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Comparison of different methods of eliciting utilities for outcome states in leprosy
PUBLIC
AND
CLINICAL
17s
POLICY
“HEPATITIS A VIRUS ANTIBODY: AN INDICATOR FOR MEASURING THE IMPACT OF SOCIO-ECONOMIC, WATER SUPPLY AND SANITARY DEVELOPMENT? Sumitr Sutra, Pensri
“HIGH FALSE POSITIVE AND FALSE NEGATIVE IN MALARIA DIAGNOSIS AS PART OF NATIONAL CONTROL PROGRAMME IN INDONESIA? Soesanto Tjokrosonto, CEU,
Kosuwon, and Aroon Chirawatkul, CEU, Khon Kaen University, Thailand. Objective: Hepatitis A is an enterically transmitted disease whose prevalence is closely related to the level of socio-economic and standard of public health. This study sought to test the validity of using anti HAV prevalence as an indicator for measuring the impact of social-economic, water supply and sanitary development. Design: Cross-sectional analytical study. Setting: Three primary schools were randomly selected from eighteen subdistricts of central district of Khon Kaen province after stratified by the level of social-economic and public health development. Participants: 191 healthy students age 6-12 years old represented school of high-middle income (group A), 128 students of middle-low income (group B) and 83 students of low income (group C) population. Main Outcome Measures: Serum sample were collected and HAV antibody was done by ELISA test. The parents were interviewed at home for socioleconomic status, water supply, latrine, food habit and housing at present and past by interviewers blinded from HAV antibody results. Results: 2.6% (5/191) of group A, 10.9% (14/128) of group B and 43.4% (36/83) of group C were positive for HAV antibodies. For univariate analysis, maternal education and income, household use of untreated water, absent of latrine, poor food habit, attend day care center and history of jaundice were significantly associated with the presence of HAV antibodies. With multiple logistic regression, history of jaundice in the past, absence of latrine and low maternal income were the strongest correlation with anti HAV antibodies. Conclusion: These finding provide strong evidence to support the validity of the new indicator to evaluate the impact of social-economic and public health development in a developing country.
Gadjah Mada University, Yogyakarta, Indonesia. Background: Microscopy is being carried out in health centers (Puskesmas) to confirm the diagnosis of malaria cases. The result of microscopy is then cross-checked by microscopist in the higher level in the district health office (Kabupaten). Since the procedure of cross-checking is carried out without blinding, disagreement between microscopists in both levels is likely to happen. Study Design: Study of agreement. Method and Analysis: An agreement study has been done in several Puskesmas in Baniarneeara Central lava Indonesia. All positive and 5% of negative blood slides from Puskesmas with different level of endemicity were randomly chosen and examined microscopically with blinding by district level, and then by microscopist from the central government (PPM) and Gadjah Mada University (GMU) as the gold standards. Agreement was measured in Kappa values, which are then tested for its significance. Results: Microscopy between GMU and central government performed high agreement (Kappa values ranged 0.75-0.91). Compared to central government, microscopist from health centers and district level produced low agreement (Kappa values ranged 0.35-0.51 and 0.36-0.61). False positive were observed as 41% and 33.3% in microscopy in health centers and district level. False negatives were recorded as 21.65% and 19.1% respectively. The sensitivity and specificity of microscopy in health centers were as high as 65% and 70% respectively, and 80% and 75% respectively in district levels. Conclusion: The spread of malaria has been occurring through high false negatives. Drugs have been given unnecessarily to false positive cases. The competence of microscopist in Health centers and district levels to diagnose malaria requires regular supervision. Monitoring of microscopy is imperative and should be carried out on the spot during visit. When low agreement is observed, prompt action is needed to evaluate the possible causes to maintain acceptable agreement of microscopy.
“COMPARISON OF DIFFERENT METHODS UTILITIES FOR OUTCOME STATES IN
OF ELICITING LEPROSY.” Tessa
TansTorres, CEU, University of The Philippines, Manila, Philippines. Objective: This study examines the validity, reliability and feasibility of three methods of elicitine utilities from oatients with oaucibacillarv lenrosv in the Philippines. Design: Five scenarios illustratina progressive decrease in qualitv of life in leprosy, were created. Using the techniques of rating scale (RS), standard gamble (SC) and time trade-off (TTO), two trained interviewers elicited the utilities of 132 subjects for the 5 scenarios. Measurement was repeated after 4 weeks (x interval = 29 + SEM 2.6 days) The rating scale was always applied first and the order of administering standard gamble and time-tradeoff was randomized within group for the first interview. The order war reversed in the second interview. Participants: The participants, all familiar with the disease of leprosy, included 35 outpatients, 27 institutionalized patients, 34 patients’ home companions and 36 health workers. Results: Results were analyzed according to content, construct, concurrent and criterium validity. For construct validity the mean utilities (per scenario) elicited by SC and T-l-0 were not statistically different from each other. Surprisingly, mean utilities (per scenario) elicited by the RS were significantly higher than those obtained by the other two methods for the worst scenario. The utility expressed by the patient for the outcome as “your health status” correlated poorly with the utility expressed by the patient for the five scenarios to which the patient was classified by the interviewers. This failure to show concurrent validity was present in the three methods (correlation coefficient or r = 0.25-0.26 for rating scale, 0.37-0.53 for standard gamble and time trade-off) and is probably due to the non exhaustive nature of the 5 scenarios. For criterium validity the patient’s cardinal utilities were transformed to ranks. 95% of the population achieved proper ranking if rating scale was used. 10% were able to achieve the same using standard gamble and time-trade-off. Correlation coefficient of utilities on test-retest were 0.54-0.82 for RS and T-l-0 and slightly lower, r = 0.49-0.61 for SC. The mean difference between utilities was not statistically different from 0.0. However if >O.lO was arbitrarily set as clinically significant difference, 74% of the subjects using RS, 69 % and 66% SC and TTO respectively, had errors. All the subjects completed both interviews. Compression of >0.80 per cent was statistically significantly correlated with >lO years of schooling. Conclusions: Despite its theoretical limitations, the rating scale performed well in terms of validity, reliability and feasibility. More studies are needed before time-trade-off and standard gamble can be adopted in the Philippines.
“THE EFFECT OF COST RECOVERY ON HOSPITAL SERVICE UTILIZATION IN KLATEN DISTRICT, CENTRAL JAVA PROVINCE, INDONESIA.” Adi Utarini and M. Sulaeman, CEU, Gadjah Mada University, Yogyakarto, Indonesia. Objective: To assess changes in hospital service utilization and to explore perceived quality of care associated with increases in user charges (Swadana policy). Design: A pre and post test design with a control group was employed in this study. In addition to quantitative data, an in-depth interview was also performed. Setting: Klaten General hospital, Central Java province and Sleman General Hospital, Yogyakarta Province. Participants: All patients admitted to Klaten and Sleman General hospitals between 1991-1994 were recruited in the study, and 23 women were involved in the qualitative study. Intervention: The swadana policy was introduced in Klaten hospital since 1992. The overall increases of fees excluding the medical treatment were between 250% and 500% in the outpatient department, whereas for the inpatient department the increases were less dramatic. Main Outcome Measures: Utilization data (i.e., outpatient services and hospital admissions) were collected I year before and 2 years after the policy, obtained from secondary sources. Result: A trend of increasing outpatient utilization and number of deliveries, and a 2.1% drop of admissions followed by a recovery to a higher level than before the Swadana policy were found. Trends in the use of the VIP and type I accommodations suggested an increase which was not resulting from the decline of use of type III accommodation. From the qualitative study, it was shown that technical and supportive aspects of care were equally significant in determining choice of place for delivery. Conclusion: Accessibility to Klaten hospital has not been hampered by this level of increase of charges. Nevertheless, this does not necessarily show the afford ability of such services. In this context, therefore, concerns of equity should then be given a high priority.
AND
CLINICAL
17s
POLICY
“HEPATITIS A VIRUS ANTIBODY: AN INDICATOR FOR MEASURING THE IMPACT OF SOCIO-ECONOMIC, WATER SUPPLY AND SANITARY DEVELOPMENT? Sumitr Sutra, Pensri
“HIGH FALSE POSITIVE AND FALSE NEGATIVE IN MALARIA DIAGNOSIS AS PART OF NATIONAL CONTROL PROGRAMME IN INDONESIA? Soesanto Tjokrosonto, CEU,
Kosuwon, and Aroon Chirawatkul, CEU, Khon Kaen University, Thailand. Objective: Hepatitis A is an enterically transmitted disease whose prevalence is closely related to the level of socio-economic and standard of public health. This study sought to test the validity of using anti HAV prevalence as an indicator for measuring the impact of social-economic, water supply and sanitary development. Design: Cross-sectional analytical study. Setting: Three primary schools were randomly selected from eighteen subdistricts of central district of Khon Kaen province after stratified by the level of social-economic and public health development. Participants: 191 healthy students age 6-12 years old represented school of high-middle income (group A), 128 students of middle-low income (group B) and 83 students of low income (group C) population. Main Outcome Measures: Serum sample were collected and HAV antibody was done by ELISA test. The parents were interviewed at home for socioleconomic status, water supply, latrine, food habit and housing at present and past by interviewers blinded from HAV antibody results. Results: 2.6% (5/191) of group A, 10.9% (14/128) of group B and 43.4% (36/83) of group C were positive for HAV antibodies. For univariate analysis, maternal education and income, household use of untreated water, absent of latrine, poor food habit, attend day care center and history of jaundice were significantly associated with the presence of HAV antibodies. With multiple logistic regression, history of jaundice in the past, absence of latrine and low maternal income were the strongest correlation with anti HAV antibodies. Conclusion: These finding provide strong evidence to support the validity of the new indicator to evaluate the impact of social-economic and public health development in a developing country.
Gadjah Mada University, Yogyakarta, Indonesia. Background: Microscopy is being carried out in health centers (Puskesmas) to confirm the diagnosis of malaria cases. The result of microscopy is then cross-checked by microscopist in the higher level in the district health office (Kabupaten). Since the procedure of cross-checking is carried out without blinding, disagreement between microscopists in both levels is likely to happen. Study Design: Study of agreement. Method and Analysis: An agreement study has been done in several Puskesmas in Baniarneeara Central lava Indonesia. All positive and 5% of negative blood slides from Puskesmas with different level of endemicity were randomly chosen and examined microscopically with blinding by district level, and then by microscopist from the central government (PPM) and Gadjah Mada University (GMU) as the gold standards. Agreement was measured in Kappa values, which are then tested for its significance. Results: Microscopy between GMU and central government performed high agreement (Kappa values ranged 0.75-0.91). Compared to central government, microscopist from health centers and district level produced low agreement (Kappa values ranged 0.35-0.51 and 0.36-0.61). False positive were observed as 41% and 33.3% in microscopy in health centers and district level. False negatives were recorded as 21.65% and 19.1% respectively. The sensitivity and specificity of microscopy in health centers were as high as 65% and 70% respectively, and 80% and 75% respectively in district levels. Conclusion: The spread of malaria has been occurring through high false negatives. Drugs have been given unnecessarily to false positive cases. The competence of microscopist in Health centers and district levels to diagnose malaria requires regular supervision. Monitoring of microscopy is imperative and should be carried out on the spot during visit. When low agreement is observed, prompt action is needed to evaluate the possible causes to maintain acceptable agreement of microscopy.
“COMPARISON OF DIFFERENT METHODS UTILITIES FOR OUTCOME STATES IN
OF ELICITING LEPROSY.” Tessa
TansTorres, CEU, University of The Philippines, Manila, Philippines. Objective: This study examines the validity, reliability and feasibility of three methods of elicitine utilities from oatients with oaucibacillarv lenrosv in the Philippines. Design: Five scenarios illustratina progressive decrease in qualitv of life in leprosy, were created. Using the techniques of rating scale (RS), standard gamble (SC) and time trade-off (TTO), two trained interviewers elicited the utilities of 132 subjects for the 5 scenarios. Measurement was repeated after 4 weeks (x interval = 29 + SEM 2.6 days) The rating scale was always applied first and the order of administering standard gamble and time-tradeoff was randomized within group for the first interview. The order war reversed in the second interview. Participants: The participants, all familiar with the disease of leprosy, included 35 outpatients, 27 institutionalized patients, 34 patients’ home companions and 36 health workers. Results: Results were analyzed according to content, construct, concurrent and criterium validity. For construct validity the mean utilities (per scenario) elicited by SC and T-l-0 were not statistically different from each other. Surprisingly, mean utilities (per scenario) elicited by the RS were significantly higher than those obtained by the other two methods for the worst scenario. The utility expressed by the patient for the outcome as “your health status” correlated poorly with the utility expressed by the patient for the five scenarios to which the patient was classified by the interviewers. This failure to show concurrent validity was present in the three methods (correlation coefficient or r = 0.25-0.26 for rating scale, 0.37-0.53 for standard gamble and time trade-off) and is probably due to the non exhaustive nature of the 5 scenarios. For criterium validity the patient’s cardinal utilities were transformed to ranks. 95% of the population achieved proper ranking if rating scale was used. 10% were able to achieve the same using standard gamble and time-trade-off. Correlation coefficient of utilities on test-retest were 0.54-0.82 for RS and T-l-0 and slightly lower, r = 0.49-0.61 for SC. The mean difference between utilities was not statistically different from 0.0. However if >O.lO was arbitrarily set as clinically significant difference, 74% of the subjects using RS, 69 % and 66% SC and TTO respectively, had errors. All the subjects completed both interviews. Compression of >0.80 per cent was statistically significantly correlated with >lO years of schooling. Conclusions: Despite its theoretical limitations, the rating scale performed well in terms of validity, reliability and feasibility. More studies are needed before time-trade-off and standard gamble can be adopted in the Philippines.
“THE EFFECT OF COST RECOVERY ON HOSPITAL SERVICE UTILIZATION IN KLATEN DISTRICT, CENTRAL JAVA PROVINCE, INDONESIA.” Adi Utarini and M. Sulaeman, CEU, Gadjah Mada University, Yogyakarto, Indonesia. Objective: To assess changes in hospital service utilization and to explore perceived quality of care associated with increases in user charges (Swadana policy). Design: A pre and post test design with a control group was employed in this study. In addition to quantitative data, an in-depth interview was also performed. Setting: Klaten General hospital, Central Java province and Sleman General Hospital, Yogyakarta Province. Participants: All patients admitted to Klaten and Sleman General hospitals between 1991-1994 were recruited in the study, and 23 women were involved in the qualitative study. Intervention: The swadana policy was introduced in Klaten hospital since 1992. The overall increases of fees excluding the medical treatment were between 250% and 500% in the outpatient department, whereas for the inpatient department the increases were less dramatic. Main Outcome Measures: Utilization data (i.e., outpatient services and hospital admissions) were collected I year before and 2 years after the policy, obtained from secondary sources. Result: A trend of increasing outpatient utilization and number of deliveries, and a 2.1% drop of admissions followed by a recovery to a higher level than before the Swadana policy were found. Trends in the use of the VIP and type I accommodations suggested an increase which was not resulting from the decline of use of type III accommodation. From the qualitative study, it was shown that technical and supportive aspects of care were equally significant in determining choice of place for delivery. Conclusion: Accessibility to Klaten hospital has not been hampered by this level of increase of charges. Nevertheless, this does not necessarily show the afford ability of such services. In this context, therefore, concerns of equity should then be given a high priority.