International review of the utilisation and cost of percutaneous transluminal coronary angioplasty

We reviewed information published between 1990 and March 2001 to ascertain trends in the utilisation of percutaneous transluminal coronary angioplasty (PTCA) and to determine the availability of cost data. Our review encompassed Australia, Canada, France, Germany, Italy, Sweden, the United Kingdom, and the United States. The number of PTCAs increased in all countries studied during the 1990s. While the rate of PTCA use in all European countries lags behind that of the US, Germany and France are approaching the US rate, and the uptake of PTCA among European countries is increasing rapidly after a slow start. With regard to PTCA cost data, direct international comparisons are difficult since patient populations, methodological factors, and the timing and location of each study contributed to the differences observed between and within the studies reviewed. The increasing number of patients receiving PTCA emphasises the need for accurate cost data.     

Patient cost sharing and physician visits by socioeconomic position: findings in three Western European countries

The association between educational level and the probability of physician visits in three Western European countries, one of which has a system of patient cost sharing was evaluated. Cross-sectional surveys were performed in France, Germany and Spain around 1990 and around 2000. People representative of the French, German and Spanish populations, aged 25-74 years were studied. The probability of physician visits decreased in the second period with respect to the first in France and Germany, but it increased in Spain. In the two periods studied, subjects with low educational level had a lower probability of physician visits than those with high educational level in France, in contrast with the general trend in Germany and Spain. In both periods, France had patient cost sharing whereas Germany and Spain did not. The existence of patient cost sharing in the healthcare systems of Western European countries raises doubts about the possibility of making use of health services independent of individual socioeconomic position.     

Homicide, suicide, motor vehicle crash, and fall mortality: United States'' experience in comparative perspective.

US mortality data on motor vehicle crashes, falls, suicide, and homicide for 1980 are compared with corresponding data for France, Japan, West Germany, and the United Kingdom. Unadjusted and age-specific death rates are presented, together with age-adjusted rates of years of life lost (YLL). A large male excess in rates is typical outside the fall category. Motor vehicle crashes are the predominant cause of YLL, and the United States manifests the highest YLL rates for each sex. US fall death rates at the older ages are exceeded by those of France and West Germany. The elderly generally manifest the greatest risk of suicide; American females exhibit a unique rate decline after ages 45-54 years, however. Beyond early adulthood, US suicide rates are lower than those of France, Japan, and West Germany. US homicide rates dwarf those of the comparison countries with 16- to 29-fold differentials separating prime-risk American males aged 25-34 years from their foreign counterparts.     

The impact of new (orphan) drug approvals on premature mortality from rare diseases in the United States and France, 1999–2007

This paper investigates the impact of the introduction of new orphan drugs on premature mortality from rare diseases using longitudinal, disease-level data obtained from a number of major databases. The analysis is performed using data from two countries: the United States (during the period 1999–2006) and France (during the period 2000–2007). For both countries, we estimate models using two alternative definitions of premature mortality, several alternative criteria for inclusion in the set of rare diseases, and several values of the potential lag between new drug approvals and premature mortality reduction. Both the United States and French estimates indicate that, overall, premature mortality from rare diseases is unrelated to the cumulative number of drugs approved 0–2 years earlier but is significantly inversely related to the cumulative number of drugs approved 3–4 years earlier. This delay is not surprising, since most patients probably do not have access to a drug until several years after it has been launched. Although the estimates for the two countries are qualitatively similar, the estimated magnitudes of the US coefficients are about four times as large as the magnitudes of the French coefficients. This may be partly due to greater errors in measuring dates of drug introduction in France. Also, access to new drugs may be more restricted in France than it is in the United States. Our estimates indicate that, in the United States, potential years of life lost to rare diseases before age 65 (PYLL65) declined at an average annual rate of 3.3% and that, in the absence of lagged new drug approvals, PYLL65 would have increased at a rate of 0.9%. Since the US population aged 0–64 was increasing at the rate of 1.0% per year, this means that PYLL65 per person under 65 would have remained approximately constant. The reduction in the US growth rate of PYLL65 attributable to lagged new drug approvals was 4.2%. In France, PYLL65 declined at an average annual rate of 1.8%. The estimates imply that, in the absence of lagged new drug approvals, it would have declined at a rate of 0.6%. The reduction in the French growth rate of PYLL65 attributable to lagged new drug approvals was 1.1%. Earlier access to orphan drugs could result in earlier reductions in premature mortality from rare diseases.     

How health insurance design affects access to care and costs, by income, in eleven countries

This 2010 survey examines the insurance-related experiences of adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United States, and the United Kingdom. The countries all have different systems of coverage, ranging from public systems to hybrid systems of public and private insurance, and with varying levels of cost sharing. Overall, the study found significant differences in access, cost burdens, and problems with health insurance that are associated with insurance design. US adults were the most likely to incur high medical expenses, even when insured, and to spend time on insurance paperwork and disputes or to have payments denied. Germans reported spending time on paperwork at rates similar to US rates but were well protected against out-of-pocket spending. Swiss out-of-pocket spending was high, yet few Swiss had access concerns or problems paying bills. For US adults, comprehensive health reforms could lead to improvements in many of these areas, including reducing differences by income observed in the study.     

医疗保险设计如何影响卫生服务的成本和可及性——根据11个国家不同收入人群的调查

2010年的调查研究了澳大利亚、加拿大、法国、德国、荷兰、新西兰、挪威、瑞典、瑞士、美国和英国成人的医保相关经历。这些国家的医保有不同的覆盖范围,体现在既有公共的又有公私合营的保险体系,并且具有不同的费用报销比例。总的来说,本次研究发现医疗保险设计导致不同保险的可及性、成本分担和问题等方面存在显著差异。即使在有保险的情况下,美国的成年人承担的医疗费用最高,需要花费大量时间填写保险书面材料和处理争议并且有可能被拒绝支付。德国人和美国人在填写书面材料上花费的时间差不多,但是不需要自付费用;瑞士人的自付费用虽然很高,但是在获得医保或者费用支付上没有任何障碍。对于美国成年人,全面的医疗改革可以在很多方面改进,包括减少本次研究中发现的因收入不同而产生的差别。     

Attitudes towards large numbers of choices in the food domain: a cross-cultural study of five countries in Europe and the USA

Telephone interviews of 6000 representative adults from France, Germany, Italy, Switzerland, the UK, and the USA, included two items on attitudes to variety. One had to do with whether the respondent preferred a choice of 10 versus 50 ice cream flavors. Ten choices were preferred by a majority of respondents from each country except the United States. A second item asked whether one expected a small or large menu choice in an upscale restaurant. A majority in all countries expected the small number of choices, but this expectation was lowest in the UK and USA. High variety expectations and preferences were weakly positively correlated (r=0.19). There was no substantial relation between a variety of demographic variables and variety preferences or expectations, except that older people were less inclined to prefer the high (50) variety in ice cream choices (r=0.28). The results suggest that the US, and the UK to some extent, focus on providing choices that cater to individual differences in preferences, whereas the continental European countries are more attached to communal eating values.     

Patient access to pharmaceuticals: an international comparison

We have identified eight sub-dimensions of patient access to pharmaceuticals: marketing approvals, time of marketing approval, coverage, cost sharing, conditions of reimbursement, speed from marketing approval to reimbursement, extent to which beneficiaries control choice of their drug benefit, and evenness of the availability of drugs to the population. For a sample of commonly used best-selling drugs in the United States (US), we measured these eight access sub-dimensions across four health systems: France, the Netherlands, the United Kingdom (UK), and the US. Although the US approved between 15 and 18% more drugs than the other three countries, the US was slower than France and the UK to approve drugs licensed in all four countries. The percentage of drugs covered is approximately the same for all four countries. For covered drugs, we observe the least cost sharing by patients in the Netherlands. The Netherlands imposes conditions of reimbursement on a much larger percentage of drugs. France seems to be the slowest in respect of speed from marketing approval to reimbursement. The US is the most flexible in terms of the extent to which beneficiaries control their choice of drug benefit but it is the least universal in terms of evenness of the availability of drugs to the population. Our study confirms the frequently cited problems of access in European countries: lag between marketing approval and reimbursement, and inflexibility in respect of the extent to which beneficiaries control their choice of drug benefit. At the same time, our study confirms, qualitatively, different kinds of access problems in the US: relatively high patient cost sharing for pharmaceuticals, and wide variation in coverage.

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A comparison of prenatal care use in the United States and Europe.

OBJECTIVES. We sought to describe prenatal care use in the United States and in three European countries where accessibility to prenatal care has been reported to be better than it is in the United States. METHODS. We analyzed the 1980 US National Natality Survey, the 1981 French National Natality Survey, a 1979 sample of Danish births, and a survey performed from 1979 to 1980 in one Belgian province. RESULTS. The proportion of women who began prenatal care late (after 15 weeks) is highest in the United States (21.2%) and lowest in France (4.0%). This contrasts with the median number of visits, which is greater in the United States (11) than in Denmark (10) or in France (7). Across all maternal ages, parities, and educational levels, late initiation of prenatal care is more frequent in the United States, and median number of visits in the United States is equal to or higher than that in the other countries. CONCLUSIONS. In countries that offer nearly universal access to prenatal care, women begin care earlier during pregnancy and have fewer visits than women in the United States.     

The burden of rheumatoid arthritis and access to treatment: uptake of new therapies

This paper presents data on international differences in use of TNF inhibitors. It is part of a study on burden and cost of RA, access to new therapies and the role of HTA in determining access and cost-effectiveness. United States has the fastest most extensive use of the new drugs, about three times the average in the western European countries and Canada. Eastern and central European countries as well as Australia, South Africa and Turkey lag far behind. However, some smaller European countries, most notably Norway and Sweden have use of the new drugs not far behind the United States. While the income level of the country, and thus the health care expenditures per capita is a major factor for determining use in low and middle income countries, there are still considerable differences among countries with similar high total health care expenditures. Differences in prices are considerable between the US and Europe due to the changes in exchange rates between the US dollar and the Euro, but high and low use is not systematically related to differences in price.     

Cost containment and health care reform: a study of the European Union

This article gives a short summary of the organisation and financing of health services of the 12 Member States of the European Union. It then describes the latest developments in cost containment in each of the countries. The third section describes the new initiatives for reform in Spain, Italy, the Netherlands, Portugal and the United Kingdom. Finally, it gives a summary of the cost containment measures in the 12 countries, listing them under a set of headings. They are classified as budget control, alternatives to hospital care, cost sharing, influencing authorizing behaviour and limits on supply. The article shows the considerable convergence of policies which is developing. Overall budget control in some form is to be found in 8 of the countries. Where providers are paid by a number of different insurers, budgets are nevertheless applied to hospitals in three countries and in another only to public hospitals. Both Germany and France have used budgets to control other items of expenditure. Profits or the prices of drug companies are controlled in 8 countries and in one indirectly. Three have adopted reference price systems for drugs and another has taken powers to do so. Two have adopted or are moving towards provider markets.     

Integrating cost-effectiveness evidence into clinical practice guidelines in Australia for acute myocardial infarction

A teaching hospital is working with the Victorian State Government and universities, integrating cost-effectiveness evidence into clinical practice guidelines (CPGs), protocols and pathways for respiratory and cardiology interventions. Acute myocardial infarction (AMI) findings are reported. Results will stimulate cost-effective practice and inform medical associations, federal and state governments and international organisations developing CPGs. Published CPGs by the American College of Cardiology/American Heart Foundation for AMI in 1999 are reviewed by a large interdisciplinary hospital-based committee given cost-effectiveness evidence. Levels of evidence criteria rating on methodological rigor for effectiveness and costs are applied. National Health and Medical Research Council (NHMRC) grades of recommendation criteria for combinations of relative effectiveness versus relative costs and cut-off points are used. Extrapolating results between countries was addressed by applying the OECD's health purchasing power parity series. Recommendations for revisions to United States guidelines and for local application are formulated. United States Guidelines require updating: Regarding angioplasty, percutaneous transluminal coronary angioplasty (PTCA) is cost-effective for men aged 60 years relative to recombinant tissue plasminogen activator (tPA), with additional cost per life year saved of 274 ecu. PTCA with discharge after 3 days is cost-effective in low-risk AMI. Regarding GP IIb/IIIa drugs, Abciximab during intervention incurred equal mean hospital costs for placebo, abciximab bolus, and abciximab bolus+infusion with incremental 6-month cost for the latter treatment costing 293 US dollars per patient. Agent recouped almost all initial therapy costs with significant benefits. Incremental cost of abciximab per event prevented is 3,258 US dollars. Tirofiban was compared to placebo after high-risk angioplasty for AMI or unstable angina. Tirofiban decreased the rate of hospital deaths, myocardial infarction, revascularisation at 2 days by 36% relative to placebo (8% vs. 12%) without increased cost. Clinical benefits were similar at 30 days. Tirofiban+heparin+aspirin was compared to heparin+aspirin. Tirofiban arm resulted in net savings of 33,418 ecu per 100 patients for the first 7 days of treatment. Regarding thrombolytics, tPA is more cost-effective than streptokinase. Incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasminogen are 31%, 45%, 97% higher in Germany, Italy and the United States than in the United Kingdom. Regarding anticoagulants, enoxaparin is a promising alternative to unfractionated heparin for hospitalised patients with non-Q-wave myocardial infarction or unstable angina, saving 1,485 Canadian dollars per patient over 12 months with 10% reduction in 1 year risk of death, myocardial infarction or recurrent angina. Regarding antiarrhymics, the cost-effectiveness of no amiodarone, amiodarone for patients with depressed heart rate variability (DHRV), and amiodarone for patients with DHRV plus positive programmed ventricular stimulation (PPVS) for high-risk post-AMI was investigated. Amiodarone for DHRV+PPVS patients was dominated by a blend of the two alternatives. Compared to no amiodarone, the incremental cost-effectiveness of amiodarone for DHRV patients was 39,422 US dollars per quality adjusted life year gained. Amiodarone for DHRV is the most appropriate. Other CPG updates concern serum markers, for example, cardiac troponin I assay (c-Tnl), cost advantages of ad hoc angioplasty and secondary prevention through antioxidants and pravastatin. Australian costs are reported later in the paper.     

Cancer survival rates and GDP expenditure on health: a comparison of England and Wales and the USA, Denmark, Netherlands, Finland, France, Germany, Italy, Spain and Switzerland in the 1990s

Health funding is central to public health planning and clinical practice, hence this comparison of GDP health expenditure and five year post-diagnostic cancer survival rates of England and Wales with the USA and eight European countries. The three lowest proportional GDP health expenditures over the period 1980-1990 were Denmark, England and Wales, and Spain. The USA had the highest proportional GDP expenditure, followed by France, Germany, and The Netherlands. Overall the USA had the best cancer survival rates in the 14 sites reviewed, followed by Switzerland, The Netherlands, and Germany. The least successful were Spain, England and Wales, and Italy. In respect to the high incidence cancers, colorectal, lung, and female breast cancers, England and Wales survival rates were the poorest of all ten countries, followed by Denmark and Spain. Higher GDP health expenditure and longer survival rates for each gender were significantly correlated indicating a possible association between fiscal input and clinical outcomes, which poses problems for the development of effective public health.     

Injuries in relation to chronic disease: an international view of premature mortality.

Injuries are compared with heart disease, cancer, and cerebrovascular disease, using 1980 mortality data for the United States, France, Japan, West Germany and the United Kingdom. Emphasis is on premature mortality, measured by a rate of potential years of life lost between ages one and 65. Injuries are the leading cause of male premature mortality, and rank first, or second to cancer, in females. The United States sustains the greatest injury losses of these five countries.     

The seroepidemiology of Bordetella pertussis infection in Western Europe

High titres of pertussis toxin (PT) antibody have been shown to be predictive of recent infection with Bordetella pertussis. The seroprevalence of standardized anti-PT antibody was determined in six Western European countries between 1994 and 1998 and related to historical surveillance and vaccine programme data. Standardized anti-PT titres were calculated for a series of whole-cell and acellular pertussis vaccine trials. For the serological surveys, high-titre sera (> 125 units/ml) were distributed throughout all age groups in both high- (> 90%) and low-coverage (< 90%) countries. High-titre sera were more likely in infants in countries using high-titre-producing vaccines in their primary programme (Italy, 11.5%; Western Germany, 13.3%; France, 4.3%; Eastern Germany, 4.0%) compared to other countries (The Netherlands, 0.5%; Finland, 0%). Recent infection was significantly more likely in adolescents (10-19 years old) and adults in high-coverage countries (Finland, The Netherlands, France, East Germany), whereas infection was more likely in children (3-9 years old) than adolescents in low-coverage (< 90%; Italy, West Germany, United Kingdom) countries. The impact and role of programmatic changes introduced after these surveys aimed at protecting infants from severe disease by accelerating the primary schedule or vaccinating older children and adolescents with booster doses can be evaluated with this approach.     

The burden of rheumatoid arthritis and access to treatment: uptake of new therapies

This paper presents data on international differences in use of TNF inhibitors. It is part of a study on burden and cost of RA, access to new therapies and the role of HTA in determining access and cost-effectiveness. United States has the fastest most extensive use of the new drugs, about three times the average in the western European countries and Canada. Eastern and central European countries as well as Australia, South Africa and Turkey lag far behind. However, some smaller European countries, most notably Norway and Sweden have use of the new drugs not far behind the United States. While the income level of the country, and thus the health care expenditures per capita is a major factor for determining use in low and middle income countries, there are still considerable differences among countries with similar high total health care expenditures. Differences in prices are considerable between the US and Europe due to the changes in exchange rates between the US dollar and the Euro, but high and low use is not systematically related to differences in price.

     

An overview of pharmaceutical policy in four countries: France, Germany, the Netherlands and the United Kingdom

The regulation of pharmaceutical markets is an important policy concern in many countries, and is generally undertaken with cost containment, efficiency, quality and equity objectives in mind. This article presents an overview of the demand-side and supply-side regulatory measures that have been introduced in four European countries, namely France, Germany, the Netherlands and the United Kingdom. More specifically, after considering some of the trends in pharmaceutical expenditure in these four countries over recent decades, the article considers the policies that have been introduced to influence patient demand, health care provider behaviour and the pharmaceutical industry. Since many of the policies are concurrently applied, it is difficult to assess the isolated impact of each, particularly because the effect of particular policies may often be country specific. However, it is clear that there is no over-riding perfect solution to balancing the cost containment, efficiency, quality and equity objectives in pharmaceutical policy. No one policy or policy combination is right for all countries, and different countries will need to meet their own objectives through policy approaches that reflect their own particular environment.     

Human rights for women: the ethical and legal discussion about Female Genital Mutilation in Germany in comparison with other Western European countries

Within Western European countries the number of women and girls already genitally mutilated or at risk, is rising due to increasing rates of migration of Africans. The article compares legislative and ethical practices within the medical profession concerning female genital mutilation (FGM) in these countries. There are considerable differences in the number of affected women and in legislation and guidelines. For example, in France, Great Britain and Austria FGM is included in the criminal code as elements of crime, whereas in Germany and Switzerland FGM is brought to trial as bodily injury. So far trials only in France and Switzerland in connection with FGM resulted in convictions. France and Great Britain as former Colonial countries serve as an example of countries with a comparably great number of African immigrants. These countries have the best possibilities to intervene preventatively, due to legislation and detailed medical guidelines. For instance, an obligation exists in France to inform administrative and medical authorities if FGM is suspected. FGM so far is not explicitly part of the curriculum for medical training in any of the examined countries.     

The Economic Value of Childhood Varicella Vaccination in France and Germany

OBJECTIVE: To determine the economic impact of childhood varicella vaccination in France and Germany. METHODS: A common methodology based on the use of a varicella transmission model was used for the two countries. Cost data (2002 per thousand) were derived from two previous studies. The analysis focused on a routine vaccination program for which three different coverage rates (CRs) were considered (90%, 70%, and 45%). Catch-up strategies were also analyzed. A societal perspective including both direct and indirect costs and a third-party payer perspective were considered (Social Security in France and Sickness Funds in Germany). RESULTS: A routine vaccination program has a clear positive impact on varicella-related morbidity in both countries. With a 90% CR, the number of varicella-related deaths was reduced by 87% in Germany and by 84% in France. In addition, with a CR of 90%, routine varicella vaccination induces savings in both countries from both societal (Germany 61%, France 60%) and third-party payer perspectives (Germany 51%, France 6.7%). For lower CRs, routine vaccination remains cost saving from a third-party payer perspective in Germany but not in France, where it is nevertheless cost-effective (cost per life-year gained of 6521 per thousand in the base case with a 45% CR). CONCLUSION: Considering the impact of vaccination on varicella morbidity and costs, a routine varicella vaccination program appears to be cost saving in Germany and France from both a societal and a third-party payer perspective. For France, routine varicella vaccination remains cost-effective in worst cases when a third-party payer perspective is adopted. Catch-up programs provide additional savings.     

Incidence of colorectal cancer and influence of dietary habits in fifteen European countries from 1971 to 2002

Objective

This study aimed to analyze the incidence of colorectal cancer in 15 European countries in recent decades and the relationship between the incidence found and changes in dietary habits.

Methods

Pearson's or Spearman's correlation coefficients were calculated by comparing incidence rates obtained from the International Agency for Research on Cancer for 1971-2002 with data on per capita consumption obtained from the Food and Agriculture Organization of the United Nations using 10-year delay intervals.

Results

Incidence rates increased in all countries except France in men and except Austria, Denmark, England and France in women. Of the dietary variables considered, there were marked increasing trends (linear regression coefficient, R ≥0.5) in red meat consumption in Germany (R = 0.9), Austria (R = 0.7), Finland (R = 0.8), Italy (R = 0.9), Poland (R = 0.5), Spain (R = 2.1), Sweden (R = 0.6), and the Netherlands (R = 0.7).

Conclusions

Changes in dietary habits may be consistent with the observed trends in the incidence of colorectal cancer in the distinct European countries.