Defining the “Health Benefit Basket” in nine European countries

The criterion of medical need figures prominently in the Dutch model for reimbursement decisions as well as in many international models for health care priority setting. Nevertheless the conception of need remains too vague and general to be applied successfully in priority decisions. This contribution explores what is wrong with the proposed definitions of medical need and identifies features in the decision-making process that inhibit implementation and usefulness of this criterion. In contrast to what is commonly assumed, the problem is not so much a failure to understand the nature of the medical need criterion and the value judgments involved. Instead the problem seems to be a mismatch between the information regarding medical need and the way in which these concerns are incorporated into policy models. Criteria—medical need, as well as other criteria such as effectiveness and cost-effectiveness—are usually perceived as hurdles, and each intervention can pass or fail assessment on the basis of each criterion and therefore be included or excluded from public funding. These models fail to understand that choices are not so much between effective and ineffective treatments, or necessary and unnecessary ones. Rather, choices are often between interventions that are somewhat effective and/or needed. Evaluation of such services requires a holistic approach and not a sequence of fail or pass judgments. To improve applicability of criteria that pertain to medical need we therefore suggest further development of these criteria beyond their original binary meaning and propose meaningful ways in which these criteria can be integrated into policy decisions.     

Hospital care for p ersons with AIDS in European‐Union countries; a cross‐country comparison

This paper compares AIDS hospital care in several European‐Union countries. For this purpose hospital‐care utilisation studies on inpatient days and outpatient contacts were analysed in a generic approach controlling for severity stages of AIDS. Lifetime hospital‐care needs for AIDS are derived, providing useful information for health‐care policy makers. In a next step, lifetime estimates are linked to estimated annual new cases of AIDS, resulting from standardised epidemiological modelling. These results on AIDS impact at the population level are reported including statistical confidence limits. Both lifetime hospital‐care needs at the patient level and AIDS impact at the population level are compared between countries and related to characteristics of the national AIDS epidemics and health‐care systems. A person with AIDS has a contact – either inpatient day or outpatient visit – with the hospital in 14% (UK) to 24% (France) of the days spent in the AIDS stage. Related to the national AIDS epidemics (epidemiological impact), Italy and Greece have high levels of outpatient contacts per million population. Estimated hospital‐bed needs for AIDS in 1995 are up to 2.13% (in Spain) of total national acute‐care hospital beds available. Estimated per‐capita needs for outpatient visits in 1995 are highest in Italy, corresponding to 108 doctor full‐time equivalents. In a case‐study for Greece and The Netherlands, differences in hospital‐care utilisation patterns were assessed to correspond with differences in their health‐care systems (number of hospital beds, doctors and nurses per capita and some qualitative characteristics of medical care in both countries). International comparison of AIDS hospital care is possible using standardised analysis of national hospital‐care utilisation data and standardised epidemiological modelling. Estimates of lifetime hospital‐care needs are an essential input for cost‐effectiveness analyses used to aid health‐care policy decision‐making. This revised version was published online in July 2006 with corrections to the Cover Date.     

Are costs derived from diagnosis-related groups suitable for use in economic evaluations? A comparison across nine European countries in the European Healthcare and Social Cost Database

The European Journal of Health Economics - Economic evaluation of health technologies requires healthcare resources, procedures and services to be valued at their opportunity cost. In practice,...     

Development of voluntary private health insurance in Nordic countries – An exploratory study on country-specific contextual factors

The Nordic countries are healthcare systems with tax-based financing and ambitions for universal access to comprehensive services. This implies that distribution of healthcare resources should be based on individual needs, not on the ability to pay. Despite this ideological orientation, significant expansion in voluntary private health insurance (VPHI) contracts has occurred in recent decades. The development and role of VPHIs are different across the Nordic countries. Complementary VPHI plays a significant role in Denmark and in Finland. Supplementary VPHI is prominent in Norway and Sweden. The aim of this paper is to explore drivers behind the developments of the VPHI markets in the Nordic countries. We analyze the developments in terms of the following aspects: the performance of the statutory system (real or perceived), lack of coverage in certain areas of healthcare, governmental interventions or inability to reform the system, policy trends and the general socio-cultural environment, and policy responses to voting behavior or lobbying by certain interest groups. It seems that the early developments in VPHI markets have been an answer to the gaps in the national health systems created by institutional contexts, political decisions, and cultural interpretations on the functioning of the system. However, once the market is created it introduces new dynamics that have less to do with gaps and inflexibilities and more with cultural factors.     

Is Europe still heading to a common price level for on-patent medicines? An exploratory study among 15 Western European countries

Background

Previous studies have suggested that medicines prices in Europe converge over time as a result of policy measures such as external price referencing.

Objective

To explore whether ex-factory prices of on-patented medicines in Western European countries have converged over a recent period of time.

Methods

Prices of ten on-patent medicines in five years (2007, 2008, 2010, 2011, 2012) of 15 European countries were analyzed. The unit of analysis was the ex-factory price in Euro per defined daily dose (exchange rate indexed to 2007). A score (deviation from the average price) per country as well as the ranges were calculated for all medicines.

Results

The prices between countries and selected products varied to a great extent from as low as an average price of € 1.3/DDD for sitagliptin in 2010–2012 to an average of € 221.5/DDD for alemtuzumab in 2011. Between 2008 and 2012, a price divergence was seen which was fully driven by two countries, Germany (up to 27% more expensive than the average) and Greece (up to 32% cheaper than the average). All other countries had stable prices and centered around the country average. Prices of less expensive as well as expensive medicines remained relatively stable or decreased over time, while only the price of sirolimus relatively increased.

Conclusions

Our study period included the time of the recession and several pricing policy measures may have affected the prices of medicines. Instead of the expected price convergence we observed a price divergence driven by price changes in only two of the 15 countries. All other European countries remained stable around the country average. Further research is needed to expand the study to a bigger sample size, and include prescribing data and Eastern European countries.     

Are different measures of self-rated health comparable? An assessment in five European countries

Objective: Self-rated health (SRH) is widely used to compare population health across countries, but comparability is often hampered by the use of different versions of this item. This study compares the WHO recommended version (ranging from ‘very good’ to ‘very bad’) with the US version (ranging from ‘excellent’ to ‘poor’) in European countries. Methods: Data came from the Survey of Health, Ageing and Retirement in Europe (SHARE). Both the WHO and US versions of SRH were measured in representative samples of Europeans aged 50+ (n = 11,643) in five countries. Concordance between the two SRH versions and differences in their associations with demographics, chronic diseases, functioning and depression were assessed using ordered probit regression. Results: The US version has a more symmetric distribution and larger variance than the WHO version. Although the WHO version discriminates better at the positive end, the US version shows better discrimination at the positive end of the scale. Sixty-nine percent of respondents provided literally concordant answers, while only about one-third provided relatively concordant answers. Overall, however, less than 10% of respondents were discordant in either sense. The two versions were strongly correlated (polychoric correlation = 0.88), had similar associations with demographics and health indicators, and showed a similar pattern of international variation. Conclusion: Health levels based on different measurements of SRH are not directly comparable and require rescaling of items. However, both versions represent parallel assessments of the same latent health variable. We did not find evidence that the WHO version is preferable to the US version as standard measure of SRH in European countries.     

What are the motivating and hindering factors for health professionals to undertake new roles in hospitals? A study among physicians,nurses and managers looking at breast cancer and acute myocardial infarction care in nine countries

BackgroundMany European countries experience health workforce skill-mix changes due to population ageing, multimorbidity and medical technology. Yet, there is limited cross-country research in hospitals.MethodsCross-sectional, observational study on staff role changes and contributing factors in nine European countries. Survey of physicians, nurses and managers (n = 1524) in 112 hospitals treating patients with breast cancer or acute myocardial infarction. Group differences were analysed across country clusters (skill-mix reform countries [England, Scotland and the Netherlands] versus no reform countries [Czech Republic, Germany, Italy, Norway, Poland and Turkey]) and stratified by physicians, nurses and managers, using Chi-squared, Mann-Whitney U and Kruskal Wallis tests.ResultsNurses in countries with major skill-mix reforms reported more frequently being motivated to undertake a new role (66.5%) and having the opportunity to do so (52.4%), compared to nurses in countries with no reforms (39.2%; 24.8%; p < .001 each). Physicians and nurses considered intrinsic motivating factors (personal satisfaction, use of qualifications) more motivating than extrinsic factors (salary, career opportunities). Reported barriers were workforce shortages, facilitators were professional and management support. Managers’ recruitment decisions on choice of staff were mainly influenced by skills, competences and experience of staff.ConclusionManagers need to know the motivational factors of their employees and enabling versus hindering factors within their organisations to govern change effectively.     

Parental attitudes and decision-making regarding MMR vaccination in an anthroposophic community in Sweden – A qualitative study

Measles outbreaks occur regularly throughout Europe, up to 31 500 cases in the previous year, particularly where there are pockets of populations with lower vaccination coverage than the recommended ≥95%. Anthroposophic communities in Europe are one of several groups with relatively low vaccination coverage. In Sweden, outbreaks of measles and rubella were reported from an anthroposophic community. Thus the aim of this qualitative study was to explore facilitators and barriers to MMR vaccination among parents living in anthroposophic communities in Sweden. Twenty parents living in an anthroposophic community were interviewed, focusing on their views and decisions on MMR vaccination. The interviews were analyzed using qualitative content analysis. Two overarching views of health emerged, differentiating broadly parents who vaccinate vs. parents who do not vaccinate. Four themes describing parental attitudes toward measles vaccination were developed and three of these, the conformers, the pragmatists and the attentive delayers describe different approaches toward vaccinations among those who actually vaccinate. The last theme, promoters of natural immunity, represents those postponing or refusing vaccination beyond childhood. This study suggests that there is a spectrum of parental beliefs regarding MMR vaccination in this anthroposophic community. Interventions specifically targeted to the anthroposophic community and strengthening health workers capacity for a constructive dialog on vaccine's benefit and risks may contribute to higher vaccination coverage. This is believed to minimize the risk of future epidemics and contribute to the WHO European Region's goal of eliminating measles.     

How is informed decision-making about breast cancer screening addressed in Europe? An international survey of 28 countries

The aim of this study was to develop a typology of approaches towards informed decision-making (IFD) about mammography screening in Europe. All countries collaborating in the European Commission Initiative on Breast Cancer were approached to participate. Experts from 28 European countries responded to a web-based survey providing data on key organisational and policy characteristics of breast screening at the national or regional level. A total of 35 responses were received including data from regionally organised breast screening in several countries. 27 respondents, covering 21 countries, reported the existence of a policy towards IFD and stated that they communicated to women about the benefit and risks. Few countries had attempted to measure the proportion of women making an informed choice. A cluster analysis of the survey responses allowed to identify three categories: countries in a confirmation phase who have adopted a policy specific to mammography screening; countries in an implementation phase with generic polices and limited administrative support dedicated yet to IFD; and countries in a decision phase who are deliberating how to address IFD. To the best of our knowledge, this study is the first to investigate the key policy and organisational characteristics of approaches taken to facilitate IFD in Europe. The results demonstrate a broad adoption of the principle of enabling IFD but indicate heterogeneity of implementation.     

The role of travel in measles outbreaks in Australia – An enhanced surveillance study

Many developed countries, like Australia, maintain a high population level immunity against measles, however, there remains a risk of acquisition of measles in non-immune travellers and subsequent importation into Australia leading to localised outbreaks. In this study, we estimate the incidence of measles and describe characteristics including immunisation and pre-travel health seeking behaviour of notified cases of measles in New South Wales and Victoria, Australia between February 2013 and January 2014. Cases were followed up by telephone interview using a questionnaire to collect information of demographic and travel characteristics. In NSW, the incidence was highest in age group 0–9 years (20/million population) whereas in Victoria the highest incidence was observed in 10–19 (23/million population) years group. Out of 44 cases interviewed, 25 (56.8%) had history of travel outside of Australia during or immediately prior to the onset of measles. Holiday (60%) was the main reason for travel with 44% (11/25) reporting visiting friends and relatives (VFR) during the trip. The major reason described for not seeking prior medical advice before travel were “no perceived risk of diseases” (41%) and “previous overseas travel without any problem” (41%). Of the 25 measles cases with recent overseas travel during the incubation period, one reported a measles vaccine prior to their recent trip. Four cases were children of parents who refused vaccination. Twenty out of 25 (80.0%) had attended mass gathering events. Young adults and VFR travellers should be a high priority for preventive strategies in order to maintain measles elimination status.     

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.     

Is the internet filling the sexual health information gap for teens? An exploratory study

At the same time that there was a decline in comprehensive school-based sex education, adolescents' use of the Internet became nearly universal. This study explores adolescents' use and evaluation of the Internet for sexual health information, with a focus on the issues of contraception and abstinence. The authors conducted 58 in-depth interviews with juniors and seniors in 3 public high schools in New York City and Indiana. Most of the adolescents used the Internet on a daily basis, but few considered it a main source of information about contraception or abstinence. Students were more likely to rely on and had greater trust in traditional sexuality education sources such as school, family members, and friends. Most of the adolescents the authors interviewed were wary of sexual health information on the Internet, and the authors describe strategies adolescents used to sort through the abundance of sex-related material. Formal and informal efforts to provide sexuality education to adolescents should include specific age- and content-appropriate Web sites because many teens are not actively searching on their own, and they express reservations about relying on the Internet as a source of sexual health information.     

Caregiver education in Parkinson’s disease: formative evaluation of a standardized program in seven European countries

Purpose  

The formative evaluation of a standardized psychosocial education program for patients with Parkinson’s disease (PD) and their caregivers. The results of the participation of the caregivers are presented next to the data of the patients.     

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.     

The risk of subjective symptoms in mobile phone users in Poland – An epidemiological study

Objectives

To assess the type and incidence of subjective symptoms related to the use of mobile phones in Polish users.

Material and Methods

The study was conducted in 2005 using a questionnaire survey. Although it has been quite a long time, up to now, no such data have been published for Poland. The questionnaire consisted of 53 questions concerning sex, age, education, general health, characteristics of a mobile phone (hand-held, loud-speaking unit) as well as the habits associated with its use (frequency and duration of calls, text messages, etc.) and complaints associated with using a mobile phone.

Results

As many as 1800 questionnaires were sent. The response was obtained from 587 subjects aged 32.6±11.3 (48.9% women, 51.1% men); the age did not differ significantly between men and women. The subjects owned a cell phone for an average of 3 years. Majority of the respondents used the phone intensively, i.e. daily (74%) or almost daily (20%). Headaches were reported significantly more often by the people who talked frequently and long in comparison with other users (63.2% of the subjects, p = 0.0029), just like the symptoms of fatigue (45%, p = 0.013). Also, the feeling of warmth around the ear and directly to the auricle was reported significantly more frequently by the intensive mobile phone users, compared with other mobile phone users (47.3%, p = 0.00004 vs. 44.6%, p = 0.00063, respectively). Most symptoms appeared during or immediately after a call and disappeared within 2 h after the call. Continuous headache, persisting for longer than 6 h since the end of a call, was reported by 26% of the subjects.

Conclusions

Our results show that the mobile phone users may experience subjective symptoms, the intensity of which depends on the intensity of use of mobile phones.