Priorities and prospect theory

Most would agree that priority setting is necessary to avoid a financial collapse in the health sector. It is much harder to find criteria how to do it. Discussions lead straight to the principles of decision making. But since all theories depend on assumptions given to make them work, debates on the assumption side are open for any kind of critic. This might be a reason hyprefernce-based methods for evaluations of different health states are not as common and popular as they could be. Indeed, it can be shown that results derived by such methods are severly biased by phenomenons which are summarized in a so-called Prospect Theory. These biases are quite obvious if one compares data of affected and unaffected people. But this theory offers, as well, a way to get results more accurate. -- Man ist sich weitgehend einig, dass eine Priorisierung im Gesundheitswesen notwendig ist, will man eine Finanzierungskrise verhindern. Die Kriterien dafür festzulegen, ist bedeutend schwieriger. Diskussionen kreisen immer wieder um die grundlegenden Annahmen, wie Entscheidungen getroffen werden. Da man gezwungen ist, Verhaltensaxiome festzulegen, sind darauf aufbauende, präferenz-basierte Methoden zur Evaluation von Gesundheitszuständen nicht so weit verbreitet, wie es denkbar wäre. Tatsächlich lässt sich zeigen, dass derart erzielte Ergebnisse verzerrt sind durch Phänomene, die von Kahneman und Tversky 1979 in der sogenannten Prospect Theory zusammengefasst wurden. Diese Verzerrungen werden deutlich im Vergleich von Evaluationen betroffener und nicht-betroffener Personen. Auf der anderen Seite bietet diese Theorie die Möglichkeit, Ergebnisse entsprechend zu korrigieren.

Utility functions for life years and health status: An additional remark

Utility-based measures for health-related quality of life gain more and more importance in cost-effectiveness analysis. The axiomatic foundation qualifies them as decision weights in use of the QALY concept. But their use is strained for they are loaded with assumptions to make them work. Pliskin et al. (1980) have impressively shown which assumptions might be reasonable to combine quality of life with length of life, those attributes fundamental to the QALY concept. One of those assumptions is the so called constant proportional tradeoff. It states that people will always sacrifice the same proportion of remaining life years in order to gain better health. This assumption restricts the underlying utility functions for life years to those consistent with constant proportional risk posture, i.e. power, logarithmic and linear function. However, these types of function might be too restrictive for they do not reflect constant absolut tradeoff. That means people might rather exchange the same number of life years for better health, independent of remaining life expectancy. Pliskin et al. mentioned that case already and suggested the exponential function as a propper function to reflect the underlying constant absolut risk posture. I will deliver its proof. In addition, a survey among Tinnitus patients is mentioned that could further stress the validity of those functions. -- Nutzen-basierte Maße für gesundheitsbezogene Lebensqualität gewinnen für Kosten-Effektivitäts-Analysen immer mehr an Bedeutung. Ihre axiomatische Fundierung qualifiziert sie im Gebrauch des QALY Konzeptes. Aber die Nutzung ist problematisch, da sie von verschiedenen Annahmen abhängt. Pliskin et al. (1980) haben gezeigt, welche Annahmen plausibel sind, Lebensqualität mit Lebenslänge zu kombinieren, jenen Attributen, die grundlegend für das QALY Konzept sind. Eine ist die sogenannte konstante proportionale Austausch Annahme. Sie besagt, dass Menschen immer eine proportionale Anzahl an Lebensjahre für bessere Gesundheit opfern würden. Diese Annahme beschränkt die zugrunde liegenden Nutzenfunktionen für Lebensjahre auf solche, die mit konstanter proportionaler Risikoeinstellung übereinstimmen, dass heisst Potenz- and Logarithmusfunktion oder eine lineare Funktion. Dennoch könnten diese Funktionstypen zu restriktiv sein, da sie nicht konstanten absoluten Austausch darstellen können. Damit ist gemeint, dass Menschen eventuell immer dieselbe Anzahl von Lebensjahren aufgeben, unabhängig ihrer verbleibenden Lebenserwartung. Pliskin et al. erwähnten diesen Fall bereits und schlugen die Exponentialfunktion als geeigneten Funktionstyp vor, die zugrunde liegende konstante absolute Risikoeinstellung wiederzugeben. Ich werde den Beweis liefern. Eine Befragung unter Tinnitus Patienten könnte darüber hinaus die Gültigkeit dieser Funktionen unter Beweis stellen.

Regional Disparities in the European Union: Convergence and Agglomeration

Economic disparities between the regions of the European Union are of constant concern both for policy and economic research. In this paper we examine whether there are overlapping trends of regional development in the EU: overall convergence on the one hand and persistent or even increasing spatial concentration (agglomeration) on the other. Kernel density estimation, Markov chain analysis and cross-sectional regressions provide evidence that convergence of regional per-capita income in the EU15 has become considerably stronger in the 1990s. The reduction of income disparities, however, is a phenomenon between nations but not between regions within the EU countries. European integration (and possibly European regional policy) foster the catching-up of lagging countries but at the same time forces for agglomeration of economic activities tend to increase disparities within the EU member states. Obviously, the productive advantages of spatial proximity do not vanish in the knowledge economy.Regional growth; Agglomeration; Markov chains

Regional Disparities in the European Union: Convergence and Agglomeration

Economic disparities between the regions of the European Union are of constant concern both for policy and economic research. In this paper we examine whether there are overlapping trends of regional development in the EU: overall convergence on the one hand and persistent or even increasing spatial concentration (agglomeration) on the other. Kernel density estimation, Markov chain analysis and cross-sectional regressions provide evidence that convergence of regional per-capita income in the EU15 has become considerably stronger in the 1990s. The reduction of income disparities, however, is a phenomenon between nations but not between regions within the EU countries. European integration (and possibly European regional policy) foster the catching-up of lagging countries but at the same time forces for agglomeration of economic activities tend to increase disparities within the EU member states. Obviously, the productive advantages of spatial proximity do not vanish in the knowledge economy. --Regional growth,agglomeration,Markov chains

Regional disparities in the European Union: Convergence and Agglomeration

Economic disparities between the regions of the European Union are of constant concern both for policy and economic research. One of the “stylised facts” from the empirical literature is that the process of absolute convergence observed for decades has slowed down or even petered out during the 1980s. In this paper we analyse whether it has resumed and persisted in the 1990s when European integration made huge steps forward. We construct a typology of regions in order to examine whether there are overlapping trends of regional development, in particular, overall convergence on the one hand and persistent or even increasing spatial concentration (agglomeration) on the other. Both of our approaches, Marcov chain analysis and dynamic panel estimation, provide evidence that regional convergence in the EU15 has become stronger in the 1990s. At the same time there appears to exist a tendency towards further agglomeration of high income economic activities. Keywords: Regional growth, agglomeration, dynamic panel estimation

Risk-Adjusted Capitation Payments: How Well Do Principal Inpatient Diagnosis-Based Models Work in the German Situation? Results From a Large Data Set

The Risk Adjustment Reform Act of 2001 mandates that a health-status-based risk adjustment mechanism has to be implemented in Germany's Statutory Health Insurance system by January 1, 2007. German parliament decided this as with the existing demographic risk adjustment model, that means there is cream skimming and sickness funds hesitate to engage in managing care for the chronical ill. Four approaches were used to test the feasibility of incorporating use of diagnosis as a proxy measure for health status in a German risk adjustment formula. The first two models used standard demographic and socio-demographic variables. The other two models are separately incorporating a simple binary indicator for hospitilization and Hierarchical Coexisting Conditions (HCCs: DxCG® Risk Adjustment Software Release 6.1) using inpatient diagnosis. Age and gender grouping accounted for 3.2% of the variation in total expenditures for concurrent as well as prospective models. The current German risk adjusters age, sex, and invalidity status account for 5.1% and 4.5% of the variance in the concurrent and prospective models respectively. There are substantial increases in explanatory power, however, when HCCs are added. Age, gender, invalidity status and HCC covariates explain about 37% of the variations of the total expenditures in a concurrent model and roughly 12% of the variations of total expenditures in a prospective model. For high-risk (cost) groups, substantial underprediction remains; conversely, for the low-risk group, represented by enrolees who did not show any health care expense in the base year, all of the models over-predict expenditure. --Risk Adjustment,HCCs,Germany

Predictors of Treatment with Duloxetine or Venlafaxine XR among Adult Patients Treated for Depression in Primary Care Practices in the United Kingdom

Background. Knowledge about real-world use of duloxetine and venlafaxine XR to treat depression in the UK is limited. Aims. To identify predictors of duloxetine or venlafaxine XR initiation. Method. Adult depressed patients who initiated duloxetine or venlafaxine XR between January 1, 2006 and September 30, 2007 were identified in the UK's General Practice Research Database. Demographic and clinical predictors of treatment initiation with duloxetine and venlafaxine XR were identified using logistic regression. Results. Patients initiating duloxetine (n = 909) were 4 years older than venlafaxine XR recipients (n = 1286). Older age, preexisting unexplained pain, respiratory disease, and pre-period use of anticonvulsants, opioids, and antihyperlipidemics were associated with increased odds of initiating duloxetine compared to venlafaxine XR. Pre-period anxiety disorder was associated with decreased odds of receiving duloxetine. Conclusion. Initial treatment choice with duloxetine versus venlafaxine XR was primarily driven by patient-specific mental and medical health characteristics. General practitioners in the UK favor duloxetine over venlafaxine XR when pain conditions coexist with depression

Excess Costs Associated with Possible Misdiagnosis of Alzheimer's Disease Among Patients with Vascular Dementia in a UK CPRD Population

The authors would like to acknowledge Julie von Ziegenweidt and Annie Burden (Research in Real Life, UK) for assistance with processing and interpretation of CPRD data, and Gillian Gummer and Caroline Spencer (Rx Communications, Mold, UK) for medical writing assistance with the preparation of this article, funded by Eli Lilly and Company. Authors’ disclosures available online (http://j-alz. com/manuscript-disclosures/15-0685r2).Peer reviewedPublisher PD

How to deal with missing longitudinal data in cost of illness analysis in Alzheimer’s disease—suggestions from the GERAS observational study

BACKGROUND: Missing data are a common problem in prospective studies with a long follow-up, and the volume, pattern and reasons for missing data may be relevant when estimating the cost of illness. We aimed to evaluate the effects of different methods for dealing with missing longitudinal cost data and for costing caregiver time on total societal costs in Alzheimer's disease (AD). METHODS: GERAS is an 18-month observational study of costs associated with AD. Total societal costs included patient health and social care costs, and caregiver health and informal care costs. Missing data were classified as missing completely at random (MCAR), missing at random (MAR) or missing not at random (MNAR). Simulation datasets were generated from baseline data with 10-40 % missing total cost data for each missing data mechanism. Datasets were also simulated to reflect the missing cost data pattern at 18 months using MAR and MNAR assumptions. Naïve and multiple imputation (MI) methods were applied to each dataset and results compared with complete GERAS 18-month cost data. Opportunity and replacement cost approaches were used for caregiver time, which was costed with and without supervision included and with time for working caregivers only being costed. RESULTS: Total costs were available for 99.4 % of 1497 patients at baseline. For MCAR datasets, naïve methods performed as well as MI methods. For MAR, MI methods performed better than naïve methods. All imputation approaches were poor for MNAR data. For all approaches, percentage bias increased with missing data volume. For datasets reflecting 18-month patterns, a combination of imputation methods provided more accurate cost estimates (e.g. bias: -1 % vs -6 % for single MI method), although different approaches to costing caregiver time had a greater impact on estimated costs (29-43 % increase over base case estimate). CONCLUSIONS: Methods used to impute missing cost data in AD will impact on accuracy of cost estimates although varying approaches to costing informal caregiver time has the greatest impact on total costs. Tailoring imputation methods to the reason for missing data will further our understanding of the best analytical approach for studies involving cost outcomes

What drives country differences in cost of Alzheimer's Disease? An explanation from resource use in the GERAS Study

BACKGROUND: Country differences in resource use and costs of Alzheimer's disease (AD) may be driven by differences in health care systems and resource availability. OBJECTIVE: To compare country resource utilization drivers of societal costs for AD dementia over 18 months. METHODS: GERAS is an observational study in France (n = 419), Germany (n = 550), and the UK (n = 526). Resource use of AD patients and caregivers contributing to >1% of total societal costs (year 2010) was assessed for country differences, adjusting for participant characteristics. RESULTS: Mean 18-month societal costs per patient were France ¿33,339, Germany ¿38,197, and UK ¿37,899 (£32,501). Caregiver time spent on basic and instrumental activities of daily living (ADL) contributed the most to societal costs (54% France, 64% Germany, 65% UK). Caregivers in France spent less time on ADL than UK caregivers and missed fewer work days than in other countries. Compared with other countries, patients in France used more community care services overall and were more likely to use home aid. Patients in Germany were least likely to use temporary accommodation or to be institutionalized at 18 months. UK caregivers spent the most time on instrumental ADL, UK patients used fewest outpatient resources, and UK patients/caregivers were most likely to receive financial support. CONCLUSION: Caregiver time on ADL contributed the most to societal costs and differed across countries, possibly due to use of community care services and institutionalization. Other resources had different patterns of use across countries, reflecting country-specific health and social care systems