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PubMed2005

An introduction to economic evaluation: what's in a name?

OBJECTIVE: This paper describes the main types of economic evaluation techniques. METHOD: To examine the strengths and limitations of different types of economic evaluations, we used a hypothetical example to review the reasoning underlying each method and to illustrate when it is appropriate to use each method. RESULTS: The choice of economic evaluation method reflects a decision about what should represent "success" and how success should be valued. Measures of benefit and cost must be considered systematically and simultaneously. Claiming that a new treatment is cost-effective requires making a value judgment based on the personal beliefs of the claimant. Even when cost and effect data are objective, a verdict of cost-effective is subjective. The conclusions of an economic study can change significantly, depending on which patient outcome is used to measure success. CONCLUSIONS: Clinicians must be sure that important patient outcomes are not excluded from economic evaluations. Economic evaluation is a process designed to produce an estimate rather than a decision. New treatment can be more costly and still be cost-effective (if the extra benefit is valued more than the extra cost to produce it). However, since economic evaluation does not explicitly consider a decision maker's available budget, a new treatment can be deemed cost-effective but too expensive to approve.

Canada↗
PubMed1995

Economic evaluation of drugs and its potential uses in policy making.

Interest in the economic evaluation of drug treatments is steadily increasing, but the impact of such evaluations on decisions concerning the use of drugs is unclear. In this article I examine different decision and policy situations where economic evaluations of drug treatments could potentially be used. Economic evaluations may be used as an aid to the development of treatment guidelines, decisions within healthcare organisations, and decisions relating to approval, reimbursement and pricing. Economic evaluations appear to be most useful in the development of treatment guidelines and as an aid to reimbursement decisions. The incentive to use economic evaluations embodied in the healthcare system is also important. It is argued that it is too early to introduce regulations that require the use economic evaluations in, for example, reimbursement decisions. A more cautious approach might be preferred, where economic evaluations are used more selectively until the methodology and the field have developed further.

Decision Making, Organizational↗
PubMed2002

Design, analysis and presentation of multinational economic studies: the need for guidance.

Over the last decade, there has been a proliferation in the number of economic evaluations of pharmaceuticals to meet the growing demand for information about the economic benefits of healthcare technologies. The majority of these studies have been commissioned by pharmaceutical companies for the purposes of drawing attention to the resource and quality-of-life aspects of new or existing products. Such information has become important in overcoming a new obstacle, namely the demonstration of cost effectiveness (the so-called 'fourth hurdle'), in addition to the three well-established criteria of quality, tolerability and efficacy. To ensure the maintenance of standards, guidance for economic evaluations has emerged lately in the form of guidelines, regulations, principles, policies and positions. Drummond outlined three purposes of these guidelines, as follows: as a requirement prior to reimbursement, as statements of methodological standards, and as a statement of ethical standards. Such guidelines are designed to assist both the economic analyst and the decision-maker. In laying out the state of the art regarding the methodology of economic evaluation, guidelines assist the analyst in performing high-quality, scientifically valid studies, and assist the decision-maker in properly interpreting and assessing their quality. In response to these growing requirements for cost-effectiveness data globally, it has become increasingly common for economic evaluations to be conducted on an international scale. However, the recommendations in pharmacoeconomics guidelines regarding the manner in which these multinational economic evaluations should be designed, analysed and presented are too limited to be of any real value. This article examines the various issues that must be taken into consideration when conducting multinational studies, and provides a review of the techniques and approaches that have been suggested to date. It concludes with recommendations for potential inclusion in future sets of pharmacoeconomic guidelines.

Drug Costs↗
PubMed1999

[Analysis of economic data and elaboration of professional guidelines].

As medicine becomes increasingly complex, economic constraints are beginning to weight more heavily on the actors of our health system. It follows that one of ANAES' missions is to initiate and promote professional guidelines that take full account of economic arguments. One of the benefits of economic evaluation is to provide professionals with information about the economic consequences of their practices. This implies determining to what extent the methodological principles used to develop clinical guidelines can also apply to the incorporation of economic criteria in professional guidelines. Economic evaluation offers those active in the field of health an information that can be absorbed into the reality of what they actually do in practice. Professionals can thus orient themselves towards practices which have not only been clinically validated but are also cost-effective. This is the objective that underlies the critical appraisal of economic evaluation publications. Such appraisals help professionals to base their choices on objective grounds.

Cost-Benefit Analysis↗
PubMed1995

Environment, health, and sustainable development: the role of economic instruments and policies.

Recent years have seen considerable progress in integrating environmental concerns into the mainstream of development policy and planning. Economic instruments designed explicitly for environmental purposes may help to achieve cost-effective solutions, and generate public revenues. Macroeconomic and sectoral policies may impact heavily upon the environment, and there is much scope for policy reforms that are justified in both economic and environmental terms. Progress in this area has been much more rapid than in the case of health objectives, even though the rationale for environmental improvement is often ultimately related to human health and well-being. It is proposed that lessons from recent experience in the use of economic instruments and policies to achieve environmental objectives are highly relevant for the health sector, which should seek and encourage support for measures that requires consumer and producers of environmentally degrading products to pay for the economic and social costs of the damage resulting from their use. Policy reform at the macroeconomic or sectoral level may yield cost-effective solutions to some health problems, and may even bring about improvements in health status that involve no net cost at all. The countrywide impact of such policies indicate that health agencies, including WHO, should develop the capacity to understand how economic policies and the adjustment process impact upon human health, not only direct through the effect on incomes, but also indirectly, via changes in the natural environment. Ability to conduct rigorous health impact assessment of economic policy reform, which requires a multidisciplinary effort, is a necessary condition if health ministries are to maximize their effectiveness in influencing overall government economic policy.

Economics↗
PubMed1996

A reader's guide to economic analysis in the GI literature.

UNLABELLED: To evaluate economic analyses and determine their value for clinical practice, the reader must have a clear understanding of how these analyses are performed and how the results can be applied to clinical practice. This second article in the "Primer on Economic Analysis for the Gastroenterologist" focuses on the critical assessment of economic evaluations in the gastrointestinal literature. OBJECTIVES: The purpose of this article is (1) to review the criteria for the critical appraisal of an economic analysis, and (2) to apply these criteria to two recent articles that examine the cost-effectiveness of screening for hemochromatosis. METHODS: The criteria for the critical appraisal of an economic analysis are outlined. To demonstrate the application of these criteria to the gastroenterology literature, they are used to evaluate two recent articles that examine the cost-effectiveness of screening for hemochromatosis. SUMMARY/CONCLUSIONS: The reader of economic analyses in the gastroenterology literature is provided with a framework for the evaluation of such analyses and how they apply to gastroenterology. A systematic method for examining economic analyses and determining their value for the reader is illustrated.

Cost-Benefit Analysis↗
PubMed1998

Economic evaluation of neonatal health protection programs for cattle.

OBJECTIVE: To develop an economic tool that can be used to help cattle producers evaluate benefits of neonatal health programs. DESIGN: Computer simulation of a multiple-year spreadsheet model, using economic and production variables. SAMPLE POPULATION: Records for a university research farm beef herd. PROCEDURE: Data from the university research farm beef herd for each year from 1990 to 1995 were evaluated to determine economic benefits for the cow-calf enterprise that would result from a decrease in morbidity and mortality. A baseline economic evaluation of returns to variable costs was performed, using actual production and marketing information. Actual economic performance was contrasted with a projected simulation in which morbidity and mortality were decreased. Sensitivity analysis for the simulation model assessment of a neonatal health program was also performed. RESULTS: Mean-per-cow increase in net income for the herd during the 6-year period for morbidity and mortality reductions of 20, 40, and 60% was $7.44, $14.93, and $22.42, respectively. Sensitivity analysis revealed that net income per cow was not sensitive to errors in projections of morbidity and mortality. CLINICAL IMPLICATIONS: Identifying potential economic benefits for implementing a neonatal health plan and quantifying the costs to implement each component of the plan can be used by veterinarians and their clients when formulating a proactive strategy to provide the greatest potential for economic reward.

Animals↗
PubMed1993

Clinical importance, statistical significance and the assessment of economic and quality-of-life outcomes.

The assessment of economic and quality-of-life outcomes of health care interventions is moving into a new era, with such assessments increasingly being made within the context of controlled clinical trials. Traditionally the measurement of many variables in economic evaluations, particularly costs, has been deterministic. In the context of clinical trials the measurement of variables is stochastic, with the standard principles of statistical inference being applied to analyse differences between treatments in terms of effectiveness. Economists participating in clinical research are therefore being called upon to specify the sample size for the economic component of the evaluation and to undertake statistical tests for differences in cost or cost-effectiveness. This paper discusses the current methodological issues surrounding stochastic measurement in clinical trials, discusses the additional issues raised by the assessment of economic and quality-of-life outcomes and specifies the challenges facing economists if they are to answer the questions now being posed about economic analysis by statisticians and clinical researchers. It is concluded that application of the standard principles of statistical inference to economic data is not straightforward and will require value judgements to be made about statistical significance and economic importance, which may differ from those already made in purely clinical studies.

Confidence Intervals↗
PubMedDate not supplied

The use of condition specific outcome measures in economic appraisal.

Despite growing concern over the use of health utility measures in economic evaluations of health care programmes, economists have been reluctant to use the wealth of knowledge contained within studies using condition specific outcome measures (CSOMs). Problems with the measurement properties of many CSOMs means that the scope for their use in economic appraisal is extremely limited. This paper examines the potential uses of CSOMs in economics, namely: to provide valid descriptive material, to provide scales for comparing the effectiveness of interventions and to 'validate' the descriptive accuracy of economic measures of benefit. It is argued that valid descriptive information is essential for economic appraisal, no matter which method of evaluation is used. Generic measures have been criticised for being too narrow and insensitive to the consequences of specific conditions. CSOMs offer a rich source of information to produce quality adjusted life years (QALYs) but two potential methods, one of mapping health states from one scale to a QALY classification (such as Rosser), and the other, developing 'exchange rates' between scales are unsatisfactory. A more rigorous approach would necessitate a major research programme of revaluing existing CSOMs using preference based methods. Another interesting avenue of research would be to use the information from CSOMs to construct health scenarios for valuation. Given the current state of development of outcome measures, it seems advisable to use CSOMs alongside economic measures in trials. Such a strategy would help demonstrate the usefulness of economic measures to clinicians and to reconcile the two measures.

Cost of Illness↗
PubMed1993

Evaluating the economic damage threshold for bont tick (Amblyomma hebraeum) control in Zimbabwe.

Controlling ticks and tick-borne diseases by frequent applications of acaricides (e.g., dipping) is costly, and can leave treated livestock vulnerable to epizootics of tick-borne diseases should the system of applying acaricides break down. The concept of only applying acaricides on an infrequent (strategic) basis often relies on the target tick population displaying a seasonal cycle. However, as adult bont tick (Amblyomma hebraeum) infestations in Zimbabwe's lowveld do not have a strictly seasonal pattern of occurrence, it is recommended that tick control only be applied when bont tick infestations are equal to, or greater than, their economic damage threshold. The economic damage threshold is the minimum average weekly standard female tick burden sufficient to cause damage equal in dollar value to the costs of applying tick control. Assuming that each standard female tick represents a 10 gram weight loss, the economic damage threshold (standard female ticks/week) is equivalent to the ratio of the producer price of beef (liveweight equivalent): per head cost of dipping (Eqn (3)). To illustrate the application of the threshold methodology, it was assumed that the producer price of beef was Z$1.63/kg (U.S.$0.33/kg) and that tick control cost Z$0.29/hd/dip (U.S.$0.06/hd/dip). This gave a threshold of 18 standard female ticks/head/week. Using tick counts obtained from 20 Brahman cattle held at Mbizi in southeastern Zimbabwe, it was shown that for the 1988 calendar year there were only 32 weeks when the economic damage threshold was met or exceeded. This is substantially less that the 44 dippings per year that have been, until very recently, legally required in Zimbabwe. Sensitivity analysis showed that a 10% rise in the cost of dipping reduced to 23 (a 28% decrease) the number of weeks when tick burdens exceeded the economic damage threshold. By further assuming that an acaricide application and residual effects will cause a 3-5 week interval before the next application may be required, the number of weeks when the tick burden was equal to or greater than the threshold of 18 standard females/week fell to just 9-12 weeks. Three factors may cause an alteration in the economic damage threshold: i) tick burdens may cause damage to the udders; ii) secondary infestations (e.g., screw-worm) may cause economic damage; and iii) nutritional stress of the cattle may reduce the actual average per tick weight loss.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1986

Vulnerability to economic stress.

A stress vulnerability model was applied to the relationship between economic stress and mental health. Longitudinal data were obtained by reinterviewing 291 respondents from a prior community survey of economic change and health (Catalano & Dooley, 1983). The follow-up survey was conducted at the height of the last recession, approximately 1 year after the first. As predicted, increases in self-reported economic stress adversely affected psychological health, controlling for prior mental health status. However, individuals with poor prior mental health status were more vulnerable to economic stress: They were more likely to experience it during this economic contraction and were somewhat less likely to recover from it. Economic stress and mental health appear to have reciprocal effects, suggesting a spiral model of adaptation. Implications for interventions concerning economic change and mental health are discussed.

Adaptation, Psychological↗
PubMed2004

Socio-economic differences in health among Slovak adolescents.

OBJECTIVES: To explore socio-economic health differences among Slovak adolescents. METHODS: Socio-economic differences in health (psychological health: GHQ-12, vitality and mental health scale of RAND, experienced health complaints, chronic illness, use of medicines, self-reported health, self-perceived vulnerability to illness) were explored among Slovak adolescents (n = 2,616, 1,370 boys, 1,246 girls; mean age 15 years). RESULTS: Adolescents from lower socio-economic groups (parents' occupation, parents' education, type of school) experienced more health complaints; less frequently experienced their health as excellent or very good, more frequently reported to fall ill easier and less frequently use non-prescribed drugs in comparison with adolescents from higher socio-economic groups. Moreover, adolescents from lower occupational group of parents and lower type of school score significantly lower in mental health and in vitality and used prescribed drugs more frequently. We did not confirm any socio-economic differences in psychological health or prevalence of chronic illness. Our findings confirmed poorer health of girls in comparison to boys. There are no gender differences with regard to socio-economic differences in health. CONCLUSION: There are significant socio-economic health differences among Slovak adolescents.

Adolescent↗
PubMed1998

Contemporary Western Rural USA Economic Composition: Potential Implications for Environmental Policy and Research

/ The rural West of the United States is considered strongly antienvironment. The traditional economic reliance of the area on natural resources has long explained this antienvironment stance. The region consistently elects federal officials who as a group consistently vote against environmental bills and seek to undo existing federal environmental regulation. These politicians defend their antienvironment actions based on their perception of the economic composition and interests of the region. Recent studies, however, have suggested that rural residents are increasingly concerned about environmental issues. These studies, however, lack a consistent theoretical basis. This article uses an alternative economic typing system to examine the economic composition of rural Idaho and suggests that the results found using the alternative typing system might provide a theoretical basis to explain why some studies are finding increased rural environmental support. The results show that rural Idaho is much more economically diverse using this alternative typing methodology compared to the outcomes of traditional USDA economic methodologies. The policy and research implications of these findings are examined.KEY WORDS: Rural; Environmental policy; Economic composition

Journal Article↗
PubMed2005

Economic impact of community-acquired and nosocomial lower respiratory tract infections in young children in Germany.

Data on the economic burden of lower respiratory tract infections (LRTI) in young children are lacking in Germany. The objective of the cost-of-illness study was to estimate the economic impact of community-acquired LRTI and nosocomial LRTI as well as of infections due to respiratory syncytial virus (RSV), parainfluenza viruses (PIV) and influenza viruses (IV). The economic analysis is part of the PRIDE study, a prospective, multi-centre, population-based epidemiological study on the impact of LRTI in children aged 0 to 36 months in Germany. The analysis includes children with community-acquired infections (1329 cases treated as outpatients, 2039 cases treated as inpatients) and nosocomial infections (90 cases). Medical services consumed were generated by chart abstraction and parental expenses data by telephone interviews within four weeks after physician visit or hospitalisation. Costs were evaluated from following perspectives: third party payer, parent and society. Total costs for outpatient treatment are Euro 123 per LRTI case. Stratified by virus type, total costs per case are Euro 163 (RSV), Euro 100 (PIV) and Euro 223 (IV). Total costs per hospitalised LRTI case amount to Euro 2579. Stratified by virus type, total costs per case are Euro 2772 (RSV), Euro 2374 (PIV) and Euro 2597 (IV). Total costs per nosocomial case are Euro 2814. Economic burden due to LRTI is Euro 213 million annually. It is concluded that treatment of LRTI in children up to age three causes a considerable economic burden in Germany. Presented results are the first data describing the economic burden of LRTI in young children assessed by means of the incidence data for Germany. This cost-of-illness study provides basic data for further decision-making, focusing on the economic assessment of preventive strategies for RSV, PIV and IV infections.

Age Distribution↗
PubMed2004

The European Network of Health Economic Evaluation Databases (EURO NHEED) Project.

This paper provides a first outline of the European Network of Health Economic Evaluation Databases (EURO NHEED) project. The project is funded by the European Commission and will implement, in 7 European centres based in France, Germany, Italy, The Netherlands, Spain, Sweden and the United Kingdom, databases on the economic evaluation of healthcare interventions. The network will be based on two existing and well-established resources, namely the UK's NHS Economic Evaluation Database (NHS EED), and France's Connaissances et Décision en EConomie de la Santé (CODECS) database. EURO NHEED will initially cover 17 European countries and will provide its users with bibliographic records, detailing the main characteristics of all included studies. In addition, structured abstracts will be provided for articles identified as full economic evaluations (cost-benefit, cost-effectiveness or cost-utility), which will offer a detailed critique of the findings and the methodology used. These databases will be accessible free of charge on the Internet. The EURO NHEED project is the first attempt to develop such a resource on a multi-national basis. The project will bring together Health Economists and Information Scientists from the European Union and beyond and is anticipated to facilitate a number of benefits and advances in the field of Health Economics. These include harmonisation and increased understanding of the theory and methodology of economic evaluation in healthcare, the interpretation of the generalisability of studies to target settings, and the influence of healthcare system variations among the European countries. The project will therefore advance the state of the art in collecting, summarising, critiquing and disseminating economic evaluations of healthcare conducted within Europe.

Cost-Benefit Analysis↗
PubMed1984

Economic differentials in cancer survival: a multivariate analysis.

This study investigates economic differentials in cancer survival using more adequate measures of economic status and controlling for confounding variables more systematically than earlier studies. For 1180 white males, a variant of the Cox regression model is employed to estimate the direct and interaction effects of economic status on survivorship, controlling for age at diagnosis, stage, severity of disease, and initial course of treatment. The results do not show a strong relationship. Estimates of direct or main economic effects rarely reach even borderline statistical significance; they are highly sensitive to model specification and the measurement of the economic variable. An equally weak interaction effect between economic status and stage is detected in several cases, but the parameter estimates are unstable. Such measurement and specification errors have probably exaggerated the importance of economic factors in cancer survival in earlier investigations.

Humans↗
PubMed1991

Socio-economic differences in mortality among children. Do they persist into adulthood?

More than 1.2 million Swedish children born 1946-60 and enumerated in the 1960 population census were followed up with respect to mortality for the period of 1961-79. Thus the children were younger than 15 years at the start of the follow-up and their age of death varied between 1 and 33 years. More than 13,000 deaths were analysed. The purpose was to examine whether or not mortality differences by socio-economic group in childhood persist into adulthood. Mortality differences by childhood socio-economic group were studied for both children/adolescents (1-19 years old) and young adults (20-33 years old). Information about the adults' own occupational status was not available. Therefore, to allow a deeper analysis, another group of adults, whose mortality could be analysed by their own socio-economic group, was used as a comparison group. Among children and adolescents there was a clear socio-economic group difference in mortality. Children in families of non-manual workers had a significantly lower mortality than children in the families of manual workers. In particular this was the case for boys. Socio-economic differences in total mortality are evident also in the age between 20 and 33 years among men but it could not be demonstrated here that these are a result of childhood socio-economic group rather than achieved socio-economic group. However, the study indicates that some differences in childhood, to a certain degree and for some diagnoses, may persist into adulthood. Of particular interest may be a tendency for cardiovascular disease mortality to be elevated among sons and daughters of manual workers.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Socio-economic health differences in The Netherlands: a review of recent empirical findings.

Evidence on variation in the frequency of health problems between socio-economic groups in the Dutch population has accumulated rapidly in recent years. This paper presents a review of these recent data. It is clear now that a lower socio-economic status is associated with a higher frequency of a wide range of health problems. This negative association has consistently been found for the following health indicators: birth weight; adult body height; prevalence of health complaints; prevalence of many chronic conditions; prevalence of disability; incidence of long-term work incapacity; perceived general health; adult mortality. Inconsistent findings were reported for: children's body height; prevalence of some chronic conditions; incidence of sickness absence (short-term work incapacity); perinatal mortality. The magnitude of the differences varies from study to study, and possibly from health problem to health problem. In studies categorizing the study population in 3-6 hierarchically ordered socio-economic groups on the basis of either education or occupational status, the Relative Risks (of the lowest versus the highest socio-economic group) mostly lie between 1 and 2. Exceptions are prevalence of disability and incidence of long-term work incapacity where Relative Risks between 2 and 4 have been found. A direct comparison with data from other countries is problematic, but at first sight the differences as observed in the Netherlands seem to be of the same order of magnitude as those observed in other industrialized countries. Although most Relative Risks imply 'weak associations' from a technical-epidemiological point of view, the Population Attributable Risks are substantial (generally between 0.25 and 0.40), underlining the public health impact of socio-economic health differences. Information on trends in health inequalities over time is limited to children's body height and adult mortality. For children's body height a substantial decrease of inequalities was found between 1964-1966 and 1980. For adult mortality, on the other hand, there is (indirect) evidence of a widening of the mortality gap between the 1950s and the 1980s. The evidence on specific factors which are involved in the 'causal chain' between socio-economic status and health problems is rather limited at the moment. A negative association with socio-economic status has been reported for the following risk factors: smoking; obesity; a number of unfavourable material living conditions; a number of unfavourable physical working conditions; psychosocial stress; lack of social support; less adequate supply/use of health care.(ABSTRACT TRUNCATED AT 400 WORDS)

Absenteeism↗