Screening asymptomatic low-risk individuals for coronary heart disease: issues and controversies.
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Clinical Trials as Topic↗
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Cost-effectiveness of myocardial perfusion imaging: a summary of the currently available literature.
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Cost-Benefit Analysis↗
The cost-effectiveness of Foscan mediated photodynamic therapy (Foscan-PDT) compared with extensive palliative surgery and palliative chemotherapy for patients with advanced head and neck cancer in the UK.
This study aimed to analyse the cost-effectiveness of Foscan mediated photodynamic therapy (Foscan-PDT) compared with palliative chemotherapy, extensive palliative surgery or 'no treatment' for patients with advanced head and neck cancer in the UK. A computerised cost-effectiveness model was constructed using published effectiveness data and unit costs for each of the treatment arms. Where possible, published resource use data were also used. In the absence of such information, expert opinion informed data input. Robust sensitivity analyses were performed to negate the effect of potential over or underestimation of the costs used for any of the interventions. The primary outcome was incremental cost/life year saved (cost/LYS); the secondary outcomes were incremental cost/overall tumour response and incremental cost/remission. Foscan-PDT was associated with the greatest health gains of all three interventions yielding 129 extra days of life compared with no treatment and extensive palliative surgery and 48 extra days of life compared with four cycles of palliative chemotherapy. The unit cost of Foscan-PDT ( pound 5741) was found to be lower than the unit cost for four cycles of palliative chemotherapy ( pound 9924) and extensive palliative surgery ( pound 16912). Foscan-PDT continued to have a lower unit cost than palliative chemotherapy until the number of chemotherapy cycles was reduced to two or fewer. Reducing the number of cycles would be likely to reduce the health gains associated with chemotherapy. However, even with assumed maintenance of chemotherapy efficacy, Foscan-PDT remained cost-effective versus two or fewer chemotherapy cycles. Compared with three or more cycles of palliative chemotherapy and extensive palliative surgery, Foscan-PDT dominated with a lower unit cost and greater health gains. Compared with giving no treatment, Foscan-PDT was a cost-effective treatment option at pound 14206/LYS. Sensitivity analysis showed that Foscan-PDT remained cost-effective when the costs used for the comparators were decreased and/or the costs used for Foscan-PDT were increased. Foscan-PDT is a clinically and cost-effective treatment option for patients with advanced head and neck cancer compared to palliative chemotherapy, extensive palliative surgery or 'no treatment'. Furthermore, Foscan-PDT offers patients, with traditionally very limited treatment options, a unique chance of tumour response, remission and increased life expectancy.
Computer Simulation↗
Estimating the value of novel interventions for Parkinson's disease: an early decision-making model with application to dopamine cell replacement.
A long-term cost-effectiveness model for early decision-making and estimation of outcomes of novel therapeutic procedures for Parkinson's disease (PD) was developed based on the Hoehn and Yahr (HY) stages of PD. Results provided support for model validity. Model application to a future dopamine cell replacement therapy indicated long-term cost offsets and gains in quality-adjusted life years (QALYs) in early onset PD (HY III-IV), as compared to standard drug therapy. The maximum price premium (i.e., profit or compensation for developmental costs) for the intervention to remain cost-effective was estimated to euro12000-64000 according to cost-per-QALY thresholds of euro38000-70000 and depending on whether all or only medical direct costs are considered. The study illustrates the value of early health economic modeling and the described model shows promise as a means to estimate outcomes and aid decision-making regarding novel interventions for PD.
Adult↗
Economic consequences of the adverse reactions related with antipsychotics: an economic model comparing tolerability of ziprasidone, olanzapine, risperidone, and haloperidol in Spain.
Frequency of adverse reactions (ARs) related with antipsychotics usage is high. Along with clinical implications, economic impact might be important. The purpose of this study was to model the economic consequences of ARs related with ziprasidone, olanzapine, risperidone, and haloperidol in Spain, by means of a cost-effectiveness model developed using a Markov modeling approach. The model simulated treatment of a cohort of 1000 schizophrenics for 12 months, initiating treatment with one of four antipsychotic drugs; haloperidol, risperidone, olanzapine and ziprasidone. Conditional probabilities of developing any of four adverse events were calculated. Treatment was modified (decrease dose, switch medication) according to incidence of ARs and physician judgments, obtained from a local cross-sectional study and clinical trials previously published. The analysis was conducted in year 2002 from a third party payer perspective. Results are shown as annual cost per month with psychotic symptoms controlled and included univariate sensitivity analysis. The therapeutic strategy starting with ziprasidone showed the lower costs and the greater number of months with symptoms controlled in most scenarios evaluated versus the other options considered, although the differences were weak: 9.6, 9.3, 9.5 and 9.5 controlled months per patient in base scenario, with annual cost per patient per month with symptoms controlled of 1035 Euros, 1084 Euros, 1087 Euros and 1090 Euros for ziprasidone, haloperidol, risperidone and olanzapine, respectively. Results were robust to one-way sensitivity analysis. Despite the unlike drug prices of antipsychotics, a considerable economic impact due to adverse reactions was seen in our setting. These results should be taken into account by health decision makers and clinicians in the management of patients with schizophrenia.
Antipsychotic Agents↗
Estimating cost-effectiveness of mass cardiopulmonary resuscitation training strategies to improve survival from cardiac arrest in private locations.
INTRODUCTION: Most cardiopulmonary resuscitation (CPR) trainees are young, and most cardiac arrests occur in private residences witnessed by older individuals. OBJECTIVE: To estimate the cost-effectiveness of a CPR training program targeted at citizens over the age of 50 years compared with that of current nontargeted public CPR training. METHODS: A model was developed using cardiac arrest and known demographic data from a single suburban zip code (population 36,325) including: local data (1997-1999) regarding cardiac arrest locations (public vs. private); incremental survival with CPR (historical survival rate 7.8%, adjusted odds ratio for CPR 2.0); arrest bystander demographics obtained from bystander telephone interviews; zip code demographics regarding population age and distribution; and 12.50 dollars per student for the cost of CPR training. Published rates of CPR training programs by age were used to estimate the numbers typically trained. Several assumptions were made: 1) there would be one bystander per. arrest; 2) the bystander would always perform CPR if trained; 3) cardiac arrest would be evenly distributed in the population; and 4) CPR training for a proportion of the population would proportionally increase CPR provision. Rates of arrest, bystanders by age, number of CPR trainees needed to result in increased arrest survival, and training cost per life saved for a one-year study period were calculated. RESULTS: There were 24.3 cardiac arrests per year, with 21.9 (90%) occurring in homes. In 66.5% of the home arrests, the bystander was more than 50 years old. To yield one additional survivor using the current CPR training strategy, 12,306 people needed to be trained (3,510 bystanders aged < or = 50 years and 8,796 bystanders aged > 50 years), which resulted in CPR provision to 7.14 additional patients. The training cost per life saved for a bystander aged < or = 50 years was 313,214 dollars, and that for a bystander aged > 50 years was 785,040 dollars. Using a strategy of training only those < or = 50 years, 583 elders per cardiac arrest would need to be trained, with a cost of 53,383 dollars per life saved. CONCLUSION: Using these assumptions, current CPR training strategy is not a cost-effective intervention for home cardiac arrests. The high rate of elders witnessing CPR mandates focused CPR interventions for this population.
Aged↗
Modelling the impact of opportunistic screening on the sequelae and public healthcare costs of infection with Chlamydia trachomatis in Australian women.
OBJECTIVES: To describe the health outcomes and public healthcare costs of a single screening for Chlamydia trachomatis in Australian women aged 15-34 years. METHODS: A decision analytic model was used to determine the epidemiological estimates of prevalence and costs of C. trachomatis infection and its diagnosis, treatment and sequelae. RESULTS: We estimate that in any female population in Australia, with a Chlamydia prevalence rate of 5.7% or higher, a single screening examination for Chlamydia is cost saving for the public healthcare system. CONCLUSIONS: We found that opportunistic screening of high-risk populations is likely to be cost saving to the public healthcare system, although there is not sufficient evidence to support periodic population screening. As our model uses conservative epidemiological and public healthcare cost estimates, the health and financial impacts of C. trachomatis used in the model may be an underestimate of the true costs of infection.
Adolescent↗
Cost and value: everything or nothing?
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Decision Making↗
Predicting the impact of population level risk reduction in cardio-vascular disease and stroke on acute hospital admission rates over a 5 year period--a pilot study.
UNLABELLED: The brief for this study was to produce a practical, evidence based, financial planning tool, which could be used to present an economic argument for funding a public health-based prevention programme in coronary heart disease (CHD) related illness on the same basis as treatment interventions. OBJECTIVES: To explore the possibility of using multivariate risk prediction equations, derived from the Framingham and other studies, to estimate how many people in a population are likely to be admitted to hospital in the next 5-10 years with cardio vascular disease (CVD) related events such as heart attacks, strokes, heart failure and kidney disease. To estimate the potential financial impact of reductions in hospital admissions, on an 'invest to save' basis, if primary care trusts (PCTs) were to invest in public health based interventions to reduce cardiovascular risk at a population level. STUDY DESIGN: The populations of five UK PCTs were entered into a spreadsheet based decision tree model, in terms of age and sex (this equated to around 620,000 adults). An estimation was made to determine how many people, in each age group, were likely to be diabetic. Population risk factors such as smoking rates, mean body mass index (BMI), mean total cholesterol and mean systolic blood pressure were entered by age group. The spreadsheet then used a variant of the Framingham equation to calculate how many non-diabetic people in each age group were likely to have a heart attack or stroke in the next 5 years. In addition heart failure and dialysis admission rates were estimated based upon risk factors for incidence. The United Kingdom Prospective Diabetes Study (UKPDS) risk engines 56 and 60 were used to calculate the risk of CHD and stroke, respectively, in people with type 2 diabetes. The spreadsheet deducted the number of people likely to die before reaching hospital and produced a predicted number of hospital admissions for each category over a 5-year period. The final part of the calculation attached a cost to the hospital activity using the UK Health Resource Grouping (HRG) tariffs. The predicted number of events in each of the primary care trusts was then compared with the actual number of events the previous year (2004/2005). METHODOLOGY: The study used a decision tree type model, which was populated with data from the research literature. The model applied the risk equations to population data from five primary care trusts to estimate how many people would suffer from an acute CVD related event over the next 5 years. The predicted number of events was then compared with the actual number of acute admissions for heart attacks, strokes, heart failure, acute hypoglycaemic attacks, renal failure and coronary bypass surgery the previous year. RESULTS: The first outcome of the model was to compare the estimated number of people in each PCT likely to suffer from a heart attack, a stroke, heart failure or chronic kidney failure with the actual number the previous year 2004/2005. The predicted number was remarkably accurate in the case of heart attack and stroke. There was some over-prediction of chronic kidney disease (CKD) which could be accounted for by known under-diagnosis in this illness group and the inability of the model to pick up, at this stage, the fact that many CKD patients die of a CHD related event before they reach the stage of requiring renal replacement. The second outcome of the model was to estimate the financial consequence of risk reduction. Moderate reductions in risk in the order of around 2-4% were estimated to lead to saving in acute admission costs or around pounds sterling 5.4 million over 5 years. More ambitious targets of risk reduction in the order of 5-6% led to estimated savings of around pounds sterling 8.7 million. CONCLUSIONS: This study is not presented as the definitive approach to predicting the economic consequences of investment in public health on the cost of secondary care. It is simply a logical, systematic approach to quantifying these issues in order to present a business case for such investment. The research team do not know if the predicted savings would accrue from such investments; it is theoretical at this stage. The point is, however, that if the predictions are correct then the savings will accrue from over 4000 people, from an adult population of around 185,000 not having a heart attack or a stroke or an acute exacerbation of heart failure.
Adolescent↗
Multinational assessment of some operational costs of teletherapy.
BACKGROUND AND PURPOSE: Decisions in planning radiotherapy facilities in countries with limited financial resources require information on economic factors to make provision for sustainability. This study aims at acquiring data on some of these factors involved in delivery of teletherapy in 11 countries of different economic status. PATIENTS AND METHODS: Representatives of three European, one African, three Latin American and four Asian countries, were identified from radiation oncology institutions that operated both cobalt and linac teletherapy machines. Productivity data were prospectively collected for the year 2002. A detailed log was recorded for each machine over an arbitrary two-week period. Data on quality assurance (QA), maintenance, the capital costs of each machine, and the source replacement costs for the cobalt units were also recorded. RESULTS: Both linear accelerators and cobalt machines treat more than 10,000 fractions per year per machine with 2.5 and 2.3 fields per fraction, respectively. The capital costs of the machines vary considerably, with a factor of more than 10 for linear accelerators. Cobalt sources show a huge variation in price. The median costs of QA and maintenance of a linac was US$ 41,000 compared to US$ 6000 for cobalt machines. This results for the economic factors considered in median costs per fraction of US$ 11.02 for linear accelerators and US$ 4.87 for cobalt machines. These figures do not include the costs for physicians. CONCLUSIONS: The variation of the costs per fraction is more due to the result of differences in machine usage and costs of equipment than of national economic status. A treatment fraction on a linac with functionality comparable to cobalt, costs 50% more than cobalt therapy. This project shows that it is possible to collect data on economic factors prospectively as well as retrospectively.
Capital Expenditures↗
Cost-effectiveness of malaria control interventions when malaria mortality is low: insecticide-treated nets versus in-house residual spraying in India.
Malaria is one of the leading causes of morbidity and mortality in the developing world and a major public health problem in India. Disillusioned by in-house residual spraying (IRS), and increasingly aware that insecticide-treated nets (ITNs) have proved to be effective in reducing malaria mortality and morbidity in various epidemiological settings, policy-makers in India are keen to identify which is the more cost-effective malaria control intervention. A community randomised controlled trial was set up in Surat to compare the effectiveness and efficiency of IRS and ITNs. Both control strategies were shown to be effective in preventing malaria over the base-case scenario of early diagnosis and prompt treatment. The mean costs per case averted for ITNs was statistically significantly lower (Rs. 1848, 1567-2209; US$ 52) than IRS (Rs. 3121, 2386-4177, US$ 87). The incremental cost-effectiveness ratio for ITNs over IRS was Rs. 799 (US$ 22). The conclusions were robust to changes in assumptions. This study expands the scope of recent comparative economic evaluations of ITNs and IRS, since it was carried out in a low mortality malaria endemic area.
Analysis of Variance↗
Portfolio theory and the alternative decision rule of cost-effectiveness analysis: theoretical and practical considerations.
Bridges and Terris (Soc. Sci. Med. (2004)) critique our paper on the alternative decision rule of economic evaluation in the presence of uncertainty and constrained resources within the context of a portfolio of health care programs (Sendi et al. Soc. Sci. Med. 57 (2003) 2207). They argue that by not adopting a formal portfolio theory approach we overlook the optimal solution. We show that these arguments stem from a fundamental misunderstanding of the alternative decision rule of economic evaluation. In particular, the portfolio theory approach advocated by Bridges and Terris is based on the same theoretical assumptions that the alternative decision rule set out to relax. Moreover, Bridges and Terris acknowledge that the proposed portfolio theory approach may not identify the optimal solution to resource allocation problems. Hence, it provides neither theoretical nor practical improvements to the proposed alternative decision rule.
Cost-Benefit Analysis↗
Portfolio evaluation of health programs: a reply to Sendi et al.
Sendi et al. (Soc. Sci. Med. 57 (2003) 2207) extend previous research on cost-effectiveness analysis to the evaluation of a portfolio of interventions with risky outcomes using a "second best" approach that can identify improvements in efficiency in the allocation of resources. This method, however, cannot be used to directly identify the optimal solution to the resource allocation problem. Theoretically, a stricter adherence to the foundations of portfolio theory would permit direct optimization in portfolio selection, however, when we include uncertainty in our analysis in addition to the traditional concept of risk (which is often mislabelled uncertainty) complexities are introduced that create significant hurdles in the development of practical applications of portfolio theory for health care policy decision making.
Cost-Benefit Analysis↗
The economics of social marketing: the case of mosquito nets in Tanzania.
There is a growing appreciation of the role of the private sector in expanding the use of key health interventions. At the policy level, this has raised questions about how public sector resources can best be used to encourage the private sector in order to achieve public health impact. Social marketing has increasingly been used to distribute public health products in developing countries. The Kilombero and Ulanga Insecticide-Treated Net Project (KINET) project used a social marketing approach in two districts of Tanzania to stimulate the development of the market for insecticide-treated mosquito nets (ITNs) for malaria control. Using evidence from household surveys, focus group discussions and a costing study in the intervention area and a control area, this paper examines two issues: (1) How does social marketing affect the market for ITNs, where this is described in terms of price and coverage levels; and (2) What does the added cost of social marketing "buy" in terms of coverage and equity, compared with an unassisted commercial sector model? It appears that supply improved in both areas, although there was a greater increase in supply in the intervention area. However, the main impact of social marketing on the market for nets was to shift demand in the intervention district, leading to a higher coverage market outcome. While social marketing was more costly per net distributed than the unassisted commercial sector, higher overall levels of coverage were achieved in the social marketing area together with higher coverage of the lowest socioeconomic group, of pregnant women and children under 5 years, and of those living on the periphery of their villages. These findings are interpreted in the context of Tanzania's national plan for scaling up ITNs.
Animals↗
Developing a scale for measuring professional equity among Canadian physicians.
This paper reports on progress made in defining and measuring the concept of professional equity through the development of a summative measure of professional equity and three of its components: financial, intrinsic and recognition equity. The study sample consisted of a stratified sample of 8375 Canadian physicians with usable responses from 2749 (32.8%). Following preliminary components analysis, items were grouped into constructs. Reliability of the constructs was then determined using Cronbach's alpha and total inter-item correlations followed by confirmatory factor analysis. A summary scale using all 15 equity items yielded a reliability: Cronbach's alpha=0.86. The sub-scales reliabilities were: financial equity (Cronbach's alpha=0.91); intrinsic equity (Cronbach's alpha=0.86); and recognition equity (Cronbach's alpha=0.70). The professional equity measures reported are therefore capable of assessing different aspects of equity and represent an advance over more general effort-reward scales or those that only measure the range of rewards.
Canada↗
Comparison or consumption? Distinguishing between different effects of income on health in Nordic welfare states.
In the relation between income and health it has been suggested that individual level mechanisms are related either to absolute or to relative income. Both absolute income level and the individual's own income in relation to that of others are likely to affect health, but to distinguish between these effects in analyses has been difficult. The aim of this study is to distinguish between the effect on health of one's own position in the income distribution and the effect on health of the individual's ability to consume. Combining data from Sweden, Finland and Norway provides a setting where individuals with the same absolute income level may occupy different positions within their national income distribution. The data come from Swedish, Finnish and Norwegian surveys of living conditions from the mid 1990s. Both the position in the income distribution and the ability to consume is measured by household disposable equivalent income. In order to eliminate differences in price levels, household income is adjusted for purchasing power parities. The outcome measure used is limiting long-standing illness. There was a clear income gradient in health over the individual's relative position in their national income distribution. Stratifying for groups of household income adjusted for purchasing power parities, we still find a significant effect of the individual's relative position. In Nordic welfare states the relative position in the income distribution is related to limiting long-standing illness independently of the ability to consume among individuals with high ability to consume.
Female↗
Economic valuation of informal care: lessons from the application of the opportunity costs and proxy good methods.
This paper reports the results of the application of the opportunity costs and proxy good methods to determine a monetary value of informal care. We developed a survey in which we asked informal caregivers in The Netherlands to indicate the different types of time forgone (paid work, unpaid work and leisure) in order to be able to provide care. Moreover, we asked informal caregivers how much time they spent on a list of 16 informal care tasks during the week before the interview. Data were obtained from surveys in two different populations: informal caregivers and their care recipients with stroke and with rheumatoid arthritis (RA). A total of 218 care recipients with stroke and their primary informal caregivers completed a survey as well as 147 caregivers and their care recipients with RA. The measurement of care according to both methods is more problematic compared to the valuation. This is especially the case for the opportunity costs method and for the housework part in the proxy good method. More precise guidelines are necessary for the consistent application of both methods in order to ensure comparability of results and of economic evaluations of health care.
Adult↗
Life-course influences on mortality at older ages: evidence from the Oslo Mortality Study.
Several studies have investigated the cumulative influence of disadvantage acting from early to adult life. And they suggest that risk of death increases in a cumulative fashion. Few studies have investigated the life-course influences on social inequality in mortality in early old age. In this study we wanted to follow a cohort through their adult working age into retirement and investigate pathways that may give increased risk of mortality. A cohort of all inhabitants in the age range 68-72 who lived in the municipality of Oslo on 1st January 1990 was selected. Data were obtained by linking censuses from 1960, 1970 and 1980 with tax registry in 1990 and death registry 1990-1998. Independent variables were occupational class in 1960, 1970 and 1980 and household income in 1990. Occupational class was coded as manual and non-manual and household income as above or below median household income. A cumulative model was developed by adding times of disadvantage. Then a pathway model was developed which investigated the specific trajectories individuals followed. Most of the increased risk of death was explained by individuals' social conditions in 1990. In the cumulative model, there was no clear gradient in the groups between the bottom and top categories. This suggests that the cumulative model is not important in the high mortality age and that the relative importance of a cumulative effect varies by stages of the life course.
Aged↗