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AimTo assess, from a United States (US) payer's perspective, the cost-effectiveness of gels designed to separate the endometrial surfaces (intrauterine spacers) placed following intrauterine surgery.Materials and methodsA decision tree model was developed to estimate the cost-effectiveness of intrauterine spacers used to facilitate endometrial repair and prevent the formation (primary prevention) and reformation (secondary prevention) of intrauterine adhesions (IUAs) and associated pregnancy- and birth-related adverse outcomes. Event rates and costs were extrapolated from data available in the existing literature. Sensitivity analyses were conducted to corroborate the base case results.ResultsIn this model, using intrauterine spacers for adhesion prevention led to net cost savings for US payers of $2,905 per patient over a 3.5-year time horizon. These savings were driven by the direct benefit of preventing procedures associated with IUA formation ($2,162 net savings) and the indirect benefit of preventing pregnancy-related complications often associated with IUA formation ($3,002). These factors offset the incremental cost of intrauterine spacer use of $1,539 based on an assumed price of $1,800 and the related increase in normal deliveries of $931. Model outcomes were sensitive to the probability of preterm and normal deliveries. Budget impact analyses show overall cost savings of $19.96 per initial member within a US healthcare plan, translating to $20 million over a 5-year time horizon for a one-million-member plan.LimitationsThere are no available data on the effects of intrauterine spacers or IUAs on patients' quality of life. Resultingly, the model could not evaluate patients' utility related to treatment with or without intrauterine spacers and instead focused on costs and events avoided.ConclusionThis analysis robustly demonstrated that intrauterine spacers would be cost-saving to healthcare payers, including both per-patient and per-plan member, through a reduction in IUAs and improvements to patients' pregnancy-related outcomes.

ObjectivesPreterm birth occurs in more than 10% of U.S. births and is the leading cause of U.S. neonatal deaths, with estimated annual costs exceeding $25 billion USD. Using real-world data, we modeled the potential clinical and economic utility of a prematurity-reduction program comprising screening in a racially and ethnically diverse population with a validated proteomic biomarker risk predictor, followed by case management with or without pharmacological treatment.MethodsThe ACCORDANT microsimulation model used individual patient data from a prespecified, randomly selected sub-cohort (N = 847) of a multicenter, observational study of U.S. subjects receiving standard obstetric care with masked risk predictor assessment (TREETOP; NCT02787213). All subjects were included in three arms across 500 simulated trials: standard of care (SoC, control); risk predictor/case management comprising increased outreach, education and specialist care (RP-CM, active); and multimodal management (risk predictor/case management with pharmacological treatment) (RP-MM, active). In the active arms, only subjects stratified as higher risk by the predictor were modeled as receiving the intervention, whereas lower-risk subjects received standard care. Higher-risk subjects' gestational ages at birth were shifted based on published efficacies, and dependent outcomes, calibrated using national datasets, were changed accordingly. Subjects otherwise retained their original TREETOP outcomes. Arms were compared using survival analysis for neonatal and maternal hospital length of stay, bootstrap intervals for neonatal cost, and Fisher's exact test for neonatal morbidity/mortality (significance, p

The Health Gap documents the large and persistent health gaps that exist across and within relatively rich countries today. Marmot argues that in developed countries, poor health does not cause low incomes; rather, low socioeconomic status leads to poor health, but not because of proximate factors like differential health care access, which can explain only a small portion of these gaps. Therefore, to eliminate health gaps, policy should focus on the deep causes of disease: poverty, education, and occupational mobility, among others. While Marmot’s ethical arguments are quite compelling, his recommendations are too strong given the current evidence. Policies need to be based on a clearer understanding of why things work, when, and for whom. (JEL H51, I10, I13, I15, I18, I28)

We use an event study approach to examine the economic consequences of hospital admissions for adults in two datasets: survey data from the Health and Retirement Study, and hospitalization data linked to credit reports. For non-elderly adults with health insurance, hospital admissions increase out-of-pocket medical spending, unpaid medical bills and bankruptcy, and reduce earnings, income, access to credit and consumer borrowing. The earnings decline is substantial compared to the out-of-pocket spending increase, and is minimally insured prior to age-eligibility for Social Security Retirement Income. Relative to the insured non-elderly, the uninsured non-elderly experience much larger increases in unpaid medical bills and bankruptcy rates following a hospital admission. Hospital admissions trigger less than 5 percent of all bankruptcies.

Background: Less is known about the impact of cancer on household assets and household financial portfolio during which cancer survivors face higher mortality risk. Economic theory predicts that cancer survivors would deplete their wealth in such a way that meets immediate financial needs for treatment and that hedges the risk of anticipated medical expenses associated with recurrence. Building upon this prediction, we examine long-term changes in household assets in response to cancer diagnosis among middle-aged and elderly Americans (age ≥ 50). Results: Using the 2000–2014 waves of the Health and Retirement Study, we estimated the household fixed effects regression that regresses household assets on time elapsed since cancer diagnosis (≤ 2 years, > 2 but ≤4 years, > 4 but ≤6 years, and > 6 but ≤8 years). Regression estimates were adjusted for demographic characteristics, general health condition, employment outcomes, and household economic attributes. Household assets were measured by total net worth as well as the amount of savings held in each asset category. The loss of household assets attributable to cancer was estimated to be $125,832 in 2015 dollars per household with a cancer patient. This change came from statistically significant reductions in investment assets, miscellaneous savings, real estate equity, and business equity, and increases in unsecured debt. We also found 17.2–28.0% increases in cash and cash-equivalent assets from + 2 years since diagnosis through the rest of the study periods. The accumulation of cash was observed for both the well-insured group (multiple coverages) and those with limited insurance (single coverage). Conclusions: The results showed evidence of both asset depletion and precautionary accumulation of liquid assets among cancer survivors, which reduces risk exposure of household financial portfolio. Our findings highlighted that household asset is an important source of liquidity to finance cancer care and to absorb the expected expenditure risk associated with cancer recurrence. We also showed that health insurance provides limited coverage of health risks associated with cancer. [ABSTRACT FROM AUTHOR]

A cluster-randomized controlled trial, WorkUp, was conducted for working-aged patients at risk of sick leave or on short-term sick leave due to acute/subacute neck and/or back pain in Sweden. The purpose of WorkUp was to facilitate participants to stay at work or in case of sick leave, return-to-work. The aim of this study was to study whether the WorkUp trial was cost-effective. Patients in the intervention and reference group received structured evidence-based physiotherapy, while patients in the intervention group also received a work place dialogue with the employer as an add-on. The participants, 352 in total, were recruited from 20 physiotherapeutic units in primary healthcare in southern Sweden. The economic evaluation was performed both from a healthcare and a societal perspective with a 12-month time frame with extensive univariate sensitivity analyses. Results were presented as incremental cost-effectiveness ratios (ICER) with outcomes measured as quality-adjusted life-years (QALY) and proportion working for at least 4 weeks in a row without reported sick leave at 12-month follow-up. From the healthcare perspective, the ICER was €23,606 (2013 price year) per QALY gain. From the societal perspective the intervention was dominating, i.e.. less costly and more effective than reference care. Bootstrap analysis showed that the probability of the intervention to be cost-effective at €50,000 willingness-to-pay per QALY was 85% from the societal perspective. Structured evidence-based physiotherapeutic care together with workplace dialogue is a cost-effective alternative from both a societal and a healthcare perspective for acute/subacute neck and/or back pain patients.Trial registration ClinicalTrials.gov: NCT02609750. [ABSTRACT FROM AUTHOR]

Previous studies have shown that recessions are typically associated with better health and health behaviors. With the exception of a few recent studies however, these studies focus on sample periods that end prior to the Great Recession. The few exceptions that extend the analysis period beyond the Great Recession suggest that the pro-cyclical relationship between macroeconomic conditions and mortality obtained in earlier studies might have weakened over time. In this paper, we revisited the relationship between state unemployment rate and a large set of outcomes of health and health behaviors using data from the Behavioral Risk Factor Surveillance System (BRFSS) between 1990 and 2014. Overall, our results suggest that state unemployment rate is weakly related to both health and health behaviors as our estimates are too small to have any meaningful implications, although they are largely imprecisely estimated. Finally, we tested whether the Great Recession played a significant role in influencing the pattern in the relationship between unemployment rate and health and health behaviors. Our results from this analysis do not reveal any measurable recession effect, although the estimates are again largely imprecise. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common chronic arrhythmia, with increasing healthcare and economic burden and a prevalence which increases with progressive ageing. This study aims to describe overall annual costs per patient for management of non-valvular AF in a primary healthcare (PHC) setting and compare these costs between the groups of patients treated with vitamin K antagonists, antiplatelets or non-treated through a population-based study conducted with electronic health records. We analysed annual costs per person of 19,787 patients in 2012; PHC visits, hospital admissions, AF-related events requiring hospital admission, referrals to secondary specialists, sick leave, diagnostic tests and laboratory tests at PHC level, including INR determinations performed in PHC, and drug therapy. Higher costs of AF management were associated with increasing age, male sex, stroke and bleeding risks, comorbidities and occurrence of events associated to AF. The sensitivity analyses conducted showed that PHC visits and hospitalizations represented the most important part of overall costs for all patients. [ABSTRACT FROM AUTHOR]

Objective: Unit costs of screening CT colonography (CTC) can be useful for cost-effectiveness analyses and for health care decision-making. We evaluated the unit costs of CTC as a primary screening test for colorectal cancer in the setting of a randomized trial in Italy.Methods: Data were collected within the randomized SAVE trial. Subjects were invited to screening CTC by mail and requested to have a pre-examination consultation. CTCs were performed with 64- and 128-slice CT scanners after reduced or full bowel preparation. Activity-based costing was used to determine unit costs per-process, per-participant to screening CTC, and per-subject with advanced neoplasia.Results: Among 5242 subjects invited to undergo screening CTC, 1312 had pre-examination consultation and 1286 ultimately underwent CTC. Among 129 subjects with a positive CTC, 126 underwent assessment colonoscopy and 67 were ultimately diagnosed with advanced neoplasia (i.e., cancer or advanced adenoma). Cost per-participant of the entire screening CTC pathway was €196.80. Average cost per-participant for the screening invitation process was €17.04 and €9.45 for the pre-examination consultation process. Average cost per-participant of the CTC execution and reading process was €146.08 and of the diagnostic assessment colonoscopy process was €24.23. Average cost per-subject with advanced neoplasia was €3777.30.Conclusions: Cost of screening CTC was €196.80 per-participant. Our data suggest that the more relevant cost of screening CTC, amenable of intervention, is related to CTC execution and reading process. [ABSTRACT FROM AUTHOR]

Objectives: Pneumocost is a prospective study that aimed at documenting the costs of the management of patients hospitalized with a pneumococcal pneumonia and the post-discharge costs during a 6-month period in the French context.Methods: Billing data were used to document hospital costs. Resource use during the follow-up period was collected through phone interviews at month 1, 3 and 6. Descriptive statistics and multivariate analyses were performed. We used generalized linear models with log-link functions to estimate parameters associated with hospital and follow-up costs of patients.Results: Five hundred twenty-four patients were enrolled in 40 public centers from October 2011 to April 2014. Average age was 63 (SD 17); 55.0% of them were male. Average length of stay was 15 days (SD 23). Average cost of stay for the French Sickness Fund was €7293 (SD €7363). Average cost of follow-up was €1242 (SD €3000) and decreased steadily through time. When controlling for patient's socioeconomic characteristics, severity of disease and hospital stay, results showed a concave relationship between hospital costs and age. Obesity, the severity of the disease and comorbidities were associated with constantly increasing inpatient costs. Concerning follow-up costs, we found the same concave relationship with age, while gender, a history of pneumonia and severity of the disease were the most important predictors of high costs after discharge.Conclusion: Pneumocost is the first French study providing a robust estimation of the cost of managing invasive pneumococcal pneumonia in the French context. [ABSTRACT FROM AUTHOR]

This study compares discounting for money and health in a field study. We applied the direct method, which measures discounting independent of utility, in a representative French sample, interviewed at home by professional interviewers. We found more discounting for money than for health. The median discount rates (6.5% for money and 2.2% for health) were close to market interest rates, suggesting that at the aggregate level the direct method solves the puzzle of unrealistically high discount rates typically observed in applied economics. Constant discounting fitted the data better than the hyperbolic discounting models that we considered. The substantial individual heterogeneity in discounting was correlated with age and occupation. [ABSTRACT FROM AUTHOR]

In this paper we empirically investigate how to appropriately model utility of wealth and health. We use a recently proposed alternative approach to value willingness to pay (WTP) for health, making use of trade-offs between income and life years or quality of life, which we extend to allow for a more realistic multiplicative utility function over health and money. Moreover, we show how reference-dependency can be incorporated into this model and derive its predictions for WTP elicitation. We propose three experimental elicitation procedures and test these in a feasibility study, analysing the responses under different assumptions about the discount rate. Several interesting results are reported: first, the data are highly skewed, but if we trim the 5% lowest and highest values, we obtain plausible WTP estimates. Second, the results differ considerably between procedures, indicating that WTP estimates are sensitive to the assumed utility function. Third, respondents appear to be loss averse for both health and money, which is consistent with assumptions from prospect theory. Finally, our results also indicate that respondents are more willing to trade quality of life than life years. [ABSTRACT FROM AUTHOR]

Background: The impact of various post-procedural complications after transcatheter aortic valve implantation (TAVI) on resource use and their consequences in the German reimbursement system has still not been properly quantified.Methods: In a retrospective observational study, we use data from the German DRG statistic on patient characteristics and in-hospital outcomes of all isolated TAVI procedures in 2013 (N = 9147). The impact of post-procedural complications on reimbursement, length of stay and mechanical ventilation was analyzed using both unadjusted and risk-adjusted linear and logistic regression analyses.Results: A total of 235 (2.57%) strokes, 583 (6.37%) bleeding events, 474 (5.18%) cases of acute kidney injury and 1428 (15.61%) pacemaker implantations were documented. The predicted reimbursement of an uncomplicated TAVI procedure was €33,272, and bleeding events were associated with highest additional reimbursement (€12,839, p < 0.001), extra length of stay (14.58 days, p < 0.001), and increased likelihood of mechanical ventilation for more than 48 h (OR 17.91, p < 0.001). A more moderate complication-related impact on resource use and reimbursement was found for acute kidney injury (additional reimbursement: €5963, p < 0.001; extra length of stay: 7.92 days, p < 0.001; ventilation >48 h: OR 6.93, p < 0.001) as well as for stroke (additional reimbursement: €4125, p < 0.001; extra length of stay: 4.68 days, p < 0.001; ventilation >48 h: OR 5.73, p < 0.001). Pacemaker implantations, in contrast, were associated with comparably small increases in reimbursement (€662, p = 0.006) and length of stay (3.54 days, p = 0.006) and no impaired likelihood of mechanical ventilation more than 48 h (OR 1.22, p = 0.156). Interestingly, these complication-related consequences remain mostly unchanged after baseline risk-adjustment.Conclusions: Post procedural complications such as bleeding events, acute kidney injuries and strokes are associated with increased resource use and substantial amounts of additional reimbursement in Germany, which has important implications for decision making outside of the usual clinical sphere. [ABSTRACT FROM AUTHOR]

Respiratory syncytial virus (RSV) is a common cause of respiratory infection that is highly prevalent in infants, particularly those with underlying medical conditions. Severe cases of RSV require hospitalisation as well as admission to intensive care and may even result in death. The objective of the study was to measure the net benefits that could arise from an immunisation programme of infants that may well eradicate RSV to a high degree and save the direct and indirect medical care costs from hospitalisation, morbidity and the gain from potential life-time earnings by reducing the probability of mortality. In this context, the majority of existing empirical investigations are based on data from clinical trials, and where relevant facts are not available, a series of strong assumptions is derived from the published literature, whereas in this study, for the first time, the hospital episode statistics database is used to calculate the cost-benefit ratios. The methodology of the analysis adopts a cost-benefit approach to assess the impact of the immunisation and whether it is beneficial to society. The underlying assumptions of the basic model are assessed by adopting a sensitivity analysis. The results show that a number of categories are cost-effective with the use of the passive drug, which means benefits by raising the life expectancy and quality as well as reducing the resource burden on society. [ABSTRACT FROM AUTHOR]

Alcohol consumption, in particular excessive alcohol consumption, imposes high costs on societies through consequences, such as lost productivity, early mortality, health-care costs, car accidents and crime. The main objective of this study is to examine how drinking behavior developed over an economic boom, subsequent crisis, and an eventual recovery. We use individual longitudinal data collected through a postal survey by The Directorate of Health in Iceland in 2007, 2009, and 2012. Pooled OLS and linear probability models are used to study four outcomes: Alcohol-consumption frequency, frequency of binge drinking, binge-drinking participation and alcohol dependence. Alcohol-consumption frequency declined during the crisis, with a further decline during the recovery period. This change is driven by female behavior between 2007 and 2009, but a combined gender effect between 2009 and 2012. This effect is suppressed by male labor-market-changes, but partly mediated by labor marked changes in the case of females. Alcohol dependence declined during the crisis, with suggestive evidence of partially reverting back to previous levels during the recovery. There is some indication that during the crisis real price changes of alcohol played a role in the decline in alcohol consumption but that is not a likely determinant of changes in alcohol consumption for the 3 year period post-crisis that we explore. Men's consumption can partly be explained through income changes while women's consumption changes are rather driven by changes in work hours or other factors. [ABSTRACT FROM AUTHOR]

Background: Little comparative evidence is available on utilisation of cancer medicines in different countries and its determinants. The aim of this study was to develop a statistical model to test the correlation between utilisation and possible determinants in selected European countries.Methods: A sample of 31 medicines for cancer treatment that obtained EU-wide marketing authorisation between 2000 and 2012 was selected. Annual data on medicines' utilisation covering the in- and out-patient public sectors were obtained from national authorities between 2008 and 2013. Possible determinants of utilisation were extracted from HTA reports and complemented by contacts with key informants. A longitudinal mixed effect model was fitted to test possible determinants of medicines utilisation in Belgium, Scotland and Sweden.Results: In the all-country model, the number of indications reimbursed positively correlated with increased consumption of medicines [one indication 2.6, 95% CI (1.8-3.6); two indications 2.4, 95% CI (1.4-4.3); three indications 4.9, 95% CI (2.2-10.9); all P < 0.01], years since EU-wide marketing authorisation [1.2, 95% CI (1.02-1.4); p < 0.05], price per DDD [0.9, 95% CI (0.998-0.999), P < 0.01], and Prescrire rating [0.5, 95% CI (0.3-0.9), P < 0.05] after adjusting for time and other covariates.Conclusions: In this study, the most important correlates of increased utilisation in a sample of cancer medicines introduced in the past 15 years were: medicines coverage and time since marketing authorisation. Prices had a negative effect on consumption in Belgium and Sweden. The positive impact of financial MEAs in Scotland suggests that the latter may remove the regressive effect of list prices on consumption. [ABSTRACT FROM AUTHOR]

EQ-5D is used in cost-effectiveness studies underlying many important health policy decisions. It comprises a survey instrument describing health states across five domains, and a system of utility values for each state. The original 3-level version of EQ-5D is being replaced with a more sensitive 5-level version but the consequences of this change are uncertain. We develop a multi-equation ordinal response model incorporating a copula specification with normal mixture marginals to analyse joint responses to EQ-5D-3L and EQ-5D-5L in a survey of people with rheumatic disease, and use it to generate mappings between the alternative descriptive systems. We revisit a major cost-effectiveness study of drug therapies for rheumatoid arthritis, mapping the original EQ-5D-3L measure onto a 5L valuation basis. Working within a comprehensive, flexible econometric framework, we find that use of simpler restricted specifications can make very large changes to cost-effectiveness estimates with serious implications for decision-making. [ABSTRACT FROM AUTHOR]

Objective: To estimate the annual societal cost of fetal alcohol syndrome (FAS) in Sweden, focusing on the secondary disabilities thought feasible to limit via early interventions.Methods: Prevalence-based cost-of-illness analysis of FAS in Sweden for 2014. Direct costs (societal support, special education, psychiatric disorders and alcohol/drug abuse) and indirect costs (reduced working capacity and informal caring), were included. The calculations were based on published Swedish studies, including a register-based follow-up study of adults with FAS, reports and databases, and experts.Results: The annual total societal cost of FAS was estimated at €76,000 per child (0-17 years) and €110,000 per adult (18-74 years), corresponding to €1.6 billion per year in the Swedish population using a prevalence of FAS of 0.2 %. The annual additional cost of FAS (difference between the FAS group and a comparison group) was estimated at €1.4 billion using a prevalence of 0.2 %. The major cost driver was the cost of societal support.Conclusions: The cost burden of FAS on the society is extensive, but likely to be underestimated. A reduction in the societal costs of FAS, both preventive and targeted interventions to children with FAS, should be prioritized. That is, the cost of early interventions such as placement in family homes or other forms of housing, and special education, represent unavoidable costs. However, these types of interventions are highly relevant to improve the individual's quality of life and future prospects, and also, within a long-term perspective, to limit the societal costs and personal suffering. [ABSTRACT FROM AUTHOR]

Productivity trend information is valuable in developing policy and for understanding changes in the 'value for money' of the care system. In this paper, we consider approaches to measuring productivity of adult social care (ASC), and particularly care home services. Productivity growth in the public sector is traditionally measured by comparing change in total output to change in total inputs, but has not accounted for changes in service quality and need. In this study, we propose a method to estimate 'quality adjusted' output based on indicators of the Adult Social Care Outcomes Toolkit (ASCOT), using data collected in the annual adult social care survey (ASCS). When combined with expenditure and activity data for 2010 to 2012, we found that this approach was feasible to implement with current data and that it altered the productivity results compared with non-adjusted productivity metrics. Overall, quality-adjusted productivity grew in most regions between 2010 and 2011 and remained unchanged for most regions from 2011 to 2012. [ABSTRACT FROM AUTHOR]

This study investigates the impact of and behavioral responses to cost sharing in Korea's National Cancer Screening Program, which provides free stomach and breast cancer screenings to those with an income below a certain cutoff. Free cancer screening substantially increases the screening take up rate, yielding more cancer detections. However, the increase in cancer detection is quickly crowded out by cancer detection through other channels such as diagnostic testing and private cancer screening. Further, compliers are much less likely to have cancer than never takers. Crowd-out and selection help explain why the program has been unable to reduce cancer mortality. [ABSTRACT FROM AUTHOR]

Using Canadian administrative data from multiple sources, we provide the first nationally representative estimates for the effect of spouses' cancer diagnoses on individuals' employment and earnings and on family income. Our identification strategy exploits unexpected health shocks and combines matching with individual fixed effects in a generalized difference-in-differences framework to control for observable and unobservable heterogeneity. While the effect of spousal health shocks on labor supply is theoretically ambiguous, we find strong evidence for a decline in employment and earnings of individuals whose spouses are diagnosed with cancer. We interpret this result as individuals reducing their labor supply to provide care to their sick spouses and to enjoy joint leisure. Family income substantially declines after spouses' cancer diagnoses, suggesting that the financial consequences of such health shocks are considerable. [ABSTRACT FROM AUTHOR]