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.     

What Are the Roles and Responsibilities of the Media in Disseminating Health Information?

BACKGROUND TO THE DEBATE: In December 2004 three news stories in the popular press suggested that the side effects of single-dose nevirapine, which has been proven to prevent mother-to-child transmission of HIV, had been covered up. Many HIV experts believed that the stories were unwarranted and that they would undermine use of the drug, leading to a rise in neonatal HIV infection. The controversy surrounding these stories prompted the PLoS Medicine editors to ask health journalists, and others with an interest in media reporting of health, to share their views on the roles and responsibilities of the media in disseminating health information.     

Reconsideration of the 1988 NIH Consensus Statement on Prevention and Treatment of Kidney Stones: Are the Recommendations Out of Date?

In 1988, a consensus conference was held at the National Institutes of Health to develop guidelines for prevention and treatment of kidney stones. The recommendations regarding the medical evaluation of stone formers and treatment directed at stone prevention are reviewed. The relevance of those 1988 guidelines is evaluated for continued pertinence. Most of the recommendations promulgated in the consensus statement remain useful today. One significant change is the current consensus that dietary calcium restriction is no longer considered appropriate therapy, as there is no evidence that it actually prevents stones and has as a consequence the potential to worsen bone demineralization.     

Point of Care Testing for the Diagnosis of Fungal Infections: Are We There Yet?

Diagnostic tools for invasive fungal infections have continuously improved within the last decades. Nowadays, cultural methods, antigen testing, and molecular tests, such as polymerase chain reaction, are widely used. These methods, however, are accompanied with different limitations as various availability, various turnaround time or high costs. A new generation of point-of-care test has shown promising results in various studies and may overcome some of these limitations. We therefore reviewed the literature for the most promising new point-of-care tests for invasive aspergillosis (Aspergillus-specific lateral-flow device test, Aspergillus proximity ligation antigen assay), cryptococcosis (cryptococcal lateral-flow assay), and for histoplasmosis (loop-mediated isothermal amplification assay).     

Red Fluorescing Phototrophic Picoplankton in the Laurentian Great Lakes: What Are They and What Are They Doing?

Epifluorescence microscopy, flow cytometry, and transmission electron microscopy were used to characterize the community of red fluorescing (emission >665 nm when excited with blue light) phototrophic picoplankton (RFPP) in lakes Huron and Michigan. A population of coccoid to ovate eukaryotic cells with a mean size of 1.2 μm dominated the RFPP community in both surface and deep water samples. Abundant prochlorophyte populations were not found in any samples. Comparisons of counts with epifluorescence microscopy and flow cytometry, revealed that RFPP were adequately enumerated with standard epifluorescence microscopy. These RFPP were significant contributors to total phototrophic picoplankton abundance in both lakes Michigan (24%) and Huron (18%), with maximum seasonal abundance during the May-June period (surface mixing layer temperatures, 3-9 °C). During thermal stratification, maximum vertical abundance was found in the metalimnion/hypolimnion at the 1-5% isolumes. RFPP were only minor contributors (1-7%) to total primary production. Growth rates of RFPP measured with dilution and small inocula growth experiments ranged from 0.05-1.0 d⁻¹. Microzooplankton grazing rates on RFPP measured with dilution experiments were similar to estimated growth rates, accounting for 52-280% of growth on any given date.     

What Is the Best NGS Enrichment Method for the Molecular Diagnosis of Monogenic Diabetes and Obesity?

Molecular diagnosis of monogenic diabetes and obesity is of paramount importance for both the patient and society, as it can result in personalized medicine associated with a better life and it eventually saves health care spending. Genetic clinical laboratories are currently switching from Sanger sequencing to next-generation sequencing (NGS) approaches but choosing the optimal protocols is not easy. Here, we compared the sequencing coverage of 43 genes involved in monogenic forms of diabetes and obesity, and variant detection rates, resulting from four enrichment methods based on the sonication of DNA (Agilent SureSelect, RainDance technologies), or using enzymes for DNA fragmentation (Illumina Nextera, Agilent HaloPlex). We analyzed coding exons and untranslated regions of the 43 genes involved in monogenic diabetes and obesity. We found that none of the methods achieves yet full sequencing of the gene targets. Nonetheless, the RainDance, SureSelect and HaloPlex enrichment methods led to the best sequencing coverage of the targets; while the Nextera method resulted in the poorest sequencing coverage. Although the sequencing coverage was high, we unexpectedly found that the HaloPlex method missed 20% of variants detected by the three other methods and Nextera missed 10%. The question of which NGS technique for genetic diagnosis yields the highest diagnosis rate is frequently discussed in the literature and the response is still unclear. Here, we showed that the RainDance enrichment method as well as SureSelect, which are both based on the sonication of DNA, resulted in a good sequencing quality and variant detection, while the use of enzymes to fragment DNA (HaloPlex or Nextera) might not be the best strategy to get an accurate sequencing.