Stephen S Lim

Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries.

Abstract Objective To determine the costs and benefits of interventions for maternal and newborn health to assess the appropriateness of current strategies and guide future plans to attain the millennium development goals. Design Cost effectiveness analysis. Setting Two regions classified by the World Health Organization according to their epidemiological grouping: Afr-E, those countries in sub-Saharan Africa with very high adult and high child mortality, and Sear-D, comprising countries in South East Asia with high adult and high child mortality. Data sources Effectiveness data from several sources, including trials, observational studies, and expert opinion. For resource inputs, quantities came from WHO guidelines, literature, and expert opinion, and prices from the WHO choosing interventions that are cost effective database. Main outcome measures Cost per disability adjusted life year (DALY) averted in year 2000 international dollars. Results The most cost effective mix of interventions was similar in Afr-E and Sear-D. These were the community based newborn care package, followed by antenatal care (tetanus toxoid, screening for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis); skilled attendance at birth, offering first level maternal and neonatal care around childbirth; and emergency obstetric and neonatal care around and after birth. Screening and treatment of maternal syphilis, community based management of neonatal pneumonia, and steroids given during the antenatal period were relatively less cost effective in Sear-D. Scaling up all of the included interventions to 95% coverage would halve neonatal and maternal deaths. Conclusion Preventive interventions at the community level for newborn babies and at the primary care level for mothers and newborn babies are extremely cost effective, but the millennium development goals for maternal and child health will not be achieved without universal access to clinical services as well.

Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study

BACKGROUNDnSwedish snus is a smokeless tobacco product that has been suggested as a tobacco harm reduction product. Our aim was to assess the potential population health effects of snus.nnnMETHODSnWe assessed the potential population health effects of snus in Australia with multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to snus use; and the potential for net population-level harm given different rates of snus uptake by current smokers, ex-smokers, and people who have never smoked.nnnFINDINGSnThere was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0.1-0.3 years for men and 0.1-0.4 years for women). For net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14-25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking.nnnINTERPRETATIONnCurrent smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.

Prevalence and management of diabetes and associated risk factors by regions of Thailand: Third National Health Examination survey 2004

OBJECTIVE—The aim of this study was to determine the prevalence of diabetes and impaired fasting glucose (IFG) and their association with cardiovascular risk factors and to evaluate the management of blood glucose, blood pressure, and cholesterol in individuals with diabetes by geographical regions of Thailand. RESEARCH DESIGN AND METHODS—With the use of a stratified, multistage sampling design, data from a nationally representative sample of 37,138 individuals aged ≥15 years were collected using questionnaires, physical examination, and blood samples. RESULTS—The prevalence of diabetes and IFG weighted to the national 2004 population was 6.7% (6.0% in men and 7.4% in women) and 12.5% (14.7% in men and 10.4% in women), respectively. Diabetes was more common in urban than in rural men but otherwise prevalence was relatively uniform across geographical regions. In more than one-half of those with diabetes, the disease had not been previously diagnosed, although the majority of those with diabetes were treated with oral antiglycemic agents or insulin. The prevalence of associated risk factors was high among individuals with diabetes as well as those with IFG. Two-thirds of those with diabetes and concomitant high blood pressure (≥130/80 mmHg) were not aware that they had high blood pressure, and >70% of those with diabetes and concomitant high cholesterol (total cholesterol ≥6.2 mmol/l) were not aware that they had high cholesterol. CONCLUSIONS—The prevalences of diabetes and IFG were uniformly high in all regions. Improvements in prevention, diagnosis, and treatment of diabetes and associated risk factors are required if the health burden of diabetes in Thailand is to be averted.

Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses

BACKGROUNDnThailands progress in reducing the under-five mortality rate (U5MR) puts the country on track to achieve the fourth Millennium Development Goal (MDG). Whether this success has been accompanied by a widening or narrowing of the child mortality gap between the poorest and richest populations is unknown. We aimed to measure changes in child-mortality inequalities by household-level socioeconomic strata of the Thai population between 1990 and 2000.nnnMETHODSnWe measured changes in the distribution of the U5MR by economic strata using data from the 1990 and 2000 censuses. Economic status was measured using household assets and characteristics. The U5MR was estimated using the Trussell version of the Brass indirect method.nnnFINDINGSnAverage household economic status improved and inequalities declined between the two censuses. There were substantially larger reductions in U5MR in the poorer segments of the population. Excess child mortality risk between the poorest and richest quintile decreased by 55% (95% CI 39% to 68%). The concentration index, measured using percentiles of economic status, in 1990 was -0.20 (-0.23 to -0.18), whereas in 2000 it had dropped to -0.12 (-0.15 to -0.08), a 43% (22% to 63%) reduction.nnnINTERPRETATIONnThese findings draw attention to the feasibility of incorporating equity measurement into census data. Thailand has achieved both an impressive average decrease in U5MR and substantial reductions in U5MR inequality over a 10 year period. Contributing factors include overall economic growth and poverty reduction, improved insurance coverage, and a scaling-up and more equitable distribution of primary health-care infrastructure and intervention coverage. Understanding the factors that have led to Thailands success could help inform countries struggling to meet the fourth MDG and reduce inequality.

Prevalence and management of prehypertension and hypertension by geographic regions of Thailand: the Third National Health Examination Survey, 2004.

Objective To determine the prevalence of prehypertension and hypertension, and management of hypertension, by geographic regions of Thailand. Methods Using a stratified, multistage sampling design, data from a nationally representative sample of 39 290 individuals aged ≥ 15 years were collected by interview, physical examination and blood sample. Results The prevalence of hypertension and prehypertension weighted to the national 2004 population was 22.0% [95% confidence interval (CI) = 20.5–23.6] and 32.8% (95% CI = 31.5–34.1), respectively, with a higher prevalence in men compared to women. Hypertension was more common in urban compared to rural men, but similar between urban and rural women. Despite some variation, the prevalence of hypertension and prehypertension was relatively uniform across geographical regions. Of those identified as having hypertension in the survey, 69.8% (95% CI = 67.8–71.7) were unaware that they had hypertension. Although the majority of those who were aware (78.2%; 95% CI = 75.8–80.5) had taken blood pressure-lowering drugs in the last 2 weeks, of these only 36.6% (95% CI = 33.3–40.0) had blood pressure < 140/90 mmHg. Rural populations and those from the economically poorer Northeast region were more likely to be unaware that they had hypertension. Conclusion Compared to previous surveys, the prevalence of hypertension and prehypertension is rising rapidly, and is spread relatively evenly across regions of Thailand. Levels of awareness of hypertension were low across the country. A challenging task remains in improving screening, treatment and control of hypertension at the same time as promoting healthier lifestyles.

Prevalence of psychoactive drug use among drivers in Thailand: A roadside survey

The objective of this study was to determine the prevalence of psychoactive drug and alcohol use among general drivers and predictors of the drug use in Thailand. One thousand six hundred and thirty-five motor vehicle drivers were randomly selected from five geographical regions of Thailand between December 2005 and May 2006. The prevalence of psychoactive drugs was determined using urine tests by gas chromatography/mass spectrometry (GC/MS). Among 1635 drivers, 5.5% were tested positive for breath alcohol with 2% having a level exceeding the legal limit (> or =50mg%). Psychoactive drug was presented in 158 (9.7%) urine samples for drug analysis. The top 3 most frequently detected licit drugs were antihistamines (2.0%), sedative cough suppressant (0.7%) and benzodiazepines (0.2%). Illicit drugs detected included amphetamine (1.8%), cannabis (1.1%), mitragynine (Kratom) (0.9%) and morphine (0.1%). Only type of driver (commercial/non-commercial) was a significant predictor with psychoactive drug use. The prevalence of psychoactive drug use among drivers not involved in road crashes in Thailand was not as low as an earlier study in Europe using objective measurements, particularly among commercial drivers. However, for illicit drugs, the prevalence detected in this study was lower than those of earlier studies from high-income countries.

Costs and benefits of smoking cessation aids: making a case for public reimbursement of nicotine replacement therapy in Australia.

Background: Tobacco smoking is the leading preventable cause of morbidity and mortality in Australia and other developed countries. Of the pharmacological aids that are available for smoking cessation, bupropion (Zyban SR) is eligible for public reimbursement on the Australian Pharmaceutical Benefits Scheme (PBS), whereas nicotine replacement therapy (NRT) is not. Information on the cost-effectiveness and financial impact of public reimbursement of these strategies can better inform debate about their inclusion or exclusion in public reimbursement schemes. Objective: To estimate the cost-effectiveness of bupropion and NRT, and the potential financial impact of public reimbursement of NRT in Australia. Design: A cost-effectiveness analysis using a deterministic Markov model, and cost per disability-adjusted life year (DALY) averted over a lifetime as the outcome measure. Population: Current smokers, motivated to quit, in Australia in 2000. Interventions: (1) NRT; (2) bupropion; and (3) a combined strategy using bupropion as the first-line treatment and NRT in those who fail to quit smoking or have adverse reactions to bupropion. Results: Quitting smoking can increase life expectancy of current smokers by 1–7.6 years depending on age at cessation and sex. Providing bupropion to current smokers who are motivated to quit would cost A

REDUCED DIETARY FAT INTAKE INCREASES PARASYMPATHETIC ACTIVITY IN HEALTHY PREMENOPAUSAL WOMEN

7900 (95% uncertainty interval A

A Model for Predicting the Future Incidence of Coronary Heart Disease Within Percentiles of Coronary Heart Disease Risk

6000 to A

Comparative effects of mibefradil and nifedipine gastrointestinal transport system on autonomic function in patients with mild to moderate essential hypertension.

10 500) for each DALY averted; NRT patches would cost A