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Economic and social impact of epidemic and pandemic influenza.

Amidst the human suffering caused an influenza epidemic it is all too easy to overlook the disease's wider social and economic impact. Not only does influenza impose huge infrastructure demands on health care systems, but it exacts substantial economic costs in terms of sickness-related absenteeism, disrupted work schedules and lost productivity to society at large. Influenza accounts for around 10% of sickness-related absence from work in Europe where the likely cost of lost productivity in France and Germany, for example, ranges from 5.6 billion pounds to 8.5 billion pounds per year, according to ESWI estimates. But how to assess the full economic impact of influenza? The direct costs are easily enough identified, but what about the indirect costs? How should these be measured? How for example, does one assess the cost of lost opportunities, and what are the economic gains of vaccination regarding avoided costs? Finally, which target groups for vaccination would generate the greatest avoided costs? Leaving aside the moral implications of such a question, the fact remains that politicians and health policymakers need the cold hard figures to optimally allocate the costs of vaccination and preventative health campaigns. These issues and more were clearly delineated during this session, co-chaired by Drs. T. Szucs of the University of Zurich and K. Nichol of the University of Minnesota

Cost of Illness↗

Economical and ecological comparison of granular activated carbon (GAC) adsorber refill strategies.

Technical constraints can leave a considerable freedom in the design of a technology, production or service strategy. Choosing between economical or ecological decision criteria then characteristically leads to controversial solutions of ideal systems. For the adaptation of granular-activated carbon (GAC) fixed beds, various technical factors determine the adsorber volume required to achieve a desired service life. In considering carbon replacement and recycling, a variety of refill strategies are available that differ in terms of refill interval, respective adsorber volume, and time-dependent use of virgin, as well as recycled GAC. Focusing on the treatment of contaminant groundwater, we compare cost-optimal reactor configurations and refill strategies to the ecologically best alternatives. Costs and consumption of GAC are quantified within a technical-economical framework. The emissions from GAC production out of hard coal, transport and recycling are equally derived through a life cycle impact assessment. It is shown how high discount rates lead to a preference of small fixed-bed volumes, and accordingly, a high number of refills. For fixed discount rates, the investigation reveals that both the economical as well as ecological assessment of refill strategies are especially sensitive to the relative valuation of virgin and recycled GAC. Since recycling results in economic and ecological benefits, optimized systems thus may differ only slightly.

Adsorption↗

Leisure-time physical activity in university students from 23 countries: associations with health beliefs, risk awareness, and national economic development.

BACKGROUND: Physical inactivity has been linked with chronic disease and obesity in most western populations. However, prevalence of inactivity, health beliefs, and knowledge of the risks of inactivity have rarely been assessed across a wide range of developed and developing countries. METHODS: A cross-sectional survey was carried out with 19,298 university students from 23 countries varying in culture and level of economic development. Data concerning leisure-time physical activity, health beliefs, and health knowledge were collected. RESULTS: The prevalence of inactivity in leisure time varied with cultural and economic developmental factors, averaging 23% (North-Western Europe and the United States), 30% (Central and Eastern Europe), 39% (Mediterranean), 42% (Pacific Asian), and 44% (developing countries). The likelihood of leisure-time physical activity was positively associated with the strength of beliefs in the health benefits of activity and with national economic development (per capita gross domestic product). Knowledge about activity and health was disappointing, with only 40-60% being aware that physical activity was relevant to risk of heart disease. CONCLUSIONS: Leisure-time physical activity is below recommended levels in a substantial proportion of students, and is related to cultural factors and stage of national economic development. The relationship between health beliefs and behavior is robust across cultures, but health knowledge remains deficient.

Adult↗

Critical issues in the economic evaluation of interventions against communicable diseases.

Economic appraisal seeks to provide policy-makers with guidance about how scarce resources can be used to derive the greatest possible social benefit. Its use in the health sector has increased dramatically over the last decade although much of it has been focused on the problems of the more developed countries. The relatively sparse literature on communicable diseases has been dominated by interventions related to HIV/AIDS, hepatitis, malaria and tropical diseases. Reviews of this literature from the perspective of specific conditions such as Hepatitis B are already available, and recently the entire literature has been evaluated against the technical criteria for economic evaluations published in standard textbooks. Accordingly, this paper focuses on issues which would make economic appraisal more useful to policy-makers than it currently is. Given that few countries have the resources to undertake all the necessary analysis in their own settings, it is important that studies in one setting are undertaken in a way that allow generalisability to similar settings. Some of the most important challenges this poses for cost-effectiveness analysis (CEA) are identified. Firstly, incremental analysis is appropriate to local decision making when policy-makers are constrained to keep the current interventions and can consider only marginal improvements. However, it does not allow re-evaluation of existing interventions and is not transferable across settings. A version of Generalised CEA is proposed as an alternative. Secondly, data on costs and effectiveness are often not presented appropriately. The challenge for effectiveness is to adjust the evidence from efficacy studies to allow for different patient or population groups, and local variations in adherence, coverage, and infrastructure. For costs, it is important for studies to report the physical resources used in an intervention as well as unit prices. Thirdly, some long-term effects are still not well incorporated into CEA, especially those affecting child development and drug resistance. These questions are technically challenging and require more concerted efforts over the next few years. Finally, it is important for analysts to provide decision-makers with estimates of the resources that would be required to implement interventions claimed to be cost-effective. These improvements would better enable the evidence from economic analyses to enter the policy debate and be weighed against the other goals and objectives of the health system when allocating scarce resources.

Communicable Disease Control↗

Abciximab therapy in percutaneous intervention: economic issues in the United States.

Whether abciximab therapy should be the standard of care during percutaneous intervention in the United States depends on its efficacy, safety, and economics. In view of the EPIC, CAPTURE, and EPILOG data, few question the superior efficacy and relative safety of abciximab compared with conventional high-dose heparin therapy during percutaneous intervention. Economic considerations have been the major issue limiting its use. Review of the economic data demonstrates that the incremental direct medical care cost of abciximab therapy is $290 to $600 per patient treated in the EPIC and EPILOG populations. In the patients with acute myocardial infarction and unstable angina, abciximab appears to reduce direct medical costs (produce cost savings) at 6 months. Given abciximab's significant incremental effectiveness, its relatively small incremental cost yielded a highly cost-effective therapy in the EPIC and EPILOG patient populations. Additional economic issues relate to minimizing bleeding complications, indirect costs, reduced frequency of emergency procedures, and rationalizing provider/payor policies and incentives to produce the optimal individual patient and societal outcomes. The currently available data concerning the efficacy, safety, and cost provide a compelling argument for embracing abciximab therapy in the treatment of patient subsets where it will be a cost-saving or cost-neutral adjunct to percutaneous coronary intervention. In other subsets, the direct medical cost will likely not be fully recouped, but the incremental cost-effectiveness will compare favorably to other widely accepted therapies.

Abciximab↗

An economic evaluation of second-trimester genetic ultrasonography for prenatal detection of down syndrome.

OBJECTIVE: The objective of this study was to perform an economic evaluation of second-trimester genetic ultrasonography for prenatal detection of Down syndrome. More specifically, we sought to determine the following: (1) the diagnostic accuracy requirements (from the cost-benefit point of view) of genetic ultrasonography versus genetic amniocentesis for women at increased risk for fetal Down syndrome and (2) the possible economic impact of second-trimester genetic ultrasonography for the US population on the basis of the ultrasonographic accuracies reported in previously published studies. STUDY DESIGN: A cost-benefit equation was developed from the hypothesis that the cost of universal genetic amniocentesis of patients at increased risk for carrying a fetus with Down syndrome should be at least equal to the cost of universal genetic ultrasonography with amniocentesis used only for those with abnormal ultrasonographic results. The main components of the equation included the diagnostic accuracy of genetic ultrasonography (sensitivity and specificity for detecting Down syndrome), the costs of the amniocentesis package and genetic ultrasonography, and the lifetime cost of Down syndrome cases not detected by the genetic ultrasonography. After appropriate manipulation of the equation a graph was constructed, representing the balance between sensitivity and false-positive rate of genetic ultrasonography; this was used to examine the accuracy of previously published studies from the cost-benefit point of view. Sensitivity analyses included individual risks for Down syndrome ranging from 1:261 (risk of a 35-year-old at 18 weeks' gestation) to 1:44 (risk of a 44-year-old at 18 weeks' gestation). This economic evaluation was conducted from the societal perspective. RESULTS: Genetic ultrasonography was found to be economically beneficial only if the overall sensitivity for detecting Down syndrome was >74%. Even then, the cost-benefit ratio depended on the corresponding false-positive rate. Of the 7 published studies that used multiple ultrasonographic markers for genetic ultrasonography, 6 had accuracies compatible with benefits. The required ultrasonographic accuracy (sensitivity and false-positive rate) varied according to the prevalence of Down syndrome in the population tested. CONCLUSIONS: The cost-benefit ratio of second-trimester genetic ultrasonography depends on its diagnostic accuracy, and it is beneficial only when its overall sensitivity for Down syndrome is >74%.

Adult↗

Economic analysis of lung volume reduction surgery as part of the National Emphysema Treatment Trial. NETT Research Group.

BACKGROUND: In today's cost-conscious health care environment, obtaining timely and accurate economic information regarding new medical technologies has become extremely important. The National Emphysema Treatment Trial, a multicenter, randomized controlled trial of lung volume reduction surgery (LVRS) plus medical therapy, versus medical therapy for patients with severe emphysema, includes a parallel cost-effectiveness analysis. METHODS: The analysis is designed to determine the cost-effectiveness of LVRS versus medical therapy for those who are eligible for the procedure. After describing theoretical foundations of cost-effectiveness analysis as they apply to this study, we describe the economic and quality of life data that are being collected alongside the clinical trial, methods of analysis, and approach to presenting the results. RESULTS: The cost-effectiveness of LVRS relative to medical therapy will be presented as costs per quality-adjusted life years gained. CONCLUSIONS: This analysis will provide timely economic data that can be considered alongside the clinical results of the National Emphysema Treatment Trial. As one of the largest clinical trials to include a parallel, prospective cost-effectiveness analyses, this study will also provide valuable practical information about conducting an economic analysis alongside a multicenter clinical trial.

Cost-Benefit Analysis↗

Social and economic burden of mood disorders.

Social and economic effects of mood disorders include functional impairment, disability or lost work productivity, and increased use of health services. Evidence for these impacts includes cross-sectional studies, longitudinal studies, and true experiments (randomized trials of specific treatments or treatment programs). With respect to unipolar depression, strong evidence demonstrates that depression is associated with significant functional impairment and that effective treatment helps to restore function. Studies of the effect of depression on work disability and health care costs show strong cross-sectional associations (i.e., greater disability and higher costs among those with depression) and longitudinal associations (i.e., improvement in depression is associated with reduced disability and lower costs). All of these findings regarding unipolar depression seem as consistent in the subgroup of patients with comorbid chronic medical illness as in the total population with depressive disorders. Fewer data are available regarding social and economic burden of bipolar disorder, but available data show cross-sectional associations between mood symptoms and functional impairment, disability, and health care costs. Taken together, these data describe the substantial social and economic burden of mood disorders and the potential benefits of more effective treatment. We must recall, however, that economic benefits of treatment for mood disorders are secondary to the principal objective of relieving human suffering.

Chronic Disease↗

Economic challenges in breast imaging. A survivor's guide to success.

Most breast imaging centers today operate under financial strain. Among strategies designed to improve their bottom line, more efficient use of the radiologist's time is the most fundamental strategy and the one most likely to succeed in all breast imaging centers. Tasks performed by the radiologist that are not directly related to interpretation and consultation should be shifted to other personnel. Other strategies that may help some breast imaging centers include accepting only self-paying patients, renegotiating the hospital contract, performing more interventional procedures, and extending the hours of operation. Measures that can improve the economic efficiency of screening mammography include batch interpretation of mammograms; paperwork reduction; brief automated reports; limiting requests for previous films from other facilities to only potentially necessary cases; dedicated screening mammography examination rooms; reduction in recall rates; and, in certain circumstances, extension of breast center hours. Measures that can improve the economic efficiency of diagnostic mammography performance and interpretation include dedicated diagnostic mammography examination rooms, automated film rotators, improved scheduling, and efficient work-flow patterns for examination performance. Measures that can improve the economic efficiency of both screening and diagnostic mammography include improved triage of screening and diagnostic patients, reminder telephone calls to confirm mammography appointments, greater use of medical assistants to help the radiologists and technologists, and streamlined film library procedures and operations. Measures that can improve the economic efficiency of breast interventional procedures include preprocedure work-up, establishment of scheduling protocols, and greater involvement of technologists and medical assistants in assisting the radiologist who performs the interventional procedures. All of these methods are intended to create a breast imaging center that is cost efficient while maintaining a patient-friendly atmosphere and diagnostic accuracy.

Allied Health Personnel↗

Introduction to health economics for physicians.

Since the 1960s, expenditure on health care in developed countries has risen faster than the general rate of inflation, thus making economic assessment of interventions an integral part of decision making in health services. This paper is the first in a series whose goal is to provide some basic principles of health economics that will allow practising physicians to understand better the economic relations between their practice of medicine, the health-care sector, and the national economy. Some of the most important principles described in this paper include opportunity costs, identifying the appropriate perspective, correctly categorising costs, and discounting costs and non-monetary benefits (eg, lives saved) over time. Economic analyses of medical interventions must also take into consideration the difference between efficacy and effectiveness. Efficacy is the maximum possible benefit, often achieved with carefully controlled trials, and effectiveness is the actual decrease in disease achieved when the intervention is applied over a large, non-homogeneous population. This introduction ends with three methods of assessing the costs and benefits of an intervention-namely, cost-benefit, cost-effectiveness, and cost-utility analyses.

Canada↗

Economic value of caregiver effort in maintaining long-term ventilator-assisted individuals at home.

OBJECTIVE: To estimate the economic value of caregivers' efforts in maintaining ventilator-assisted individuals at home. DESIGN: Nonexperimental, cross-sectional survey. SETTING: Households of home-based ventilator-assisted individuals residing in 37 states. PARTICIPANTS: Caregivers of 1404 ventilator-assisted individuals; 277 (19.7%) responses were received. OUTCOME MEASURES: The Home Ventilator Care Cost and Utilization Survey and the Modified Katz Index. METHODS: The economic value of caregiver effort was estimated deterministically by opportunity cost, aggregated market value, and aggregated replacement cost and estimated stochastically by ordinary least squares regression. Cost of formal home care services was estimated with the Medicare Schedule of Limits for Home Health Agency Costs. Estimates of total cost of home care for each method of valuing caregiver effort were calculated by summing the cost of formal home care services with the value of caregiver effort. RESULTS: The average monthly cost of formal home care services was estimated to be $6411 (SD, $8490; median, $2006; range, $0 to $38,607). After adding various values of caregiver effort to the cost of formal home care services, the average cost of home care increases by $960 to $12,483, depending on the method used to calculate the value of the caregiver's time; the median total cost of home care increased by $1403 to $17,793. Data also showed that, depending on the figure used to estimate the cost of long-term care and which method was used to calculate caregiver value, home care was more expensive for at least 4.6% of ventilator-assisted individuals and for as many as 36.7%. CONCLUSIONS: The incorporation of the caregiver's time value into cost estimates did not substantially reduce the proportion of patients for whom home care was the least expensive alternative, except when caregiver effort was valued at a registered nurse's wage rate. However, the methods used to place an economic value on caregiver effort did not take into consideration the long-term economic impact on caregivers who reduce their work hours or forego employment or educational opportunities, nor did they take into account the lost wages of the ventilator-assisted individual or the extent to which the caregiver was financially dependent on the ventilator-assisted individual.

Adult↗

Future directions in air quality research: economic issues.

Our challenge was to address future directions in air quality research that involve economic issues. The paper outlines the role of economics in the evaluation of air pollution impacts on environmental systems and describes existing research. We identify studies that address economic effects in the agricultural sector, in the commercial forest sector, and in unmanaged natural systems. Effects related to ozone exposure are highlighted. The summary of available research is followed by a discussion of research recommendations. Several short-term recommendations are identified that can augment some of the new research being considered by scientists. A more ambitious, long-term research project is outlined for valuing air pollution impacts in unmanaged natural environments. Specifically, the paper describes possible advantages of an 'integrated assessment' framework that more formally brings together the complex relationships that exist in both ecological and economic systems. A final section contains thoughts on the importance of education (i.e., information transfer) in the research process, especially in relation to policy. It is further noted that education should be inclusive of all members of the research team, throughout all stages of the research process.

Agriculture↗

Economic aspects of cataract.

In most countries, there are concerns about health care utilization and costs. Therefore, those arguing for more funds to be devoted to eye health care need economic data in support of their claims. This article examines the methods for estimating the economic effect of blindness and discusses the approaches to economic evaluation of health care interventions in the field of cataract. Some suggestions are also given for undertaking economic analysis alongside clinical trials in the field of ophthalmology.

Blindness↗

The association of socio-economic factors with physical and mental capacity in elderly men and women.

The association of socio-economic factors with functional capacity has received less research attention than their association with diseases and mortality. However, functional capacity is an important measure of health and independence in the elderly. This study explores the associations of socio-economic factors with physical and mental capacity as measured in laboratory tests and on the basis of self-report. The data were drawn from the Evergreen project, comprising all persons aged 75 (N=388) and 80 (N=291) in Jyväskylä, central Finland. Women with a higher level of education showed better functional capacity on all indicators, among men higher education was only associated with better vital capacity and cognitive capacity. Better perceived financial situation was associated with better functional capacity in both men and women. The association between socio-economic factors and functional capacity remained even when the number of chronic diseases was controlled for. The results lend support to the assumption that socio-economic factors are associated with physical and mental capacity in elderly people.

Journal Article↗

The economic impact of malaria in Africa: a critical review of the evidence.

Information on the economic burden of malaria in Africa is needed to target interventions efficiently and equitably, and to justify investment in research and control. A standard method of estimation has been to sum the direct costs of expenditure on prevention and treatment, and the indirect costs of productive labour time lost. This paper discusses the many problems in using such data to reflect the burden to society or the potential benefits from control. Studies have generally focussed on febrile illness, overestimating the burden of uncomplicated malaria, but underestimating the costs of severe illness, other debilitating manifestations, and mortality. Many use weak data to calculate indirect costs, which fail to account for seasonal variations, the difference between the average and marginal product of labour, and the ways households and firms 'cope' in response to illness episodes. Perhaps most importantly, the costs of coping mechanisms in response to the risk of disease are excluded, although they may significantly affect productive strategies and economic growth. Future work should be rooted in a sound understanding of the health burden of malaria and the organisation of economic activities, and address the impact on the productive environment, and epidemiological and socio-economic geographical variation.

Adaptation, Psychological↗

Using risk analysis in Health Impact Assessment: the impact of different relative risks for men and women in different socio-economic groups.

The aim of this study is to contribute to the emerging field of quantification of Health Impact Assessment (HIA), by analysing how different relative risks affect the burden of disease for various socio-economic groups (SES). Risk analysis, utilising attributable and impact fraction, raises several methodological considerations. The present study illustrates this by measuring the impact of changed distribution levels of smoking on lung cancer, ischemic heart disease (IHD), chronic obstructive lung disorder (COLD) and stroke for the highest and lowest socio-economic groups measured in disability adjusted life years (DALY). The material is based on relative risks obtained from various international studies, smoking prevalence (SP) data and the number of DALY based on data available for Sweden. The results show that if smoking would have been eliminated (attributable fraction, AF), the inequality between the highest and lowest socio-economic groups may decrease by 75% or increase by 21% depending on the size of the relative risk. Assuming the same smoking prevalence for the lowest socio-economic group as for the highest (impact fraction), then the inequality may decrease by 7-26%. Consequently, the size of the relative risk used may have a significant impact, leading to substantial biases and therefore should be taken into serious consideration in HIA.

Adult↗

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↗

[The economic and labor impact of no staff replacement in primary care. Why and how we should measure it].

OBJECTIVES: To quantify the effect of not replacing staff in both job (mean overloads in time -MOT- and in users -MOU-) and economic terms. To calculate the effective real time worked (ERTW). DESIGN: Cross-sectional descriptive study. SETTING: Primary care, San Fernando Health Centre, Móstoles, Madrid. PARTICIPANTS: The 41 people in the team. MEASUREMENTS AND MAIN RESULTS: Records of time off in 1999, with economic and labour costs. Comparison of the mean patients per shift -MOU- with the gold standard: Royal Decree 1575/1993. 72.63% (14,227,538 pesetas) of the cost of time off (19,589,226 pesetas) was assumed by the team (negative cost, economic impact). The MOT per health professional was 6.6 weeks per year for doctors, 6.5 for nurses and 4.2 for paediatricians. The ERTW per professional was 44.1 weeks a year for paediatricians, 39.4 for doctors and 39.1 for nurses. The MOU on a professional being absent raises the lists to 2471 (medicine) and 2179 (paediatrics) on the morning shift; and to 2296 (medicine) and 1662 (paediatrics) on the afternoon one. CONCLUSIONS: The team assumes most of the economic burden, with no counter-benefit. The MOT is high and exceeds the number of weeks per year of formally allowed time off. In practice, therefore, each professional covers for their full allowed time off. The ERTW is much below the 52 weeks on which the team was assessed. RD 1575/1993 is frequently broken by current MOU. It is suggested that coordinators use these indicators in negotiating the Contract of Care Management and the Portfolio of Services.

Costs and Cost Analysis↗