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PubMed1998

Disease-staging for modelling current and future health-care impact of disease: illustrations for diabetes mellitus and AIDS.

This paper addresses the economic relevance of appropriately staging progression of disease for cost assessment and projection. Illustrations are drawn from two Dutch cost-of-illness studies for Diabetes Mellitus (DM) and AIDS. Our disease-staging specifies a separate late stage to capture terminal high-intensity care for end-stage complications. Data are used from a registration of national hospital resource utilization for DM and from a detailed database on AIDS hospital care and costs. In particular, differences in average length of hospital stay for several potential DM end-stage complications are compared with non-DM patients. Neglecting the separation of a specific late stage is estimated to possibly miscalculate 15-20% of the hospital bed needs for DM and AIDS in the Netherlands. In particular, confidence intervals of future projections for AIDS hospital beds--using respectively staged and non-staged models--do not overlap. AIDS hospital costs are overprojected by almost 11% in the non-staged model. Our estimation of DM hospital bed needs raises the percentage in total Dutch hospital beds from 1.7% (neglecting a specific late stage) to 2.0%. For DM and AIDS an appropriate disease-staging averts structural biases in estimations of bed needs and costs, and therefore benefits the planning of hospital care facilities. Obviously, gathering comparable information and developing similar methodology on other diseases, such as respiratory disease, cardiovascular disease and cancer, is needed and could benefit planning in these fields.

Acquired Immunodeficiency Syndrome↗
PubMed1998

Income-based incentives in UK general practice.

Since 1990, income-based economic incentives have ostensibly become more important in the remuneration structure of UK general practitioners. For incentives to fulfil their role, however, GPs must possess discretion over income-generating activity and be assumed to be income maximisers. Evidence from one English health authority suggests that a very high proportion of GP income continues to be determined by patient characteristics and the scope for a discretionary response to income incentives is correspondingly small. Where discretion does exist, higher levels of GP incomes do not appear to militate against further discretionary income raising, except in the case where this income and budgetary discipline are in conflict.

Analysis of Variance↗
PubMed1999

Analysis of the eligibility of published economic evaluations for transfer to a given health care system. Methodological approach and application to the French health care system.

CONTEXT: Economic evaluations are costly and cannot always be carried out locally. Therefore, decision-makers may wish to use studies already performed in other settings. OBJECTIVE: To define a method for assessing the eligibility of published economic evaluations for transfer to a given health care system and apply it to the french health care system in the clinical situation of adjuvant therapy for women with breast cancer. METHODS: (1) Literature search in six databases from 1982 to 1996; (2) critical appraisal of articles based on four inclusion criteria; and (3) assessment of the eligibility of the studies for transfer based on five indicators. RESULTS: We identified 26 published economic evaluations concerning adjuvant therapy in women with breast cancer. Six (23%) met all four criteria used to select studies, but none of these studies were eligible for transfer to the french health care system. The main reason was that cost data was not reported in a transparent way. CONCLUSIONS: To improve the transferability of economic evaluations, we recommend that requirements for data provision in publications be standardized and international collaboration strengthened.

Bibliometrics↗
PubMed2001

Potential cost-effectiveness of one-time screening for lung cancer (LC) in a high risk cohort.

The development of low-dose helical computed-tomography (CT) scanning to detect nodules as small as a few mm has sparked renewed interest in lung cancer (LC) screening. The objective of this study was to assess the potential health effects and cost-effectiveness of a one-time low-dose helical CT scan to screen for LC. We created a decision analysis model using baseline results from the Early Lung Cancer Action Project (ELCAP); Surveillance, Epidemiology and End Results (SEER) registry public-use database; screening program costs estimated from 1999 Medicare reimbursement rates; and annual costs of managing cancer and non-cancer patients from Riley et al. (1995) [Med Care 1995;33(8):828-841] and Taplin et al. (1995) [J Natl Cancer Inst 1995;87(6):417-26]. The main outcome measures included years of life, cost estimates of baseline diagnostic screening and follow up, and cost-effectiveness of screening. We found that in a very high-risk cohort (LC prevalence of 2.7%) of patients between 60 and 74 years of age, a one-time screen appears to be cost-effective at $5940 per life year saved. In a lower risk general population of smokers (LC prevalence of 0.7%), a one-time screen appears to be cost-effective at $23100 per life year. Even when a lead-time bias of 1 year is incorporated into the model for a low risk population, the cost-effectiveness is estimated at $58183 per life year. Based on the assumptions embedded in this model, one-time screening of elderly high-risk patients for LC appears to be cost-effective.

Aged↗
PubMed1996

Fluconazole versus oral polyenes in the prophylaxis of immunocompromised patients: a cost-minimization analysis.

This study compares 100 mg daily fluconazole with oral polyenes four times daily in the prophylaxis of fungal infections in immunocompromised patients, to determine a cost-minimization strategy. Data was gathered through a literature survey and clinical interviews conducted in nine different UK hospitals. This was used to construct a decision tree, modelling the drug choices available to a clinician at various stages of a patient's treatment, and assigning probabilities to the different corresponding outcomes. UK cost data were fed into this model to determine the expected cost per patient of the different prophylaxis strategies. Two different patient groups were considered: chemotherapy-only patients, and bone-marrow-transplant (BMT) patients who have higher risks of fungal infection. Probabilities derived from the literature suggest that a cost-minimization strategy to manage both chemotherapy patients and BMT patients is to administer oral fluconazole, both as prophylaxis and as first line treatment, against superficial fungal infection. Probabilities gathered from clinical interviews yield similar results, suggesting that the cost-minimization strategy with chemotherapy-only patients is to administer oral polyenes as prophylaxis, and oral fluconazole in case of superficial fungal infection, while for BMT patients it is a combination of fluconazole and oral polyenes as prophylaxis, with oral fluconazole for the treatment of superficial fungal infections. Using the probabilities from the literature, the lowest cost strategies produce an expected cost of pounds 567.20 for chemotherapy-only patients, and an expected cost of pounds 804.87 for BMT patients for a course of treatment lasting from seven to 28 days. The clinical interview probabilities produce expected costs of pounds 826.48 and pounds 1529.43, respectively. Sensitivity analysis was then conducted, and it was found that in the majority of cases, using the literature probabilities, the cost-minimizing strategy remained prophylaxis with oral fluconazole. The sensitivity analysis for chemotherapy-only patients using the interview probabilities tended to favour oral polyenes as the cost-minimization strategy, whereas for BMT patients the sensitivity analysis favoured a combination of fluconazole and oral polyenes in the majority of cases. The key economic advantage of prophylaxis with fluconazole or a combination of fluconazole with oral polyenes in the prophylaxis of fungal infection in immunocompromised patients, results from the reduction of the expected cost of subsequent fungal infection among those who are most at risk.

Antifungal Agents↗
PubMed2000

Watching the bottom line: enhancing the role and impact of infection control in a managed care environment.

Health care expenditures exceeded $1 trillion in 1997, with projections for $2.2 trillion in expenditures by 2008. Decreasing organizational revenues and efforts to reduce operating costs have had a direct impact on infection control programs. Senior managers in hospitals and other provider organizations are focusing on achieving and maintaining revenues while controlling costs. Infection control professionals must align themselves and their programs with these organizational goals by (1) identifying areas in which the infection control program can support and enhances revenues, (2) facilitating the avoidance of excess costs for care, especially those related to nosocomial infection, (3) identifying opportunities for cost reduction through value analysis, and (4) participating in efforts to measure and prevent other adverse outcomes of care.

Cost Control↗
PubMed1997

The difference in mean costs as a pharmacoeconomic outcome variable: power considerations.

The difference in mean costs between a placebo and a drug treated group is used for the pharmacoeconomic evaluation of a new drug. The distribution of costs without treatment (null hypothesis) is determined through hospital records. The sampling properties are established by simulation. The results of the simulation allow determination of a break point of differences corresponding to a given level of significance. For power determination, using this break point, clinical hypotheses are used to generate the distribution of costs under treatment (alternative hypothesis).

Cardiovascular Diseases↗
PubMed2004

[Do we spend too much on medications? Pharmaceutical expenditures, an absolutely essential item in European countries].

OBJECTIVE: To find out if the performance of the pharmaceutical expenditure between the most developed European countries come close more to a luxury good or a necessary good. To compare the pharmaceutical Spanish expenditure with the one of those countries. DESIGN: Cross-sectional study. SETTING: International. Europe. PARTICIPANTS: European countries members of the Organisation for Economic Co-operation and Development (OECD) and the European Union. METHODS: The data come from the OECD reports and other papers with the same source of information. The majority of the data refer to year 2000. The relationship between pharmaceutical expenditure and other variables as expenditure on health, on research and development (R&D), and socio-demographic variables are analysed with correlation and multiple linear regression. RESULTS: In both groups of countries, the Gross Domestic Product per capita (GDPPC) is positively and significantly correlated with the expenditure per capita on health (public and total) and on R&D, but not with pharmaceutical expenditure per capita (PhEPC). The pharmaceutical expenditure as part of total expenditure on health (PhE/TE) or as percentage of GDP (PhE/GDP), is negatively and significantly correlated with income (GDPPC). The regression model accepts as explicative variables of PhE/GDP: the income (negatively), the employment in health (negatively) and the PhEPC (positively). The PhEPC in Spain is situated in the average of the most developed European countries, and expressed as PhE/TE or as PhE/GDP is situated in the group of the countries with greater pharmaceutical expenditure, the majority of them with a lower GDPPC to the Spanish one. CONCLUSIONS: The performance of the pharmaceutical expenditure between the countries studied come close to a necessary good than to a luxury good. The PhEPC in Spain is situated in the average of these countries and, expressed as PhE/GDP or as PhE/TE, would be according to the Spanish income.

Drug Costs↗
PubMedDate not supplied

[Evaluating health interventions without experiments].

This paper summarizes recent literature on quantitative techniques for the evaluation of non experimental reforms. We closely look at the application of the methods to health economics and health management. The methods of matching and difference in differences combined with matching have been analysed in greatest detail. We have focused our attention on the estimation of the average treatment for the treated as the relevant parameter to be estimated. Along the paper, we have assumed that gains from the reform are heterogeneous in non observable variables across eligible individuals. The methods are described in a non technical manner to motivate further reading.

Health Services Research↗
PubMed2001

China's one-child policy: the economic choices and consequences faced by pregnant women.

This paper addresses the important issue of the effect of China's one-child policy on prenatal and obstetric care utilization. The paper provides the first detailed empirical approach to this question, exploiting a unique high quality household survey. China officially codified a set of rules and regulations in 1979 governing the approved size of Chinese families, commonly known as the one-child policy. The policy imposed economic and social costs on families failing to adhere to the family size limits. In particular, the policy raised the price of obstetric medical services for unapproved pregnancies in comparison to approved pregnancies and imposed fines on families with unapproved births. Using data from an eight-province longitudinal household survey (The China Health and Nutrition Survey), we investigate whether or not the one-child policy's financial penalties were associated with the avoidance of obstetric care by pregnant Chinese women with unapproved pregnancies. The one-child policy variables of particular interest were a dichotomous measure of the approval status of the pregnancy, a continuous measure of the fine imposed upon families with unapproved births, and a continuous measure of the prices of prenatal care and delivery services net of any subsidy available for approved births. The results partially confirm the hypotheses that the one-child policy's economic and social costs caused women to forego seeking modern obstetric care services. The fine was found to be a significant deterrent to the utilization of prenatal care. Additionally, the unapproved-status of a pregnancy was strongly negatively associated with "the use of obstetric care. However, higher prices were not consistently found to be a significant deterrent to the use of obstetric care.

Adolescent↗
PubMed2001

Do high levels of unemployment influence the health of those who are not unemployed? A gendered comparison of young men and women during boom and recession.

Research has shown that health among young people, particularly women, deteriorates during a recession compared to a boom. It seems that the trade cycle mainly affects the health of those who are not long-term unemployed. The aim of this study was to analyse the relation between the health of non-unemployed people and the levels of unemployment in society. Two groups of young people aged 21 were surveyed, one in 1986 (the boom group, n = 1083) and one in 1994 (the recession group, n = 898). The non-response rate was 2% in the first and 10% in the second group. Both groups were investigated with a self-administered questionnaire, which included questions about somatic and psychological health, as well as experiences of employment, unemployment, education and labour market programmes. Young men and women generally reported more somatic and psychological symptoms during recession than boom. The only exception was psychological symptoms among men, which was of the same magnitude during both periods. Poorer health during recession was found among women in work and in labour market programmes, as well as among both male and female students. Multiple regression analysis was performed in order to analyse if the occupational-related health effects of the trade cycle remained after controlling for possible moderating factors. The effects of unemployment in society on young people's health may be mediated through pessimism about the future, high demands and financial problems. Lack of control over the work situation may also be an important contributing factor to ill health among women during recession. The trade cycle was correlated with ill health among women only. Possible explanations for poorer health among women during a recession were discussed.

Adult↗
PubMed2002

Letting the Gini out of the bottle? Challenges facing the relative income hypothesis.

The relative income hypothesis interprets statistical associations between income inequality and average health status at the population level, as evidence that income inequality has a deleterious psychosocial effect on individual health. An alternative explanation is that these, population-level associations, are statistical artefacts of curvilinear, individual-level relationships between income and health. Indeed, provided the cost-benefit ratio of health-enhancing goods and services vary, the law of diminishing returns should produce curvilinear, asymptotic relationships between income and health at the individual level, which create ('artefactual') associations between income inequality and health at the population level. However, proponents of the relative income hypothesis have argued that these relationships are unlikely to be responsible for the associations observed between income inequality and average health status amongst high-income populations. In these populations, the individual-level relationships between income and health would be nearer their asymptotes, where a shallower slope should ensure that income inequality has little (if any) 'artefactual' effect on average health status. Yet this argument was based on analyses of population-level data which underestimated the slope and curvilinearity of underlying, individual-level relationships between income and health. It is therefore likely that (at least some part of) the population-level associations between income inequality and average health status (amongst low-, middle- and high-income populations) are 'artefacts' of curvilinear, individual-level relationships between income and health. Nevertheless, it is also possible that income inequality is somehow (partly or wholly) responsible for the curvilinear nature of individual-level relationships between income and health. Likewise, it is possible that income inequality alters the height, slope and/or curvilinearity of these relationships in such a way that income inequality has an independent effect on individual health. In either instance, the 'artefactual' effect of curvilinear relationships between income and health at the individual level would simply reflect the mechanism underlying the relative income hypothesis.

Female↗
PubMed2002

Income, income inequality and health: what can we learn from aggregate data?

It has been suggested that, especially in countries with high per capita income, there is an independent effect of income distribution on the health of individuals. One source of evidence in support of this relative income hypothesis is the analysis of aggregate cross-section data on population health, per capita income and income inequality. We examine the empirical robustness of cross-section analyses by using a new data set to replicate and extend the methodology in a frequently cited paper. The estimated relationship between income inequality and population health is not significant in any of our estimated models. We also argue there are serious conceptual difficulties in using aggregate cross-sections as a means of testing hypotheses about the effect of income, and its distribution, on the health of individuals.

Cross-Sectional Studies↗
PubMed2002

The impact of hospices on health care expenditures--the case of Taiwan.

Cancer has been the leading cause of death in Taiwan since 1982, with nearly one out of four deaths caused by malignant neoplasm. The huge amount of money being spent in the acute care setting for terminally ill cancer patients does not increase their wellbeing. In this study, we employ an Instrumental Variable (IV) model to correct for the self-selection problem and use population-based insurance claim data to test two null hypotheses: there is no difference in total expenditures between hospice care and conventional care, and that there is no difference in total expenditures between hospital-based hospice care and home hospice care. Both null hypotheses are rejected.

Adolescent↗
PubMed2002

The contingent ranking method--a feasible and valid method when eliciting preferences for health care?

The Contingent Ranking Method--a feasible and valid method when eliciting preferences for health care? The objective of the study was to determine the feasibility and validity of the contingent ranking method, when eliciting preferences and measuring willingness to pay for health care. A measurement experiment based on ranking data is reported. Marginal willingness to pay for alleviation of rheumatoid arthritis symptoms that may be the outcome of a treatment with a novel anti-rheumatic agent, cA2 (now called TNF-alpha blockade) was calculated. The estimated marginal willingness to pay value was 650 DKK ($93). With regard to the health status variables and income variable the signs of the coefficients were, as expected, positive. The contingent ranking method is a feasible and valid method for eliciting preferences and determining willingness to pay estimates.

Aged↗
PubMed2002

Understanding household demand for indoor air pollution control in developing countries.

More than 2 billion people rely on solid fuels and traditional stoves or open fires for cooking, lighting, and/or heating. Exposure to emissions caused by burning these fuels is believed to be responsible for a significant share of the global burden of disease. To achieve widespread health improvements, interventions that reduce exposures to indoor air pollution will need to be adopted and consistently used by large numbers of households in the developing world. Given that such interventions remain to be adopted by large numbers of these households, much remains to be learned about household demand for interventions designed (in part at least) to reduce indoor air pollution. A general household framework is developed that identifies in detail the determinants of household demand for indoor air pollution interventions, where demand for an intervention is expressed in terms of willingness to pay. Household demand is shown to be a combination of three terms: (1) the direct consumption effect; (2) the child health effect; and (3) the adult health effect. While micro-level data are not available to estimate directly this model, existing data and information are used to estimate just the health effects component of household demand. Based on such existing information, it might be concluded that household demand should seemingly be strong given that willingness to pay, based on existing information, is seemingly large compared to costs for common interventions like improved stoves. Given that household demand is not strong for existing interventions, this analysis shows that more clearly focused research on household demand for interventions is needed if such interventions are going to be demanded (i.e. adopted and used) by large numbers of households throughout the developing world. Four priority areas for future research are: (1) improving information on dose-response relationships between indoor air pollution and various health effects (e.g. increased mortality and morbidity risks); (2) improving information on impacts from interventions in terms of air pollution reductions and also cooking times, fuel use, and heat intensities; (3) improving information on household shadow values for improved health, with separate information for adult and child health; and (4) considering more directly household information, and its adequacy, for their ability to evaluate the relationships between fuel use and health.

Adult↗
PubMed2002

An analysis of private health insurance purchasing decisions with national health insurance in Taiwan.

The Taiwanese health insurance industry is just over 30 years old. Originally private and domestic, the industry underwent substantial institutional changes when it opened to foreign competition between 1987 and 1994 and when the Taiwanese government established national health insurance (NHI) coverage in 1995. Congruent with these changes, rapid growth occurred in the Taiwanese demand for private health insurance. In order to better understand the recent performance of the Taiwanese health insurance industry, the structure of the NHI system is described and then household decisions to purchase private health insurance are analyzed using a two-part (hurdle) model on 1998 Survey of Family Income and Expenditure data. Logistic and OLS regressions are used to examine the factors influencing the probability and amount of private health insurance purchased. Generally, factors affecting the probability of having insurance also influence the amount of insurance coverage purchased. Higher income and education levels are associated with increased probabilities and larger quantities of private insurance purchases. Married females, the employed, and household heads working in state-run enterprises are more likely to purchase private insurance than their counterparts. The probability of private insurance purchases varies by region, with northern Taiwanese households having higher odds of owning private insurance than non-northern households. Compared to those in rural villages, households in cities and towns are more likely to have private insurance. The likelihood of private insurance purchase also tends to rise with advancing age and larger family sizes. In addition, one important implication in the private health insurance market is highlighted. There is no complementarity between the public and private systems.

Adult↗
PubMed2003

Technical and cost efficiency of oral health care provision in Finnish health centres.

In this study we measured the productive efficiency of public dental health provision across Finland. The analysis was based on data envelopment analysis (DEA) using linear programming. In addition, we investigated various factors explaining the technical and cost efficiency of public dental care using a parametric Tobit model. These analyses revealed substantial variation in productive efficiency between health centres in different municipalities. The level of cost inefficiency was generally between 20% and 30%. Good dental health of the population, high rates of unemployment and high per capita expenditure on primary care in the municipality were associated with technical and cost inefficiency. According to the results, cost efficiency would not be improved by shifting input allocation towards more auxiliary manpower in health centres. Individual efficiency scores were clearly sensitive to the choice of output specification. Changing the unit of output measurement from visit- to patient-based measures affected markedly the ranking of dental health centres. However, the set of exogenous correlates associated to inefficiency was strikingly similar for both types of output specification. More resources are needed if the coverage of public dental care is extended to all age groups. The health centre specific efficiency scores obtained in this study can be used locally to evaluate, design and implement structural changes in the production processes.

Adolescent↗