Do diagnosis-related groups appropriately explain variations in costs and length of stay of hip replacement? A comparative assessment of DRG systems across 10 European countries

This paper assesses the variations in costs and length of stay for hip replacement cases in Austria, England, Estonia, Finland, France, Germany, Ireland, Poland, Spain and Sweden and examines the ability of national diagnosis-related group (DRG) systems to explain the variation in resource use against a set of patient characteristic and treatment specific variables. In total, 195,810 cases clustered in 712 hospitals were analyzed using OLS fixed effects models for cost data (n=125,698) and negative binominal models for length-of-stay data (n=70,112). The number of DRGs differs widely across the 10 European countries (range: 2-14). Underlying this wide range is a different use of classification variables, especially secondary diagnoses and treatment options are considered to a different extent. In six countries, a standard set of patient characteristics and treatment variables explain the variation in costs or length of stay better than the DRG variables. This raises questions about the adequacy of the countries' DRG system or the lack of specific criteria, which could be used as classification variables.     

How well do diagnosis-related groups for appendectomy explain variations in resource use? An analysis of patient-level data from 10 European countries

Appendectomy is a common and relatively simple procedure to remove an inflamed appendix, but the rate of appendectomy varies widely across Europe. This paper investigates factors that explain differences in resource use for appendectomy. We analysed 106,929 appendectomy patients treated in 939 hospitals in 10 European countries. In stage 1, we tested the performance of three models in explaining variation in the (log of) cost of the inpatient stay (seven countries) or length of stay (three countries). The first model used only the diagnosis-related groups (DRGs) to which patients were coded, the second model used a core set of general patient-level and appendectomy-specific variables, and the third model combined both sets of variables. In stage two, we investigated hospital-level variation. In classifying appendectomy patients, most DRG systems take account of complex diagnoses and comorbidities but use different numbers of DRGs (range: 2 to 8). The capacity of DRGs and patient-level variables to explain patient-level cost variation ranges from 34% in Spain to over 60% in England and France. All DRG systems can make better use of administrative data such as the patient's age, diagnoses and procedures, and all countries have outlying hospitals that could improve their management of resources for appendectomy.     

Does deregulation in community pharmacy impact accessibility of medicines,quality of pharmacy services and costs? Evidence from nine European countries

Objective

To analyse the impact of deregulation in community pharmacy on accessibility of medicines, quality of pharmacy services and costs.

Methods

We analysed and compared community pharmacy systems in five rather deregulated countries (England, Ireland, the Netherlands, Norway, Sweden) and four rather regulated countries (Austria, Denmark, Finland, Spain). Data were collected by literature review, a questionnaire survey and interviews.

Results

Following a deregulation, several new pharmacies and dispensaries of Over-the-Counter (OTC) medicines tended to be established, predominantly in urban areas. Unless prevented by regulation, specific stakeholders, e.g. wholesalers, were seen to gain market dominance which limited envisaged competition. There were indications for an increased workload for pharmacists in some deregulated countries. Economic pressure to increase the pharmacy turnover through the sale of OTC medicines and non-pharmaceuticals was observed in deregulated and regulated countries. Prices of OTC medicines were not found to decrease after a deregulation in pharmacy.

Conclusions

Access to pharmacies usually increases after a deregulation but this is likely to favour urban populations with already good accessibility. Policy-makers are recommended to take action to ensure equitable accessibility and sustainable competition in a more deregulated environment. No association between pharmaceutical expenditure and the extent of regulation/deregulation appears to exist.     

Does the inclusion of societal costs change the economic evaluations recommendations? A systematic review for multiple sclerosis disease

Background

Multiple sclerosis imposes a heavy burden on the person who suffers from it and on the relatives, due to the caregiving load involved. The objective was to analyse whether the inclusion of social costs in economic evaluations of multiple sclerosis-related interventions changed results and/or conclusions.

Methods

A systematic review was launched using Medline and the Cost-Effectiveness Analysis Registry of Tufts University (2000–2019). Included studies should: (1) be an original study published in a scientific journal, (2) be an economic evaluation of any multiple sclerosis-related intervention, (3) include productivity losses and/or informal care costs (social costs), (4) be written in English, (5) use quality-adjusted life years as outcome, and (6) separate the results according to the perspective applied.

Results

Twenty-nine articles were selected, resulting in 67 economic evaluation estimations. Social costs were included in 47% of the studies. Productivity losses were assessed in 90% of the estimations (the human capital approach was the most frequently used method), whereas informal care costs were included in nearly two-thirds of the estimations (applying the opportunity and the replacement-cost methods equally). The inclusion of social costs modified the figures for incremental costs in 15 estimations, leading to a change in the conclusions in 10 estimations, 6 of them changing from not recommended from the healthcare perspective to implemented from the societal perspective. The inclusion of social costs also altered the results from cost-effective to dominant in five additional estimations.

Conclusions

The inclusion of social costs affected the results/conclusions in multiple sclerosis-related interventions, helping to identify the most appropriate interventions for reducing its economic burden from a broader perspective.

     

How well do diagnosis-related groups explain variations in costs or length of stay among patients and across hospitals? Methods for analysing routine patient data

We set out an analytical strategy to examine variations in resource use, whether cost or length of stay, of patients hospitalised with different conditions. The methods are designed to evaluate (i) how well diagnosis-related groups (DRGs) capture variation in resource use relative to other patient characteristics and (ii) what influence the hospital has on their resource use. In a first step, we examine the influence of variables that describe each individual patient, including the DRG to which the patients are assigned and a range of personal and treatment-related characteristics. In a second step, we explore the influence that hospitals have on the average cost or length of stay of their patients, purged of the influence of the variables accounted for in the first stage. We provide a rationale for the variables used in both stages of the analysis and detail how each is defined. The analytical strategy allows us (i) to identify those factors that explain variation in resource use across patients, (ii) to assess the explanatory power of DRGs relative to other patient and treatment characteristics and (iii) to assess relative hospital performance in managing resources and the characteristics of hospitals that explain this performance.     

A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs

Productivity costs can strongly impact cost-effectiveness outcomes. This study investigated the impact in the context of expensive hospital drugs. This study aimed to: (1) investigate the effect of productivity costs on cost-effectiveness outcomes, (2) determine whether economic evaluations of expensive drugs commonly include productivity costs related to paid and unpaid work, and (3) explore potential reasons for excluding productivity costs from the economic evaluation. We conducted a systematic literature review to identify economic evaluations of 33 expensive drugs. We analysed whether evaluations included productivity costs and whether inclusion or exclusion was related to the study population’s age, health and national health economic guidelines. The impact on cost-effectiveness outcomes was assessed in studies that included productivity costs. Of 249 identified economic evaluations of expensive drugs, 22 (9 %) included productivity costs related to paid work. One study included unpaid productivity. Mostly, productivity cost exclusion could not be explained by the study population’s age and health status, but national guidelines appeared influential. Productivity costs proved often highly influential. This study indicates that productivity costs in economic evaluations of expensive hospital drugs are commonly and inconsistently ignored in economic evaluations. This warrants caution in interpreting and comparing the results of these evaluations.     

Is educational differentiation associated with smoking and smoking inequalities in adolescence? A multilevel analysis across 27 European and North American countries

This study aims to determine whether educational differentiation (i.e. early and long tracking to different school types) relate to socioeconomic inequalities in adolescent smoking. Data were collected from the WHO‐Collaborative ‘Health Behaviour in School‐aged Children (HBSC)’ study 2005/2006, which included 48,025 15‐year‐old students (N_boys = 23,008, N_girls = 25,017) from 27 European and North American countries. Socioeconomic position was measured using the HBSC family affluence scale. Educational differentiation was determined by the number of different school types, age of selection, and length of differentiated curriculum at the country‐level. We used multilevel logistic regression to assess the association of daily smoking and early smoking initiation predicted by family affluence, educational differentiation, and their interactions. Socioeconomic inequalities in both smoking outcomes were larger in countries that are characterised by a lower degree of educational differentiation (e.g. Canada, Scandinavia and the United Kingdom) than in countries with higher levels of educational differentiation (e.g. Austria, Belgium, Hungary and The Netherlands). This study found that high educational differentiation does not relate to greater relative inequalities in smoking. Features of educational systems are important to consider as they are related to overall prevalence in smoking and smoking inequalities in adolescence.     

How do Canadian hospitals do it? A comparison of utilization and costs in the United States and Canada

In 1990 Canadian hospitals provided more services at less cost than did acute care facilities in the United States. Canadians spent $2,720 less per discharge for 48 percent longer stays. If U.S. acute care facilities had achieved an average discharge cost comparable to that in Canada, the annual savings among hospitals in the United States would have totalled $84.3 billion. In a comparative study of volumes and costs in medium-size and teaching hospitals, it was found that U.S. hospitals had greater costs for delivering services than Canadian acute care facilities did in almost every department.     

Are perceived stress, depressive symptoms and religiosity associated with alcohol consumption? A survey of freshmen university students across five European countries

ABSTRACT: BACKGROUND: The aim of this study was to investigate the association of perceived stress, depressive symptoms and religiosity with frequent alcohol consumption and problem drinking among freshmen university students from five European countries. METHODS: 2529 university freshmen (mean age 20.37, 64.9% females) from Germany (n=654), Poland (n=561), Bulgaria (n=688), the UK (n=311) and Slovakia (n=315) completed a questionnaire containing the modified Beck Depression Inventory for measuring depressive symptoms, the Cohen's perceived stress scale for measuring perceived stress, the CAGE-questionnaire for measuring problem drinking and questions concerning frequency of alcohol use and the personal importance of religious faith. RESULTS: Neither perceived stress nor depressive symptoms were associated with a high frequency of drinking (several times per week), but were associated with problem drinking. Religiosity (personal importance of faith) was associated with a lower risk for both alcohol-related variables among females. There were also country differences in the relationship between perceived stress and problem drinking. CONCLUSION: The association between perceived stress and depressive symptoms on the one side and problem drinking on the other demonstrates the importance of intervention programs to improve the coping with stress.     

Systematic reviews and economic evaluations conducted for the National Institute for Health and Clinical Excellence in the United Kingdom: a game of two halves?

BACKGROUND: Decision analytic models, as used in economic evaluations, require data on several clinical parameters. The gold standard approach is to conduct a systematic review of the relevant clinical literature, although reviews of economic evaluations indicate that this is rarely done. Technology appraisals for the National Institute for Health and Clinical Excellence (NICE), which are fully funded, represent the best case scenario for the close integration of economic evaluations and systematic reviews. The objective of this study was to assess the extent to which the systematic review of the clinical literature informs the economic evaluation in NICE technology appraisals. METHODS: All NICE technology assessment reports (TARs) published between January 2003 and July 2006 were considered. Data were abstracted on the TAR topics, the primary measure of clinical effectiveness, the approach to pooling in the clinical review, the measure of economic benefit and the use, or non-use, of the systematic review in the economic evaluation. RESULTS: Forty-one TARs were published in the period studied, all of which contained a systematic review. Most of the economic evaluations (85 percent) were cost-utility analyses, reflecting NICE's guidelines for economic evaluation. In seventeen cases, the clinical data were not pooled in the review, owing to heterogeneity in the clinical data or the limited number of studies. In these cases, the economists used alternative approaches for estimating the key effectiveness parameter in the model. The results of the review (when pooled) were always used when the primary clinical effectiveness measure corresponded with the measure of economic benefit (e.g., survival). However, because preference-based quality of life measures are rarely included in clinical trials, the results of the systematic review were never directly used in the cost-utility analyses. Nevertheless, the outputs of the systematic review were used when the data were useful in estimating components of the quality-adjusted life-year (QALY) (e.g., the life-years gained, or the frequencies of health states to which QALYs could be assigned). Problems occurred mainly when the clinical data were not pooled, or when the measure of clinical benefit could not be converted into health states to which QALYs could be assigned. CONCLUSIONS: Economic evaluations can benefit from systematic reviews of the clinical literature. However, such reviews are not a panacea for conducting a good economic evaluation. Much of the relevant data for estimating QALYs are not contained in such reviews and the chosen method for summarizing the clinical data may inhibit the assessment of economic benefit. Problems would be reduced if those undertaking the technology assessments discussed the data requirements for the economic model at an early stage.     

Are economic evaluations and health technology assessments increasingly demanded in times of rationing health services? The case of the Argentine financial crisis

OBJECTIVES: After 4 years of deepening recession, Argentina's economy plummeted after default in 2002. This crisis critically affected health expenditures and triggered acute rationing. Our objective was to explore health decision-makers' knowledge and attitudes about economic evaluations (EE) and whether health technology assessment (HTA) were increasingly used for decision making. METHODS: A qualitative design based on semistructured interviews and focus groups was used to explore how decision makers belonging to different health sectors implement resource allocation decisions. RESULTS: Informants were mostly unaware of EE. The most important criteria mentioned to adopt a treatment were evidence of effectiveness, social/stakeholder demand, or resource availability. Despite general positive attitudes about EE, knowledge was rather limited. Although cost considerations were widely accepted by purchasers and managers, clinicians argued about these issues as interfering with the doctor-patient relationship. Other important perceived barriers to HTA use were lack of confidence in the transferability of studies conducted in developed countries and institutional fragmentation of the Argentine healthcare system. The new macroeconomic context was cited as a justification of implicit rationing measures. Although explicit priority setting was implemented by many purchasers and managers, HTA was not used to improve technical and/or allocative efficiency. CONCLUSIONS: The crisis seems to be a strong incentive to extend the use of HTA in Argentina, provided decision makers are aware as well as involved in the generation of local studies.     

Health, environmental, and economic costs from the use of a stabilized diesel/ethanol mixture in the city of São Paulo, Brazil

In Greater Metropolitan S?o Paulo, Brazil, fossil fuel combustion in the transportation system is a major cause of outdoor air pollution. Air quality improvement requires additional policies and technological upgrades in fuels and vehicle engines. The current study thus simulated the environmental and social impacts resulting from the use of a stabilized diesel/ethanol mixture in the bus and truck fleet in Greater Metropolitan S?o Paulo. The evaluation showed reductions in air pollutants, mainly PM10, which would help avert a number of disease events and deaths, as estimated through dose-response functions of epidemiological studies on respiratory and cardiovascular diseases. Valuation of the impacts using an environmental cost-benefit analysis considered operational installation, job generation, potential carbon credits, and health costs, with an overall positive balance of US$ 2.851 million. Adding the estimated qualitative benefits to the quantitative ones, the project's benefits far outweigh the measured costs. Greater Metropolitan S?o Paulo would benefit from any form of biodiesel use, producing environmental, health and socioeconomic gains, the three pillars of sustainability.     

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.     

A surplus of physicians in Israel: any lessons for the United States and other industrialized countries?

In Israel, there is a consensus that there is a surplus of physicians. An examination of the Israeli situation may suggest some responses that will be taken by policy makers and physicians in the United States and other industrialized countries as the supply of physicians continues to increase. Specifically, we examine the impact of rising physician supply on the geographic distribution of physicians in Israel, the length of the training period for residency programs, the interaction between physicians and other professionals, and the level of physician incomes compared to other Israeli workers.     

Social inequalities in "sickness": does welfare state regime type make a difference? A multilevel analysis of men and women in 26 European countries

In comparative studies of health inequalities, public health researchers have usually studied only disease and illness. Recent studies have also examined the sickness dimension of health, that is, the extent to which ill health is accompanied by joblessness, and how this association varies by education within different welfare contexts. This research has used either a limited number of countries or quantitative welfare state measures in studies of many countries. In this study, the authors expand on this knowledge by investigating whether a regime approach to the welfare state produces consistent results. They analyze data from the European Union Statistics on Income and Living Conditions (EU-SILC); health was measured by limiting longstanding illness (LLSI). Results show that for both men and women reporting LLSI in combination with low educational level, the probabilities of non-employment were particularly high in the Anglo-Saxon and Eastern welfare regimes, and lowest in the Scandinavian regime. For men, absolute and relative social inequalities in sickness were lowest in the Southern regime; for women, inequalities were lowest in the Scandinavian regime. The authors conclude that the Scandinavian welfare regime is more able than other regimes to protect against non-employment in the face of illness, especially for individuals with low educational level.     

Anaemia in adolescent women: A priority for the nutrition agenda in Mexico. A comparison of data from the ENSANUT 2012 and 2018–2019 surveys

The risk of anaemia in adolescence increases due to accelerated growth. This study aims to: (1) estimate the prevalence of anaemia in 2012 and 2018–2019 (Encuesta Nacional de Salud y Nutricion – ENSANUT [n = 5841 in 2012 and n = 2380 in 2018–2019]) in non-pregnant, Mexican adolescent women aged 12–19 years, and the changes in prevalence over this period according to sociodemographic, health and nutrition characteristics; (2) estimate the associations between anaemia and sociodemographic, health and nutrition characteristics in each year and overall, in non-pregnant Mexican adolescent women. Anaemia was defined as capillary haemoglobin <12 g/dL. The distribution of characteristics and their changes between 2012 and 2018–2019 were described. The covariate-adjusted prevalence of anaemia in 2012 and 2018–2019 and the changes over that period were estimated from a multiple log-binomial regression model and the factors associated with anaemia were assessed in each survey year and in both years combined. The prevalence of anaemia was 7.7% in 2012 and 13.1% in 2018–2019 (69% increase, Prevalence Ratio: PR = 1.69; 95%CI: 1.35, 2.13). The covariate-adjusted prevalence of anaemia increased from 6.9% to 10.5% in the overall population (PR = 1.53, 95%CI: 1.19, 1.96), and increased considerably in the age group 12–14 years (PR = 1.94, 95%CI: 1.36, 2.75), and in the northern region (PR = 3.68, 95%CI: 2.55, 5.32). Those receiving iron supplements or school breakfasts did not register a significant increase. A higher household wellbeing status and older age were associated with a lower prevalence of anaemia. Anaemia in non-pregnant adolescent women continues to be a public health problem. To improve the development and health of adolescent women in Mexico and to pave the way to a healthy pregnancy for the next generation, the causes of anaemia should be identified.     

Individual differences in the relationship between ovarian hormones and emotional eating across the menstrual cycle: A role for personality?

Within-person changes in estradiol and progesterone predict changes in binge eating tendencies across the menstrual cycle. However, all women have menstrual-cycle fluctuations in hormones, but few experience binge eating. Personality traits may be critical individual difference factors that influence who will engage in emotional eating in the presence of a vulnerable hormonal environment. Women (N = 239) provided self-reports of emotional eating and saliva samples for hormone measurement for 45 consecutive days. Negative urgency and negative emotionality were measured once and were examined as moderators of hormone-emotional eating associations. Consistent with prior research, within-person changes in the interaction between estradiol and progesterone predicted emotional eating. Neither negative urgency nor negative emotionality interacted with changes in estradiol and progesterone to predict changes in emotional eating. Additional factors, other than the two personality traits examined, may account for individual differences in within-person associations between hormones and emotional eating.