQOL of TGCT patients substantially deteriorates over time.

Population ageing is one of the current challenges that most societies are facing, with great implications for health systems and social services, including long-term care. This increasing long-term care use is particularly rising for dependent older people, motivating the implementation of regional dependency laws to ensure their care needs’ coverage. Using data from the Survey of Health, Ageing, and Retirement in Europe (SHARE) from the year 2004 until 2017, the aim of this study is to assess the impact that the Spanish System for Personal Autonomy and Dependency might have on (i) household income, according to different needs for care levels, by running Generalized Linear Models (GLMs), and (ii) formal and informal care use depending on the income-related determinant through the performance of logit random-effects regression models. We show that the different degrees of needs for personal care are associated with a lower household income, being associated with an income reduction from €3300 to nearly €3800, depending on the covariates included, per year for the more severely in-need-for-care older adults. Moreover, our findings point towards a higher use of formal and informal care services by the moderate and severe dependents groups, regardless of the household income group and time period. Bearing in mind the demographic ageing, our results highlight the need for the identification of potentially vulnerable populations and the efficient planification of long-term care systems and social support services.

Background: The economic burden of diabetes from a societal perspective is well docu mented in the cost-of-illness literature. However, the effect of considering social costs in the results and conclusions of economic evaluations of diabetes-related interventions remains unknown. Objective: To investigate whether the inclusion of social costs (productivity losses and/or informal care) might change the results and conclusions of economic evaluations of diabetes related interventions. Methods: A systematic review was designed and launched on Medline and the Cost Effectiveness Analysis Registry from the University of Tufts, from the year 2000 until 2018. Included studies had to fulfil the following criteria: i) being an original study published in a scientific journal, ii) being an economic evaluation of an intervention on diabetes, iii) including social costs, iv) being written in English, v) using quality-adjusted life years as outcome, and vi) separating the results according to the perspective applied. Results: From the 691 records identified, 47 studies (6.8%) were selected. Productivity losses were included in 45 of the selected articles (73% used the human capital approach) whereas informal care costs in only 13 (when stated, the opportunity cost method was used in seven studies and the replacement cost in one). The 47 studies resulted in 110 economic evaluation estimations. The inclusion of social costs changed the conclusions in 8 estimations (17%), 6 of them switching from not cost-effective from the healthcare perspective to cost-effective or dominant from the societal per spective. Considering social costs altered the results from cost-effective to dominant in 9 estimations (19%). Conclusion: When social costs are considered, the results and conclusions of economic evaluations performed in diabetes-related interventions can alter. Wide methodological variations have been observed, which limit the comparability of studies and advocate for the inclusion of a wider perspective via the consideration of social costs in economic evaluations and methodological guidelines relating to their estimation and valuation.

Summary Background & aims Poor nutritional status leads to multiple adverse outcomes, but few studies have assessed its role as a risk factor for incident frailty and death in community-dwelling older adults. Hence, the aim of this paper is to assess the role of nutritional status using the Global Leadership Initiative on Malnutrition (GLIM) criteria in the risk of frailty and mortality in Spanish community-dwelling older adults. Methods We used data from two waves (waves 2 (2011–2013) and 3 (2015–2017)) from the Toledo Study of Healthy Ageing, which is an observational, prospective cohort (average follow-up = 3.18 years) of 1660 older (≥65 years) adults living in the community. Nutritional status categories were defined according to the GLIM criteria, which uses a two-step approach. First, screening for malnutrition risk. Once positive, individuals were classified as malnourished according to some phenotypic (body mass index, grip strength and unintentional weight loss) and etiologic (disease burden/inflammation and reduced food intake or assimilation) criteria. Frailty was assessed using both the Frailty Index (FI) and Frailty Trait Scale (FTS). Mortality data was obtained through the National Death Index. Results From the 1660 older adults, 248 participants (14.04%) were classified as ‘at malnutrition risk’ (AMR) and 209 (12.59%) as malnourished (MN). AMR and MN subjects were older and with worse functional status (frailer). Adjusted cross-sectional analysis showed an association between nutritional status and frailty by both FI and FTS. Adjusted longitudinal analyses showed that AMR was associated with higher risk of frailty, using both the FTS (OR: 1.262; 95% CI: 1.078–1.815) and the FI (OR: 1.116; 95% CI: 1.098–1.686), while being malnourished was associated with higher mortality risk (OR: 1.748; 95% CI: 1.073–2.849), but not with incident frailty at follow-up period. Conclusions Nutritional status, assessed through GLIM, predicts in a dose-dependent manner the risk of frailty and death. Being at malnutrition risk predicts the risk of becoming frail at follow-up period, whereas being malnourished predicts mortality. These findings highlight the importance of assessing the nutritional status of community-dwelling older adults to identify the ones at risk of developing frailty or death and inform targeted nutrition-focused interventions.

Aims To assess the impact of diabetes and diabetes-related complications on two measures of productivity for people in the labour force and out of it, namely “being afraid health limits ability to work before retirement” and “volunteering”. Methods and data Logistic regressions were run to test the impact of diabetes and its complications on the probability of being afraid health limits work and being a formal volunteer. The longitudinal sample for the former outcome includes 53,631 observations, clustered in 34,393 individuals, aged 50–65 years old whereas the latter consists of 45,384 observations, grouped in 29,104 individuals aged 65 and above across twelve European countries taken from the Survey of Health, Ageing and Retirement in Europe, from 2006 to 2013. Results Diabetes increased the probability of being afraid health limited work by nearly 11% points, adjusted by clinical complications, and reduced the likelihood of being a formal volunteer by 2.7% points, additionally adjusted by mobility problems. We also found that both the probability of being afraid health limits work and the probability of being a formal volunteer increased during and after the crisis. Moreover, having diabetes had a larger effect on being afraid health limits work during the year 2010, possibly related to the financial crisis. Conclusions Our findings show that diabetes significantly affects the perception of people regarding the effects of their condition on work, increasing the fear that health limits their ability to work, especially during the crisis year 2010, as well as the participation in volunteering work among retired people. Electronic supplementary material The online version of this article (doi:10.1007/s10198-017-0911-9) contains supplementary material, which is available to authorized users.

This paper introduces a framework for modelling the impact that diabetes has on employment status and wages, improving the existing literature by controlling for diabetes-related complications. Using the last wave of the Spanish National Health Survey, we find that 1710 adults out of the original sample of 36,087 have diabetes, reporting higher rates of unemployment. Our empirical results suggest that persons with diabetes, compared with non-diabetic persons, have poorer labor outcomes in terms of length of unemployment and lower income. However, diabetes is not significantly associated with unemployment probabilities, suggesting that the burden of diabetes on employment is mediated by lifestyle factors and clinical and functional complications. In addition, there are mixed outcomes to this econometric approach, depending on age and gender, among other factors. This interesting finding has several implications for research and policy on strategies to get lower health inequalities. (C) 2017 Elsevier B.V. All rights reserved.

Objectives: To analyze whether the adoption of a societal perspective would alter the results and conclusions of economic evaluations for rare disease–related healthcare technologies. Methods: A search strategy involving all the active substances considered as orphan drugs by the European Medicines Agency plus a list of 76 rare diseases combined with economic-related terms was conducted on Medline and the Cost-Effectiveness Registry from the beginning of 2000 until November 2018. We included studies that considered quality-adjusted life years as an outcome, were published in a scientific journal, were written in English, included informal care costs or productivity losses, and separated the results according to the applied perspective. Results: We found 14 articles that fulfilled the inclusion criteria. Productivity losses were considered in 12 studies, the human capital approach being the method most frequently used. Exclusively, informal care was considered in 2 articles, being valued through the opportunity cost method. The 14 articles selected resulted in 26 economic evaluation estimations, from which incremental cost-utility ratio values changed from cost-effective to dominant in 3 estimates, but the consideration of societal costs only modified the authors’ conclusion in 1 study. Conclusions: The presence of societal costs in the economic evaluation of rare diseases did not affect the conclusions of the studies except in a single specific case. In those studies where the societal perspective was considered, we did not find significant changes in the economic evaluation results due to the higher costs of treatments and the low quality-adjusted life years gained.

OBJECTIVE To analyze the differences in health care costs according to glycemic control in people with type 2 diabetes. RESEARCH DESIGN AND METHODS Data on health care resource utilization from 100,391 people with type 2 diabetes were extracted from the electronic database used at the Catalan Health Institute. Multivariate regression models were carried out to test the impact of glycemic control (HbA1c) on total health care, hospital admission, and medication costs; model 1 adjusted for a variety of covariates, and model 2 also included micro- and macrovascular complications. Glycemic control was classified as good for HbA1c RESULTS Mean per patient annual direct medical costs were €3,039 ± SD €6,581. Worse glycemic control was associated with higher total health care costs: compared with good glycemic control, health care costs increased by 18% (€509.82) and 23% (€661.35) in patients with very poor and poor glycemic control, respectively, when unadjusted and by €428.3 and €395.1, respectively, in model 2. Medication costs increased by 12% in patients with fair control and by 28% in those with very poor control (model 2). Patients with poor control had a higher probability of hospitalization than those with good control (5% in model 2) and a greater average cost when hospitalization occurred (€811). CONCLUSIONS Poor glycemic control was directly related to higher total health care, hospitalization, and medication costs. Preventive strategies and good glycemic control in people with type 2 diabetes could reduce the economic impact associated with this disease.

A correction to this paper has been published: https://doi.org/10.1007/s10198-021-01323-y

Climate change is one of the main threats to rural livelihoods in Central America, especially for small and medium-sized farmers. Climate change vulnerability assessment (CCVA) integrates biophysical and socioeconomic information to support policy decisions. We present a CCVA of agricultural livelihoods of four countries in Central America, at the municipality level. We use the IPCC definition of vulnerability, and address the potential impact of climate change on suitability for major crops and adaptive capacity using indicators of basic human needs, as well as resources for innovation and action framed in a livelihoods approach. Adaptive capacity was estimated using ranking techniques for municipalities and descriptive multivariate analysis. Projected changes in climate suitability for crops show a wide variation between Guatemala, El Salvador, Honduras and Nicaragua, and within each country. Cluster analysis of adaptive capacity values shows a gradient between higher values close to urban areas and lower values in agricultural frontier areas and in those prone to drought. Municipalities with a high proportional area under subsistence crops tend to have less resources to promote innovation and action for adaptation. Our results suggest that a full spectrum of adaptation levels and strategies must be considered in the region to achieve different adaptation goals. They also show that the adaptive capacity ranking and characterization are complementary and support geographical prioritization and identification of adaptation strategies, respectively.

Background The main objective of this study was to analyse how the inclusion (exclusion) of social costs can alter the results and conclusions of economic evaluations in the field of Alzheimer’s disease interventions. Methods We designed a systematic review that included economic evaluations in Alzheimer’s disease. The search strategy was launched in 2000 and ran until November 2018. The inclusion criteria were: being an original study published in a scientific journal, being an economic evaluation of any intervention related to Alzheimer’s disease, including social costs (informal care costs and/or productivity losses), being written in English, using QALYs as an outcome for the incremental cost–utility analysis, and separating the results according to the perspective applied. Results It was finally included 27 studies and 55 economic evaluations. Around 11% of economic evaluations changed their main conclusions. More precisely, three of them concluded that the new intervention became cost-effective when the societal perspective was considered, whereas when using just the health care payer perspective, the new intervention did not result in a cost–utility ratio below the threshold considered. Nevertheless, the inclusion of social cost can also influence the results, as 37% of the economic evaluations included became the dominant strategy after including social costs when they were already cost-effective in the health care perspective. Conclusions Social costs can substantially modify the results of the economic evaluations. Therefore, taking into account social costs in diseases such as Alzheimer’s can be a key element in making decisions about public financing and pricing of health interventions.

The aim of this study is to explain the trends in socioeconomic inequality and diabetes outcomes in terms of hospital admission and death in old European people. The sample includes 73,301 individuals, across 16 European countries taken from the Survey of Health, Ageing and Retirement in Europe (SHARE). People being diagnosed of diabetes were more likely to be admitted to hospital than those without diabetes, although its effect dropped after controlling for clinical and functional complications. Largest asscociations were observed in women, people aged 50–65 years old, with medium educational level and medium household income. Diabetes was significant and positively related to mortality in the whole sample. Diabetes is significantly associated with mortality risk especially in males, oldest old people, low education and medium income people. These findings have important implications for public policies to reduce socioeconomic-related health inequalities.

International audience; Coffee production is impacting the climate by emitting greenhouse gasses. Coffee production is also vulnerable to climate change. As a consequence, the coffee sector is interested in climate-friendly forms of coffee production, but there is no consensus of what exactly this implies. Therefore, we studied two aspects of the climate impact of coffee production: the standing carbon stocks in the production systems and the product carbon footprint, which measures the greenhouse gas emissions per unit weight of coffee produced. We collected data from 116 coffee farms in five Latin American countries, Mexico, Guatemala, Nicaragua, El Salvador, and Colombia, for four coffee production systems: (1) traditional polycultures, (2) commercial polycultures, (3) shaded monocultures, and (4) unshaded monocultures. We found that polycultures have a lower mean carbon footprint, of 6.2–7.3 kg CO2-equivalent kg−1 of parchment coffee, than monocultures, of 9.0–10.8 kg. We also found that traditional polycultures have much higher carbon stocks in the vegetation, of 42.5 Mg per ha, than unshaded monocultures, of 10.5 Mg. We designed a graphic system to classify production systems according to their climate friendliness. We identified several strategies to increase positive and reduce negative climate impacts of coffee production. Strategies include diversification of coffee farms with trees, the use of their wood to substitute for fossil fuel and energy-intensive building materials, the targeted use of fertilizer, and the use of dry or ecological processing methods for coffee instead of the traditional fully washed process.

BackgroundTo analyse and compare the impact of cardiovascular risk factors and disease on health-related quality of life (HRQoL) in people with and without diabetes living in the community.MethodsWe used data of 1,905 people with diabetes and 19,031 people without diabetes from the last Spanish National Health Survey (years 2011 +/- 2012). The HRQoL instrument used was the EuroQol 5D-5L, based on time trade-off scores. Matching methods were used to assess any differences in the HRQoL in people with and without diabetes with the same characteristics (age, gender, education level, and healthy lifestyle), according to cardiovascular risk factors and diseases. Disparities were also analysed for every dimension of HRQoL: mobility, daily activities, personal care, pain/discomfort, and anxiety/depression.ResultsThere were no significant differences in time trade-off scores between people with and without diabetes when cardiovascular risk factors or established cardiovascular disease were not present. However, when cardiovascular risk factors were present, the HRQoL score was significantly lower in people with diabetes than in those without. This difference was indeed greater when cardiovascular diseases were present. More precisely, people with diabetes and any of the cardiovascular risk factors, who have not yet developed any cardiovascular disease, report lower HRQoL, 0.046 TTO score points over 1 (7.93 over 100 in the VAS score) compared to those without diabetes, and 0.14 TTO score points of difference (14.61 over 100 in the VAS score) if cardiovascular diseases were present. In fact, when the three risk factors were present in people with diabetes, HRQoL was significantly lower (0.10 TTO score points over 1 and 10.86 points over 100 in VAS score), obesity being the most influential risk factor.ConclusionsThe presence of established cardiovascular disease and/or cardiovascular risk factors, specially obesity, account for impaired quality of life in people with diabetes.

OBJECTIVE: To identify the main factors associated with the use of nursing home facilities and to calculate their costs among older people with diabetes in Europe.METHODS: The sample included 48,464 individuals aged 50 years and older in 12 European countries participating in the Survey of Health, Aging, and Retirement in Europe study from 2004 to 2010. Cost data were obtained from the Organization for Economic Cooperation and Development and the World Bank. Logit regressions were used to assess the impact of diabetes, comorbidities, and functional status on the frequency of nursing home admission. Etiologic fractions were calculated to obtain the nursing home costs attributable to diabetes and its clinical and functional complications.RESULTS: Diabetes is a predictor for institutionalization. When adjusted for clinical and functional complications, impairment of physical function [mild: odds ratio (OR) 3.27; 95% confidence interval (CI) 2.60-4.19; moderate: OR 8.48, 95% CI 6.02-13.09; severe: OR 12.53, 95% CI 8.03-19.98] and cognition (OR 2.00, 95% CI 1.60-2.68), as well as stroke (OR 2.08, 95% CI 1.61-2.80) showed the strongest association with increased risk of institutionalization. Moreover, this relationship between diabetes, function, and cost was age-dependent, increasing as people get older. Total average nursing home costs incurred by patients with diabetes reached nearly US $13/capita, ranging between countries from US $61 to $0.5. Diabetes-related complications accounted for one-third of these costs (US $4) and, of these, 78% resulted from functional impairment.CONCLUSIONS: Diabetes is associated with higher risk of institutionalization even after adjusting for complications. Among them, functional impairment explains the major part of the association between diabetes and nursing home admission and leads to increasing costs.

En el marco del proyecto Actualización e investigación con intervención pedagógica intercultural, realizamos una evaluación de lectura, escritura y reflexión sobre la lengua en español a los alumnos de los 14 docentes participantes de este proyecto. El proyecto se desarrolló en 14 zonas indígenas de 12 entidades federativas, en las que abarcamos 13 lenguas diferentes. De los resultados de este proyecto, mostraremos el análisis de respuestas dadas por los niños a una tarea de lectura, y a una de reflexión sobre la lengua. Nos interesa mostrar cómo es que los niños se equivocan al responder ante estas tareas, ya que sus dificultades nos permitirán iniciar el planteamiento de los distintos aspectos a los que se les deberá dar énfasis en la construcción de una didáctica de la enseñanza del español, y aportarán datos para orientar nuevos estudios acerca de las reflexiones realizadas por los alumnos —hablantes de una lengua indígena— aprendices del español.

IntroductionThe Quality and Outcomes Framework, or QOF, rewards primary care doctors (GPs) in the UK for providing certain types of care. Since 2006, GPs have been paid to identify patients with dementia and to conduct an annual review of their mental and physical health. During the review, the GP also assesses the carer's support needs, including impact of caring, and ensures that services are co-ordinated across care settings. In principle, this type of care should reduce the risk of admission to long-term residential care directly from an acute hospital ward, a phenomenon considered to be indicative of poor quality care. However, this potential effect has not previously been tested.MethodsUsing English data from 2006/07 to 2010/11, we ran multilevel logit models to assess the impact of the QOF review on the risk of care home placement following emergency admission to acute hospital. Emergency admissions were defined for (a) people with a primary diagnosis of dementia and (b) people with dementia admitted for treatment of an ambulatory care sensitive condition. We adjusted for a wide range of potential confounding factors.ResultsOver the study period, 19% of individuals admitted to hospital with a primary diagnosis of dementia (N = 31,120) were discharged to a care home; of those admitted for an ambulatory care sensitive condition (N = 139,267), the corresponding figure was 14%. Risk factors for subsequent care home placement included older age, female gender, vascular dementia, incontinence, fall, hip fracture, and number of comorbidities. Better performance on the QOF review was associated with a lower risk of care home placement but only when the admission was for an ambulatory care sensitive condition.ConclusionsThe QOF dementia review may help to reduce the risk of long-term care home placement following acute hospital admission.

Objective To estimate whether becoming widowed had a significant effect on individual’s health status as well as on healthcare and non-healthcare resources use, compared to people who remained in a couple in Europe. Data and method It was used the Survey of Health, Aging and Retirement in Europe from 2004 to 2015. The statistical technique used was genetic matching which analysed the differences in wellbeing, mental health, health status, risk of death, health care resources and long-term care utilization of people who have become widowed, comparing with people who remained married or with a partner. We considered shortterm and medium-term effects. Results In the short term, those who became widowed had a worse wellbeing and mental health, in addition to a greater probability of receiving formal care and informal care from outside the household. There seems to be a significant effect in the use of formal and informal care from outside the household in the medium term. Conclusions The results might help to concentrate a major effort of any policy or strategy, not only in the field of health but also in the provision of long-term care, immediately after the negative shock occurs.