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PubMed2001

Impact of abciximab versus eptifibatide on length of hospital stay for PCI patients.

The purpose of this study is to compare the profile of percutaneous coronary intervention (PCI) patients who receive abciximab versus eptifibatide, as well as to compare the effect of abciximab versus eptifibatide on hospital length of stay. Retrospective data were obtained from HCIA's Clinical Pathways Database on 5,446 coronary angioplasty patients who were administered either abciximab or eptifibatide. Estimation was conducted via a two-stage sample selection model. In the first stage, a probit regression was employed to determine which factors were associated with a higher probability of being administered abciximab versus eptifibatide. In the second stage, a negative binomial model was used to estimate the impact of a wide range of factors (selection of GPIIb/IIIa, patient demographics, insurance provider, health conditions, admission information, and hospital characteristics) on total hospital length of stay, as well as on postprocedural length of stay. After controlling for high-risk indications and other sources of selection bias, results indicate that receipt of abciximab was associated with a significantly shorter length of total hospital stay (0.83 fewer days; P < 0.001) than receipt of eptifibatide. Additionally, receipt of abciximab was found to be associated with a significantly shorter postprocedural hospital length of stay (0.48 fewer days; P = 0.002) compared to receipt of eptifibatide. Results of this study indicate that PCI patients who are administered abciximab versus eptifibatide have a significantly shorter length of hospital stay (both total and postprocedural). This finding is important since hospital length of stay reflects the occurrence of complications and has been found to be directly related to the resources consumed during in-patient management of patients. Cathet Cardiovasc Intervent 2001;53:296-303.

Abciximab↗
PubMed2001

A comparison of total hospital costs for percutaneous coronary intervention patients receiving abciximab versus tirofiban.

The purpose of this study was to examine the total hospital costs associated with the receipt of abciximab versus tirofiban for percutaneous coronary intervention (PCI) patients. Hospital billing data for patients with a primary procedure of PCI was examined for the period of July 1998 to June 1999 from HCIA-Sach's Clinical Pathways Database. Data were analyzed for all patient discharges whose records indicated use of abciximab or tirofiban with a PCI. Results are reported for 3,967 patients. Multivariate analysis was used to control for a wide range of factors (GP IIb/IIIa selection, patient demographics, stent use, insurance type, health conditions, admission information, and hospital characteristics) that may influence the cost of hospitalization. A two-stage sample selection model was used to estimate total costs. The first stage of the analysis utilizes a probit regression to determine the factors associated with the likelihood of receiving abciximab versus tirofiban. The second stage of the analysis examines the factors associated with total hospital costs, while controlling for unobserved factors that may be correlated with the patient's likelihood of receiving abciximab. The mean unadjusted cost per hospitalization, including drug costs, was $10,762 (abciximab $10,813 and tirofiban $10,567). After controlling for high-risk indications and selection bias with the two-stage sample selection model, results indicate there was no significant difference in costs associated with the receipt of abciximab versus tirofiban. However, the results also indicate that the two-stage sample selection model may not be needed (lambda was not statistically significant) hence, the cost equation was reestimated using ordinary least-squares methodology (OLS). In the OLS analysis, receipt of abciximab versus tirofiban was associated with a significant reduction in costs ($470 reduction; P = 0.05). This study uses real-world data to examine the total hospital costs for PCI patients who receive abciximab versus tirofiban. Results of the two-stage sample selection model indicate there is no difference in total hospital costs (including drug costs) between abciximab- and tirofiban-treated patients. If the results of the OLS model are considered, a slight decrease in total hospital costs is observed in abciximab recipients. Cost-containment strategies that focus on component costs may not lead to intended overall cost savings.

Abciximab↗
PubMed2003

Assessment of health economics in Alzheimer's disease (AHEAD): treatment with galantamine in the UK.

OBJECTIVE: To assess the long-term health and economic impact of treating mild to moderate Alzheimer's disease (AD) with galantamine (16 mg or 24 mg per day) compared to no cholinesterase therapy in the UK. METHODS: The long-term costs and outcomes were assessed using a model developed from longitudinal data on a cohort of AD patients. The model predicts the time until patients require full-time care, defined as the consistent requirement for a significant amount of care and supervision each day. Efficacy data were obtained from three clinical trials comparing galantamine with placebo, forecasts were made for ten years. Costs were determined in 2001 British pounds and discounted at 6% per annum, while outcomes such as time to full-time care were discounted at 1.5%. RESULTS: Without pharmacological treatment, patients are expected to incur costs of 28,134 British pounds over ten years, 70% of costs accrue from providing full-time care. Galantamine (16 mg per day) is predicted to reduce the duration of the full-time care state by 12%; approximately five patients need to be treated to avoid one year of full-time care. The ten-year incremental costs per month of full-time care avoided average pound 192 British pounds per patient and 8,693 British pounds per QALY. Savings (1380 British pounds) are predicted for patients who continue treatment beyond six months and whose cognitive function is maintained or improved. Comparable results were estimated for the 24 mg dose. CONCLUSION: In addition to the clinical benefits associated with galantamine treatment, the savings predicted from delaying when full-time care is needed may offset the treatment costs.

Aged↗
PubMed2005

Auctions vs negotiations: a study of price differentials.

Recent contributions in auction and bargaining theory suggest that a procurer should place more faith in the power of competition among alternative suppliers than in his or her own negotiating skill. Based on data from 216 contracts between procurers and suppliers of medical and surgical articles, we test whether auctions and bargaining result in significantly different prices. The main results are that auctions give 'thicker' markets compared with negotiations, as expected, but that auctions do not result in significantly lower prices compared with negotiations.

Commerce↗
PubMed2006

Pharmaceutical promotion and GP prescription behaviour.

The aim of this paper is to empirically analyse the responses by general practitioners to promotional activities for ethical drugs by pharmaceutical companies. Promotion can be beneficial as a means of providing information, but it can also be harmful in the sense that it lowers price sensitivity of doctors and it merely is a means of maintaining market share, even when cheaper, therapeutically equivalent drugs are available. A model is estimated that includes interactions of promotion expenditures and prices and that explicitly exploits the panel structure of the data, allowing for drug specific effects and dynamic adjustments, or habit persistence. The data used are aggregate monthly GP prescriptions per drug together with monthly outlays on drug promotion for the period 1994-1999 for 11 therapeutic markets, covering more than half of the total prescription drug market in the Netherlands. Identification of price effects is aided by the introduction of the Pharmaceutical Prices Act, which established that Dutch drugs prices became a weighted average of the prices in surrounding countries after June 1996. We conclude that GP drug price sensitivity is small, but adversely affected by promotion. Ltd.

Drug Costs↗
PubMed2005

Socioeconomic status, depression disparities, and financial strain: what lies behind the income-depression relationship?

Prior studies have consistently found the incidence and persistence of depression to be higher among persons with low incomes, but causal mechanisms for this relationship are not well understood. This study uses the National Longitudinal Survey of Youth 1979 cohort to test several hypotheses about the robustness of the depression-income relationship among adults. In regressions of depression symptoms on income and sociodemographic variables, income is significantly associated with depression. However, when controls for other economic variables are included, the effect of income is considerably reduced, and generally not significant. Employment status and the ratio of debts-to-assets are both highly significant for men and for women both above and below the median income. Fixed-effects estimates suggest that employment status and financial strain are causally related to depression, but income is not. Instrumental variable estimates suggest that financial strain may not lead to depression.

Adult↗
PubMed2006

Revisiting physicians' financial incentives in Quebec: a panel system approach.

Do Primary Care Physicians (PCPs) react strategically to financial incentives and if so how? To address this question, we follow a quasi-natural experiment in Quebec, using a panel system technique. In so doing, we both correct for underestimation biases in earlier time series findings and generate new results on the issue of complementarity/substitution between consultations with varying levels of technicality. Under both techniques, we show that PCPs are sensitive to the enforcement and subsequent temporary removals of expenditure caps and more generally, to changes in consultations' relative prices over time. These results support the existence of a discretionary power over the choice of consultation, PCPs increasing strategically the number of the more technical (and therefore more lucrative) consultations when pressed to defend their income. This finding for primary care parallels the now well-established DRG creep in hospitals. The panel system approach offers a better account of the complexity surrounding PCPs' decision-making process. In particular, it successfully addresses issues of physician heterogeneity, jointness between consultations and temporal breaks and generates robust estimates of PCPs volume and quality reactions to regulatory changes.

Budgets↗
PubMed2006

Horizontal equity in utilisation of care and fairness of health financing: a comparison of micro-health insurance and user fees in Rwanda.

This paper uses two methods to compare the impact of health care payments under insurance and user fees. Concentration indices for insured and uninsured groups are computed following the indirect standardisation method to evaluate horizontal inequity in utilisation of basic health care services. The minimum standard approach analyses the extent to which out-of-pocket health spending contributed to increased poverty. The analysis uses cross-sectional household survey data collected in Rwanda in 2000 in the context of the introduction of community-based health insurance. Results indicate that health spending had a small impact on the socio-economic situation of uninsured and insured households; however, this is at the expense of horizontal inequity in utilisation of care for user-fee paying individuals who reported significantly lower visit rates than the insured.

Cost Sharing↗
PubMed2006

Making health continuous: implications of different methods on the measurement of inequality.

In most national surveys, health is measured as a categorical variable. However, in order to be able to calculate socio-economic inequalities in health, a continuous variable is needed. The recently developed interval regression approach was shown to outperform to other approaches like ordered probit. In this research we investigate the impact of using different sets of external data to estimate health inequalities: the EQ-index and the Canadian HUI. We found that the concentration index differs, but the income-related health mobility index and its decomposition are highly similar.

Adult↗
PubMed2006

National road casualties and economic development.

OBJECTIVE: This paper explores why traffic fatalities increase with GDP per capita in lower income countries and decrease with GDP per capita in wealthy countries. METHODS: Data from 41 countries for the period 1992-1996 were obtained on road transport crashes, injuries, and fatalities as well as numbers of vehicles, kilometers of roadway, oil consumption, population, and GDP. Fixed effects regression was used to control for unobservable heterogeneity among countries. RESULTS: A 10% increase in GDP in a lower income country (GDP/Capita <1600) is expected to raise the number of crashes by 7.9%, the number of traffic injuries by 4.7%, and the number of deaths by 3.1% through a mechanism that is independent of population size, vehicle counts, oil use, and roadway availability. Increases in GDP in richer countries appear to reduce the number of traffic deaths, but do not reduce the number of crashes or injuries, all else equal. Greater petrol use and alcohol use are related to more traffic fatalities in rich countries, all else equal. CONCLUSION: In lower income countries a rise in traffic-related crashes, injuries, and deaths accompanies economic growth. At a threshold of around 1,500 dollars-8,000 dollars per capita economic growth no longer leads to additional traffic deaths, although crashes and traffic injuries continue to increase with growth. The negative association between GDP and traffic deaths in rich countries may be mediated by lower injury severity and post-injury ambulance transport and medical care.

Accidents, Traffic↗
PubMed2006

Are mental health insurance mandates effective? Evidence from suicides.

Many states in the US have passed laws mandating insurance companies to provide or offer some form of mental health benefits. These laws presumably lower the price of obtaining mental health services for many adults, and as a result, might improve health outcomes. This paper analyzes the effectiveness of mental health insurance mandates by examining the influence of mandates on adult suicides, which are strongly correlated with mental illness. Data on completed suicides in each state for the period 1981-2000 are analyzed. Ordinary least squares and two-stage least squares results show that mental health mandates are not effective in reducing suicide rates.

Adult↗
PubMed2005

Estimating the price elasticity of expenditure for prescription drugs in the presence of non-linear price schedules: an illustration from Quebec, Canada.

The price elasticity of demand for prescription drugs is a crucial parameter of interest in designing pharmaceutical benefit plans. Estimating the elasticity using micro-data, however, is challenging because insurance coverage that includes deductibles, co-insurance provisions and maximum expenditure limits create a non-linear price schedule, making price endogenous (a function of drug consumption). In this paper we exploit an exogenous change in cost-sharing within the Quebec (Canada) public Pharmacare program to estimate the price elasticity of expenditure for drugs using IV methods. This approach corrects for the endogeneity of price and incorporates the concept of a 'rational' consumer who factors into consumption decisions the price they expect to face at the margin given their expected needs. The IV method is adapted from an approach developed in the public finance literature used to estimate income responses to changes in tax schedules. The instrument is based on the price an individual would face under the new cost-sharing policy if their consumption remained at the pre-policy level. Our preferred specification leads to expenditure elasticities that are in the low range of previous estimates (between -0.12 and -0.16). Naïve OLS estimates are between 1 and 4 times these magnitudes.

Aged↗
PubMed2005

Assessing household health expenditure with Box-Cox censoring models.

In order to assess the combined presence of zero expenditures and a heavily skewed distribution of positive expenditures, the Box-Cox transformation with location parameter is used to define a set of models generalising the standard Tobit, Heckman selection and double-hurdle models. Extended flexibility with respect to previous specifications is introduced, notably regarding negative transformation parameters, which may prove necessary for medical expenditures, and corner-solution outcomes. An illustration is provided by the analysis of household health expenditure in Switzerland.

Family Characteristics↗
PubMed2005

Waiting lists, waiting times and admissions: an empirical analysis at hospital and general practice level.

We report an empirical analysis of the responses of the supply and demand for secondary care to waiting list size and waiting times. Whereas previous empirical analyses have used data aggregated to area level, our analysis focuses on the supply responses of a single hospital and the demand responses of the GP practices it serves, and distinguishes between first outpatient visits, inpatient admissions, day-case treatment and emergency admissions. The results are plausible and in line with the theoretical model. For example: the demand from practices for first outpatient visits is negatively affected by waiting times and distance to the hospital. Increases in waiting times and waiting lists lead to increases in supply; the supply of elective inpatient admissions is affected negatively by current emergency admissions and positively by lagged waiting list and waiting time. We use the empirical results to investigate the dynamic responses to one off policy measures to reduce waiting times and lists by increasing supply.

Health Services Needs and Demand↗
PubMed2005

Road injuries and long-run effects on income and employment.

This paper investigates whether unexpected shocks in terms of road injuries 'cause' a permanent change in disposable income, earnings, employment, and public transfer income. We use 'propensity score matching' and apply a difference-in-difference matching method to estimate the counterfactual of what the disposable income, earnings, employment, and the amount of public transfer income would have been of a particular group of persons injured by road accidents if they had not in fact been injured. We find that road injuries have important consequences. Older injured persons and injured persons in the lower part of the income distribution have significantly lower disposable incomes than older and low-income non-injured persons. In both the short and the long run the employment rates for the injured men are significantly lower than for non-injured persons. No effects on the employment rate are found for women. Besides, earnings are reduced in the long run for men where significant effects are only found for older women. The analysis shows that both injured men and women are compensated in terms of a significant increase in public transfer incomes in both the short and the long run.

Accidents, Traffic↗
PubMed2005

Utilization of public health centres in Portugal: effect of time costs and other determinants. Finite mixture models applied to truncated samples.

The impact of time costs on the utilization of medical care has been a subject of theoretical and empirical research since the early 1970s. The main goal of this paper is to show the effect of time costs on the number of visits to general practitioners (GP) in Portuguese public health centres. We measured the elasticity of primary health care utilization relative to the total time spent in the health centre and relative to travel time. We also provided evidence regarding the impact of an appointment delay on the utilization of public GP services. Our data resulted from the application of an endogenous sampling scheme, resulting in a truncated-at-zero data set. To model our dependent variable, number of visits, and accounting for the truncated nature of the data we used a finite mixture model specification. The data were obtained from the most recent implementation in Portugal of the 2003/2004 Europep Survey. The two-component negative binomial II finite mixture model led to the identification of two different latent classes of health centre users: a low-users class that comprises 88% of patients with an estimated utilization mean of 4.3 GP visits per year and a frequent-users class with an estimated utilization mean of 11.1 visits for the remaining 12% of the population. We failed to find any statistically significant elasticity of time cost utilization, when this variable is measured as the total time spent in the health centre. Regarding the effect of an appointment delay on health centre utilization we concluded that individuals respond to this variable by lowering the number of GP visits. This last finding may have policy implications, which will be discussed at the end of the paper.

Animals↗
PubMed2005

Latent class models for use of primary care: evidence from a British panel.

This paper models access to and utilisation of primary care using data from the British Household Panel Survey for the period 1991-2001. A latent class panel data framework is adopted to model individual unobserved heterogeneity in a flexible way. Accounting for the panel structure of the data leads to a substantial improvement in fit, and permits the identification of latent classes of users of health care. Analysis by gender shows that men and women respond differently to some factors, in particular, to age and income. There is evidence of a positive impact of income on the probability of seeking primary care. This effect is especially significant in the case of women. For both genders, the marginal effect of income on the propensity to visit a GP is greater for individuals who are less likely to seek primary care. A latent class aggregated count data model for the number of GP visits classifies individuals in three latent classes and shows a positive income effect particularly amongst those with lower levels of utilisation.

Adolescent↗
PubMed2006

Health status and labour force participation: evidence from Australia.

This paper examines the effect of health on labour force participation using the Household, Income and Labour Dynamics in Australia (HILDA) Survey. The potential endogeneity of health, especially self-assessed health, in the labour force participation equation is addressed by estimating the health equation and the labour force participation equation simultaneously. Taking into account the correlation between the error terms in the two equations, the estimation is conducted separately for males aged 15-49, males aged 50-64, females aged 15-49 and females aged 50-60. The results indicate that better health increases the probability of labour force participation for all four groups. However, the effect is larger for the older groups and for women. As for the feedback effect, it is found that labour force participation has a significant positive impact on older females' health, and a significant negative effect on younger males' health. For younger females and older males, the impact of labour force participation on health is not significant. The null-hypothesis of exogeneity of health to labour force participation is rejected for all groups.

Adolescent↗