Throughout Europe and in a number of other industrialized countries, the coming decades have been predicted to feature an increase in the proportion of patients who are elderly. This has led to considerable concern with respect to financing the health care system and has also increased the concerns about the efficiency of health care. Integrating ageing and efficiency issues, this paper examines the effects of age on the cost-effectiveness of medical interventions and its impact on decision making. First, at the clinical level, the relation between age and the cost-effectiveness of medical interventions is analysed. Second, at the population level, a framework is presented which allows researchers and decision makers to assess the impact of these effects on the decision-making process. It is shown that the allocation of health care resources at the macro-level is seriously impaired when age is ignored as a variable in cost-effectiveness analysis. Because clinical trials typically employ 'young' populations, when the data are extrapolated to the whole population the attractiveness of medical interventions in terms of cost-effectiveness may be considerably overestimated. Furthermore, the cost-effectiveness ratio may vary across countries or over time as a result of demographic or epidemiological variation. Economic evaluators should describe the impact of age, which should then be considered by decision makers to control for age effects.

Age Factors↗

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The interpretation of results of economic evaluation: explicating the value of health.

Theoretically it can be proven that an optimal allocation of resources within a constrained budget can be reached by considering cost-effectiveness ratios (CERs). In this paper, the complex priority setting process regarding compatible and incompatible alternatives of medical interventions is clarified. Priority setting in the context of compatible alternatives may refer to the selection of more than one, possibly all, alternatives. Inherent to a set of incompatible alternatives is that only one alternative can be selected. This latter situation frequently occurs in health care. The value that society attaches to a unit of effectiveness (e.g. a QALY) has an important impact on the priority ranking of medical interventions. By explicating this value and by using the 'net-value' approach, a graphical framework is presented that allows decision-makers a better understanding on the impact of particular levels of these values on their optimal policy choices. For illustrative purposes, it is shown that by the erroneous application of decision rules, some recent papers have provided sub-optimal recommendations for health care policy.

Adult↗

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The usefulness of ratios for allocation decisions: the case of stroke.

Economic evaluation is becoming increasingly important in the field of stroke as well. The results of economic evaluation can be expressed in cost per quality-adjusted life years (QALY) gained, which enables policy makers to compare the relative efficiency of different interventions regarding different diseases. Although using the concept of QALY is preferable from a theoretical point of view, in medical practice more often cost-effectiveness analysis (CEA), and not cost-utility analysis, is applied for practical reasons. One of the main limitations of CEA is that the results may be compared only with results of other CEAs, using the same effect parameter. The calculation of cost-effectiveness ratios (CERs) in many cases is misleading for resource allocation. Effects should be expressed in interval or ratio scales in order to calculate CERs, which is rarely the case. The calculation of a CER in a CEA should only be performed if, and only if, the investigator is convinced that there is a constant relation between the specific effect parameter and the ultimate gain in health.

Cost-Benefit Analysis↗

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[Cost effectiveness of vaccination against pneumococcal bacteremia in the elderly: the results in Belgium].

BACKGROUND: Several studies have shown that pneumococcal vaccination of older persons would be cost-effective in preventing pneumococcal pneumonia, but evidence of clinical protection for this condition is uncertain. Given much better evidence of vaccination effectiveness against invasive disease, studies showing that vaccination is cost-effective in preventing invasive disease alone could provide strong support for public policies to vaccinate older persons. METHODS: We examined the cost-effectiveness of preventing invasive pneumococcal infection by vaccination with the 23-valent pneumococcal polysaccharide vaccine of persons > or = 65 years in age in Belgium. The direct medical costs expressed per quality adjusted life year (QALYs) of a cohort of vaccinated persons was compared with the costs per QALY in a cohort of persons who are not vaccinated. RESULTS: Preventing invasive pneumococcal infections by vaccinating elderly persons clearly benefits people's health. By vaccinating 10,000 persons over 65 years of age, approximately eight QALYs can be gained compared with no vaccination. Achieving these health benefits however requires additional costs,: 30,000 ECU per QALY gained. The cost-effectiveness ratio is slightly better (i.e. 25,000 ECU per QALY) for the age group 65-75 years, and slightly worse (i.e. 35,000 ECU per QALY) for the age group 75-84 years. It increases sharply to 77,000 ECU per QALY for the persons over 85 years of age. An extensive one-dimensional sensitivity analysis did not greatly affect these results. If vaccination is also clinically effective in preventing pneumococcal pneumonia, vaccinating all elderly persons is cost saving. CONCLUSION: Using empirical epidemiological data, pneumococcal vaccination to prevent invasive pneumococcal disease is acceptably to moderately cost-effective in Belgium. On the basis of our findings, we believe public health authorities should consider policies for encouraging pneumococcal vaccination for all persons > or = 65 years in age.

Age Factors↗