Application of the simultaneous equation models to temporary disability prescriptions in primary health care centres

[EN] Non-medical characteristics of primary healthcare centres (PHCs) influence the prescription of temporary disability leaves (incidence and absence rates) due to anxiety, as studied in the Valencian Community (E Spain; 5,111,706 inhabitants, 2009), where 485 centres (66%) were analysed. A structural two-equation model was used to explain which centres' factors impact prescriptions more. This model determined the influence of PHCs' factors (location, delay in specialized care, sick leave duration, etc.) on the incidence and absence rates, and on the interdependence between both rates. The results suggest the need to improve centres' management (clinical guidelines) and labour market regulations, and to control the disability benefits paid. © 2013 © 2013 Taylor & Francis.Guadalajara Olmeda, MN.; Barrachina Martínez, I. (2014). Application of the simultaneous equation models to temporary disability prescriptions in primary health care centres. International Journal of Computer Mathematics. 91(2):252-260. doi:10.1080/0020716.2013.808334S25226091

Social health insurance systems in European countries: the role of the insurer in the health care system: a comparative study of four European countries

This paper examines the role of social health insurance in four European countries: Germany, Switzerland, France and the Netherlands. It attempts to elucidate the organisational structure, regulation and management of the social insurance schemes, as well as the relationships between the insurers, providers and consumers in the various countries with the aim of uncovering some of the inherent strengths, weaknesses and tradeoffs hich exist within social insurance systems.health care systems, Europe, insurance

Challenges and opportunities of off-label prescription

Tese de mestrado, Regulação e Avaliação de Medicamentos e Produtos de Saúde , 2020, Universidade de Lisboa, Faculdade de Farmácia.O princípio subjacente à legislação farmacêutica é a proteção da saúde pública e como tal, um medicamento antes de ser colocado no mercado da União Europeia tem de ter comprovada a sua segurança, eficácia e qualidade. O uso de medicamentos fora dos termos aprovados na autorização de introdução no mercado é considerado off-label- não conformidade com a rotulagem. As razões que motivam a utilização de medicamentos fora das especificações definidas na rotulagem são diversas e complexas. O uso off-label é particularmente motivado para colmatar as necessidades específicas dos pacientes e para responder a situações médicas insatisfeitas. Esta modalidade clínica é uma prática generalizada , representando uma realidade inevitável nos sistemas de saúde modernos. No entanto, devido à ausência de uma avaliação rigorosa do benefício- risco , a prescrição off-label levanta questões éticas, colocando riscos óbvios à segurança do paciente e, por essa razão, deve apenas ser considerada excecionalmente. Os vários intervenientes na área do medicamento- autoridades reguladoras, profissionais de saúde, empresas farmacêuticas, decisores na área da saúde e os pacientes -estão constantemente a ser desafiados pela necessidade de gerir situações que surgem do uso off-label. Assim, eles beneficiariam da existência de um enquadramento universal e harmonizado desta matéria. Atualmente, não existem normas harmonizadas ao nível da União Europeia. Várias abordagens para regular o uso off-label de medicamentos têm sido propostas nalguns estados membros. Contudo, a situação permanece insatisfatória e nenhuma destas medidas parece resolver adequadamente o problema. Tendo em conta a importância e a contorvérsia deste tema , é mais relevante do que nunca promover discussões para gerir eficazmente o uso off-label de medicamentos. Este trabalho pretende apresentar uma revisão narrativa da literatura deste tema, numa tentativa de descrever e caracterizar esta prática. Este visa ainda discutir as oportunidades e desafios inerentes a certas propostas de regulação , assim como as implicações e contradições mais evidentes que podem surgir do uso off-label de medicamentos.The main principle underlying global pharmaceutical legislation is the protection of public health and, as such, before a medicine can be marketed in the European Union (EU), its safety, quality and efficacy have to be proven. The use of medicines outside the approved terms of their marketing authorisation (MA) is considered off-label- not in accordance with the label. The reasons for using a medicine outside the specifications laid down in the label are diverse and complex. Off-label use is particularly driven to fulfil specific patients’ needs and to respond to unmet medical situations. This clinical modality is a widespread practice, representing an unavoidable reality in modern health systems. However, due to the lack of rigorous risk-benefit assessment, offlabel prescription raises ethical issues by posing obvious risks to patient’s safety and should, for that reason, only be considered exceptionally. The various stakeholders involved in the medicines field - regulatory authorities, health care professionals (HCPs), pharmaceutical companies, policy makers and patientsare constantly challenged by the need to manage situations that could arise from an offlabel use. Therefore, they would benefit from the existence of a universal and harmonized framework on this matter. Currently, there are no harmonized rules at EU level. Several approaches for regulating the off-label use of medicines have been proposed in some members states. Nevertheless, the situation remains unsatisfactory and none of these measures seems to be able to adequately address the problem. Given the importance and controversy of the topic, it is more relevant than ever to promote discussions to effectively manage the off-label use of medicines. This work intends to present a narrative literature review of the subject, in an attempt to describe and characterize this practice. It also aims to discuss the challenges and opportunities associated with certain regulation proposals, as well as the most evident implications and contradictions that could arise from the widespread off-label use of medicines

What health care for undocumented migrants in Belgium?

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The future of work: Towards a progressive agenda for all. EPC Issue Paper 9 DECEMBER 2019

Europe’s labour markets and the world of work in general are being transformed by the megatrends of globalisation, the fragmentation of the production and value chain, demographic ageing, new societal aspirations and the digitalisation of the economy. This Issue Paper presents the findings and policy recommendations of “The future of work – Towards a progressive agenda for all”, a European Policy Centre research project. Its main objectives were to expand public knowledge about these profound changes and to reverse the negative narrative often associated with this topic. It aimed to show how human decisions and the right policies can mitigate upcoming disruptions and provide European and national policymakers with a comprehensive toolkit for a progressive agenda for the new world of work

Preferred providers, health insurance and primary health care in Chile

PhDReforms in the early 1980s created Chile's mixed system of health care provision and finance. Since then Chileans have had to choose between a statesubsidised public health insurance system or the private health plans offered by several insurance companies. In the public system, users may be restricted to the public facility network, with no choice of doctor or medical centre, or they may opt for a free choice mode (preferred providers), which lets them choose both doctor and place of attention. Private insurance providers offer a wide variety of health plans, giving the customer a reasonable range of care options. Although this public-private mix has now been operating for more than 20 years, there has been no empirical study of the factors determining the choice of the preferred providers' mode by public beneficiaries. Likewise, few studies have looked at the determinants in the choice between public and private insurance, and the relationship between the latter choice and the use of health services. The first two empirical chapters of this thesis look at the determinants of these sources of choice, using different econometric tools: the choice of preferred providers is examined using a logit model; the analysis into the choice between public and private insurance uses a probit model; and the impact of holding private insurance as a factor in determining use of health services is estimated through a two-stage tobit model. A further significant aspect of the reforms of the '80s was the process of decentralisation for primary health care provision. Since then a substantial part of preventive health care and promotion occurs locally, and among these services children's health checks are an important policy objective. To encourage attendance parents are given free food supplements if they keep to the timetable for their child's check-ups. However these free food handouts partially account for attendance at the check-ups. Thus the final empirical chapter of the thesis uses a probabilistic model to look at the monetary and non-monetary factors that lead parents to request health checks for their children

Work disability, economic situation, and societal costs of multiple sclerosis in Sweden

Background: Multiple sclerosis (MS) affects many aspects of life and often leads to a reduction in an individual’s work capacity. This reduction, referred to as work disability, may lead to the use of social protections to replace lost earnings upon being absent and societal costs from the lost production. This thesis aimed to investigate the working life and economic situation of individuals in the early stages of their MS as well as the societal costs of MS. Methods: Four cohort studies using Swedish register data of working-aged individuals were conducted. Work disability was operationalised as net days with sickness absence (SA) and/or disability pension (DP). In Study I, the heterogeneity of disposable income (DI) trajectories from 7 years before to 4 years after the diagnosis year (2008-9) of 1528 people with MS (PwMS) was explored with group-based trajectory modelling. The trajectory members were characterised through use of chi2-tests and multinomial logistic regressions. In Study II, common patterns of working life among 2652 PwMS diagnosed in 2008-11 were identified with sequence analysis. Sequences from 1 year before and 5 years after the diagnosis year were constructed and the members of the sequence types were characterised with multinomial logistic regressions and dependent t-tests. In Study III and IV, productivity losses were calculated with the human capital approach from the days with work disability. Healthcare costs included the costs of specialised out- and inpatient healthcare as well as dispensed drugs. Excess costs of MS were estimated by comparing the all-cause costs of PwMS with the costs of matched references with independent t-tests. Study III quantified the annual excess costs of 1988 PwMS and 7981 matched references without MS from 4 years before to 4 years after the diagnosis year (2010-12). Generalised estimation equation (GEE) models tested the interaction of MS and time. In Study IV, the excess costs from resource use in 2018 with bootstrapped 95% CIs were estimated for 2806 PwMS in Stockholm and 28,060 matched references without MS. Primary healthcare and disease modifying therapies were also costed, with analyses stratified by time since diagnosis. Results: Seven DI trajectories were identified in Study I: Four increasing with different gradients (39.0% of individuals), two constantly low (50.7%), and one decreasing (10.3%). Older age profiles and higher proportions of men were observed in the increasing trajectories and higher proportions with work disability and without university education in the decreasing and constantly low trajectories. In Study II, six types of working life sequences were identified: Stable High Activity (48.4% of the sequences), three types with mixed activity and varying SA/DP regarding the number of days per year and timing (32.6%), Stable High SA/DP (14.5%), and Other (4.5%). Stable High Activity had the highest odds for university education. All sequence types, except Stable High SA/DP, had higher DI in the final study year than the first. In Study III, excess costs of MS were observed already before MS diagnosis. Mean annual excess costs of MS of 2285 SEK (95% CI: 613-3956) per person for healthcare costs and 16,310 SEK (95% CI: 8980-23,640) for productivity losses were observed four years before diagnosis. The excess costs of MS increased thereafter and were reflected in the MS and time interaction estimates. In Study IV, the mean annual excess healthcare costs of MS were 77,383 SEK (95% CI: 73,299-81,950) per person with MS. Primary healthcare accounted for 9% and disease modifying therapies for 48% of the excess healthcare costs. The mean annual excess productivity losses of MS were 138,121 SEK (95% CI: 149,224-146,985) per person with MS, mostly due to DP (79%). The resource use behind the excess costs of MS differed by time since diagnosis. Conclusions: The findings describe the economic situation of PwMS and quantify the excess societal costs of early MS. Most PwMS were in work and had increasing or stable DI in the study periods close to MS diagnosis. However, work disability was often and increasingly a part of PwMS’ working life and was associated with decreasing DI trajectories or relatively low levels of DI as well as unstable working life sequences. Excess costs of MS for lost production and healthcare use were incurred already before MS diagnosis and increased thereafter. The progression of the excess costs of MS reflected different patterns of resource use with time from MS diagnosis. The increasing excess costs of MS from productivity losses began in the early stages of MS and may reflect unmet needs of PwMS regarding morbidity and work capacity which early intervention may ameliorate

In search for more confidence in health economic modelling : reducing uncertainty associated with modelling studies

Every government is eager to control the increase of expenses by the implementation of central cost containment policies particularly in relation to pharmaceuticals. For the most part. those measures have relied on budgeting or price controls. including negotiated prospective budgets for hospitals. centralized negotiated budgets for ambulatory physicians including drug prescriptions, and limitations on payments for particular medications. Because those traditional central cost containment measures were only partially successfuL due to lack of incentives. the health authorities in Europe started to establish incentives for efficient healthcare delivery. Both traditional and recent containment measures focus especially on the pharmaceutical drugs sector in many countries. as these constitute a health technology that is relatively easy to introduce and implement compared to other forms of care. Financing prescription medicines in ambulatory care has been a central responsibility based on the traditional clinical trial outcomes (efficacy/safety parameters) used for registration. Although there is large variety betvveen the various countries. there are three related trends: decentralization of the healthcare decision-making process. prescription restrictions, and extra data requirements. One can distinguish various extra data requirements which all relate to the use of the drug in real daily practice. while the traditional clinical trial outcomes are only derived from randomised clinical trials. At a central level the demand for cost-effectiveness and budgetary impact data is increasing. The requirement for health economic data resulted to formal reporting requirements in some countries already (e.g. Canada, Australia. The Netherlands. UK. Portugal and Finland). Although the most evident impact of health economic studies is expected to be on central reimbursement audiences. evidence for the use of health economic studies by other audiences is expected to increase (e.g. patients, hospitals. insurers. formulary committees). This background information is described in more detail in Chapter 2. which is the introduction to this thesis