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PubMed1996

Pharmacoeconomics and formulary decision making.

Pharmacoeconomic assessment of formulary actions has become increasingly common in local, national, and international formulary decision making. Tactics for managing medication use include formulary management and drug policies. Pharmacoeconomic data can provide support for these formulary decisions. For example, pharmacoeconomic data can support the inclusion or exclusion of a drug on or from the formulary and support practice guidelines that promote the most cost-effective or appropriate utilisation of pharmaceutical products. Various strategies can be used to incorporate pharmacoeconomics into formulary decision making. These include using published pharmacoeconomic studies and economic modelling techniques, and conducting local pharmacoeconomic research. Criteria for evaluating the pharmacoeconomic literature, suggestions for employing economic models, and suggested guidelines for conducting pharmacoeconomic projects are discussed. Although most formularies are viewed as cost-containment tools, formularies should not be a list of the 'cheapest' alternatives. Today's formulary should contain agents that optimise therapeutic outcomes while controlling cost. Pharmacoeconomic assessments of formulary decisions help to ensure that the agents promoted by our formularies yield the highest outcome per dollar spent. A discussion of the process for formulary action in a US hospital, the influence of pharmacoeconomics on US formularies, and strategies for incorporating pharmacoeconomics into formulary decision making are presented in this paper.

Decision Making, Organizational↗
PubMed2006

The generalisability of pharmacoeconomic studies: issues and challenges ahead.

Developing from a previous review, this article revisits the generalisability theme to summarise recent advances in methodology and provide an update of challenges faced by producers and users of pharmacoeconomic data. Our original evaluative criteria encompassed technical issues, applicability and transferability. The technical elements of best practice are comparatively uncontroversial: choosing relevant alternatives; transparent reporting of methods and findings; accessing and applying the best-quality evidence; using best methods to synthesise data; and using deterministic sensitivity analysis to explore potential systematic bias whilst employing probabilistic sensitivity analysis to explore the influence of random error at the whole model level. The applicability of economic findings within their original policy context (e.g. national analyses based on generalisable within-country data) can be determined, provided that best practice guidelines for economic modelling are adhered to. The transferability of economic findings (from one policy setting to another, e.g. country, region, clinical setting or patient population) requires careful exploration of changes in resource implications, unit prices and outcomes, a process facilitated again by transparent reporting of methods, adjustment for baseline risk and potentially by recent statistical developments intended to deal with hierarchically structured data. Although there is considerable consensus in the published literature about these key issues, limitations remain for economic analysis as implemented because of its opaqueness of method, failure to reflect the opportunity cost of decisions and lack of societal mandate. If the primary purpose of health economic evaluation is to help society to obtain the best value from limited resources, then, at a time when most technologically advanced societies need to engage with the realities of limited healthcare funding, technocratic solutions alone appear insufficient. Making health economic findings accessible to patients, clinicians and society, in the form of relevant narratives, will help this essential debate and expose assumptions underpinning economic analysis to broader critical inspection.

Economics, Pharmaceutical↗
PubMed2000

A model for economic comparison of swine insemination programs.

Optimal artificial insemination schedules are those that result in a high farrowing rate and litter size, while minimizing costs of semen and labor by avoiding unnecessary inseminations. A simulation model programmed in a commercial spreadsheet was developed to permit comparison of alternative schedules. Farrowing rate and litter size for a particular schedule were dependent on the timing of insemination relative to the time of ovulation. Economic return was calculated by multiplying the number of pigs born per bred sow by $33.00 and subtracting the cost of producing a litter of pigs and raising them to weaning ($222.88 per sow plus $2.44 per pig born) and the cost of detection of estrus and breeding. Seven insemination schedules combined with once versus twice per day detection of estrus were simulated in 500 herds of 100 sows each. Inseminations were simulated to occur on schedules of: 1) 0, 12, 24 and 36 h; 2) 12, 24 and 36 h; 3) 0 and 24 h; 4) 12 and 36 h; 5) 12 h; 6) 24 h; and 7) 36 h after first detection of estrus. Schedule 1 was predicted to yield the highest farrowing rate and litter size. Economic return was highest for Schedule 2 with twice per day detection of estrus followed closely by Schedule 1 with once per day detection of estrus at $14.90 and $13.75 per bred sow, respectively. High performance was dependent on insuring that inseminations occurred at an optimum time in as great a proportion of sows as possible.

Animals↗
PubMed2000

Could chest X-ray screening for lung cancer be cost-effective?

BACKGROUND: Currently, no screening program for lung cancer is advocated, yet recent review of the clinical trials has raised questions about the conclusion that it would not be effective. If a screening program is to be considered, its potential economic impact needs to be assessed. METHODS: An economic model was created comparing lung cancer mortality in male smokers ages 45-80 years, screened versus unscreened. Estimates of the potential reduction in mortality and cost of screening are applied. The outcomes of the model include deaths avoided, life years gained, net costs, and cost-effectiveness. RESULTS: The base analysis (mortality reduction of 18%) estimates that nearly 3000 deaths would be avoided in a population of 100,000 male smokers age 40-80 years, at a cost-effectiveness of $9000 per undiscounted life year gained. A program resulting in only 6% mortality reduction would increase the ratio to $25,000 per undiscounted life years gained. CONCLUSIONS: If further examination of lung cancer screening supports its effectiveness, the results of this model suggest that implementation would be economically efficient.

Adult↗
PubMedDate not supplied

Bileaflet valve replacement: complications and costs.

A meta-analysis of the available literature on the CarboMedics and St. Jude Medical valves was conducted to compare their clinical performance. Frequency of valve-related complications for aortic, mitral, and double-valve replacements served as a measure of performance. An economic model was created to estimate the economic impact of valve-related complications. Overall, fewer events occurred with the St. Jude Medical valve than with the CarboMedics valve. As a result, use of the St. Jude Medical valve is expected to save up to $13,201 over 10 years.

Adolescent↗
PubMed2001

A cost-cost study comparing etanercept with infliximab in rheumatoid arthritis.

OBJECTIVE: The objective of this study was to compare the total costs associated with the administration of two different tumour necrosis factor (TNF) strategies used in the treatment of rheumatoid arthritis (RA): etanercept, a soluble TNF receptor that can be administered at home by subcutaneous injection, versus infliximab, an antibody that requires an intravenous infusion in a hospital outpatient setting. DESIGN AND SETTING: The main analytical framework of the study was a cost-cost analysis comparing the total annual costs associated with the administration of etanercept and infliximab in adult RA patients. The perspective of the study was that of the Dutch society. An economic model was constructed to determine the costs of both treatments. The cost evaluation included direct medical costs, direct nonmedical costs and indirect costs. The base-case analysis compared monotherapy with etanercept versus a combination therapy with infliximab and methotrexate. Data for the economic model came from published literature, expert opinion and official price and tariff lists. All costs were in 1999 values. PATIENTS AND PARTICIPANTS: The analysis was performed for the adult RA population eligible for treatment with etanercept or infliximab in The Netherlands. MAIN OUTCOME MEASURES AND RESULTS: The analysis showed that the total annual drug costs per patient do not differ substantially between infliximab and etanercept, with costs of Netherland guilders (NLG)31,526 (12,610 US dollars) and NLG31,334 (12,534 US dollars), respectively. However, the other medical costs (i.e. excluding the costs of the two drugs themselves) are substantially higher for infliximab due to the additional costs associated with administration in an outpatient clinic and the use of methotrexate [NLG 12,621 (5048 US dollars) versus NLG269 (107 US dollars) for etanercept]. The impact of direct nonmedical costs (transportation) and indirect costs were negligible. Overall treatment with infliximab is more expensive than treatment with etanercept with total costs of NLG45 115 (18,046 US dollars) and NLG3I,621 (12,648 US dollars), respectively (42.7% increase). CONCLUSIONS: Based on the assumptions used in the model, we may conclude that the use of etanercept compares favourably with infliximab from a budgetary and health economic perspective: the total costs are substantially lower when the efficacy of etanercept is assumed to be at least equivalent to the efficacy of infliximab.

Adult↗
PubMed2001

The economics of daily dialysis.

Research suggests that daily hemodialysis improves clinical outcomes and patient quality of life when compared with conventional hemodialysis; however, little is known about its economic impact. In this article, we review the literature on the costs of daily hemodialysis (n = 170). We also present updated results from an economic model we constructed that compares 1-year treatment costs for short daily in-center, short daily at-home, nocturnal, and conventional hemodialysis. Clinical parameters for the model were drawn from our review of the clinical literature. Resource use during daily hemodialysis was modeled after the experience of 2 ongoing programs in the United States, a short daily program in California (n = 26) and a nocturnal program in Virginia (n = 13). Reports from the literature and our economic model suggest daily hemodialysis might provide better outcomes and savings when compared with conventional hemodialysis. However, larger, longer controlled studies are needed to see if daily dialysis fulfills these promises. We discuss several issues researchers should keep in mind in designing future studies about the economics of daily dialysis.

Appointments and Schedules↗
PubMed2001

Anaerobic treatment of domestic wastewater in temperate climates: treatment plant modelling with economic considerations.

Although research suggests that anaerobic treatment of low-strength domestic wastewater is possible in temperate climates, to date, full-scale applications have only been pioneered in hot regions. However, burgeoning environmental legislation in developed countries is giving the impetus to develop anaerobic wastewater treatment systems due to potential economic and environmental benefits they hold over traditional aerobic techniques. In this paper a design rationale for low-temperature, low-strength (COD < 1,000 mgl(-1)), two-phase anaerobic wastewater treatment is developed through empirical modelling of data from published research, and from assumptions arising from a literature review. Model calculations are applied to typical domestic sewage characteristics at two different flow rates, based on population equivalents. Results indicate that soluble COD production in the model hydrolytic tank are similar to those achieved in pilot scale plants in the Netherlands. Model anaerobic reactor sludge characteristics are similar to those achieved in pilot and full-scale anaerobic reactors treating low-strength wastewaters. Indicative cost figures for a two-phase anaerobic treatment plant are given, but are incomplete without an assessment of the cost of post-treatment processes. Anaerobic treatment is likely to become more attractive in the future as new legislation relating to sludge disposal and renewable energy generation are introduced.

Bacteria, Anaerobic↗
PubMed2005

Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost-utility study.

OBJECTIVE: To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. DESIGN: Cost-utility analysis of audit based patient subgroups by means of a simple economic model. SETTING: Tertiary care. PARTICIPANTS: 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. MAIN OUTCOME MEASURES: Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. RESULTS: Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non-elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be 112 pound sterling (212 USD, 162 pound sterling) (sirolimus stents) or 89 pound sterling (167 USD, 130 pound sterling) (paclitaxel stents). CONCLUSIONS: At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

Aged↗
PubMed2005

Are cost benefits of anticoagulation for stroke prevention in atrial fibrillation underestimated?

BACKGROUND AND PURPOSE: Stroke outcomes in patients with atrial fibrillation (AF) tend to be worse than those in patients without AF. The objective of this study was to evaluate whether the cost benefits of anticoagulation for stroke prevention in AF may currently be underestimated by existing economic models that do not distinguish between different stroke outcomes. METHODS: A literature review was conducted in 3 areas: (1) studies comparing stroke outcomes in AF and non-AF patients; (2) studies providing long-term cost of stroke estimates; and (3) studies modeling the cost-effectiveness of anticoagulation with a vitamin K antagonist (eg, warfarin) in AF patients. RESULTS: There is considerable evidence that stroke in AF patients has a worse outcome than in patients without AF, including higher mortality, severity, and recurrence rates, and greater functional impairment and dependency. Estimates of the long-term cost of stroke of different severities were between US 24,991 dollars for a mild stroke over 5 years and US 142,251 dollars for a major ischemic stroke over a lifetime (2004 prices). The cost of a severe ischemic stroke may typically be 3-times that of mild stroke. However, cost-effectiveness models for anticoagulation in patients with AF have used average (not AF-specific) cost-of-stroke data, and most have used stroke severity distributions derived from clinical trials, which may differ from those in clinical practice. CONCLUSIONS: Existing economic models underestimate the cost benefits of anticoagulation for stroke prevention because they do not adjust for poorer outcomes associated with cardioembolic strokes.

Aged↗
PubMed2005

Dietary balanced protein in broiler chickens. 2. An economic analysis.

An economic model was developed that calculates economic optimal dietary balanced protein (DBP) contents for broiler chickens, based on performance input and prices of meat and feed. Input on broiler responses to DBP content (growth rate, feed conversion, carcase yield and breast meat yield) was obtained from the model described by Eits et al. (2005). Changes in broiler age, price of protein-rich raw materials and large changes (40%) in meat prices resulted in economic relevant differences in DBP content for maximum profit. Effects of changes in sex or feed price on DBP content for maximum profit were negligible. Formulating diets for maximum profit instead of maximum broiler performance can strongly increase the profitability of a broiler production enterprise. DBP content for maximum profitability depends on how the broilers are marketed; as whole birds, carcase or portions.

Animal Feed↗
PubMed2004

A behavioural economic analysis of alcohol, amphetamine, cocaine and ecstasy purchases by polysubstance misusers.

Behavioural economic models of substance choice describe the relationship between changes in unit price and consumption. As the majority of UK non-dependent substance misusers are polysubstance misusers, we investigated the influence of price upon hypothetical purchases of alcohol, amphetamine, cocaine and ecstasy. Forty-three current polysubstance misusers (25 males, 18 females; mean age 21.3 +/- 2.8) were recruited into the study. As the price of alcohol rose, demand was inelastic. Amphetamine was a substitute for alcohol, cocaine was a compliment drug and ecstasy was independent. Demand for amphetamine was elastic as its price rose, but only alcohol was identified as a substitute drug and other drug purchases were independent of amphetamine price. As the price of cocaine increased, demand was elastic. Alcohol and ecstasy were substitute drugs but amphetamine purchase was independent, indicating asymmetrical substitution of alcohol and cocaine. Finally, demand for ecstasy was also elastic, but only cocaine substituted as ecstasy price rose. These results extend previous findings in substance dependent populations using behavioural economic models and support the opinion that purchasing substances is a complex process, involving both socio-economic and psychopharmacological factors. Whilst subjects expressed a preference for ecstasy, these behavioural findings indicated that alcohol was their drug of choice when economic considerations were brought into play. Self-reported drug preference, although facilitating between subjects experimental design, may therefore not accurately represent real world polysubstance misuse.

Adolescent↗
PubMed1992

The synthesis economic fertility model: a latent variable investigation of some critical attributes.

"This study uses Nicaraguan data to estimate a latent variable system of reduced-form demands for births, infant mortality, contraception, nutrition and breastfeeding. The estimates support some of the synthesis extensions to the standard fertility model, such as the concurrent increase of contraception, health, nutrition and fertility and decline in breastfeeding with income increases from initial low levels.... The initial stages of development may experience an increase in family size despite an increase in contraceptive use...as well as a profertility impact of reduced breastfeeding." Data are from a survey of women aged 15-45 that was conducted in Nicaragua from 1977 to 1978.

Americas↗
PubMed2000

The future of orthopaedics in the United States: an analysis of the effects of managed care in the face of an excess supply of orthopaedic surgeons.

Recent technological advances in orthopaedic surgery have propelled both the volume of surgical cases and their complexity, resulting in increased costs, which should naturally result in higher incomes for surgeons. However, the transition from a fee-for-service model of physician compensation to a managed care model has resulted in major shifts in economic resource allocation. An economic model of this market based on imperfect competition shows that these changes have shifted market power from surgeons to the managed care organizations. Our model predicts that practicing surgeons will retire earlier, medical students will begin to select other specialties, and innovation will be slowed. Antitrust laws limit surgeons' ability to combat this trend through meaningful collective bargaining, creating the potential for future shortages as the baby boom generation reaches retirement age and the demand for orthopaedic services increases dramatically.

Education, Medical↗
PubMed1985

Demographic-economic analysis in a multi-zonal region: a case study of Nordrhein-Westfalen.

"This paper develops a series of spatially-disaggregated demographic-economic models, based on an extended Leontief type input-output model. Travel between residence and place of work and residence and place of shopping is included in the models, and a detailed decomposition of a range of multipliers identified. A model explicitly involving travel to work is developed empirically for the state of Nordrhein-Westfalen in West Germany, and sets of multipliers presented which relate changes in demographic and economic variables in particular zones of the state with changes in economic output and employment-related variables in other zones."

Behavior↗
PubMed1995

[QALYS or not QALYS: that is the question?].

The article discusses the proposal of some health economists to use the "cost per QALY (quality-adjusted-life year)" ratio as an universal indicator for economic assessment of medical interventions, in the so-called "cost-utility" analyses. Authors argue that QALYs are not a straightforward application of expected utility theory, which is the standard economic model of individual behaviours toward risk and uncertainty. Indeed, QALYs are compatible with economic utility theory only if individuals' preferences regarding health states satisfy certain very restrictive properties: utility independence between length of life and quality of life, constancy of the proportional trade-off between quality of life and length of life, risk neutrality towards health states, constancy through time of the utility associated with each health state. Aggregation of individual QALYs to obtain an indicator for patient groups at the societal level also raises complex equity problems. Last but not least, from the epistemological point of view, QALYs are based on the hypothesis that health interventions only affect the health of the individual and not any other aspects of his well-being. The authors conclude that the "cost per QALY" approach should be abandoned in order to avoid ambiguities that could impede the development of health economics in the medical field.

Choice Behavior↗
PubMed1999

Assessing the potential cost effectiveness of pneumococcal vaccines in the US: methodological issues and current evidence.

Pneumococcal disease imposes a notable burden on society, particularly in the elderly and those at high risk of complications. Preventive strategies, especially vaccines, are possibly the best way to minimise such a burden. We report on the conduct and results of a preliminary exploratory review of the economics of pneumococcal vaccines in the elderly population in the US. After extensive electronic and manual searches, we identified 5 economic evaluations that fulfilled our study criteria. From these we extracted key economic variables and assessed the quality of the studies against the criteria in the checklist for authors and peer reviewers of economic submissions to the British Medical Journal. We found variation of quality of study design such as a lack of clarity in the treatment of indirect costs and a failure to present the data on resource use and costs separately. We carried out supplementary searches to assess the quality of the epidemiological and efficacy evidence upon which the economic models were based and found contradictory evidence of effects of the vaccines, which included the results of 2 meta-analyses. One of these meta-analyses reported that retrospective studies, especially case-control studies, tended to underestimate the protective efficacy of the vaccine by as much as 20%. We believe that a well resourced Cochrane review of the clinical evidence of the effects of the vaccines should be carried out before any further economic studies. No more economic modelling should take place before such a review is undertaken.

Bacterial Vaccines↗