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PubMed2004

Economic rewarding of smoking cessation-facilitating drugs--a comparison of over-the-counter and prescribed nicotine replacement therapy.

Smoking cessation represents a very difficult task for the smoker, often requiring medical assistance. The introduction of smoking cessation drugs has been crucial to this process. Currently, there are two standardly used treatments: nicotine replacement therapy (NRT) and the antidepressant bupropion. Soon after their introduction, NRTs were sold over-the-counter (OTC), as oppose to on prescription, although in most countries, bupropion remains available only on prescription. Both prescribed and OTC NRTs have similar efficacy (i.e., their use approximately doubles the cessation rate among users and their use has shown a high level of economic rewarding). The most important advantage of OTC NRT is availability, as some patients may not be comfortable with the use of prescribed drugs. The introduction of OTC NRT has led to a substantial rise in their use, increasing the proportion of ex-smokers in the population. However, there are a lack of published, cost-benefit analysis data comparing prescription with OTC NRT. Considering the different economic, social and cultural conditions within particular countries, it is difficult to formulate a common optimal economic model for the distribution of NRT. Authentic studies and trials in this field in order to develop the appropriate policies in each particular country, are clearly required.

Bupropion↗
PubMed2003

Antimicrobial resistance: cost and containment.

There is growing evidence that antimicrobial resistance causes serious consequences for individuals as well as leading to increased healthcare costs. The containment of resistance is therefore a policy problem which will impact on all health systems in the next few years. Unfortunately, there is, as yet, no definitive evidence suggesting that particular control measures are successful in containing either the emergence or transmission of antimicrobial resistance. Furthermore, few studies contain information about costs and even where there is such information it is generally inadequate because of the narrow perspectives from which analyses are conducted. In part, this is due to methodological problems associated with the inclusion of cost data: measuring and valuing what are often intangible costs; identifying costs associated with organizational change; and accounting for interaction between costs at levels from the individual to the international. Good quality research, including both economic evaluation and comprehensive economic modelling, is required to determine the most cost-effective combination of strategies to pursue in combating resistance, and to find ways around these methodological difficulties.

Animals↗
PubMed2005

Cost-effectiveness of linezolid versus vancomycin in mechanical ventilation-associated nosocomial pneumonia caused by methicillin-resistant staphylococcus aureus.

UNLABELLED: Linezolid, an oxazolidinone-class antimicrobial agent, is a new drug; its use has frequently been questioned due to its high price. However, recent trials have demonstrated that the use of linezolid in mechanical ventilation-associated nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus (VAP-MRSA) may be justified due to its improved efficacy compared to vancomycin. Price and cost have different magnitudes, and clinical efficacy should always be considered in the decision-making process. Our objective was to determine whether linezolid treatment was more cost-effective than vancomycin for treating VAP-MRSA. METHODOLOGY: Elaboration of an economic model from a metanalysis of previous clinical trials comparing both drugs, through a cost-effectiveness analysis. Costs of the treatments were calculated using Brazilian parameters and were compared to the results obtained in the metanalysis. In order to compare the results with real life conditions, costs were calculated for both name brand and for generic vancomycin. RESULTS: The cost (May/2004) per unit (vial, ampoule or bag) was R$ 47.73 for the name-brand vancomycin, R$ 14.45 for generic vancomycin and R$ 214.04 for linezolid. Linezolid's efficacy in VAP-MRSA according to the metanalysis was 62.2% and vancomycin's efficacy was 21.2%. The total cost per cured patient was R$ 13,231.65 for the name-brand vancomycin, R$ 11,277.59 for generic vancomycin and R$ 7,764.72 for linezolid. CONCLUSION: Despite the higher price per unit, linezolid was more cost-effective than vancomycin.

Acetamides↗
PubMed1987

Consumption-leisure tradeoffs in pigeons: Effects of changing marginal wage rates by varying amount of reinforcement.

Pigeons' rates of responding and food reinforcement under simple random-ratio schedules were compared with those obtained under comparable ratio schedules in which free food deliveries were added, but the duration of each food delivery was halved. These ratio-with-free-food schedules were constructed so that, were the pigeon to maintain the same rate of responding as it had under the simple ratio schedule, total food obtained (earned plus free) would remain unchanged. However, any reduction in responding would reduce total food consumption below that under the simple ratio schedule. These "compensated wage decreases" led to decreases in responding and decreases in food consumption, as predicted by an economic model of labor supply. Moreover, the reductions in responding increased as the ratio value increased (i.e., as wage rates decreased). Pigeons, therefore, substituted leisure for consumption. The relationship between these procedures and negative-income-tax programs is noted.

Journal Article↗
PubMed1988

Information on response requirements compared with information on food density as a reinforcer of observing in pigeons.

On a variable-interval schedule, pecking the key to the pigeon's right (observing response) produced red or green displays relating to the delivery of grain and its dependence on pecking the key to the left (food key). During various blocks of sessions, mixed (no stimulus change) schedules including the following pairs of components were temporarily converted by the observing response to their corresponding multiple (correlated stimuli) schedules: variable-interval 60-s, extinction; variable-interval 60-s, variable-time (response-independent) 60-s; extinction, variable-time 60-s. Differences in food delivery maintained substantial rates of responding on the observing key, without regard to pecking requirements on the food key. Although stimuli correlated with differences in the response requirement on the food key maintained higher observing rates than those maintained by uncorrelated stimuli, they were much lower than those based on food. The value of predictive stimuli as reinforcers is determined by the value of the events predicted. In particular, the cost of pecking appears to be low, and this may place limitations on the applicability of energy-based and economic models of behavior.

Journal Article↗
PubMed1995

Assessing preference for reinforcers using demand curves, work-rate functions, and expansion paths.

A BEHAVIORAL ECONOMIC MODEL THAT EXPLAINS THE CHOICE AND ALLOCATION OF WORK RATE IS USED TO PREDICT PERFORMANCE PATTERNS IN THREE CONTEXTS: with single schedules, with concurrent schedules when total reinforcement is low, and with concurrent schedules when reinforcement increases. Performance in the three contexts is predicted to change in orderly ways depending on how the subject evaluates the reinforcers earned. Quadrant diagrams are used to generate reinforcer demand functions, work-rate supply functions, and reinforcement-rate expansion paths. Preference between reinforcers is viewed as being a variable, with preference reversing in some situations.

Journal Article↗
PubMed2003

Early intervention in multiple sclerosis : better outcomes for patients and society?

Multiple sclerosis (MS) is thought to be a chronic inflammatory disorder of the CNS. The past decade has seen the introduction of the new immunomodulatory drugs, interferon (IFN)-beta and glatiramer acetate, that have considerably improved the therapeutic options for this often disabling disease. The efficacy of these treatments in terms of reducing relapse rate and slowing progression has been proven in several large, multicentre, randomised, controlled trials. Similarly, early IFNbeta treatment of patients with clinically isolated syndromes suggestive of MS has been shown to lengthen time to conversion into definite MS. Cost-effectiveness has been questioned with the increasing use of these innovative and, therefore, costly therapies; however, modern studies with appropriate economic modelling suggest that treatment with IFNbeta may indeed be cost-effective. Since increasing disability is associated with increasing costs, stabilisation of the disease at low functional grades of disability should aim at not only improving quality of life for the individual patient, but provide for prospective cost-benefit analysis focussing on the socioeconomic aspects of MS.

Clinical Trials as Topic↗
PubMed1997

Some aspects of the cost of schizophrenia in France.

This study aimed to investigate how patients with schizophrenia were treated and to evaluate the cost of treatment in medical and social terms in France. The study was questionnaire-based. 6000 French hospital and community psychiatrists in the public and private sectors received the questionnaire. The 494 psychiatrists who responded described the treatment prescribed for, and social assistance provided to, the last patient consulting for schizophrenia-as defined by the criteria of the third edition (revised) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R)-either as an outpatient or as an impatient in the last year. The clinical, epidemiological and therapeutic data collected on 356 (72%) patients receiving outpatient treatment and 138 (28%) patients receiving impatient treatment in the public (242 patients; 49%) or private (252 patients; 51%) sectors were processed by medical and economic modelling. The mean (+/-standard deviation) time from symptom onset to study entry was 11 +/- 8 years, while the mean time from first hospital admission to study entry was 9.5 +/- 8 years. The mean time from symptom onset to initial hospitalisation was 25 +/- 4 months. 224 patients had been hospitalised in a psychiatric ward at least once in the previous year (45%). The average duration of hospitalisation was 82 +/- 96 days. During the year of the study, 122 patients received part-time treatment in a day hospital or intermediate facility (e.g. occupational therapy centres, therapeutic workshops and therapeutic apartments), 39 (8%) on a daily basis and 83 (17%) one or more times a week; medical care lasted 130 +/- 137 days and 107 +/- 89 days, respectively. The annual complete cost of medical management of the 477 evaluable patients in the study was F27471511 (1992 values). The overall annual treatment cost (medical and social) was F1533724 for medication (5.6% of the complete cost), F2600673 for visits (9.5%), F8285900 for intermediate facilities (30.1%) and F15051214 (54.8%) for hospitalisation. The social allowance cost was F10926000. The average annual costs of medical care and social allowance per patient with schizophrenia were respectively estimated at F54970 and F22905. The annual cost of medical management of schizophrenia in France was thus F12.37 billion ($US2.34 billion).

Adult↗
PubMed1999

Choice of cost-effectiveness measure in the economic evaluation of cholesterol-modifying pharmacotherapy. An illustrative example focusing on the primary prevention of coronary heart disease in Canada.

OBJECTIVE: To evaluate the effect of using different cost-effectiveness measures in the economic evaluation of cholesterol-modifying pharmacotherapy. DESIGN AND SETTING: An economic model was used to examine the extent to which the relative cost effectiveness of cholesterol-modifying agents varies depending upon the cost-effectiveness measure used. The perspective taken was that of the Canadian public healthcare system. PATIENTS: Individuals without coronary heart disease (CHD) with low-density lipoprotein cholesterol (LDL-C) levels in excess of 190 mg/dl. INTERVENTIONS: Cholesterol-modifying pharmacotherapies available in Canada. MAIN OUTCOME MEASURES AND RESULTS: Cost per 1% reduction in LDL-C level; incremental cost per life-year gained; least-cost agent achieving the LDL-C reduction required to meet the target level of 160 mg/dl; incremental cost per life-year gained of agents reaching the target LDL-C level of 160 mg/dl relative to no therapy; incremental cost per life-year gained of agents achieving the target LDL-C level of 160 mg/dl relative to the least-cost agent reaching the target. Each cost-effectiveness measure had a different informational content to decision-makers, both in terms of the usefulness of the information they provided, and in terms of the extent to which they showed one agent to be more cost effective than another. The most cost-effective treatment regimens were fluvastatin 20 mg per day, fluvastatin 40 mg per day, atorvastatin 10 mg per day and atorvastatin 20 mg per day, depending on the pretreatment LDL-C level and the cost-effectiveness measure used. CONCLUSIONS: We recommend that the cost effectiveness of cholesterol-modifying pharmacotherapy be measured using incremental cost per life-year gained in reaching a predefined target LDL-C level.

Anticholesteremic Agents↗
PubMed2000

Pharmacoeconomic analysis of antidepressants for major depressive disorder in the United Kingdom.

OBJECTIVE: To estimate the cost effectiveness of different classes of antidepressants in the UK National Health Service. DESIGN, PATIENTS AND INTERVENTIONS: The use of the serotonin (5-hydroxytryptamine; 5-HT) and noradrenaline (norepinephrine) reuptake inhibitor (SNRI) venlafaxine was compared with that of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) in patients with major depressive disorder (MDD). A meta-analysis determined the clinical success rate, and a decision tree was constructed by interviewing general practitioners and psychiatrists. Adding pharmacological and nonpharmacological treatment costs, meta-analytic rates were applied to the decision tree to calculate the expected cost and outcome for each drug. Cost effectiveness was determined using a composite measure of outcome [symptom-free days (SFD)]. MAIN OUTCOME MEASURES AND RESULTS: The meta-analysis included data from 44 studies on 4033 patients. The highest overall efficacy rate for outpatients with MDD was with venlafaxine use (73.7%), compared with 61.4% for SSRIs and 59.3% for TCAs. Treatment with venlafaxine yielded the lowest outpatient cost for a SFD (10.53 Pounds), compared with 13.23 Pounds for SSRIs and 15.52 Pounds for TCAs (1998 values). CONCLUSIONS: Using this economic model, venlafaxine appears to be a cost-effective treatment for outpatients with MDD in the UK.

Antidepressive Agents↗
PubMed2001

Using health outcomes data to inform decision-making: a pharmaceutical industry perspective.

Within the pharmaceutical industry, there is increasing interest in collecting health outcomes data in order to inform decision-making, both internally and externally. The overall aim of generating the health outcomes information is to determine the value of the product, from the perspective of all the stakeholders. In addition to studies carried out during phase II and III of clinical development, pharmaceutical companies have recently begun to collect health outcomes information earlier, with the expected requirements for reimbursement and market access considered during the preclinical and phase I stages. However, there are a number of challenges to the demonstration of product value during drug development, particularly relating to the limitations of clinical trials. One way that pharmaceutical companies are addressing these challenges is through the use of economic modelling, to provide a framework to test assumptions and assess uncertainty, and examine the budget impact of treatments. Although different countries may use the information differently, health outcomes evidence generated by the pharmaceutical industry is generally used to inform decision-making about pricing, reimbursement, treatment guidelines and inclusion of drugs on formularies. A wide variety of health outcomes information is produced by the industry in order to provide data on product value that are appropriate for the different perspectives of the stakeholders in the healthcare system.

Asthma↗
PubMed2001

Using health outcomes data to inform decision-making: healthcare payer perspective.

Healthcare payers are charged with the responsibility of achieving maximum profits or output within their limited budget. As the demands are always greater than the budget, there is growing interest in tools that can inform decisions on the allocation of limited resources. Healthcare payers are using health outcomes data to assist the decision-making process, although the way in which such information is being used may differ between payers. From the perspective of the French sickness fund, there is a need for real-world information to supplement the results of clinical trials and inform negotiations on pricing. In the US, the large databases of healthcare insurers are being examined in order to carry out retrospective cohort studies that go some way towards providing such real-world information on outcomes with alternative treatments. Another approach to health outcomes information has been taken by an Israeli healthcare organisation, Maccabi Healthcare Services, which introduced a disease management programme in order to improve outcomes of asthma management. Clearly, healthcare payers are using health outcomes information in a variety of ways to inform decision-making. The extensive databases available to payers may be used to good effect, to obtain real-life information that supplements clinical trial data and economic models of outcomes and costs, and to enable the targeting of interventions.

Asthma↗
PubMed2002

Meeting the challenges to European healthcare: lessons learned from the 'Stockholm Revolution'.

Healthcare is a political 'hot potato' in Sweden, just as it is throughout Europe. Regardless of whether the focus is on the 'Swedish model' or a 'European model', the operative term should be 'Culture - a set of values common to European healthcare systems'. An analysis of change and challenge in European healthcare systems must examine these values in the context of technological and societal forces before addressing the overarching concerns of where the money will come from. Discussion of the reform evidenced by the 'Stockholm Revolution' will serve as a model of how European healthcare systems can adapt to new conditions by the following approaches: modernising services through incentives; making the consumer a partner by focusing on consumer-related outcomes; building employee networks that encourage responsibility and problem solving; making healthcare an attractive labour market; and creating self-employment opportunities in the healthcare market to increase efficiency and emphasis on consumer satisfaction.

Consumer Advocacy↗
PubMed2004

Reconciliation of economic concerns and health policy: illustration of an equity adjustment procedure using proportional shortfall.

Economic evaluations have become an important and much used tool in aiding decision makers in deciding on reimbursement or implementation of new healthcare technologies. Nevertheless, the impact of economic evaluations on reimbursement decisions has been modest; results of economic evaluations do not have a good record in predicting funding decisions. This is usually explained in terms of fairness; there is increasing awareness that valuations of QALYs may differ when the QALYs accrue to different patients. The problem, however, is that these equity concerns often remain implicit, and therefore frustrate explicitness and transparency in evidence-based decision making. It has been suggested that a so-called equity adjustment procedure may (partially) solve this problem. Typically this would involve the application of so-called equity weights, which can be used to recalculate the value of QALY gains for different patients. This paper explores such an equity adjustment procedure, using the equity concept of proportional shortfall. Proportional shortfall assumes that measurement of inequalities in health should concentrate on the fraction of QALYs that people lose relative to their remaining life expectancy, and not on the absolute number of QALYs lost or gained. It is the ratio of QALYs lost over the QALYs remaining. This equity concept combines elements of two popular but conflicting notions of equity: fair innings and severity-of-illness. We applied the concept of proportional shortfall to ten conditions and tentatively explored how an equity adjustment procedure using proportional shortfall might affect priority setting. Our equity adjustment procedure lowered the cost-effectiveness threshold when a condition was relatively mild. Because the proportional shortfall caused by the ten conditions differed considerably, the equity-adjustment procedure discriminated strongly between the ten conditions, and this experiment provided a good opportunity to explore the impact of equity adjustment for healthcare reimbursement decisions. In conclusion, our results suggest that equity can be measured and that integration of equity concerns into an economic evaluation improves the fit between economic models and reimbursement decisions. It is recommended that cost-effectiveness driven health policy systems consider equity adjustments.

Cost-Benefit Analysis↗
PubMed2005

Economic implications of biological therapies for Crohn's disease: review of infliximab.

Crohn's disease is a chronic, relapsing inflammatory bowel disease that may require extensive medical and surgical interventions. Traditional therapies include 5-aminosalicylates, corticosteroids, immunosuppressants (e.g. azathioprine, mercaptopurine), defined formula diets, antibacterials and surgery. Infliximab is an anticytokine therapy for Crohn's disease that targets tumour necrosis factor-alpha. Infusions of infliximab have been shown to be superior to placebo in the induction and maintenance of remission in moderately severe and/or fistulising Crohn's disease. This review briefly summarises the data for clinical effectiveness of infliximab and then considers the economic implications of its use. Available economic modelling exercises suggest that infliximab has a relatively high incremental cost per QALY compared with standard care. However, there are limitations to these theoretical data and there has been no direct assessment of cost effectiveness within a controlled trial. Effective alternative treatment options for moderate-to-severe Crohn's disease are relatively lacking. More data are needed relating to the long-term safety of infliximab and the extent to which this new biological therapy produces lasting clinical benefits.

Antibodies, Monoclonal↗
PubMed1999

Income inequality, social cohesion, and class relations: a critique of Wilkinson's neo-Durkheimian research program.

Wilkinson's "income inequality and social cohesion" model has emerged as a leading research program in social epidemiology. Public health scholars and activists working toward the elimination of social inequalities in health can find several appealing features in Wilkinson's research. In particular, it provides a sociological alternative to former models that emphasize poverty, health behaviors, or the cultural aspects of social relations as determinants of population health. Wilkinson's model calls for social explanations, avoids the subjectivist legacy of U.S. functionalist sociology that is evident in "status" approaches to understanding social inequalities in health, and calls for broad policies of income redistribution. Nevertheless, Wilkinson's research program has characteristics that limit its explanatory power and its ability to inform social policies directed toward reducing social inequalities in health. The model ignores class relations, an approach that might help explain how income inequalities are generated and account for both relative and absolute deprivation. Furthermore, Wilkinson's model implies that social cohesion rather than political change is the major determinant of population health. Historical evidence suggests that class formation could determine both reductions in social inequalities and increases in social cohesion. Drawing on recent examples, the authors argue that an emphasis on social cohesion can be used to render communities responsible for their mortality and morbidity rates: a community-level version of "blaming the victim." Such use of social cohesion is related to current policy initiatives in the United States and Britain under the New Democrat and New Labor governments.

Community Health Planning↗
PubMed2002

Fluid milk processing costs: current state and comparisons.

An economic-engineering model is used to derive the theoretically minimum cost of processing and distributing fluid white milk for the state of Maine. This model represents a state-of-the-art milk processing facility and is used to evaluate three questions: 1) the components of total processing costs; 2) whether the cost of milk processing declines with increasing plant size; and 3) the minimum processing volume to financially justify inplant blow-molding technology. The model indicates that significant savings in per-container processing costs can be achieved by increasing plant size. However, distribution costs, related to the geographical distribution of consumer demand and plant location in the state of Maine do not favor large centralized plants. In addition, this model is compared with results published in 1993 to evaluate cost trends over a 7-yr period. The model indicates import shifts to more technologically advanced processing equipment and a dramatic increase in labor costs. Overall, processing costs have risen 2.9% annually above the rate of inflation. Dairies that are unable to respond to increased labor costs through capital investment and expansion will likely find it more difficult to remain competitive in the milk processing industry.

Animals↗