Societal discounting of health effects in cost-effectiveness analyses: the influence of life expectancy

BACKGROUND: Increasing life expectancy and decreasing marginal valuation of additional QALYs over time may serve as a basis for discounting future health effects from a societal perspective. Therefore, we tested the hypothesis that societal time preference for health is related to perceived future life expectancy. METHODS: A sample of 223 people from the general population prioritised healthcare programmes with differential timing of health benefits and costs from a societal perspective. Furthermore, we asked respondents to estimate future life expectancy. RESULTS: The relationship between future life expectancy and time preference for health is ambiguous. We observed that people who expected a higher future life expectancy elicited higher discount rates for health effects than those with lower life expectancy growth expectations for all four time periods (5, 10, 20 and 40 years into the future), but the differences were never significant. On average, providing explicit information on growth in life expectancy did significantly alter discount rates in the expected direction but, on an individual level, the results were rather inconsistent. We observed a significantly stronger time preference (i.e. higher discount rates) for health effects than for costs. As commonly observed, discount rates for health and money decreased with time delay following a hyperbolic function. CONCLUSION: Our data indicate that it is troublesome to elicit societal discount rates empirically, especially rates that are in line with the theoretical arguments on societal discounting. The influence of life expectancy remains ambiguous, but there seems to be at least some positive relationship between growth in life expectancy and discount rates that deserves additional attention.     

Economic valuation of informal care: the conjoint measurement method applied to informal caregiving

This paper reports the results of the application of the conjoint measurement method (CM) to determine a monetary value of informal care. Compared to the normally recommended valuation methods, like the opportunity cost method and proxy good method, CM is probably better able to capture the heterogeneity of informal care. We developed a survey in which informal caregivers were asked to rate four different hypothetical informal caregiving situations, which differed with respect to care hours, care tasks and monetary compensation. Data were obtained from postal surveys. A total of 135 pairs of informal caregivers and care recipients with rheumatoid arthritis (RA) from the Netherlands returned a completed survey and were used in the analysis. Informal caregivers require an extra compensation of 1.00 euro per hour for providing one additional hour of the same informal care task (meaning that from the seventh to the eighth hour, they require 8 euro). For providing two extra hours of care, they require 2.00 euro compensation per hour. The relative valuation of informal care tasks is very diverse. Respondents require a compensation of 13.43 euro per hour for switching from providing light housework to personal care and 0.56 euro per hour for switching from providing personal care to heavy housework. Though CM is sometimes regarded as cognitively complex, 70% of the respondents were able and willing to evaluate the hypothetical caregiving scenarios. Elderly respondents especially had more difficulty with the method. In sum, CM is seen as a promising alternative for existing methods to determine a monetary value of informal care. The presented valuations of informal care can be incorporated in the numerator of a cost-effectiveness ratio in economic evaluations of health care.     

Dietary vitamin E does not inhibit the promotion of liver carcinogenesis by polychlorinated biphenyls in rats

In this study, the effect of dietary vitamin E on the hepatic tumor-promoting activity of PCB-77 and PCB-153 in female Sprague-Dawley rats (175-200 g) was investigated. One week after diethylnitrosamine injection, rats were fed purified diets containing 10, 50, or 250 mg/kg vitamin E in the form of alpha-tocopheryl acetate. Starting 1 wk later, we injected rats i.p. with vehicle (corn oil) or PCB-77 or PCB-153 (300 mumol/kg) every 14 d for 4 injections. All rats were killed 10 d after the last PCB injection. The number and volume of placental glutathione S-transferase (PGST)-positive foci were increased by PCB-77 but not by PCB-153. Vitamin E did not affect the induction of PGST-positive foci. PCB-77, but not PCB-153, increased hepatic NF-kappaB activity. In conclusion, dietary vitamin E supplementation does not protect against the induction of altered hepatic focal lesions by PCBs.     

Pancreatic pseudocyst simulating perinephric abscess

A case of pseudocyst of the pancreas simulating perinephric abscess is described. This condition is rare compared with most reported cases of pseudocyst causing pyelographic abnormalities by extrinsic compression. Spontaneous rupture of the pseudocyst is proposed as the mechanism by which the normally protective Gerota's fascia is penetrated.     

Final results of treatment with human growth hormone

The authors report the results of treatment with human growth hormone (hGH) (for 3 1/2 years to 11 3/4 years, mean: 5 years 4 months) in 34 children presenting with complete growth hormone deficiency and an average growth failure reaching 3.9 standard deviations (SD). Treatment was discontinued, after spontaneous or induced puberty, when bone age reached or was beyond 15 years in boys, and 13 years in girls. A partial correction was obtained in almost all cases. However, average height remained at -2.4 SD with respect to age and -1.75 with respect to bone age, reaching normal limits in only half of the patients. School and professional performances were not appreciably different from those which are observed in normal adolescents. Although the acceptance of the diagnosis and therapy was not always good, the medical support associated with the supervision of the treatment seems to have had a favourable psychological effect.     

Primary amenorrhea in adolescent girls. Incidence of isolated delayed menarche

In its strict meaning, primary amenorrhea is defined as the absence of any menstruation in a young girl without genital malformations who has reached her complete morphological development. Twenty-four cases corresponding to this definition, with bone ages of at least 15 years, breasts for at least 2 years, and adult type pubic hair were examined. In only 10 could a cause be found: anorexia nervosa, slight hyperandrogenism, acquired intracranial lesion. The other 14 girls, mean age of 16.2 +/- 1.4 years, were considered as presenting with simple delayed menarche. They were not given treatment, although 4 of them had been given steroids in artificial cyclical form previously. The 8 who were followed finally spontaneously developed normal cycles at a mean age of 17.6 +/- 2.8 years, one not until 24 years. Such data should lead to avoiding unnecessary treatments.