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PubMed1997

Socioeconomic and demographic factors are associated with worldwide patterns of stunting and wasting of children.

We estimated the variability among nations in the prevalence of stunting and wasting, evaluated which national factors are associated with stunting and wasting and examined the relationship of stunting with wasting. The World Health Organization Global Database on Child Growth, a comprehensive conceptual model and a database of national factors were used with variance components and regression analyses. There was substantial variability among nations and among provinces within nations. Most national variability for stunting (76%) and wasting (66%) was explained by national factors and geographic region. Higher energy availability, female literacy and gross product were the most important factors associated with lower prevalence of stunting. The association of health expenditures and stunting differed by region. Higher immunization rate and, for Asia only, energy availability were the most important factors associated with lower prevalence of wasting. Regional differences in the relationship between stunting and wasting were accounted for by national factors. Some factors associated with stunting and wasting differ at the national level. Child malnutrition within a household is greatly influenced by issues at national and provincial levels, and intervention should be considered at all three levels.

Child Nutritional Physiological Phenomena↗
PubMed2005

Review of cost-effectiveness analyses in hormonal therapies in advanced breast cancer.

Many new cancer treatments that slow progression and extend survival are emerging. These advances bring new hope to patients and physicians, but often increase health expenditures in an already cost-conscious environment. To help guide resource allocation decisions, cost-effectiveness models are constructed to compare the costs and outcomes of new treatments with current options, and to encourage the uptake of new technologies. This study focuses on the cost-effectiveness studies published since 1997 for hormonal treatment options in advanced breast cancer. This paper: i) examines the quality of studies in terms of reporting methods and transparency of the models; ii) compares the calculated cost-effectiveness ratios; and iii) makes recommendations for future cost-effectiveness models in advanced breast cancer.

Antineoplastic Agents, Hormonal↗
PubMed1998

Surviving social assistance: 12-month prevalence of depression in sole-support parents receiving social assistance.

BACKGROUND: Although it is generally recognized that poverty and depression can coexist among single parents receiving social assistance, there is insufficient research on this topic. The goals of this study therefore were to investigate the prevalence, correlates and health care expenditures associated with depression among sole-support parents receiving social assistance. METHODS: Sole-support parents who had applied for social assistance in 2 regions of southwestern Ontario were included in the study. Depression was diagnosed with the 1994 University of Michigan Composite International Diagnostic Interview short forms. RESULTS: The 12-month prevalence rate of depressive disorder among the parents interviewed was 45.4% (345/760). A total of 247 (32.5%) had major depressive disorder alone, 19 (2.5%) had dysthymia, and 79 (10.4%) had both major depressive disorder and dysthymia ("double depression"). Those with major depressive disorder, particularly double depression, had significantly higher rates of coexisting psychiatric disorder than those without depressive disorders. Parents with depression reported higher rates of developmental delay and behaviour problems in their children than parents without depression. Expenditures for health care services were higher for parents with depression and for their children than for parents without depressive disorder and their children. INTERPRETATION: Single parents receiving social assistance have high rates of depression. Such parents with depression also have higher rates of other psychiatric disorders and higher expenditures for health care services, and their children have higher rates of developmental delay and behaviour problems.

Adaptation, Psychological↗
PubMed1998

On the success, cost and efficiency of modern medicine: an international comparison.

OBJECTIVE: To study the success and cost of modern medicine in industrialized, rich countries from 1980 to 1990. DESIGN: Cost per capita and per cent of gross domestic product (GDP) spent on health was related to: (i) mortality in six diseases amenable to treatment by modern medicine; (ii) the sum of those six diseases (avoidable disease); (iii) death due to other, unavoidable diseases; (iv) maternal and infant mortality; (v) life expectancy at birth; (vi) renal dialysis and transplantation rates. Efficiency was studied by comparing a country's avoidable mortality rates multiplied by expenses, to the mean for all countries. RESULTS: During the 10 years, avoidable death rate decreased 38% but unavoidable death rate only 10%. Life expectancy increased 3%. Cost per capita increased 107% but health expenditures, as per cent of GDP only 10%. There was a reasonable correlation between expenses and avoidable mortality but none between expenses and unavoidable death rate. In 1990 avoidable mortality was lowest in Canada, and highest in Japan. Cost was lowest in New Zealand, and highest in the USA. The efficiency index was highest for Australia, and lowest in the USA. CONCLUSION: Modern medicine as we have studied it is successful. Avoidable death rate shows a steep uninterrupted decline over the last 50 years while unavoidable death rate shows only small decreases. Cost as per cent of GDP has increased only moderately. There is a correlation between expenses and mortality from avoidable but not from unavoidable diseases, and a large variation in efficiency.

Clinical Medicine↗
PubMed1998

[Pharmaco-economic aspects of the treatment of hypertension].

Hypertension affects a large proportion of the adult population. Subsequently any change in treatment strategy may have a drastic impact on health expenditure especially when one decides to decrease the limits of arterial pressure beyond which a treatment is started. Results of pharmaco-economic studies are often controversial because they are mainly based on an evaluation of short-term absolute risks, maybe underestimating the benefit of a treatment in younger population with mild to moderate hypertension. All groups of antihypertensive drugs are able to reduce the blood pressure and most of them can induce a light improvement of patient quality of life. Diuretics and beta-blockers have a lower cost/effectiveness ratio. ACE inhibitors and calcium antagonists may be preferred when other drugs are badly tolerated or when some other morbidities affect the patient.

Adrenergic beta-Antagonists↗
PubMed2003

Drivers of healthcare expenditures associated with physician services.

OBJECTIVE: To identify and rank the key contributors to increases in healthcare costs for physician services. STUDY DESIGN: We performed regression analysis using state-level physician cost data from the state health expenditure accounts maintained by the Centers for Medicare and Medicaid Services (CMS) and a national, private (commercial) health insurer. RESULTS: We estimated that during 1990 to 2000, nominal physician expenditures per capita grew 4.7% annually. Forty-two percent of this growth was attributable to general price inflation measured by the gross domestic product price deflator. The category of general economic variables and demographics was the next largest contributor to growth at 17%, followed by physician supply and provider structure (12%) and technology and treatment patterns (11%). Operating costs, health status, healthcare regulation, and health insurance benefit and product design comprised the remaining 18% of the growth. CONCLUSIONS: Because physicians are central to the healthcare system in the United States, efforts to contain physician spending reverberate through all healthcare services. The combined effect of an increase in the number and proportion of specialty care physicians, the continued development of clinical approaches for the control of chronic disease, and an aging population requiring intensive medical care imply that the current increase in healthcare expenditures could continue unabated, unless effective cost-control devices are deployed. To be effective, emerging strategies for influencing the affordability of healthcare services are likely to require a greater level of partnership between payers, providers, and other stakeholders.

Adolescent↗
PubMed2005

Extraordinary longevity: individual and societal issues.

The likelihood of substantial increases in average life spans and the potential for profound longevity increases (to 100, 110, or 120 years on average) raises a host of societal issues. These include huge increases in the number of old and very old persons, the likelihood of a massive increase in health expenditures for the population aged 65 and older, the potential for outliving financial resources, challenges to the viability of Social Security and pensions, concerns about quality of life, and possible intergenerational antagonisms. If marked increases occur in average life spans worldwide, several billions could be added to world population at eventual stability, and that could become a sustainability issue. To prepare for what is likely to be our demographic future requires a major shift in thinking about this type of complex issue; we must change from a simple linear to a much broader systems approach. Changes in retirement age, strengthening (but then replacing) the Social Security system, retaining older persons in the labor force, mandating retirement savings during working years, and many other actions must be considered in a debate that should start now about life span increase and the future; if we dawdle, we risk the consequences of being unprepared for the dramatic demographic changes that are likely to occur in the coming decades.

Aged↗
PubMed1992

The pharmacoeconomics of HIV disease.

Human immunodeficiency virus (HIV) infection is a major public health problem in all parts of the world. For the United States, federal spending on HIV disease for 1982 to 1989 was $US5.5 billion. Projections indicate that AIDS spending may reach 1.6% of total health expenditures in 1992, while the indirect costs of HIV infection may be 5 times as great as the direct costs. In the developing world, the cost per person with HIV infection may be 0.8- to 9-fold greater than the per capita gross national product (GNP). Pharmacoeconomic analysis has been used to assess 2 important therapeutic options in caring for HIV patients: zidovudine therapy for asymptomatic illness, and prophylaxis for Pneumocystis carinii pneumonia (PCP). The cost-effectiveness ratio for zidovudine therapy, $US6553 to $US70 526 per year of life saved, compares favourably with ratios for other medical therapies. Prophylaxis against Pneumocystis carinii pneumonia has been shown to be most efficient using oral dapsone or cotrimoxazole (trimethoprim-sulfamethoxazole). Pharmacological therapy for HIV is costly, however, and may limit the access to new therapies for patients in the developing world. Concurrent economic assessment of therapies during phase III trials may serve as an essential part of the research that will advance international efforts to combat this disease.

Cost-Benefit Analysis↗
PubMed1994

A comparative study of costs for dental services and dentists' income in the United States and Norway.

The United States and Norway have approximately the same per capita Gross Domestic Product (GDP) and average personal income, but their per capita health spending patterns are quite different. In 1982, the US spent 6.5% of its total health expenditures on dental services while Norway spent 5.4%. A higher percentage of Norwegian adults see a dentist annually as compared to US adults. In 1984, the mean net income of dentists in private practice was $66,940 in the US and $27,125 in Norway; this is respectively 5 and 1 3/4 times the average per capita income in those countries. The American publicly-employed dentist earned approximately two-thirds of what the American private practitioner made, while still earning approximately 50% more than his Norwegian counterpart. Some basic information concerning the ratios of dentists, specialists, and dental hygienists to the population is given. The relative proportion of women dentists in the two countries is contrasted. Finally, data on graduates from the dental schools, enrollment cuts, and estimated dentist to population ratios by the year 2000 are described to compare future manpower that will be available to the two countries. Several dissimilarities in the political and social systems are described and discussed. It is emphasized that caution should be used when interpreting and comparing data about countries with different dental delivery, political, and social systems.

Dental Health Services↗
PubMed1997

Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study.

BACKGROUND: Prevention and control of disease and injury require information about the leading medical causes of illness and exposures or risk factors. The assessment of the public-health importance of these has been hampered by the lack of common methods to investigate the overall, worldwide burden. The Global Burden of Disease Study (GBD) provides a standardised approach to epidemiological assessment and uses a standard unit, the disability-adjusted life year (DALY), to aid comparisons. METHODS: DALYs for each age-sex group in each GBD region for 107 disorders were calculated, based on the estimates of mortality by cause, incidence, average age of onset, duration, and disability severity. Estimates of the burden and prevalence of exposure in different regions of disorders attributable to malnutrition, poor water supply, sanitation and personal and domestic hygiene, unsafe sex, tobacco use, alcohol, occupation, hypertension, physical inactivity, use of illicit drugs, and air pollution were developed. FINDINGS: Developed regions account for 11.6% of the worldwide burden from all causes of death and disability, and account for 90.2% of health expenditure worldwide. Communicable, maternal, perinatal, and nutritional disorders explain 43.9%; non-communicable causes 40.9%; injuries 15.1%; malignant neoplasms 5.1%; neuropsychiatric conditions 10.5%; and cardiovascular conditions 9.7% of DALYs worldwide. The ten leading specific causes of global DALYs are, in descending order, lower respiratory infections, diarrhoeal diseases, perinatal disorders, unipolar major depression, ischaemic heart disease, cerebrovascular disease, tuberculosis, measles, road-traffic accidents, and congenital anomalies. 15.9% of DALYs worldwide are attributable to childhood malnutrition and 6.8% to poor water, and sanitation and personal and domestic hygiene. INTERPRETATION: The three leading contributors to the burden of disease are communicable and perinatal disorders affecting children. The substantial burdens of neuropsychiatric disorders and injuries are under-recognised. The epidemiological transition in terms of DALYs has progressed substantially in China, Latin America and the Caribbean, other Asia and islands, and the middle eastern crescent. If the burdens of disability and death are taken into account, our list differs substantially from other lists of the leading causes of death. DALYs provide a common metric to aid meaningful comparison of the burden of risk factors, diseases, and injuries.

Adolescent↗
PubMed2003

Paying for pharmaceutical registration in developing countries.

Fees charged by drug regulatory authorities (DRAs) may be used as a policy instrument to speed up regulatory approval, to encourage retention of quality staff and to stimulate introduction of generics versus new chemical entities. Often, the cost recovery function of these registration fees is not related to the true cost of the pharmaceutical regulatory process. In this paper, we scaled new drug registration fees of various DRAs to indices of economic development - the GNP per capita and the total government health expenditure per capita. Based on our analyses of 34 countries, most DRA registration fees for new drug applications for developing/non-OECD countries are less than the current GNP/capita of that country or are about US dollars 5000 for each US dollars 1000 spent per capita on healthcare. At present, each US dollars 1000 new drug registration fee for the developing/non-OECD countries analyzed corresponds to a total pharmaceutical market share of about US dollars 85 million. Our analyses further suggest little relationship between DRA registration fees and drug approval times in developing countries. The situation is complex, however, as policy tradeoffs are important to consider. Differential registration fees, presumably designed to encourage locally produced versus imported products, may violate international trade regulations. Moreover, certain DRA registration fees may provide perverse incentives for the pharmaceutical industry. Developing countries should require that DRA registration fees be based on accurate accounting of the cost of services provided. At present levels, these fees could be increased without disincentive to the pharmaceutical industry. For new drug registration fees, our analyses suggest that developing countries could charge between 1-5 times their GNP per capita or between US dollars 17000 and US dollars 80000 for each US dollars 1000 spent per capita on healthcare.

Developing Countries↗
PubMed1998

What is the economic case for treating obesity?

From both societal and payer perspectives, the economic effect of obesity in the United States is substantial, estimated at approximately 6% of our national health expenditure and cost of care in a major health maintenance organization. The number of physician visits related to obesity has increased 88% in a 6-year period. The morbidity cost (lost productivity) and functional capability of the patient with obesity is increasing rapidly (50% increase in lost productivity, 36% increase in restricted activity, and 28% increase in number of bed-days). Cost savings of treating obesity are comparable to those of treating other chronic diseases such as coronary heart disease and diabetes. Most studies indicate that most of the direct health care costs of obesity are from type 2 diabetes, coronary heart disease and hypertension. To date, however, there have been no published reports of the cost effectiveness of the medical management of obesity treatment. In conclusion, the cost of obesity is comparable to that of other chronic diseases, yet it receives disproportionately less attention. Cost effectiveness studies need to be initiated promptly.

Coronary Disease↗
PubMed2005

Clarifying efficiency-equity tradeoffs through explicit criteria, with a focus on developing countries.

Expenditures on health in many developing countries are being disproportionately spent on health services that have a low overall health impact, and that disproportionately benefit the rich. Without explicit consideration of priority setting, this situation is likely to remain unchanged: resource allocation is too often dictated by historical patterns, and maintains vested interests. This paper explores how prioritization between different health interventions can be rationalised by the use of clearly defined criteria. A number of key efficiency and equity criteria are examined, in particular analysing how potential tradeoffs could be incorporated into the decision making process.

Cost-Benefit Analysis↗
PubMed2006

The influence of child abuse on the pattern of expenditures in women's adult health service utilization in Ontario, Canada.

Childhood maltreatment is a common and serious problem for women, particularly in relation to impairment in adulthood. To our knowledge, no system-wide study has addressed the influence of childhood maltreatment on the cost of these women's adult health service utilization. This paper examines this relationship. The 1990 Ontario Health Survey (OHS) gathered information regarding determinants of physical health status and the use of health services. The 1991 Ontario Mental Health Supplement (OHSUP) examined a variety of childhood experiences as well as the prevalence of psychiatric disorders from a sample of OHS respondents. These were province-wide population health surveys of a probability-based sample of persons aged 15 years and older living in household dwellings in Ontario. The OHSUP randomly selected one member from each participating OHS household to be interviewed regarding personal experiences and mental health. This analysis used data from women aged 15-64 who participated in both the OHS and OHSUP. Self-reported health service utilization was collected in four groups of women--those who reported no history of child abuse, those with a history of physical abuse only, those who reported sexual abuse only, and those who reported both physical and sexual (combined) abuse. We hypothesized that a history of child abuse would result in greater adult health care costs. The results indicated that having a history of combined abuse nearly doubles mean annual ambulatory self-reported health care costs to 775 dollars (95% CI 504 dollars-1045 dollars) compared to a mean cost of 400 dollars with no abuse (95% CI 357 dollars-443 dollars). Median annual ambulatory self-reported health care costs were also increased in the combined abuse group, to 314 dollars (95% CI 220 dollars-429 dollars), compared to 138 dollars (95% CI 132 dollars-169 dollars) in those with no abuse. We conclude that child abuse in women is significantly associated with increased adult self-reported health care costs.

Adolescent↗
PubMed1996

The tension between cost containment and the underutilization of effective health services.

One of the common ingredients in all attempts to slow escalating health care costs is to control the utilization of services that provide little or uncertain benefit. To reform existing delivery systems, the organization, provision, and financing of health care need to be evaluated critically. Successful reform requires that more rational methods be used to determine which services to provide. The preferences of physicians, patients, and payers of care do not appear optimal from a societal perspective in choosing health care services. While reducing the use of interventions of little or unknown benefit should save money, a policy to restrict the use of medical services may lead to an unwanted result: the underutilization of interventions of proven clinical benefit. Through the determination of the value--by rigorous assessment of both costs and benefits of available alternatives--in a context sensitive to the unique cultural, political, and economic characteristics of individual nations, the health of the population should be improved and growth of health expenditures constrained. This is the first step in health care reform.

Cost Control↗
PubMed2000

Future prospects of voluntary health insurance in Thailand.

Voluntary health insurance schemes in Thailand are still under development and have yet to seriously address the questions of equity and efficiency, while private health insurance is limited to people who can afford the premium. One form of insurance, commonly known as the health insurance card scheme, was first introduced as the Health Card Program in 1983. This program is based on risk sharing of health expenditures, with no cost sharing, in a voluntary health insurance prepayment scheme. With the uncertain performance of the Thai economy, program sustainability and the efficient use of resources are major concerns. The Health Card Program needs enough enrollees to ensure a sufficient pool of risks. This study looks at health card purchase and utilization patterns, using data from Khon Kaen Province, and finds that employment, education levels and the presence of illness are significant factors influencing card purchase. The last factor is related to the problem of adverse selection of the program; families with symptoms of sickness are more likely to buy cards, resulting in greater use of health services. The results also show an improvement in accessibility to health care and a high level of satisfaction among card holders, both key objectives of the program. It is suggested that changes in the health card system could enable it to evolve into a community-based compulsory health insurance scheme for rural areas.

Adolescent↗
PubMed1995

The doctor's dilemma.

The close relationship between expenditure on health care and the countless individual judgements made by doctors for their patients means that any discussion about rationing must involve the process of clinical decision-making. Increasingly, doctors are being drawn into rationing by two powerful forces. Firstly, through the corporate responsibilities of those working within a managed health care system in which organisational objectives and budgetary constraints are agreed and specified in a much more explicit way than ever before. Secondly, by the professionally-led movement towards more clinically effective practice. These, in combination, are leading towards a fundamental review of the nature and ethical basis of clinical practice in which the duty of doctors to individual patients must be balanced against the wider considerations.

Cost-Benefit Analysis↗
PubMed1999

Partners in care: a model of collaboration.

It is estimated that 3 million persons in the United States have congestive heart failure. This diagnosis accounts for more than 5% of total health expenditures. A method to decrease the costs of health care was initiated through the partners-in-care model of collaborative practice. A research study exploring the use of nurse case managers in collaboration with cardiologists and primary care physicians is being conducted with persons older than 65 years. This care encompasses both inpatient and outpatient care. The intervention comprises nurse visits in the hospital and in the home as well as telephone support for 6 months after the index hospitalization. The outcomes of quality of life, functional status, mortality, morbidity, and costs are being examined. Collaborative health care partnerships may be an effective strategy to decrease health care costs and improve quality of life and functional status of older persons with congestive heart failure.

Aged↗