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PubMed2001

The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.

BACKGROUND: Geographic variations in the incidence of deliberate self-harm (DSH) and suicide have been shown to be associated with area-based measures of socio-economic deprivation and social fragmentation. Previous studies have been subject to methodological limitations. None has investigated whether ecological associations are reflected in characteristics of individuals involved in suicidal behaviour. METHODS: DSH patients presenting to a general hospital between 1985 and 1995 and suicides (including open verdicts) from the same catchment area were studied. Mean annual rates of DSH and suicide by gender were calculated for electoral wards. The wards were amalgamated into 20 groups according to their ranking for socio-economic deprivation (Townsend) and social fragmentation scores. Associations of these variables with DSH and suicide rates were investigated. Characteristics of DSH patients living in ward groups with the highest and lowest socio-economic deprivation and social fragmentation scores were compared. RESULTS: Socio-economic deprivation was associated with DSH rates among males (r = 0.89) and females (r = 0.87). After controlling for social fragmentation the associations remained relatively strong, particularly in young males. Associations with social fragmentation in both genders (males, r = 0.83; females, r = 0.86) were attenuated after controlling for socio-economic deprivation. For suicide, the only significant association was with socio-economic deprivation in males (r = 0.79), but this was attenuated after controlling for social fragmentation. The characteristics of individual DSH patients reflected those of the areas where they lived. CONCLUSIONS: Reducing socio-economic deprivation and its associated problems may be an important strategy in the prevention of suicidal behaviour, especially in young men.

Adolescent↗
PubMed2006

Health economic evaluation in Greece.

OBJECTIVES: There is a growing volume of literature on health economic evaluation, with this form of analysis becoming increasingly influential at the decision-making level worldwide. The purpose of this study was to review the current state of health economic evaluation in Greece, with a view to uncovering reasons why its use in this country is limited. METHODS: A search of the NHS Economic Evaluation Database was undertaken. The search included cost, cost-of-illness, cost-minimization, cost-effectiveness, cost-consequences, cost-utility, and cost-benefit analyses and was narrowed only to Greek authors undertaking solo or joint health economic evaluation in Greece. RESULTS: The search revealed that, in Greece, very little health economic evaluation has been undertaken. The main reason for the lack of interest is that the current chaotic healthcare system structure and financing does not provide the appropriate incentives to stimulate a powerful interest in this type of research. This condition is a result of the lack of a long-term national health policy and the hesitation of the present and past Greek governments to date to proceed to large-scale reforms because of political considerations. The Greek governments have also been content with the good health indicators being achieved. CONCLUSIONS: Even if it is accepted that good health prevails in Greece, slower economic growth rates, an ageing population, and the continuous immigration will place increasing pressure on healthcare resources and will necessitate a more rational use of these resources. Health economic evaluation, by weighing benefits against costs, therefore, has an important role to play.

Costs and Cost Analysis↗
PubMed1999

Ethical issues in the economic assessment of health care technologies.

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare.

Bioethical Issues↗
PubMed1998

Prospective economic evaluation accompanying a trial of GM-CSF/IL-3 in patients undergoing autologous bone marrow transplantation for Hodgkin's and non-Hodgkin's lymphoma. IL-3 BMT Study Team.

Our objective was to assess the economic impact of a new cytokine therapy that was being compared to standard therapy as supportive care in patients receiving autologous bone marrow transplantation for treatment of lymphoma. We performed an economic study accompanying a multicenter, randomized, controlled clinical trial in academic medical centers. One hundred and fifteen patients consented to participate in a parallel economic study of a randomized controlled trial of sequential IL-3 followed by GM-CSF vs GM-CSF alone after autologous bone marrow transplantation. We measured costs and quality-adjusted survival over a 13-month follow-up period. For the 13-month study period, the total cost estimates were $79892 (95% CI $69343 to $90544) for patients receiving GM-CSF alone and $89651 (95% CI $79769 to $102114) for patients receiving IL-3/GM-CSF. The difference was not statistically significant. During the 13-month study period, the total number of quality-adjusted life-months in the GM-CSF arm was 6.67 (95% CI 5.75 to 7.56) months, while the total number of quality-adjusted life-months in the IL-3 arm was 6.26 (95% CI 5.34 to 7.15) months. The difference in quality-adjusted life-months between the two treatment arms was not statistically significant. We conclude that economic analysis of a phase III clinical trial of IL-3/GM-CSF compared with GM-CSF alone showed no significant effect of IL-3 on the costs of care for patients undergoing bone marrow transplantation for a period of up to 13 months after the procedure. This study demonstrates the feasibility of prospective economic evaluation within phase III trials of new cancer therapies. Data from this type of economic protocol could be used to help physicians, patients and managed care organizations understand the effect of new treatments from both a clinical and an economic perspective.

Bone Marrow Transplantation↗
PubMed2003

Selective COX-2 inhibitors: a health economic perspective.

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is common in patients with osteoarthritis and rheumatoid arthritis. However, due to gastrointestinal side effects, the health-related and economic burden related to these drugs is considerable. Therefore, substituting or supplementing conventional NSAIDs with safer drugs that have a better risk profile not only may avoid serious complications but may also be an efficient allocation of scarce resources. Because of their better gastrointestinal risk profile, the newly developed selective COX-2 inhibitors celecoxib and rofecoxib are discussed as cost-effective alternatives to common NSAIDs. This paper provides an overview of health economic evaluations, conducted during the last few years, that investigate the economic consequences of switching patients from traditional NSAIDs to selective COX-2 inhibitors. This review of the health economic literature shows that results of the health economic assessments of COX-2 inhibitors are highly contradictory. The main divergence between studies occurs in estimated economic consequences of adopting COX-2 inhibitors in patients at low or average risk for developing gastrointestinal side effects. The economic consequences of the introduction of COX-2 inhibitors as well as the asynchronous development of scientific acceptance of the benefit of the new drugs and their actual diffusion and spread are discussed taking a broader, healthcare-system perspective.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2002

The economic burden of low back pain: a review of studies published between 1996 and 2001.

Low back pain (LBP) poses an economic burden to society, mainly in terms of the large number of work days lost by a small percentage of patients who develop chronic LBP. The object of this review is to gain a better understanding of the societal costs of LBP and to see whether current clinical management follows evidence-based guidelines and is economically attractive, by reviewing studies on LBP with economic implications. To this end, the Medline database was searched between 1996 and 2001 using appropriate keywords, broadly defined. A total of 372 abstracts were screened and paper copies of 73 potentially relevant articles were obtained. It was found that the cost of LBP illness was high and was comparable to other disorders such as headache, heart disease, depression or diabetes, but actual cost estimates varied depending on the costing methodology employed. A small percentage of patients with chronic LBP accounts for a large fraction of the costs. Excessive and inappropriate use of diagnostic or therapeutic services can be documented but varied by region and provider type. Management according to evidence-based guidelines was not necessarily economically attractive. Interventions for acute or chronic LBP failed to show economic benefits, but demonstrated modest clinical benefits, which suggested a weak relationship between clinical and economic outcomes. The conclusion was that common definitions and costing methodologies need to be found to gain a better understanding of the true costs to society and to make studies comparable. A better definition is needed for the type for patient with LBP for whom therapeutic management is most likely to have a long-lasting economic benefit.

Cost of Illness↗
PubMed2004

The quality of published health economic analyses in digestive diseases: a systematic review and quantitative appraisal.

BACKGROUND & AIMS: Health economic analyses are increasingly common in the digestive diseases literature and often are cited to frame practice guidelines. Although clinical trials are subjected routinely to critical appraisal, there has been no attempt to appraise the quality of health economic analyses with a validated instrument. We sought to appraise the quality of health economic analyses in digestive diseases, and to identify predictors of study quality. METHODS: We performed a systematic review to identify digestive disease health economic analyses published since 1980. We assessed these studies using the Quality of Health Economic Studies (QHES), a validated quality-scoring instrument (score range = 0-100; >75 = high quality). We conducted regression analysis to identify predictors of high quality. RESULTS: Of 186 identified analyses, 29% were high quality, 71% failed to address potential model biases, 52% failed to disclose conflicts of interest, and 74% failed to describe methods for deriving the model assumptions. Four factors predicted high quality in logistic regression: (1) one or more authors had an advanced degree in health services or a related field (odds ratio for high quality, 5.0; 95% confidence interval, 2.6-9.3); (2) the study used decision-analysis software package (odds ratio, 2.4; 95% confidence interval, 1.2-4.7); (3) the study was federally funded (odds ratio, 2.2; 95% confidence interval, 1.2-4.1); and (4) the study cited the National Panel on Cost Effectiveness guidelines (odds ratio, 2.1; 95% confidence interval, 1.1-4.2). CONCLUSIONS: Less than one third of health economic analyses in digestive diseases meet criteria for high quality. Study quality is limited by factors that potentially can be remedied. These data may be used to focus the attention of journal editors and peer reviewers to ensure the future high quality of health economic analyses in digestive diseases.

Cost-Benefit Analysis↗
PubMedDate not supplied

Growth of children living in the outskirts of Ankara: impact of low socio-economic status.

BACKGROUND: Most studies of the growth of Turkish schoolchildren are limited to large cities and to subjects from high socio-economic background. Very little is known about growth and development of rural, suburban and low socio-economic children in Turkey. AIM: The purpose of this study is to compare height and weight of school-aged children of low socio-economic background with available growth data from high socio-economic strata, and to verify the possible influences of three socio-demographic parameters on their growth. SUBJECTS AND METHODS: The sample consisted of 1,052 girls and 1,223 boys, aged between 7-17 years, living in the outskirts of Ankara, a suburban area of poor socio-economic background. Centile distributions for height and weight were estimated by the LMS-method. ANOVA and Student's t-test were used to compare mean z-scores for height and weight among the various categories of the socio-demographic parameters. RESULTS: Children living in the outskirts of Ankara have lower mean values for height and weight when compared with growth data of upper socio-economic strata children. The differences were most pronounced during adolescence. Skinfolds were higher in girls than in boys at all ages (largest p = 0.007). There was no clear relationship between growth and the number of siblings, the number of rooms in the house, the mother's and father's education, and the father's professional status (p > 0.05), except for the height of girls (p < 0.05). CONCLUSION: It is suggested that the lower growth status of children living in the outskirts of Ankara is attributable to the poor socio-economic status of this suburban population, which has not changed over the past decades. It is postulated that the growth impairment during adolescence might be due to a reduced tempo of growth in these children.

Adolescent↗
PubMed1998

Functional digestive disorders (FDD) in the year 2000--economic impact.

OBJECTIVE: The objective of this study is to quantify the future worldwide economic impact of functional gastrointestinal disease and to describe international differences that might exist between major industrialized countries. DESIGN: This study employs an econometric projection using data from the only known survey of national economic impact of functional gastrointestinal disease. Economic costs from this survey are combined with country specific population estimates, health care spending characteristics, and growth rates to estimate economic impact for major industrial countries. RESULTS: The estimated economic impact of functional gastrointestinal disease for eight major industrial countries is over 41 billion U.S. dollars annually. This estimate includes both direct and indirect costs of disease. CONCLUSION: The economic impact of functional gastrointestinal disease is large. Economic estimates are useful in policy decision making regarding the allocation of health care resources.

Canada↗
PubMed2005

Economic effectiveness of disease management programs: a meta-analysis.

The economic effectiveness of disease management programs, which are designed to improve the clinical and economic outcomes for chronically ill individuals, has been evaluated extensively. A literature search was performed with MEDLINE and other published sources for the period covering January 1995 to September 2003. The search was limited to empirical articles that measured the direct economic outcomes for asthma, diabetes, and heart disease management programs. Of the 360 articles and presentations evaluated, only 67 met the selection criteria for meta-analysis, which included 32,041 subjects. Although some studies contained multiple measurements of direct economic outcomes, only one average effect size per study was included in the meta-analysis. Based on the studies included in the research, a meta-analysis provided a statistically significant answer to the question of whether disease management programs are economically effective. The magnitude of the observed average effect size for equally weighted studies was 0.311 (95% CI = 0.272-0.350). Statistically significant differences of effect sizes by study design, disease type and intensity of disease management program interventions were not found after a moderating variable, disease severity, was taken into consideration. The results suggest that disease management programs are more effective economically with severely ill enrollees and that chronic disease program interventions are most effective when coordinated with the overall level of disease severity. The findings can be generalized, which may assist health care policy makers and practitioners in addressing the issue of providing economically effective care for the growing number of individuals with chronic illness.

Analysis of Variance↗
PubMed2004

A census of economic evaluations in health promotion.

While policy makers argue for a greater share of health resources to go to health promotion, action is stalled by, among other things, the perception that little is known about which interventions offer the best health returns. Additionally, what is missing is any sense of what the economic literature in health promotion looks like overall. Where is the economic evidence plentiful and where is it scant? The project described here compiled a census of economic evaluations in health promotion. Studies were classified according to a four-part typology that documented the strategic intent of the intervention, the risk factor being addressed, the population most affected and the setting in which the intervention took place. Since 1990, there have been over 400 economic evaluations of health-promoting interventions in the peer review and grey literatures. Of these, 90% address biological or behavioral determinants of health. Relatively little is known about the economics of population health advocacy or interventions to tackle the social and economic determinants of health. Initiatives are in place to increase the availability of economic evidence. Research is also needed into how to support decision makers' use of imperfect, incomplete and uncertain information.

Cost-Benefit Analysis↗
PubMed1999

How does the prevalence of specific morbidities compare with measures of socio-economic status at small area level?

BACKGROUND: Evidence from other studies has show large, systematic differences between the health of social groups. It is not clear whether this relationship applies equally to all areas of health need. We assess whether a variety of areas of ill health show positive correlations with increasing socioeconomic disadvantage, and whether there are indicators of socio-economic disadvantage that are better than others at predicting the prevalence of specific morbidities at a population level. METHODS: The prevalence of a range of common morbidities was determined by a postal questionnaire sent to 16,750 subjects (response rate 79 per cent), and compared with socio-economic information obtained from the 1991 Census. RESULTS: There was substantial variation in the degree to which the various morbidities were related to the socioeconomic variables. When compared with socio-economic variables, long-term limiting illness, respiratory conditions and depression had high correlations of +0.8 or more. Cardiovascular conditions were less related (r = +0.60 to +0.79). None of the disorders of the gastrointestinal system showed a high correlation with socio-economic variables. There was also substantial variation in the degree of correlation of the socio-economic measures with each area of morbidity. The measures that showed the highest correlations were in respect of household characteristics such as car ownership and single parent households. Variables describing household amenities such as lacking a bath or central heating were least related to the morbidity measures. CONCLUSIONS: Some areas of morbidity show strong associations with socio-economic disadvantage, but others show only modest or no relationship. The optimum choice of socio-economic variable as a proxy for health need depends on the area of illness being considered.

Adolescent↗
PubMed1993

Economic impact of the AIDS epidemic in the European Community: towards multinational scenarios on hospital care and costs.

OBJECTIVE: To underpin multinational public-health HIV/AIDS strategy planning in the European Community (EC) by integrating national studies on HIV/AIDS in scenario analysis. METHOD: Three types of data are used: routine surveillance data, information on disease progression and observational studies on the economic impact. The HIV/AIDS epidemic is simulated using two models (MIDAS and PC-Based AIDS Scenarios). Selected simulations, consistent with surveillance data, are connected to economic impact (hospital-bed needs and annual hospital costs for AIDS patients). Parameter values expressing per person-year economic impacts are derived from a structured review of publications on economic aspects of AIDS. RESULTS: Evaluation of published studies on hospital resource use and costs in EC countries shows that there are significant differences between both countries and studies, even after conversion to similar measures (for example, using purchasing power parities). These differences are partly due to factors such as the composition of the patient population. Differences in methodology may also have influenced the results. Economic impact is analysed for combinations of three factors; survival time after AIDS diagnosis, hospital inpatient days needed per person-year and corresponding hospital costs per person-year. All scenarios indicate 1995 hospital-bed needs above the 1990 level of 5400 beds. Hospital cost projections for 1995 vary (up to US$1050 million). CONCLUSIONS: (1) For economic impact assessment, there are important gaps in epidemiological and economic data, and in the methods for linking these. (2) Standardization of studies on the resource use and costs of HIV/AIDS is necessary to provide a sound basis for multinational scenarios. (3) Preliminary multinational scenarios show that by 1995 hospital-bed needs for AIDS might reach 0.45% of all hospital beds available in the EC, and that hospital cost projections for AIDS in that year will range from 0.15% to 0.30% of EC health-care expenditure.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

A comparison of economic and social reward in patients with chronic nonmalignant back pain.

OBJECTIVE: Patients with chronic nonmalignant back pain are often exposed to multiple sources of economic and social reward. At issue in the present study was whether these rewards are 1) correlated with similar or dissimilar outcome variables and 2) able to account for unique variance in regression models of illness behavior. METHODS: A 2 x 2 factorial design was used in which patients were retrospectively assigned to one of four independent groups: low economic/low social reward, low economic/high social reward, high economic/low social reward, and high economic/high social reward. Of 265 consecutive patients enrolled at a tertiary pain service, 75 met eligibility criteria and had chronic nonmalignant back pain. RESULTS: Preexisting differences in health status were not associated with differences in illness behavior or pain ratings. With social reward held constant, patients in the high economic reward group missed more days from work (p < .005), had more domestic disability (p < .05), and were more depressed (p < .05) than patients in the low economic reward group. With economic reward held constant, patients in the high social reward group missed more days from work (p < .05), had more domestic disability (p < .01), and were more depressed (p < .01) than patients in the low social reward group. Unlike patients in the high economic reward group, however, patients in the high social reward group had higher levels of pain (p < .05) and more nonspecific medical complaints (p < .01). CONCLUSIONS: Economic and social rewards were both associated with increased disability and depression, but only social rewards were associated with increased symptom reporting. Exposure to economic and social rewards may account for unique variance in illness behavior that cannot be explained by differences in medical diagnosis, symptom duration, pain intensity, depression, or somatization.

Adult↗
PubMed2006

Hearing-impaired children in the United Kingdom, III: cochlear implantation and the economic costs incurred by families.

OBJECTIVES: This article addresses two questions. First, are there differences in the economic costs incurred by families of hearing-impaired children depending on whether or not children have cochlear implants? Second, are these differences important when assessed from the perspective of society? METHODS: In a cross-sectional survey, parents of a representative sample of hearing-impaired children provided data about annual resources used by the family because of their child's hearing impairment. The data yielded estimates of two variables: out-of-pocket expenditure and time away from normal activities by parents. The economic cost of the two variables was estimated in euros at 2001/2 price levels, and summed to estimate the overall economic cost incurred by the family. Linear regression was used to estimate the association between costs and implantation, while controlling for average (unaided, preoperative) hearing level, age at onset of hearing impairment, age, gender, the number of additional disabilities, parental occupational skill level, ethnicity, and parental hearing status. The cumulative economic cost incurred by the families of implanted children, between implantation and age 16 yr, was calculated from estimates of the overall economic cost associated with implantation and compared with estimates of the incremental health-sector cost of implantation. RESULTS: Data were provided by the families of 2858 children, 468 of whom had received a cochlear implant. Compared with the families of nonimplanted children, out-of-pocket expenditure was estimated to be significantly higher for families when children were implanted before the age of 5 yr and had used their implant for less than 2 yr, as was lost productivity when children had used their implants for less than 2 yr. Overall economic cost was estimated to be significantly higher for the families of implanted children who had used their implants for less than 2 yr. The cumulative economic cost was estimated to be 3355 euros for a family whose child was implanted at age 3 yr and 949 euros for a child implanted at age 6 yr. These costs correspond, at most, to 3% of the incremental health-sector costs of implantation. CONCLUSIONS: Compared with families of nonimplanted children, families of implanted children incur additional costs in the 2 yr after implantation. These costs are small in relation to the health-sector costs of providing implantation.

Adult↗
PubMed2001

Economic analysis as a basis for large-scale nitrogen control decisions: reducing nitrogen loads to the Gulf of Mexico.

Economic analysis can be a guide to determining the level of actions taken to reduce nitrogen (N) losses and reduce environmental risk in a cost-effective manner while also allowing consideration of relative costs of controls to various groups. The biophysical science of N control, especially from nonpoint sources such as agriculture, is not certain. Widespread precise data do not exist for a river basin (or often even for a watershed) that couples management practices and other actions to reduce nonpoint N losses with specific delivery from the basin. The causal relationships are clouded by other factors influencing N flows, such as weather, temperature, and soil characteristics. Even when the science is certain, economic analysis has its own sets of uncertainties and simplifying economic assumptions. The economic analysis of the National Hypoxia Assessment provides an example of economic analysis based on less than complete scientific information that can still provide guidance to policy makers about the economic consequences of alternative approaches. One critical value to policy makers comes from bounding the economic magnitude of the consequences of alternative actions. Another value is the identification of impacts outside the sphere of initial concerns. Such analysis can successfully assess relative impacts of different degrees of control of N losses within the basin as well as outside the basin. It can demonstrate the extent to which costs of control of any one action increase with the intensity of application of control.

Agriculture↗
PubMed2004

The impact of economic information on medical decision making in primary care.

BACKGROUND: Many general practitioners (GPs) are concerned about the increasing dominance of economic issues in major decisions about clinical care, and feel their opinions on economic matters have not been heard. It is unclear whether this information has any impact on everyday clinical practice in a primary care setting. AIM: To investigate GPs' perspectives on the use of economic information in medical decision making. DESIGN OF STUDY: Cross-sectional survey. SETTING: GP members of the West of Scotland Primary Care Research and Development Network (WestNet). METHODS: Questionnaire survey sent to GPs by post and by email. RESULTS: The overall response rate was 44%, favouring postal over email responses. All respondents indicated that economic information has previously influenced them and should be incorporated into their medical decision making. The most common source of this information was generated by local authorities such as health boards, primary care groups and local prescribing advisors--used by 80% of the respondents. However, publications, such as the British Journal of General Practice, locally produced newsletters and prescribing formularies, and feedback from the General Practice Administration System for Scotland, were used as sources of economic information by 20%, 27% and 33%, respectively. Published materials--in particular, locally specific information and summarized information in leaflet format--were favoured (54%) in comparison to verbally presented material. CONCLUSIONS: GPs believe that economic information should be incorporated in medical decision making. The need for precise and summarized information, produced locally, has been highlighted. Better understanding towards the type of economic evidence GPs find useful and comprehensible is required.

Cross-Sectional Studies↗
PubMed2006

Secular trends in socio-economic status and the implications for preterm birth.

The rate of preterm birth in the developed world has been shown to be increasing, in part attributable to obstetric intervention. It has been suggested that this may be a differential increase between socio-economic groups. We aimed to assess whether the preterm rate in Norway is different in socio-economic groups defined by maternal education, and to determine the extent to which a difference is attributable to a socio-economic differential in obstetrical intervention, in terms of caesarean section or induction of labour. We used data from the Medical Birth Registry of Norway from 1980 to 1998 with preterm rate as the outcome and maternal educational level, marital status and obstetric intervention as exposure variables. In multivariable analyses, adjustment was made for maternal age, year of birth and birth order, and secular trends were assessed according to year of birth. The preterm birth rate was highest in the lowest socio-economic group. An increase of 25.2% in the preterm rate was seen over the observation period. No apparent differential was seen in the increase of the crude preterm rates between socio-economic groups, although in multivariable analyses there was a significant interaction between socio-economic group and time, implying a stronger effect of low education towards the end of the observation period attributable to demographic change. In conclusion, the preterm birth rate increased over time, but was mainly due to an increase in obstetric interventions. No closing of the gap between socio-economic groups was observed.

Cesarean Section↗