How do incentive-based formularies influence drug selection and spending for hypertension?

This study examined the association between incentive-based formularies and antihypertensive drug selection and spending. We compared the use of drugs from five drug classes by the number of tiers and copayment differentials. We found that raising copayments within a single-tier formulary system had a relatively modest impact on use of antihypertensives, compared with raising them in multi-tier systems. Likelihood of using ACE inhibitors and angiotensin II receptor blockers was lower among two-tier plans with generic/brand differentials of dollars 10 relative to flat-copayment plans. Incentive formularies were associated with lower total antihypertensive spending by plans, but enrollees paid more out of pocket.     

How can policy makers use available evidence on the cost benefits of drug treatement?

All the studies on the cost benefits of drug treatment reviewed by Cartwright in this issue suggest benefits outweigh costs by some margin. What lessons does this review of mainly American data have for European policy makers? Drug treatments are associated with a wide range of consequences outside the health sector and there are considerable differences in treatment regimes across countries. This could well influence results. There are also considerable differences in methodologies used across available studies and many lack strong study designs. An interesting feature is the lack of valuation of individual drug users benefits, does this imply that policy makers in the US do not care about drug misusers. Would the situation be the same in Europe or other parts of the world? There is a lot of research to be done and perhaps specific guidelines are required to ensure economic evaluations in this area can be used to guide policy decisions with more confidence.     

Does expenditure on pharmaceuticals give good value for money?: current evidence and policy implications

Drugs are becoming a particular target for health care cost containment measures, as part of the increasing pressure to improve the value for money from the use of health care resources. This has led to an exponential growth in the number of economic evaluations of pharmaceuticals, many of which have been funded by pharmaceutical companies. A review of the existing literature on economic evaluation of pharmaceuticals was conducted in order to classify studies and to document their results. The review identified 85 evaluations, published between 1986 and 1991, that were suitable for analysis. In most published studies it was found that in the treatment or prevention of a disease, a drug intervention was more cost-effective than no intervention and, in a number of cases, drug interventions were at least as cost-effective as other forms of intervention. In evaluating the published evidence it is important to note that positive studies are more likely to be published and that the quality of study methods varies. However, the studies can be of use to policy makers with an interest in securing more value for money, although economic assessments should be applied equally to all health technologies.     

Paying for and receiving benefits from health services in South Africa: is the health system equitable?

There is a global challenge for health systems to ensure equity in both the delivery and financing of health care. However, many African countries still do not have equitable health systems. Traditionally, equity in the delivery and the financing of health care are assessed separately, in what may be termed 'partial' analyses. The current debate on countries moving toward universal health systems, however, requires a holistic understanding of equity in both the delivery and the financing of health care. The number of studies combining these aspects to date is limited, especially in Africa. An assessment of overall health system equity involves assessing health care financing in relation to the principles of contributing to financing according to ability to pay and benefiting from health services according to need for care. Currently South Africa is considering major health systems restructuring toward a universal system. This paper examines together, for both the public and the private sectors, equity in the delivery and financing of health care in South Africa. Using nationally representative datasets and standard methodologies for assessing progressivity in health care financing and benefit incidence, this paper reports an overall progressive financing system but a pro-rich distribution of health care benefits. The progressive financing system is driven mainly by progressive private medical schemes that cover a small portion of the population, mainly the rich. The distribution of health care benefits is not only pro-rich, but also not in line with the need for health care; richer groups receive a far greater share of service benefits within both public and private sectors despite having a relatively lower share of the ill-health burden. The importance of the findings for the design of a universal health system is discussed.     

Who benefits most from guided self-help for binge eating? An investigation into the clinical features of completers and non-completers

Guided self-help (GSH) is a recommended first step in treatment for bulimia nervosa (BN) and binge eating disorder (BED) (NICE, 2004). It remains unclear what makes some individuals more likely to respond to this form of treatment than others. Forty-eight patients participated in this study using a GSH programme for binge eating. Profiles of treatment completers and non-completers are compared, and reasons for non-completion explored. Completion of treatment was associated with significant improvements in mood, general functioning and on measures of dietary restraint, frequency of objective binge eating (OBE), laxative misuse, self-induced vomiting (SIV) and driven exercise. Improvements were maintained at follow-up. Treatment non-completers reported significantly higher pre-treatment levels of depression and weight concern, and lower levels of general health and vitality. Reasons for discontinuing treatment were related to perceptions of the GSH programme; practicalities of the programme; and readiness to change. Whilst GSH can be effective for a sub-group of patients, factors such as pre-morbid level of depression, degree of weight concern, perceptions of the programme, and readiness to change may increase the likelihood of non-completion.     

Why invest in a national public health program for stroke?: An example using Australian data to estimate the potential benefits and cost implications

OBJECTIVES: Stroke is the world's second leading cause of death in people aged over 60 years. Approximately 50,000 strokes occur annually in Australia with numbers predicted to increase by about one third over 10-years. Our objectives were to assess the economic implications of a public health program for stroke by: (1) predicting what potential health-gains and cost-offsets could be achieved; and (2) determining the net level of annual investment that would offer value-for-money. METHODS: Lifetime costs and outcomes were calculated for additional cases that would benefit if 'current practice' was feasibly improved, estimated for one indicative year using: (i) local epidemiological data, coverage rates and costs; and (ii) pooled effect sizes from systematic reviews. Interventions: blood pressure lowering; warfarin for atrial fibrillation; increased access to stroke units; intravenous thrombolysis and aspirin for ischemic events; and carotid endarterectomy. Value-for-money threshold: AUD$30,000/DALY recovered. RESULTS: Improved, prevention and management could prevent about 27,000 (38%) strokes in 2015. In present terms (2004), about 85,000 DALYs and AUD$1.06 billion in lifetime cost-offsets could be recovered. The net level of annual warranted investment was AUD$3.63 billion. CONCLUSIONS: Primary prevention, in particular blood pressure lowering, was most effective. A public health program for stroke is warranted.     

Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries

Objective

To synthesize the data available – on costs, efficiency and economies of scale and scope – for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries.

Methods

The relevant peer-reviewed and “grey” literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Findings

Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence.

Conclusion

HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery – which is, potentially, more efficient than the implementation of stand-alone services – should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost–effectiveness of each service-delivery model.     

Estimating the Minimum Number of Judges Required for Test-centred Standard Setting on Written Assessments. Do Discussion and Iteration have an Influence?

Absolute standard setting procedures are recommended for assessment in medical education. Absolute, test-centred standard setting procedures were introduced for written assessments in the Liverpool MBChB in 2001. The modified Angoff and Ebel methods have been used for short answer question-based and extended matching question-based papers, respectively. Data collected has been analysed to investigate whether reliable standards can be achieved for small-scale, medical school-based assessments, to establish the minimum number of judges required and the effect of a discussion phase on reliability. The root mean squared error (RMSE) has been used as a measure of reliability and used to compute 95% confidence intervals for comparison to the examination statistics. The RMSE has been used to calculate the minimum number of judges required to obtain a predetermined minimum level of reliability, and the effect of the number of judges and number of items have been examined. Values of the RMSE obtained vary from 0.9 to 2.2%. Using average variances across each paper type, the minimum number of judges to obtain a RMSE of less than 2% is 10 or more judges before discussion or 6 or more judges after discussion. The results indicate that including a discussion phase improves the reliability and reduces the minimum number of judges required. Decision studies indicate that increasing the number of questions included in the assessments would not significantly improve the reliability of the standard setting.     

Are community-living and institutionalized dementia patients cared for differently? Evidence on service utilization and costs of care from German insurance claims data

Background

The validity of survey-based health care utilization estimates in the older population has been poorly researched. Owing to data protection legislation and a great number of different health care insurance providers, the assessment of recall and non-response bias is challenging to impossible in many countries. The objective of our study was to compare estimates from a population-based study in older German adults with external secondary data.

Methods

We used data from the German KORA-Age study, which included 4,127 people aged 65–94 years. Self-report questions covered the utilization of long-term care services, inpatient services, outpatient services, and pharmaceuticals. We calculated age- and sex-standardized mean utilization rates in each domain and compared them with the corresponding estimates derived from official statistics and independent statutory health insurance data.

Results

The KORA-Age study underestimated the use of long-term care services (?52%), in-hospital days (?21%) and physician visits (?70%). In contrast, the assessment of drug consumption by postal self-report questionnaires yielded similar estimates to the analysis of insurance claims data (?9%).

Conclusion

Survey estimates based on self-report tend to underestimate true health care utilization in the older population. Direct validation studies are needed to disentangle the impact of recall and non-response bias.     

Antiretroviral therapy in HIV-infected individuals in clinical practice: Are the criteria for initiating and choosing the type of drug regimen based only on immunologic and virologic values?

Objectives: To determine factors associated with beginning antiretroviral therapy and with the number of drugs used. Methods: Longitudinal study of 3169 HIV-infected individuals naïve from anti-retroviral drugs at enrolment in 65 infectious disease clinics in Italy. Initiation of antiretroviral therapy and number of drugs used (i.e., <3 vs. 3 drugs) were the main outcome measures. Adjusted odds ratios were calculated by logistic models to establish cofactors of these two measures. Results: From January 1997 to December 1998, 1288 (40.6%) individuals started therapy, 58.0% of whom were given a triple combination regimen. This regimen became more frequent over time. By multivariate analysis, high levels of HIV-RNA and low CD4 counts were the most important independent predictors of starting any type of therapy. A significant association was also found with HIV exposure category, reason for being antiretroviral-naïve, presence/absence of liver disease, presence/absence of a new AIDS-defining disease, and clinical centre. High levels of HIV-RNA and low CD4 counts were also the most important predictors of starting with 3 drugs, compared to < 3 drugs, and men had an independent higher probability of starting with 3 drugs, compared to women. The probability of starting with 3 drugs significantly increased with calendar time. Conclusions: CD4 and HIV-RNA were the main cofactors of initiating both any type of therapy and therapy with 3 drugs. The large variability among clinical centres suggests that clinicians are uncertain as to the exact timing of beginning therapy and the specific regimen, especially among women.     

Do the poor cost much more? The relationship between small area income deprivation and length of stay for elective hip replacement in the English NHS from 2001 to 2008

The Blair/Brown reforms of the English NHS in the early to mid 2000s gave hospitals strong new incentives to reduce waiting times and length of stay for elective surgery. One concern was that these efficiency-oriented reforms might harm equity, by giving hospitals new incentives to select against socio-economically disadvantaged patients who stay longer and cost more to treat. This paper aims to assess the magnitude of these new selection incentives in the test case of hip replacement. Anonymous hospital records are extracted on 274,679 patients admitted to English NHS Hospital Trusts for elective total hip replacement from 2001/2 through 2007/8. The relationship between length of stay and small area income deprivation is modelled allowing for other patient characteristics (age, sex, number and type of diagnoses, procedure type) and hospital effects. After adjusting for these factors, we find that patients from the most deprived tenth of areas stayed just 6% longer than others in 2001/2, falling to 2% by 2007/8. By comparison, patients aged 85 or over stayed 57% longer than others in 2001/2, rising to 71% by 2007/8, and patients with seven or more diagnoses stayed 58% longer than others in 2001/2, rising to 73% by 2007/8. We conclude that the Blair/Brown reforms did not give NHS hospitals strong new incentives to select against socio-economically deprived hip replacement patients.     

Does socio-demographic status influence the effect of pollens and molds on hospitalization for asthma? Results from a time-series study in 10 Canadian cities

PURPOSE: Social status influences asthma morbidity but the mechanisms are not well understood. To determine if sociodemographics influence the susceptibility to ambient aeroallergens, we determined the association between daily hospitalizations for asthma and daily concentrations of ambient pollens and molds in 10 large Canadian cities. METHODS: Daily time-series analyses were performed and results were adjusted for day of the week, temperature, barometric pressure, relative humidity, ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide. Results were then stratified by age, gender, and neighborhood family education and income. RESULTS: There appeared to be age and gender interactions in the relation between aeroallergens and asthma. An increase in basidiomycetes equivalent to its mean value, about 300/m3, increased asthma admissions for younger males (under 13 years of age) by 9.3% (95% CI, 4.8%, 13.8%) vs. 4.2% (95% CI, - 0.1%, 8.5%) for older males. The reverse was true among females with increased effect in the older age group: 2.3% (95% CI, 1.2%, 5.8%) in those under 13 years vs. 7.1% (95% CI, 4.1%, 10.1%) for older females. Associations were seen between aeroallergens and asthma hospitalization in the lowest but not the highest education group. CONCLUSIONS: Our results suggest that younger males and those within less educated families may be more vulnerable to aeroallergens as reflected by hospitalization for asthma.