Seasonal influenza vaccination of healthy working-age adults: a review of economic evaluations

The recent impact of influenza on the working-age population of the US has led to changes in the recommendations for vaccination against seasonal influenza; however, the implications of vaccinating such a population have been debated. A review of cost-effectiveness analyses of vaccinating the working-age population of the US against seasonal influenza was conducted using articles published between January 1990 and January 2010. Studies considered for inclusion were identified using MEDLINE, EMBASE and Econlit. Reviewers worked in pairs, and each team member independently extracted relevant data using a standard abstraction form. The source and appropriateness of parameters (epidemiological data, probabilities and costs), the designs employed and the sufficiency of sensitivity analysis were considered during review. Key inputs extracted from the selected studies included influenza or influenza-like illness attack rates, outpatient visits averted, total vaccination days and lost workdays. Seven studies were identified as appropriate for this review. All studies were conducted in the US and from the societal perspective; three were randomized controlled trials and the remaining four were economic simulation models comparing vaccination and influenza antiviral drugs or no intervention; analyses focused on healthy working-age adults aged 18-49 years. Results ranged from net savings of $US68.96 to net costs of $US85.92 per person vaccinated (four studies) and net costs of $US104-1005 per episode of influenza averted (one study). Only two studies reported cost-effectiveness ratios; these ranged from $US26,565 to $US50,512 per quality-adjusted life-year gained. Nearly all of the studies conducted sensitivity analysis; results were most sensitive to variation in wage rates, levels of worker productivity, the costs and effectiveness of vaccination, and the rate of influenza illness. Review of the included studies suggests that seasonal influenza vaccination of healthy, working-age adults is generally not cost saving, requiring an investment to generate health benefits. The decision to vaccinate such a group will depend upon the societal and payer valuation of those benefits.     

Pharmacoeconomics of influenza vaccination for healthy working adults: reviewing the available evidence

A favourable pharmacoeconomic profile has been well established for influenza vaccination in the elderly. For employers relevant benefits seem to exist for vaccinating healthy working adults to avert absenteeism and related production losses. From a pharmacoeconomic point of view it is relevant to consider whether societal benefits of vaccination for healthy working adults is worthwhile given the costs of vaccination for the community. We searched Medline and Embase using the key words influenza (vaccination) in combination with cost, cost-benefit, cost-effectiveness, efficiency, economic evaluation, health-policy and pharmacoeconomics. From this primary search, we selected 11 studies concerned with the group of healthy working adults. We reviewed these studies according to several criteria: benefit-to-cost (B/C) ratio;vaccine effectiveness, influenza incidence, number of days of work absence due to illness; and relative cost of the vaccine. Three studies on vaccinating healthy working adults found costs exceeding the benefits (B/C-ratio <1). The remaining eight pharmacoeconomic studies found a B/C-ratio of almost two or more. Cost savings are strongly related to the inclusion of indirect benefits related to averted production losses. After exclusion of indirect costs and benefits of production gains/losses, only one of the eight studies remains cost saving. Considering the available pharmacoeconomic evidence, vaccination of healthy working adults in Western countries may be an intervention with favourable cost-effectiveness and cost-saving potentials if indirect benefits of averted production losses are included. Excluding indirect benefits and costs of production losses/gains, cost-saving potentials are limited. Recent international guidelines for pharmacoeconomic research advise the inclusion of production gains and losses in the preferred societal perspective. Hence, on the basis of the available evidence, influenza vaccination of healthy working adults may be recommended from pharmacoeconomic point of view. Pharmacoeconomics do, however, present only one argument for consideration aside from ethical issues, budgetary limits and psychosocial aspects.     

A model to estimate the cost benefit of an occupational vaccination programme for influenza with Influvac in the UK

OBJECTIVES: To model the economic impact of introducing an occupational vaccination programme for influenza with an inactivated influenza subunit vaccine (Influvac) in the UK. DESIGN AND SETTING: Using published sources, a decision tree was constructed which modelled the costs and benefits of introducing an influenza vaccine in a business in the UK from the perspective of an employer. STUDY PARTICIPANTS AND INTERVENTIONS: The model considered the implementation of an occupational vaccination programme with Influvac in a business employing 1000 normal healthy adults earning the national average wage in the UK. The model assumed that 95% of employees would be absent from work after contracting influenza for a mean of 5 days and that the level of productivity would be reduced by 60% for one day by 85% of sick employees returning to work. MAIN OUTCOME MEASURES AND RESULTS: The expected probability of an employee being absent from work following an influenza vaccination would be reduced from 5.7 to 1.8% when the incidence of influenza in the community is 6%. Accordingly, if all 1000 employees were vaccinated, a business would be expected to reduce absenteeism from work attributable to an influenza outbreak by 220 days. Moreover, the expected return on every pound invested by an employer would be UK pounds 1.03, UK pounds 3.09 and UK pounds 5.15 (2000 values) when the annual incidence of influenza in the community is 2, 6 and 10%, respectively. CONCLUSIONS: Implementation of an occupational vaccination programme with Influvac would be expected to reduce the incidence of influenza among a workforce leading to less absenteeism from work and averted lost productivity. Even if the incidence of influenza was as low as 2% it may be a worthwhile investment for UK employers to vaccinate their employees with Influvac.     

Non-traditional settings for influenza vaccination of adults: costs and cost effectiveness

OBJECTIVE: Influenza vaccination rates remain far below national goals in the US. Expanding influenza vaccination in non-traditional settings such as worksites and pharmacies may be a way to enhance vaccination coverage for adults, but scant data exist on the cost effectiveness of this strategy. The aims of this study were to (i) describe the costs of vaccination in non-traditional settings such as pharmacies and mass vaccination clinics; and (ii) evaluate the projected health benefits, costs and cost effectiveness of delivering influenza vaccination to adults of varying ages and risk groups in non-traditional settings compared with scheduled doctor's office visits. All analyses are from the US societal perspective. METHODS: We evaluated the costs of influenza vaccination in non-traditional settings via detailed telephone interviews with representatives of organizations that conduct mass vaccination clinics and pharmacies that use pharmacists to deliver vaccinations. Next, we constructed a decision tree to compare the projected health benefits and costs of influenza vaccination delivered via non-traditional settings or during scheduled doctor's office visits with no vaccination. The target population was stratified by age (18-49, 50-64 and >or=65 years) and risk status (high or low risk for influenza-related complications). Probabilities and costs (direct and opportunity) for uncomplicated influenza illness, outpatient visits, hospitalizations, deaths, vaccination and vaccine adverse events were derived from primary data and from published and unpublished sources. RESULTS: The mean cost (year 2004 values) of vaccination was lower in mass vaccination (dollars US 17.04) and pharmacy (dollars US 11.57) settings than in scheduled doctor's office visits (dollars US 28.67). Vaccination in non-traditional settings was projected to be cost saving for healthy adults aged >or=50 years, and for high-risk adults of all ages. For healthy adults aged 18-49 years, preventing an episode of influenza would cost dollars US 90 if vaccination were delivered via the pharmacy setting, dollars US 210 via the mass vaccination setting and dollars US 870 via a scheduled doctor's office visit. Results were sensitive to assumptions on the incidence of influenza illness, the costs of vaccination (including recipient time costs) and vaccine effectiveness. CONCLUSION: Using non-traditional settings to deliver routine influenza vaccination to adults is likely to be cost saving for healthy adults aged 50-64 years and relatively cost effective for healthy adults aged 18-49 years when preferences for averted morbidity are included.     

Cost-benefit analysis of a Haemophilus influenzae type b meningitis prevention programme in The Philippines

BACKGROUND: Haemophilus influenzae type b (Hib) meningitis is associated with high mortality and serious sequelae in children under 5 years of age. Vaccines which can prevent this infection are available. OBJECTIVE: To evaluate the costs and benefits of a 3-dose immunisation schedule in Manila, Philippines. PERSPECTIVE: Government and societal perspectives. DESIGN AND PARTICIPANTS: A cost-benefit analysis based on a birth cohort of 100,000 children. The state of health of the cohort with and without a Hib immunisation programme was modelled over a 5-year period. A survey of medical records of patients with Hib in Manila provided data on the extent and cost of sequelae following infection. INTERVENTION: A 3-dose Hib vaccination programme given at ages 2, 3 and 4 months. RESULTS: The model predicted that vaccinating children against Hib meningitis would prevent 553 cases per year in a birth cohort of 100,000, at a cost of 56,200 Philippine pesos (PHP) [$US1,605; 1998 exchange rate] per case (base case assumptions of 90% vaccine efficacy rate, 95 per 100,000 Hib incidence rate, 85% vaccination coverage). Results from the cost-benefit analyses indicated that the saving to the government would be around PHP39 million ($US1.11 million), and the saving to society would be PHP255 million ($US7.28 million). CONCLUSION: There would be a positive economic benefit for the Philippine government and for the Filipino society if a Hib vaccination programme was introduced in Manila.     

Economic evaluation of vaccination

With increasing expenditures in healthcare, in absolute terms as well as in relative terms, interest in the efficiency of certain interventions in healthcare has also increased. Faced with the limitations of the healthcare budget, budget holders try to find the optimal way of dividing their funds over different healthcare provisions, without discarding human and medical considerations. In economic terms, this process could be called the 'optimal allocation of scarce resources over the inputs of a function of production'. The means of production would then be 'the provision of healthcare', whereas the output would be 'improvement of health'. Clearly choices have to be made with regard to spending the healthcare budget. One of the instruments that can help in making such choices is the economic evaluation. In economic evaluations of vaccinations, different vaccination strategies are defined. The consequences in terms of costs and effects of each strategy are being calculated and compared with a reference strategy, which is often the nonintervention strategy, i.e. 'no vaccination'. According to the way in which the benefit or the output of vaccination-'improvement of health'-is measured, a distinction is made between various methods of economic evaluation: in a cost-effectiveness analysis, health gains are measured in natural units (e.g. prevented infections, prevented illness days, life-years gained, etc.); in a cost-utility analysis, the quality of the health gains is taken into account (e.g. quality-adjusted life-year); and in a cost-benefit analysis, health gains are converted into monetary units. Costs can be divided into direct and indirect costs. Direct costs are directly related to medical treatments (medication, laboratory tests, consultations, etc.) or to vaccination (e.g. purchasing price of the vaccine, costs for administering the vaccine, treatment of side effects, etc.). Costs indirectly related to treatments and vaccination are mainly costs of lost productivity due to disease morbidity or mortality, and opportunity costs. In comparison with other vaccine-preventable infections, influenza vaccination for the elderly seems acceptable from an economic point of view (about $US650 per life-year gained, in 1981). Cost-effectiveness ratios of other vaccinations range from about $US720 per life-year gained for universal hepatitis B vaccination to about $US190,000 per life-year gained for universal Haemophilus influenzae type by vaccination. Because of differences in methods, the representation of results, and country-specific parameters, different economic evaluations of the same vaccination strategy may show divergent results. Therefore, until sufficient standardisation of economic evaluations exists, comparisons of the sort we are making here should be interpreted with prudence.     

Issues in the economic evaluation of influenza vaccination by injection of healthy working adults in the US: a review and decision analysis of ten published studies

The objective was to review recent economic evaluations of influenza vaccination by injection in the US, assess their evidence, and conclude on their collective findings. The literature was searched for economic evaluations of influenza vaccination injection in healthy working adults in the US published since 1995. Ten evaluations described in nine papers were identified. These were synopsized and their results evaluated, the basic structure of all evaluations was ascertained, and sensitivity of outcomes to changes in parameter values were explored using a decision model. Areas to improve economic evaluations were noted. Eight of nine evaluations with credible economic outcomes were favourable to vaccination, representing a statistically significant result compared with a proportion of 50% that would be expected if vaccination and no vaccination were economically equivalent. Evaluations shared a basic structure, but differed considerably with respect to cost components, assumptions, methods, and parameter estimates. Sensitivity analysis indicated that changes in parameter values within the feasible range, individually or simultaneously, could reverse economic outcomes. Given stated misgivings, the methods of estimating influenza reduction ascribed to vaccination must be researched to confirm that they produce accurate and reliable estimates. Research is also needed to improve estimates of the costs per case of influenza illness and the costs of vaccination. Based on their assumptions, the reviewed papers collectively appear to support the economic benefits of influenza vaccination of healthy adults. Yet the underlying assumptions, methods and parameter estimates themselves warrant further research to confirm they are accurate, reliable and appropriate to economic evaluation purposes.     

Review of cost-benefit analyses of influenza vaccine

Vaccination is an underutilised, low cost and effective method of preventing illness. Cost-effectiveness analysis discloses a beneficial role of influenza vaccination in preventing illness especially in patients over 65 years of age and in high risk patients. In one large study, when 150 million doses of influenza vaccine were given between 1971 and 1977 in the US, over 13 million more years of life were gained at a cost of only $US63 per year of life gained (1978 dollars). The vaccination programmes also resulted in productivity gains of approximately 5 million days which was valued at $US250 million. Other studies from Canada, Finland and the US found similar benefits. The findings of these studies are reviewed. In order to increase the use of influenza immunisation substantially, there has to be a greater acceptance of the value of immunisation by healthcare providers and the public.     

Universal vaccination of healthy children against influenza: a role for the cold-adapted intranasal influenza vaccine

The incidence of influenza in children well exceeds that of the elderly and has been identified as the basis for 20% of doctor visits for children during the winter. The disease results in over 100 hospitalizations per 100000 person-months in children <2 years of age. Furthermore, children serve as the major vector in the community; thus, influenza in children results in significant costs to society. Although efficacious, the current intramuscular, inactivated influenza vaccine is infrequently used in children, and is currently targeted only at children at high risk and those who are household members of such individuals. Experts believe that vaccinating only high risk individuals has little impact on the cycle of annual epidemics, but that universal vaccination of children may very well have a substantial impact. Experimental data support this. A recently published cost-benefit analysis indicated that routine, school-aged vaccination through individual visits to a clinician would save 4 US dollars per child vaccinated. A group program such as a school-based one would save 35 US dollars. One obstacle to universal vaccination includes the real and perceived resistance to the addition of yet another annual injection to the already crowded schedule of routine childhood immunizations. Nearing licensure is an intranasal, live attenuated, cold-adapted intranasal influenza vaccine. Cold-adaptation prevents replication in the lower respiratory tract. Trials have demonstrated immunogenicity, safety, and tolerability in adults as well as children. Placebo-controlled trials have shown efficacy rates of 83 to 94%. This novel vaccine addresses obstacles to universal childhood immunization and would permit a program of routine use that would dramatically reduce transmission and stem epidemics of influenza.     

Cost-benefit analysis of riluzole for the treatment of amyotrophic lateral sclerosis

We conducted a cost-benefit analysis of riluzole therapy in patients with amyotrophic lateral sclerosis (ALS; motor neuron disease; Lou Gehrig's disease). The survival of patients with ALS increased by around 3 months as a result of riluzole therapy, from 3 to 3.25 years. A 3-month delay in hospitalisation was also expected as a result of riluzole therapy, resulting in a saving of $US40 per patient (1996 values). This gain was opposed by the additional costs per patient of bi-monthly serum ALT monitoring ($US234), 2 days of extra day-hospital observation ($US369) and other medical costs ($US79), as well as extra outpatient visits ($US26) and costs of medication other than riluzole ($US90), resulting from increased longevity. Using riluzole (at a cost of $US2247 per patient) resulted in an extra burden of $US757 on health services for the gain of an extra 3 months of life expectancy. Thus, health-service costs per life-year gained were $US12,013. Despite the increase in health-service costs as a result of increased longevity, the overall resource benefits to society from using riluzole amounted to $US2884 due to increased productivity benefits, giving a benefit: cost ratio of 1.28:1. Total benefits to society, including a valuation of 3 extra months of life ($US3599), amounted to $US6483, giving a benefit: cost ratio of 2.89:1. Therefore, from a societal perspective, the potential benefits of riluzole in patients with ALS clearly exceed costs.     

Economic evaluation of vaccination against influenza in New Zealand

The objective of this study was to evaluate the costs and benefits of influenza vaccination for the population aged 65 years and over, from the perspectives of individuals and health insurers, government and society. The annual incremental direct medical costs and benefits of influenza vaccination (compared with the nonvaccination, or 'do nothing', option) were evaluated using New Zealand healthcare resource usage and unit cost data [in 1992 New Zealand dollars ($NZ); $NZ1 = $US0.5458, June 1992] applied to cohort studies reported in the literature. The costs and benefits to society as a result of vaccination of people aged 65 years and older (20% of people in this age group are currently vaccinated) were estimated to be: (i) additional direct medical costs of vaccination of $NZ1.42 million [$NZ17.78 per vaccination]; (ii) direct medical costs avoided of $NZ5.35 million ($NZ67.18 per vaccination); and (iii) net benefits of $NZ3.93 million ($NZ49.40 per vaccination). The direct medical costs avoided per dollar cost of vaccination were $NZ1.04 for individuals, $NZ4.69 for government and $NZ3.78 for society as a whole. If the vaccination uptake for this group is increased in 20% increments, the net benefit to society increases by a further $NZ3.93 million per year at each step. If the economic evaluation is extended to include vaccination of at-risk individuals under 65 years of age, net benefits to society increase by 15%. Influenza vaccination for people aged 65 years and over is cost effective from the perspective of society, government and the individual. If the vaccination rate for at-risk individuals in New Zealand could be increased to 60%, the net benefits reported in this study would increase by 200%. However, the costs of promotion and education to achieve this vaccination rate would need to be deducted from the net benefits. Strategies to increase the vaccination rate include altering the cost of vaccinations to the individual, intensifying education and promotion programmes, and changing the mode of delivery.     

Cost-effectiveness of adjuvanted influenza vaccination of healthy children 6 to 60 months of age

This study estimated the health and economic outcomes of universal administration of a adjuvanted influenza vaccine to healthy preschool children, as compared with current immunization practice. A Markov model simulated a cohort of 3 million children and their households undergoing five influenza seasons. Assuming a vaccine uptake rate of 30%, at the current acquisition cost of Euro 5.50 per vaccine dose influenza vaccination (two doses for unprimed children) of 6- to 60-month- (5-year) old children averted more than 1 million clinical influenza episodes and saved Euro 63 million, from the perspective of the Italian society. From the perspective of the Italian health care service, influenza vaccination of 6- to 60- and of 6- to 24-month-old children cost Euro 10,000 and Euro 13,333 per quality-adjusted life year (QALY) saved, respectively. Administration of a adjuvanted influenza vaccine to children aged 6 to 60 months was highly cost-effective for the health care service and cost saving for the society.     

Cost-effectiveness analysis of pneumococcal vaccination for elderly individuals in The Netherlands

OBJECTIVE: To assess the cost effectiveness (net costs per life year gained) of pneumococcal vaccination of elderly individuals aged 65 years and over in The Netherlands. DESIGN AND SETTING: A pharmacoeconomic analysis was conducted from the healthcare perspective in The Netherlands. The gender- and age-specific modelling framework linked epidemiological aspects of invasive pneumococcal disease (e.g. incidence, mortality, life years lost) to vaccination and hospital resource use. To derive 90% confidence limits for net costs per life year gained a stochastic analysis was performed. INTERVENTION: Pneumococcal vaccination in the elderly with the 23-valent vaccine. Effectiveness of the vaccine in preventing invasive pneumococcal disease was derived from international studies. MAIN OUTCOME MEASURES AND RESULTS: Pneumococcal vaccination in the elderly was not found to be cost saving. At baseline, stochastic and univariate sensitivity analysis net costs per life year gained were estimated to be between 6000 and 16,000 euro (EUR) [EUR1 = 1.1 US dollars; cost level 1995]. A scenario analysis on alternative age-dependent vaccination strategies indicated even higher net costs per life year gained, up to EUR28,000 for vaccinating only those elderly aged 85 years and over. CONCLUSIONS: Pneumococcal vaccination is associated with net costs per life year gained of EUR10,100 (at baseline assumptions). These costs are higher than those for influenza vaccination (EUR5500). Our pharmacoeconomic approach, which needs to be considered in conjunction with social, psychological and budgetary issues, is intended to contribute to rational decision-making in healthcare policy.     

Pharmacoeconomics of influenza vaccination in the elderly: reviewing the available evidence

Most western countries have influenza vaccination programmes for citizens aged > or = 65 years. This paper reviews the available evidence on whether elderly influenza vaccination is worthwhile from a pharmacoeconomic point of view. A search on Medline and EMBASE resulted in a primary selection of approximately 100 studies on the pharmacoeconomics of influenza vaccination in the elderly. Further selection of studies to be included in the review was based on several criteria such as original research paper, cost-benefit or cost-effectiveness analysis. influenza vaccination in the elderly, and publication between 1980 and 1999. The 10 studies included in the final selection were evaluated regarding 3 main aspects: benefit-cost ratio and cost-effectiveness ratio; vaccine effectiveness; and relative costing of the vaccine. In general, differences in benefit-cost ratios could be explained by differences in effectiveness and relative costing of the vaccine. Considering the available pharmacoeconomic evidence, influenza vaccination of the elderly in western countries is an intervention with favourable cost-effectiveness in terms of net costs per life-year gained and even has cost-saving potential. In particular, influenza vaccination among elderly people at higher risk, such as the chronically ill elderly, is generally found to be cost saving. Relatively favourable cost-effectiveness among non-high-risk elderly justifies universal influenza vaccination of the elderly from a pharmacoeconomic point of view.     

Cost effectiveness of pneumococcal vaccination for infants and children with the conjugate vaccine PnC-7 in Germany

BACKGROUND: The introduction of the conjugate vaccine PnC-7 implies that a pneumococcal vaccine is available, for the first time, which also gives children under the age of 2 years reliable protection against invasive pneumococcal infections and offers some protection against non-invasive pneumococcal infections. OBJECTIVE AND PERSPECTIVE: In the context of a multiple-period Markov model, a cost-effectiveness analysis of a recommendation for general pneumococcal vaccination in Germany for infants and children under the age of 2 years was performed from the healthcare payer, public authority and societal perspectives. DESIGN: Various published data on age-specific incidence rates, mortality rates, efficacy of the conjugate vaccine PnC-7 and treatment costs of pneumococcal infections were incorporated into a Markov model to quantify the consequences of vaccinating versus not vaccinating. RESULTS: From a German healthcare payers' perspective, general vaccination with the conjugate vaccine would redeem 51.1% of the vaccination costs due to avoidable treatment costs, whereas, from a broader point of view, the benefits, expressed in monetary terms, would exceed the cost of vaccination. The conjugate vaccine would require an investment of euro72 866 per life-year saved (discounted, healthcare payers' viewpoint). Besides this benchmark, there are further outcome measures which cannot be ignored by those deciding on a general vaccination recommendation: 450 000 preventable episodes of illness and 134 cases of sequelae which can be prevented. CONCLUSIONS: The vaccination with the conjugate vaccine PnC-7 is cost saving from a broader perspective and the results should not be ignored by policy makers in regard to a general vaccination recommendation.     

Household income losses associated with ischaemic heart disease for US employees

OBJECTIVE: To estimate the cost of lost work days due to ischaemic heart disease (IHD), and the cost of this reduced productivity using reduction in household income. DESIGN AND SETTING: Using 2 years of nationally representative observational data, this study examined the effect on household income of IHD. This effect was estimated after accounting for unemployment, days lost to illness and other effects of illness on the income of workers aged 18 to 64 years. MAIN OUTCOME MEASURES AND RESULTS: Previous measures of indirect costs of disease have typically not included the loss in productivity due to suboptimal work performance. Among workers in this age group, IHD was associated with a reduction of $US3013 in annual household income; this reduction was independent of occupational class, age, size of household and educational level. Such a reduction may be because of reduced on-the-job performance, employer perception of this, or unrelated lifestyle choices. It represents an estimated $US6.05 billion annual loss in productivity in 1992 dollars (or $US6.45 billion in 1996 dollars). CONCLUSIONS: Estimates of the indirect costs of chronic disease that do not account fully for the lost income of employees may significantly underestimate the benefits to employers and society of treatment and prevention.     

Cost-of-illness of epilepsy in Italy. Data from a multicentre observational study (Episcreen)

OBJECTIVE: To investigate the impact of epilepsy in Italy on healthcare resources, producing an average cost per patient per year of follow-up. DESIGN AND SETTING: The Episcreen Project is a multicentre longitudinal Italian observational study; its methodology, organisational network and case report form have been reported in detail elsewhere. Using a subset of patients with epilepsy from this project, we conducted a retrospective cost-of-illness analysis based on clinical records. The analysis was performed from the societal (community) perspective, including both direct and indirect costs. Hospital admissions, day-hospital visits, specialist visits, instrumental examinations, drugs and productivity losses because of visits and hospitalisation were analysed. Each cost variable was valued in 1996 Italian liras (L) using published national tariffs (except for drugs for which published prices were used). A sensitivity analysis was conducted on indirect costs to test the robustness of the assumption that 1 working day lost for each day hospital visit would produce a change of 0.3% in the weight of indirect costs. PATIENTS AND PARTICIPANTS: Patients analysed in this study were registered in the Episcreen database as at 21 November 1996. They were diagnosed with epilepsy at the last visit, had at least 1 follow-up visit (i.e. at least 1 visit after the enrolment visit), and had at least 12 months of follow-up. RESULTS: The average cost per patient per year was L2,726,116 ($US1767). The average cost per patient was higher for children than for adults [L3,629,997 ($US2353) and L2,362,134 ($US1531), respectively), and for newly diagnosed patients for whom the first diagnosis of epilepsy was addressed at the first Episcreen visit [adults: old referrals L1,304,353 ($US845), new referrals L6,901,374 ($US4473); children: old referrals L2,810,504 ($US1822), new referrals L7,814,400 ($US5065)]. Direct costs represented 87.6% of total costs. The major cost driver was hospitalisation (63.7%), followed by drugs (10.5%), day-hospital visits (4.1%), out-patient visits (3.85%), other tests (3.1%) and electroencephalographs (2.3%). Indirect costs (lost productivity) represented 12.4% of total costs. Sensitivity analysis showed that the results are sensitive to the value attributed to lost productivity. CONCLUSIONS: The cost of managing a patient with epilepsy in Italy is influenced by age, syndrome and modality of referral to the centre for epilepsy.     

The cost of gastro-oesophageal reflux disease, dyspepsia and peptic ulcer disease in Sweden

BACKGROUND AND OBJECTIVE: Dyspepsia, peptic ulcer disease (PUD) and gastro-oesophageal reflux disease (GORD) involve a substantial cost to Swedish society. There is a lack of up-to-date nationwide cost estimates after 1985. This study was conducted to present a comprehensive and updated cost analysis and study the change over time of the national cost of these disorders. DESIGN AND SETTING: Primarily, data from National Swedish databases and secondly, data from databases from the County of Uppsala for 1997 were used for the calculations and estimations. PERSPECTIVE: Swedish societal perspective. RESULTS: The total cost to Swedish society of dyspepsia, PUD and GORD in 1997 was $US424 million, or $US63 per adult. Direct costs totalled $US258 million (61%) while indirect costs totalled $US166 million (39%). The highest proportions of costs were due to drugs and sick leave, these being 37 and 34%, respectively. CONCLUSIONS: The cost of dyspepsia and GORD is substantial for patients, health providers and society. Since 1985, drug costs have increased substantially while the cost of sick leave has decreased.     

Economic assessment of the secondary prevention of ischaemic events with lysine acetylsalicylate

OBJECTIVE: To analyse the economic benefits, in comparison with placebo, of the secondary prevention of ischaemic stroke and myocardial infarction (MI) with lysine acetylsalicylate (Kardégic) in patients with a history of ischaemic stroke, MI or stable and unstable angina pectoris. DESIGN AND SETTING: This was a modelling study from the perspectives of direct medical costs, the social security system and society in France. METHODS: Efficacy data for the secondary prevention of ischaemic events were derived from the Antiplatelet Trialists' Collaboration meta-analysis on antithrombotics. The rates and costs of ischaemic disease and of serious gastrointestinal adverse affects arising from long term aspirin treatment, as well as the costs of treatment with lysine acetylsalicylate, were taken from published sources, using French data where possible. RESULTS: From the social security perspective, the estimated cost-effectiveness ratios show that the prevention of MI in patients with a history of unstable angina (with a 1-year follow-up) is a cost-saving strategy, with net benefits ranging from $US5703 (1996 prices) per avoided MI for lysine acetylsalicylate 300 mg/day to $US5761 per avoided MI for lysine acetylsalicylate 75 mg/day. The prevention of MI and stroke is also a cost-saving strategy in patients with prior MI [net benefits in a 2-year follow-up (5% discount rate) ranging from $US15 to $US494 per avoided MI and from $US37 to $US1170 per avoided stroke]. This was also true in patients with prior ischaemic stroke (net benefits in a 3-year follow-up ranging from $US610 to $US2082 per avoided MI and from $US176 to $US599 per avoided stroke). Finally, a 4-year follow-up in patients with a history of stable angina pectoris shows that prophylactic treatment with lysine acetylsalicylate is associated with net costs per avoided MI, ranging from $US4375 to $US3608 per avoided event. Sensitivity analysis confirmed that prophylaxis with lysine acetylsalicylate in patients at high risk of cardiovascular and cerebrovascular events results in savings in social security expenditure. CONCLUSIONS: Our results underline the high economic benefit of using lysine acetylsalicylate to prevent secondary ischaemic stroke and MI in patients at high risk of cardiovascular and/or cerebrovascular events, leading to savings for the social security system and society.