Hospital Expenditure at the End-of-Life: What Are the Impacts of Health Status and Health Risks?

Background

It is important for health policy and expenditure projections to understand the relationship between age, death and expenditure on health care (HC). Research has shown that older age groups incur lower hospital costs than previously anticipated and that remaining time to death (TTD) was a much stronger indicator for expenditure than age. How health behaviour or risk factors impact on HC utilisation and costs at the end of life is relatively unknown. Smoking and Body Mass Index (BMI) have featured most prominently and mixed findings exist as to the exact nature of this association.

Methods

This paper considers the relationship between TTD, age and expenditure for inpatient care in the last 12 quarters of life; and introduces measures of health status and risks. A longitudinal dataset covering 35 years is utilised, including baseline survey data linked to hospital and death records. The effect of age, TTD and health indicators on expenditure for inpatient care is estimated using a two-part model.

Results

As individuals approach death costs increase. This effect is highly significant (p<0.01) from the last until the 8th quarter before death and influenced by age. Statistically significant effects on costs were found for: smoking status, systolic blood pressure and lung function (FEV1). On average, smokers incurred lower quarterly costs in their last 12 quarters of life than non-smokers (~7%). Participants’ BMI at baseline did show a negative association with probability of HC utilisation however this effect disappeared when costs were estimated.

Conclusions

Health risk measures obtained at baseline provide a good indication of individuals’ probability of needing medical attention later in life and incurring costs, despite the small size of the effect. Utilising a linked dataset, where such measures are available can add substantially to our ability to explain the relationship between TTD and costs.     

Age‐dependent investment in death‐feigning behaviour in the sweetpotato weevil Cylas formicarius

Because life‐history theory predicts that risky behaviours such as mating should increase as life expectancy decreases, predatory avoidance is expected to decrease with age. However, this prediction has not been examined. In the present study, the effect of age on death‐feigning behaviour, a form of predatory avoidance behaviour in the sweetpotato weevil Cylas formicarius (Summers) (Coleoptera: Brentidae), is investigated by performing a longitudinal study. Because the effects of mating history and age usually cannot be distinguished, mating history is controlled. The results show that only female weevils decrease the investment in death‐feigning behaviour with age, whereas male weevils do not show any age‐related change. In addition, death‐feigning behaviour of mated females is longer than that of virgin females, possibly because additional mating partners would be not needed by mated females.     

Do socioeconomic differences in mortality persist after retirement? 25 year follow up of civil servants from the first Whitehall study.

OBJECTIVE: To assess the risk of death associated with work based and non-work based measures of socioeconomic status before and after retirement age. DESIGN: Follow up study of mortality in relation to employment grade and car ownership over 25 years. SETTING: The first Whitehall study. SUBJECTS: 18,133 male civil servants aged 40-69 years who attended a screening examination between 1967 and 1970. MAIN OUTCOME MEASURE: Death. RESULTS: Grade of employment was a strong predictor of mortality before retirement. For men dying at ages 40-64 the lowest employment grade had 3.12 times the mortality of the highest grade (95% confidence interval 2.4 to 4.1). After retirement the ability of grade to predict mortality declined (rate ratio 1.86; 1.6 to 2.2). A non-work based measure of socioeconomic status (car ownership) predicted mortality less well than employment grade before retirement but its ability to predict mortality declined less after retirement. Using a relative index of inequality that was sensitive to the distribution among socioeconomic groups showed employment grade and car ownership to have independent associations with mortality that were of equal magnitude after retirement. The absolute difference in death rates between the lowest and highest employment grades increased with age from 12.9 per 1000 person years at ages 40-64 to 38.3 per 1000 at ages 70-89. CONCLUSIONS: Socioeconomic differences in mortality persist beyond retirement age and in magnitude increase with age. Social differentials in mortality based on an occupational status measure seem to decrease to a greater degree after retirement than those based on a non-work measure. This suggests that alongside other socioeconomic factors work itself may play an important part in generating social inequalities in health in men of working age.     

A long-term "memory" of HIF induction in response to chronic mild decreased oxygen after oxygen normalization

Background

Cardiovascular diseases (CVD) are the leading cause of death and the third cause of disability in Europe. Prevention programmes should include interventions aimed at a reduction of medical risk factors (hypertension, hypercholesterol, hyperglycemia, overweight and obesity) as well as behavioural risk factors (sedentary lifestyle, high fat intake and low fruit and vegetable intake, smoking). The aim of this study is to investigate the effects of a multifaceted, multidisciplinary electronic prevention programme on cardiovascular risk factors.

Methods/Design

In a randomized controlled trial, one group will receive a maximal intervention (= intervention group). The intervention group will be compared to the control group receiving a minimal intervention. An inclusion of 350 patients in total, with a follow-up of 3 years is foreseen. The inclusion criteria are age between 25–65 and insured by the Onderlinge Ziekenkas, insuring for guaranteed income in case of illness for self-employed. The maximal intervention group receives several prevention consultations by their general practitioner (GP) using a new type of cardiovascular risk calculator with personalised feedback on behavioural risk factors. These patients receive a follow-up with intensive support of health behaviour change via different methods, i.e. a tailored website and personal advice of a multidisciplinary team (psychologist, physiotherapist and dietician). The aim of this strategy is to reduce cardiovascular risk factors according to the guidelines. The primary outcome measures will be cardiovascular risk factors. The secondary outcome measures are cardiovascular events, quality of life, costs and incremental cost effectiveness ratios. The control group receives prevention consultations using a new type of cardiovascular risk calculator and general feedback.

Discussion

This trial incorporates interventions by GPs and other health professionals aiming at a reduction of medical and behavioural cardiovascular risk factors. An assessment of clinical, psychological and economical outcome measures will be performed.

Trial registration

ISRCTN23940498     

Contemporary patterns of adolescent sexuality in urban Botswana

In Botswana, as in other areas in southern Africa, there is a growing concern about the risks associated with adolescent sexuality. To facilitate the design of policies that can address these problems, it is necessary to gain a thorough understanding of contemporary patterns of adolescent sexual behaviour, and the factors that affect them. This paper examines these issues using data from the 1995 Botswana Adolescent Reproductive Health Survey in conjunction with data from focus group discussions. The results suggest that adolescents become sexually active at an early age, and that many of them, males and females alike, have multiple sex partners. This early sexual initiation implies that adolescent reproductive health programmes should target youths aged 13 or younger. For school-based programmes this implies starting no later than Grade 6 or Standard 1, and preferably earlier. Young males appear to be a particularly vulnerable group that needs further attention. Adolescents perceive that teachers, peers and parents have the largest influence on their reproductive health attitudes. Schools appear to have the most potential for providing reproductive health information, because they reach youths both directly and indirectly by educating their peers. The results also show that male and female sexual behaviour is affected by different factors. Among males, having secondary education strongly increases the odds of being sexually active, presumably because such males make attractive partners. Among females, on the other hand, being in school significantly reduces the odds of being sexually active. This finding is consistent with the policy imposing a one-year school expulsion for pregnant schoolgirls, which was implemented as a deterrent to schoolgirl pregnancy.     

Personal Health Promotion

Mortality data on the leading causes of death conceal the relationship to underlying risk factors; if we classified deaths according to risk factors, annually there might be an estimated 350,000 smoking-related deaths, 200,000 alcohol-related deaths and 135,000 nutrition-related cancer deaths. Similarly, five causes of death—heart disease, lung cancer, cirrhosis of the liver, suicide and motor vehicle accidents—contribute most to the risk of dying in the next ten years for a 40-year-old white man. Review of protective factors shows that adopting and maintaining a healthful life-style can contribute to reducing risk. Practicing physicians can assume both direct and indirect roles in promoting personal health maintenance.     

Establishing a health demographic surveillance site in Bhaktapur district, Nepal: initial experiences and findings

ABSTRACT: BACKGROUND: A health demographic surveillance site (HDSS) provides longitudinal data regarding health and demography in countries with coverage error and poor quality data on vital registration systems due to lack of public awareness, inadequate legal basis and limited use of data in health planning. The health system in Nepal, a low-income country, does not focus primarily on health registration, and does not conduct regular health data collection. This study aimed to initiate and establish the first HDSS in Nepal. RESULTS: We conducted a baseline survey in Jhaukhel and Duwakot, two villages in Bhaktapur district. The study surveyed 2,712 households comprising a total population of 13,669. The sex ratio in the study area was 101 males per 100 females and the average household size was 5. The crude birth and death rates were 9.7 and 3.9/1,000 population/year, respectively. About 11% of births occurred at home, and we found no mortality in infants and children less than 5 years of age. Various health problems were found commonly and some of them include respiratory problems (41.9%); headache, vertigo and dizziness (16.7%); bone and joint pain (14.4%); gastrointestinal problems (13.9%); heart disease, including hypertension (8.8%); accidents and injuries (2.9%); and diabetes mellitus (2.6%). The prevalence of non-communicable disease (NCD) was 4.3% (95% CI: 3.83; 4.86) among individuals older than 30 years. Age-adjusted odds ratios showed that risk factors, such as sex, ethnic group, occupation and education, associated with NCD. CONCLUSION: Our baseline survey demonstrated that it is possible to collect accurate and reliable data in a village setting in Nepal, and this study successfully established an HDSS site. We determined that both maternal and child health are better in the surveillance site compared to the entire country. Risk factors associated with NCDs dominated morbidity and mortality patterns.     

Health Hazard Appraisal Counseling—Continuing Evaluation

A program of annual health examinations was expanded to include counseling based on a computerized appraisal of individual patients'' specific health risk factors. Data obtained from a specially designed questionnaire, laboratory tests and a physical examination yielded a health hazard appraisal showing a number of weighted risk factors and their relation to ten leading causes of death as determined for that patient. From all of this information, a “risk age” was developed which could then be compared with the patient''s “true age.” The results were reviewed with each patient, and methods of correcting health hazards were stressed. The first annual retesting of a group of 107 examinees showed a net risk age reduction of 1.4 years (formerly reported in this journal). The longer term follow-up reported in this paper showed a net risk reduction of 2.38 years in a group of 26 examinees. The net risk age reduction in the two groups represented 32 and 40 percent, respectively, of the achievable risk age reduction when patients comply with suggestions made during risk reduction counseling. These findings indicate that health hazard appraisal counseling is an effective method of altering priorities of health practices.     

Community nurse assessment of cardiovascular behavioural risk factors--a qualitative analysis within the CroHort study

The aim of our study was to identify major determinants of cardiovascular behavioural risk factors among subjects at increased risk of cardiovascular disease (CVD). The data for the qualitative analysis were obtained from the Croatian Adult Health Cohort Study (CroHort). The data analysis was based on the principles of Grounded Theory. We have generated the concept of an individual in a vicious circle of risky health behaviour, defined by the low level of motivation and unfavourable personal characteristics which in interaction with unsupportive social environment adversely influence one's health behaviour, leading to negative health outcomes that produce negative effects on one's motivation and social environment. Community nurses assessed that the respondents often weren't adequately recognising their CVD risk and were very reluctant about the change in their risky habits. Our results are supported by the quantitative analysis and are complementing other analyses of the cardiovascular risks within the CroHort study.     

Tooth loss and associated factors in long-term institutionalised elderly patients

Objective: To compare partial and total tooth loss in dependent institutionalised elderly patients and identify any associated factors. Background: A poor oral health status, together with a reduction of autonomy can seriously affect the general health and increase the risk of death in elderly people. Those with total tooth loss and in need of assistance are the most at risk. Materials and methods: In 2004, a cross‐sectional study of 321 elderly patients was conducted in long‐term hospital services provided in Montpellier, France. Socio‐demographic, behavioural, medical and oral health information was recorded for each patient. Multivariate logistic regression models were performed to test the relationship between those covariates and partial or total tooth loss. Pearson chi‐squared tests were used for bivariate analyses. Results: The proportion of edentulousness was 26.9%; among these12.6% had no dentures. The factors significantly associated with edentulism were: an age ‘older than 87 years’ [odds ratio (OR) = 9.4], the presence of a nephropathy (OR = 6.8), and inadequate oral hygiene (OR = 0.1). The factors most significantly associated with partial tooth loss (at least 21 missing teeth) were ‘cancerous disease’ (OR = 9.9), the presence of a nephropathy (OR = 5.6) and the presence of a neurological disease (OR = 4.1). The factors significantly related to dentate status (20 or more natural teeth retained) were ‘hypertension treatment’ (OR = 2.4), and ‘cortisone treatment’ (OR = 0.2). Conclusion: General health problems as well as a poor oral condition were significant risk indicators for tooth loss among the long‐term institutionalised elderly. This suggests that the number of remaining teeth has a strong effect on oral health‐related quality of life.     

Social life factors affecting the mortality, longevity, and birth rate of total Japanese population: effects of rapid industrialization and urbanization

To expand upon the findings that lower mortality was found in Japanese urban areas in contrast to the Western model where in the US and Britain the risk of death was higher in metropolitan areas and conurbations, 22 social life indicators are examined among 46 prefectures in Japan in terms of their effect on age specific mortality, life expectancy, and age adjusted marriage, divorce, and birth rates. The effects of these factors on age adjusted mortality for 8 major working and nonworking male populations, where also analyzed. The 22 social life factors were selected from among 227 indicators in the system of Statistical Indicators on Life. Factor analysis was used to classify the indicators into 8 groups of factors for 1970 and 7 for 1975. Factors 1-3 for both years were rural or urban residence, low income and unemployment, and prefectural age distribution. The 4th for 1970 was home help for the elderly and for 1975, social mobility. The social life indicators were classified form 1 to 8 as rural residence in 1970 and 1975, urban residence, low income, high employment, old age, young age, social mobility, and home help for the elderly which moved from 8th place in 1970 to 1st in 1975. Between 1960-75, rapid urbanization took place with the proportion of farmers, fishermen, and workers declining from 43% in 1960 to 19% in 1975. The results of stepwise regression analysis indicate a positive relationship of urban residence with mortality of men and women except school-aged and middle-aged women, and the working populations, as well as life expectancy at birth for males and females and ages 20 and 40 years for males. Rural residence was positively associated with the male marriage rate, whereas the marriage rate for females was affected by industrialization and urbanization. High employment and social mobility were positively related to the female marriage rate. Low income was positively related to the divorce rate for males and females. Rural residence and high employment were positively related to the birth rate. The birth rate is higher in rural areas. Mortality of professional, engineering, and administrative workers was slightly lower than the total working population, while sales workers, those in farming, fishing, and forestry, and in personal and domestic service had significantly higher mortality. The mortality of the nonworking population was 6-8 times higher than sales, transportation, and communication, and personal and domestic service as well as the total population.     

Assessing Stress in Zoo-Housed Western Lowland Gorillas (<Emphasis Type="Italic">Gorilla gorilla gorilla</Emphasis>) Using Allostatic Load

Stress contributes to the development of chronic degenerative diseases in primates. Allostatic load is an estimate of stress-induced physiological dysregulation based on an index of multiple biomarkers. It has been applied to humans to measure effects of stress and predict health outcomes. Assessing allostatic load in nonhuman primates may aid in understanding factors promoting compromised health and longevity in captive populations, as well as risk assessment among wild populations following human activities. We applied an allostatic load index to gorillas housed at the Columbus Zoo and Aquarium (N = 27, 1956–2014) using data from medical records and biomarkers from banked serum. We estimated allostatic load using seven biomarkers (albumin, cortisol, corticotropin-releasing hormone, dehydroepiandrosterone sulfate, glucose, interleukin-6, and tumor necrosis factor alpha) and then examined this index for associations with age, sex, number of stressful events, parturition, physiological health measures, and age at death. Stressful events were defined as agonistic interactions with wounding, translocations, and anesthetizations. Allostatic load positively associated with age and total number of lifetime stressful events. Allostatic load was significantly higher in females than in males. Allostatic load was not associated with number of pregnancies and was not different between nulliparous and parous females. Allostatic load associated positively with serum creatinine and triglyceride levels, showed a nonsignificant negative association with cholesterol, and did not associate significantly with age at death. These results demonstrate the potential utility of allostatic load for exploring long-term stress and health risks, as well as for evaluating environmental stressors for gorillas and other nonhuman primates in captivity and in the wild.     

Health Hazard Appraisal in Patient Counseling

A program of annual health examinations was expanded to include counseling based on a computerized appraisal of individual patients'' specific health hazard factors. Data obtained from a specially designed questionnaire, laboratory tests and a physical examination yielded a printout showing a number of weighted risk factors and their relation to ten leading causes of death as determined for that patient. From all of this information, a risk (“apparent”) age was developed for the patient. The results were reviewed with each patient, and methods of correcting health hazards were stressed. A total of 488 persons were appraised, and 107 were randomly reappraised in less than a year, with the finding that the net risk age was reduced by 1.4 years. Such a reduction in risk age is significant; it indicates that appraisal-based counseling is an effective method of altering priorities of health practices.     

Does plasma cholesterol concentration predict mortality from coronary heart disease in elderly people? 18 year follow up in Whitehall study.

OBJECTIVE--To explore the extent to which the relation between plasma cholesterol concentration and risk of death from coronary heart disease in men persists into old age. DESIGN--18 year follow up of male Whitehall civil servants. Plasma cholesterol concentrations and other risk factors were determined at first examination in 1967-9 when they were aged 40-69. Death of men up to 31 January 1987 was recorded. SUBJECTS--18,296 male civil servants, 4155 of whom died during follow up. MAIN OUTCOME MEASURES--Cause and age of death. Cholesterol concentration in 1967-9 and number of years elapsed between testing and death. RESULTS--1676 men died of coronary heart disease. The mean cholesterol concentration in these men was 0.32 mmol/l higher than that in all other men (95% confidence interval 0.26 to 0.37 mmol/l). This difference in cholesterol concentrations fell 0.15 mmol/l with every 10 years'' increase in age at screening. The risk of raised cholesterol concentration fell with age at death. Compared with other men cholesterol concentration in those who died of coronary heart disease was 0.44 mmol/l higher in those who died aged less than 60 and 0.26 mmol/l higher in those aged 60-79 (p = 0.03). For a given age at death the longer the gap between cholesterol measurement and death the more predictive the cholesterol concentration, both for coronary heart disease and all cause mortality (trend test p = 0.06 and 0.03 respectively). CONCLUSION--Reducing plasma cholesterol concentrations in middle age may influence the risk of death from coronary heart disease in old age.     

Age as a factor in breast cancer knowledge,attitudes and screening behaviour.

OBJECTIVE: To determine whether there are age-related differences in knowledge, attitudes and behaviour with respect to breast cancer and whether the differences reflect the age-specific Canadian recommendations on breast cancer screening. DESIGN: Telephone survey. SETTING: Two cities and five towns and their surrounding areas in Alberta. PARTICIPANTS: The age-specific, randomly selected sample comprised 1284 women aged 40 to 75 years who did not have breast cancer. Of the 1741 eligible women who were contacted, 1350 (78%) agreed to participate; 66 were excluded because of age ineligibility or a history of breast cancer. MAIN OUTCOME MEASURE: Frequency of knowledge, attitudes and behaviour with respect to breast cancer, by age group. RESULTS: Knowledge of breast cancer risk factors was generally low and decreased with age. Few women were aware of the Canadian recommendations on breast self-examination, physical examination of the breasts by a health care practitioner and mammographic screening. Older women believed they were less susceptible to breast cancer than younger women and were less likely to have positive attitudes toward screening. Self-examination was performed 9 to 15 times per year by 424 women (33%), and 810 (63%) had been examined by a health care professional in the past year. Although 664 (52%) had undergone mammography, the proportion decreased with age after age 59. The main barriers to mammography were lack of physician referral and the woman''s belief that the procedure is unnecessary if she is healthy. CONCLUSIONS: Education is needed to increase breast cancer knowledge, promote the Canadian recommendations for early detection of breast cancer and decrease negative beliefs about the disease. Changes in the behaviour of women and physicians are needed to increase the use of breast self-examination, clinical breast examination by a health care professional and mammographic screening. Reaching women in the upper range (60 to 69 years) of the target group for mammographic screening should be a focus in promoting early detection of breast cancer.     

Carbon monoxide yield of cigarettes and its relation to cardiorespiratory disease.

Estimates of the carbon monoxide yield of their cigarettes have been obtained for 4910 smokers (68% of all smokers) in the Whitehall study of men aged 40 to 64. In the 10 years after examination 635 men died. When men smoking cigarettes with high carbon monoxide yield were compared with those smoking cigarettes with a low yield, and after adjusting for age, employment grade, amount smoked, and tar yield, the risk of death was 32% lower for coronary heart disease, 49% higher for lung cancer, and 10% lower for total mortality; these differences were not statistically significant. Among men who said that they inhaled the risk of fatal coronary heart disease was 51% lower in the high carbon monoxide group (p less than 0.01), while the risk of lung cancer was 75% higher. These results provide no evidence that a smoker can reduce his risk of death by smoking a brand with a low carbon monoxide yield; he might even increase it. The complex interactions between characteristics of the smoker, smoking behaviour, constituents of tobacco smoke, and health are again demonstrated.     

Type A behaviour and ischaemic heart disease in middle aged British men.

The Bortner questionnaire, which measures aspects of type A (coronary prone) behaviour was completed by 5936 men aged 40-59 selected at random from one general practice in each of 19 British towns. The presence of ischaemic heart disease was determined at initial examination and the men were followed up for an average of 6.2 years for morbidity and mortality from myocardial infarction and for sudden cardiac death. Non-manual workers had significantly higher scores (more type A) than manual workers and the score decreased (less type A) with increasing age. After adjustment for social class and age men with higher scores had higher prevalences of ischaemic heart disease less marked for electrocardiographic evidence and more marked for response to a chest pain questionnaire (angina or possible myocardial infarction). A man''s recall of a doctor''s diagnosis of ischaemic heart disease, however, did not relate to his Bortner score. There was no significant relation between the Bortner score and the attack rate or incidence of major ischaemic heart disease events. In this study type A behaviour, as measured by the Bortner questionnaire, did not predict major ischaemic heart disease events in British middle aged men.     

The effect of long or chopped straw on pig behaviour

In the EU, pigs must have permanent access to manipulable materials such as straw, rope, wood, etc. Long straw can fulfil this function, but can increase labour requirements for cleaning pens, and result in problems with blocked slatted floors and slurry systems. Chopped straw might be more practical, but what is the effect on pigs’ behaviour of using chopped straw instead of long straw? Commercial pigs in 1/3 slatted, 2/3 solid pens of 15 pigs were provided with either 100 g/pig per day of long straw (20 pens) or of chopped straw (19 pens). Behavioural observations were made of three focal pigs per pen (one from each of small, medium and large weight tertiles) for one full day between 0600 and 2300 h at each of ~40 and ~80 kg. The time spent rooting/investigating overall (709 s/pig per hour at 40 kg to 533 s/pig per hour at 80 kg), or directed to the straw/solid floor (497 s/pig per hour at 40 kg to 343 s/pig per hour at 80 kg), was not affected by straw length but reduced with age. Time spent investigating other pigs (83 s/pig per hour at 40 kg), the slatted floor (57 s/pig per hour) or pen fixtures (21 s/pig per hour) was not affected by age or straw length. Aggressive behaviour was infrequent, but lasted about twice as long in pens with chopped straw (2.3 s/pig per hour at 40 kg) compared with pens with long straw (1.0 s/pig per hour at 40 kg, P=0.060). There were no significant effects of straw length on tail or ear lesions, but shoulders were significantly more likely to have minor scratches with chopped straw (P=0.031), which may reflect the higher levels of aggression. Smaller pigs showed more rooting/investigatory behaviour, and in particular directed towards the straw/solid floor and the slatted floor than their larger pen-mates. Females exhibited more straw and pen fixture-directed behaviour than males. There were no effects of pig size or sex on behaviour directed towards other pigs. In summary, pigs spent similar amounts of time interacting with straw/solid floor when long and chopped straw were provided, and most aspects of pig-directed behaviour and injuries were not affected by straw length. There was an increase in pigs with minor shoulder lesions with chopped straw, perhaps because of increased aggression. The use of chopped straw as an enrichment material for pigs warrants further investigation in larger and more detailed studies.     

Meiosis in man

The study of human meiosis impinges on clinically important areas such as infertility and aneuploidy, and an understanding of the behaviour of chromosomes in the germ line is essential for those engaged in genetic counselling. Recent advances in cytological techniques are allowing detailed observation of chromosomes in the prophase stage. Important problems such as the effects of structural and numerical chromosome abnormalities, and the relationship between abnormal meiotic chromosome behaviour and germ-cell death are being explored, while studies on mouse oocytes are beginning to shed light on the basis of the maternal age effect for aneuploidy such as in Down syndrome in man. Work at the molecular level promises to yield further advances.